How is the mesh attached 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 dissection and hernia reduction, the mesh prosthesis is placed in the extraperitoneal space. The authors typically use a piece of lightweight polypropylene mesh that is approximately 12 × 16 cm; this can be trimmed as necessary to fit the potential space. The mesh is rolled longitudinally and introduced with a grasper through the 11-mm trocar. It is then spread in the peritoneal cavity and positioned with two graspers (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Mesh placement.

Early in the learning curve, the surgeon may find it difficult to position the mesh appropriately in the preperitoneal space. To facilitate proper placement, the corner of the mesh that is to rest on the pubic bone can be grasped with a blunt grasper and placed through the trocar while the surgeon’s other hand holds the opposite corner of the mesh outside the trocar.

With one hand, the surgeon uses a grasper to push the mesh in and places the grasper on the pubic bone. With the other hand, he or she uses a blunt grasper placed through the 5-mm trocar to help position the mesh in the preperitoneal space. In the course of this process, it is important to use both hands and always hold the mesh in place in one area while pushing or pulling the mesh in the other direction. If the mesh becomes tangled or turned around, it is sometimes quicker and easier to remove it and start over.

In cases where placement of a flat sheet of polypropylene mesh proves challenging, a potential solution is to consider one of the preformed polypropylene meshes that have a right side and a left side; these are generally easier to place. When positioned correctly, the mesh should cover the direct, indirect, and femoral spaces for a potential hernia.

Once proper positioning has been confirmed, the mesh is anchored into place with a 5-mm laparoscopic tacking device. A common approach is to place two tacks in the pubis or Cooper ligament and two tacks on the anterior abdominal wall, medially and laterally, for fixation (see the video below).

Laparoscopic inguinal hernia repair: TAPP. Mesh fixation.

If absorbable tacks are being used, they may have to be placed in the Cooper ligament rather than the pubis; some absorbable tacks may not penetrate the pubic bone. Although it can be tempting to place more tacks in an effort to guarantee that the mesh will be adequately secured, the temptation should be resisted; the use of too many tacks has been associated with postoperative pain. [63]

Once the mesh is fixed to the pubis or Cooper ligament, it is spread out laterally to remove any folds. Placement of the anteromedial and anterolateral tacks is done with a bimanual technique, in which the surgeon places one hand on the outside of the abdominal wall and applies pressure so that he or she can feel the tacking device and ensure proper placement above the iliopubic tract at a perpendicular angle. Avoiding tack placement posterior to the iliopubic tract helps avoid damage to the neural structures located below in the triangle of pain.


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