How is the hernia sac dissected and reduced 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

Before dissection of the hernia sac, the following important structures should be identified:

  • Pubic symphysis
  • Cooper ligament
  • Iliopubic tract

During the dissection, care should be taken to identify the triangle of doom, which contains the external iliac vessels and is bounded by the vas deferens medially and the gonadal vessels laterally. If the hernia sac is not reduced in conjunction with the dissection of the peritoneal flap, it can usually be reduced by means of gentle traction on the peritoneal attachments within the defect (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Reduction of indirect hernia with gentle traction.

The spermatic cord is then skeletonized by means of careful dissection. Once the cord structures have been clearly identified, any peritoneum of an indirect component is identified, separated from cord structures, and reduced. If there is a long indirect sac, the sac can be transected. It is essential, however, to minimize the risk of injury by first identifying the cord structures and reducing any peritoneal contents of the sac (see the images below).

Laparoscopic inguinal hernia repair: TAPP. Reducti Laparoscopic inguinal hernia repair: TAPP. Reduction of hernia sac and lipoma with upward traction.
Laparoscopic inguinal hernia repair: TAPP. Dissect Laparoscopic inguinal hernia repair: TAPP. Dissection of remaining hernia sac by blunt dissection using traction and countertraction.
Laparoscopic inguinal hernia repair: TAPP. Reducti Laparoscopic inguinal hernia repair: TAPP. Reduction of hernia, showing hernia defect.
Laparoscopic inguinal hernia repair: TAPP. Evaluat Laparoscopic inguinal hernia repair: TAPP. Evaluation of peritoneum to ensure that entire hernia sac has been reduced.

Complete dissection of the pubis should be carried out to facilitate placement of the mesh prosthesis. The Cooper ligament should be cleared of preperitoneal fat and identified completely, and the musculoaponeurotic arch of the transversus abdominis should be cleared to approximately 2 cm superior and lateral to the internal inguinal ring.


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