Ipsilateral Port Technique in Laparoscopic TAPP Inguinal Hernia Repair

Introduction

Inguinal hernia repair is one of the most common surgeries performed worldwide. Among the various techniques available, laparoscopic approaches have gained significant popularity due to their advantages in terms of reduced postoperative pain, quicker recovery, and lower recurrence rates compared to open repair. Transabdominal preperitoneal (TAPP) repair is one of the primary laparoscopic methods used. This article explores a specific variant of the TAPP approach: the ipsilateral port technique.

Overview of TAPP Repair

Transabdominal preperitoneal (TAPP) repair involves accessing the preperitoneal space via the abdominal cavity to place a synthetic mesh over the hernia defect. The standard TAPP procedure typically utilizes a contralateral port placement strategy, where the working ports are positioned on the opposite side of the hernia. While effective, this technique can sometimes pose ergonomic challenges and may increase the risk of complications.

The Ipsilateral Port Technique

The ipsilateral port technique modifies the standard TAPP approach by placing all the laparoscopic ports on the same side as the hernia. This adjustment aims to enhance surgeon ergonomics, improve instrument handling, and potentially reduce the risk of complications.

Port Placement

In the ipsilateral port technique, three ports are generally used:

1. Optical Port: A 10-12 mm port is placed at the umbilicus for the laparoscope.
2. Primary Working Port: A 5 mm port is placed in the midline, a few centimeters above the pubic symphysis.
3. Secondary Working Port: Another 5 mm port is placed in the lower abdomen, on the same side as the hernia, typically in the midclavicular line.

This configuration allows the surgeon to work in a more intuitive and comfortable manner, reducing the need for extensive instrument crossing and potentially lowering the operative time.

Surgical Steps

1. Patient Positioning and Anesthesia: The patient is placed in a supine position with slight Trendelenburg tilt to facilitate bowel retraction. General anesthesia is administered.

2. Port Insertion: After establishing pneumoperitoneum using a Veress needle or an open technique, the laparoscope is introduced through the umbilical port. The other two ports are then inserted under direct vision.

3. Peritoneal Incision: A peritoneal incision is made starting from the lateral umbilical ligament extending laterally and inferiorly to expose the hernia defect and the surrounding anatomy.

4. Hernia Sac Reduction: The hernia sac is carefully dissected and reduced back into the abdominal cavity. For indirect hernias, the sac is separated from the spermatic cord structures. In the case of direct hernias, the defect is reduced by blunt dissection.

5. Mesh Placement: A pre-shaped mesh is introduced through the umbilical port and positioned over the myopectineal orifice, covering both the direct and indirect hernia spaces. The mesh is typically fixed using tackers or glue to ensure it stays in place.

6. Peritoneal Closure: The peritoneum is closed using sutures or tacks to cover the mesh completely, preventing direct contact with the intra-abdominal contents.

7. Desufflation and Closure: The pneumoperitoneum is released, and the ports are removed. The port sites are closed with sutures or staples, as appropriate.

Advantages of the Ipsilateral Port Technique

1. Ergonomics: By placing all ports on the same side, the surgeon can work more comfortably, with instruments operating in parallel rather than crossing each other. This can reduce fatigue and improve precision.

2. Reduced Operative Time: The improved ergonomics and more intuitive instrument handling can lead to faster dissection and mesh placement, potentially reducing overall operative time.

3. Lower Risk of Complications: The ipsilateral approach minimizes the need for instrument crossing and excessive manipulation, which can reduce the risk of inadvertent injuries to the bowel, blood vessels, and other intra-abdominal structures.

4. Improved Access: This technique provides better access to the hernia defect and surrounding anatomy, facilitating thorough dissection and more accurate mesh placement.

Challenges and Considerations

While the ipsilateral port technique offers several benefits, it is not without challenges. Surgeons must be adept at laparoscopic skills and familiar with the anatomical variations of the inguinal region. Additionally, patient selection is crucial; cases with bilateral hernias or large, complicated defects may still benefit from the standard contralateral approach.

Surgeons should also be mindful of potential limitations in port placement, especially in patients with a history of lower abdominal surgeries or those with significant obesity. Careful preoperative planning and patient assessment are essential to ensure the suitability of the ipsilateral port technique for each individual case.

Conclusion

The ipsilateral port technique in laparoscopic TAPP inguinal hernia repair represents an innovative and ergonomically advantageous approach. By placing all ports on the same side as the hernia, surgeons can achieve improved instrument handling, reduced operative times, and potentially lower complication rates. As with any surgical technique, success relies on thorough understanding, careful patient selection, and meticulous execution. Continued research and clinical experience will further refine this technique, solidifying its place in the repertoire of advanced laparoscopic hernia repair methods.