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WJOLS

Combined TAPP and TEP: A New Modified Technique for Laparoscopic Inguinal Hernia Repair

through which another Veress needle or 5 mm trochar was right indirect inguinal hernia, 51 patients (21.7%) suffered
introduced to the preperitoneal space under transperitoneal from left indirect inguinal hernia. One hundred and sixty-
scope direct vision. The preperitoneal space was insufflated one cases (68.5%) were bubonocele and 74 cases (31.5%)
by CO to a pressure of 10 mm Hg so that the peritoneum were funicular type of inguinoscrotal hernia, complete
2
and fascia transversalis were dissected off anterior scrotal cases were not included. Patients’ average age was
abdominal wall under visual control by the intraperitoneal 34 years (Table 1).
scope (Fig. 1A). All procedures were completed laparoscopically. The
After that, the second Veress needle was withdrawn, operative time, defined as the time from skin incision to
insertion of two 5 mm midclavicular routine working trochar skin closure, ranged from 30.2 minutes up to 44.6 minutes
to intraperitoneal space and complete the operation as with average operative time of 39.8 minutes in the first group
classical TAPP by transverse incision of the peritoneum, while in the second group; it ranged from 40.6 minutes up
dissection of the preperitoneal space and put 15 × 10 cm to 49.2 minutes with average of 44.3 minutes. In the first
mesh to cover all three groin hernia orifices (Fig. 1B). Our group, we used Veress needle in preperitoneal inflation in
protocol was routinely not to fix the mesh regarding that 88 cases and 5 mm trochar in 49 cases, we found it easier
the laying space is roomy enough for it to be spread by trochar but there was no significant difference in
satisfactorily. In some cases where the surgeon was not operative time recorded which was 39.4 in needle group
satisfied, the mesh was sutured to the pubic bone, Cooper’s versus 36.2 minutes in trochar one (p = 0.79). In the first
ligament and the muscle layers anteriorly but not into the group, mesh was fixed in 30 patients (21.9%) while in the
ileopubic tract or posterior to this. None of our cases had second group, it was fixed in 81 patients (40.9%; Table 2).
bilateral hernia. Closure of transverse peritoneal incision There were no intraoperative or postoperative
was done in all cases using continuous 3-0 Vycril intra- complications except for postoperative port site infection
corporeal sutures. At the end of procedure, routine
inspection of the abdomen, deflation of the pneumo- which occurred in three patients (2.19%). No perioperative
peritoneum and closure of the skin incision by subcuticular deaths occurred. All patients were discharged within two
absorbable fine sutures were done. days of surgery. Their activity was not restricted
All our patients were followed up for 6 to 18 months postoperatively in all patients. No recurrence was observed
with an average of 10 months by 3 months OPC visits. All in regular follow-up visits for 6 to 18 months with average
intraoperative and postoperative complications, operative 10 months, and patient satisfaction was subjectively
time, hernia recurrence, the need for mesh fixation and excellent, as determined by office interview.
patients’ satisfaction were recorded and statistically
analyzed. DISCUSSION
Hernia repair is currently the most commonly performed
RESULTS
general surgical operation; it occurs with a greater frequency
Two hundred and thirty-five male patients were included in men than women (12:1 ratio) and accounts for nearly
in this study. Of them, 184 patients (78.3%) suffered from 800,000 cases per year in the United States. The goals of
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successful hernia repair must include achievement of an
effective repair with the lowest possible recurrence, minimal
operative and postoperative discomfort with a rapid return
to normal activity, and also cost-effective. Success of groin
hernia repair depends largely on the surgeon’s understanding
of the functional anatomy and pathophysiology of the
abdominal wall and groin, as well as knowledge of how to
use the currently available techniques and materials most
effectively.

Table 1: Patients’ demographic data
Patients
A B • Age (yrs) 27-51 (average, 34)
• Hernia
Figs 1A and B: (A) Inflation of preperitoneal space by Veress needle – Right 184 (78.3% )
under vision of transperitoneal scope, (B) complete operation as – Left 51 (21.7%)
classical TAPP
World Journal of Laparoscopic Surgery, May-August 2012;5(2):72-75 73