TEP repair of a recurrent right inguinal hernia following failed TAPP repair: world’s first report
Epublication WebSurg.com, Mar 2011;11(03). URL: http://websurg.com/doi/vd01en3234
A 10mm paraumbilical balloon-tipped port was inserted into the preperitoneal space under direct vision and CO2 was insufflated. Blunt dissection of the preperitoneal space to the pubis inferiorly and towards the left hernial orifices was performed using the 10mm laparoscope. A further 10mm port was introduced into the pre-peritoneal space midway between the pubic symphysis and umbilicus. An atraumatic grasper was used to aid with further pre-peritoneal dissection. An indirect sac was identified on the left, freed from the adherent cord and then reduced. After excluding a direct hernia on the ipsilateral side and ensuring adequate clearance for mesh placement, a third 5mm port was introduced. This was inserted 1cm above and medial to the left anterior superior iliac spine Dissection of the right pre-peritoneal space was performed using a combination of atraumatic graspers, scissors and diathermy. The mesh from the previous repair was identified and noted to be very adherent to the anterior abdominal wall. Careful and patient mobilisation revealed that this mesh had curled up and formed part of the contents of a direct inguinal hernia on the right. After meticulous dissection, the mesh was entirely freed from the anterior abdominal wall and direct space and reduced inferiorly remaining adherent to the underlying peritoneum. The inferior epigastric vessels were then identified. Preperitoneal dissection had resulted in distortion of their position such that they had been pulled down away from the anterior abdominal wall. Care was required not to injure these vessels as they were mobilised and lifted up to their normal anatomical position. The cord on this side was examined and after confirming the absence of an indirect sac, further preperitoneal dissection was performed to ensure adequate space for mesh placement. Bilateral Bard™ 3D meshes were inserted ensuring adequate cover of all hernial orifices with overlapping of meshes in the midline. The left indirect sac and right direct hernia contents, consisting mainly of old mesh, were well clear of the new meshes. No tackers were used. CO2 insufflation was stopped and the preperitoneal space was allowed to close under vision ensuring no mesh displacement. Ports were closed via a standard technique.