How is the initial incision made in transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair?

Updated: Apr 16, 2020
  • Author: Danny A Sherwinter, MD; Chief Editor: Kurt E Roberts, MD  more...
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Answer

After the anatomy is identified, laparoscopic scissors are used to make a small incision in the peritoneum at (or just lateral to) the medial umbilical ligament, just below the umbilicus (see the videos below).

Laparoscopic inguinal hernia repair: TAPP. Cutting of peritoneum and dissection of pubis.
Laparoscopic inguinal hernia repair: TAPP. Cutting of peritoneum.

This incision is then extended laterally to the ASIS with scissors (see the image below). A common mistake is to make this incision too inferiorly. Special attention is required to keep the incision superior to the potential spaces for both direct and indirect hernia defects. The peritoneal flap must be extended far enough cephalad to ensure that it can cover the mesh and completely exclude it from the peritoneal cavity.

Laparoscopic inguinal hernia repair: TAPP. Sharp d Laparoscopic inguinal hernia repair: TAPP. Sharp dissection to take down peritoneum for access to inguinal region.

Next, the peritoneum is bluntly dissected away from the abdominal wall with blunt laparoscopic graspers. This is best done by grasping the edge of the peritoneal flap with one instrument and retracting superiorly and posteriorly while making an upward sweeping motion with the other instrument to sweep away the tissue of the posterior abdominal wall. The result should be an avascular plane, which is first carried down along the medial border of the flap until the pubis is identified and then dissected laterally in the same fashion.


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