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LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
D Mutter, J Marescaux
Surgical intervention
1 year ago
20420 views
1413 likes
0 comments
25:14
LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach
We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood.

The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized.

After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance.

The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.
TAPP laparoscopic repair of right inguinal hernia after artificial sphincter placement for post-prostatectomy urinary incontinence
Incapacitating post-prostatectomy urinary incontinence may be managed by the placement of an artificial sphincter. This sphincter is composed of an inflatable circular tape (the sphincter itself), a remote control located in the scrotum, and of a reservoir connected to the sphincter by a catheter. This reservoir is positioned within the preperitoneal space using an anterior inguinal approach through a mini-incision in the transversalis fascia which weakens the posterior wall of the inguinal canal, hence increasing the risk of inguinal hernia.
This film demonstrates a typical case management of such hernia. The anterior approach is delicate as repair of the inguinal canal may well induce trauma to the catheter connected to the retromuscular balloon. The posterior approach is therefore valuable as it allows to see the balloon prior to dissecting the preperitoneal space. The film highlights the specific issues to be dealt with as well as the tips and tricks related to this approach.
J Leroy, C Saussine, J Marescaux
Surgical intervention
5 years ago
5325 views
109 likes
0 comments
08:18
TAPP laparoscopic repair of right inguinal hernia after artificial sphincter placement for post-prostatectomy urinary incontinence
Incapacitating post-prostatectomy urinary incontinence may be managed by the placement of an artificial sphincter. This sphincter is composed of an inflatable circular tape (the sphincter itself), a remote control located in the scrotum, and of a reservoir connected to the sphincter by a catheter. This reservoir is positioned within the preperitoneal space using an anterior inguinal approach through a mini-incision in the transversalis fascia which weakens the posterior wall of the inguinal canal, hence increasing the risk of inguinal hernia.
This film demonstrates a typical case management of such hernia. The anterior approach is delicate as repair of the inguinal canal may well induce trauma to the catheter connected to the retromuscular balloon. The posterior approach is therefore valuable as it allows to see the balloon prior to dissecting the preperitoneal space. The film highlights the specific issues to be dealt with as well as the tips and tricks related to this approach.
Laparoscopic TAPP for bilateral inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to bilateral hernia repair. Dr. Joel Leroy performs the repair using two separate meshes, one side at a time. This procedure is recommended to a general surgical audience.
The author uses a 3-trocar approach with a 0-degree 10mm optical scope. Exploration reveals some vivid landmarks, including abdominal wall adhesions from a previous appendectomy. The midline of the urinary bladder, umbilical ligament, vas deferens duct crossing behind the umbilical artery from behind —a key landmark the author will use during dissection of the peritoneum — and spermatic vessels all come into view. The direct hernia is visible between the epigastric vessels, retracted medially, and the umbilical ligament, retracted into the sac. When the author tries to reduce the sac, pressure pushes it back.
J Leroy
Surgical intervention
12 years ago
5525 views
130 likes
0 comments
12:37
Laparoscopic TAPP for bilateral inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to bilateral hernia repair. Dr. Joel Leroy performs the repair using two separate meshes, one side at a time. This procedure is recommended to a general surgical audience.
The author uses a 3-trocar approach with a 0-degree 10mm optical scope. Exploration reveals some vivid landmarks, including abdominal wall adhesions from a previous appendectomy. The midline of the urinary bladder, umbilical ligament, vas deferens duct crossing behind the umbilical artery from behind —a key landmark the author will use during dissection of the peritoneum — and spermatic vessels all come into view. The direct hernia is visible between the epigastric vessels, retracted medially, and the umbilical ligament, retracted into the sac. When the author tries to reduce the sac, pressure pushes it back.
Anatomical landmarks and TAPP approach for right inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to unilateral hernia repair. A detailed discussion of the technique is presented by Dr. Joel Leroy. This procedure is recommended to a general surgical audience.
The author carries out this transabdominal preperitoneal approach using 3 trocars: a 12mm (for mesh and camera), and two 5mm trocars. After exploration to assess the anatomy, the author proceeds to determine the landmarks. With the left trocar, he takes down adhesions from a previous appendectomy. Using low-energy coagulation, he carries out the vertical incision. The procedure continues as he carries out the dissection laterally and then places the mesh.
J Leroy
Surgical intervention
12 years ago
7078 views
206 likes
2 comments
12:55
Anatomical landmarks and TAPP approach for right inguinal hernia
This video, recorded live during a surgical course, demonstrates the TAPP approach to unilateral hernia repair. A detailed discussion of the technique is presented by Dr. Joel Leroy. This procedure is recommended to a general surgical audience.
The author carries out this transabdominal preperitoneal approach using 3 trocars: a 12mm (for mesh and camera), and two 5mm trocars. After exploration to assess the anatomy, the author proceeds to determine the landmarks. With the left trocar, he takes down adhesions from a previous appendectomy. Using low-energy coagulation, he carries out the vertical incision. The procedure continues as he carries out the dissection laterally and then places the mesh.
Transabdominal preperitoneal approach (TAPP)
The description of the transabdominal preperitoneal approach (TAPP) covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: hernia types, Nyhus classification, laparoscopic classification, exposure and exploration, incision of peritoneum, preperitoneal dissection, hernia sac dissection, preperitoneal space, the mesh, mesh placement, fixing the mesh, closing the peritoneum.
Consequently, this operating technique is well standardized for the management of this condition.
J Leroy
Operative technique
18 years ago
17319 views
472 likes
0 comments
Transabdominal preperitoneal approach (TAPP)
The description of the transabdominal preperitoneal approach (TAPP) covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: hernia types, Nyhus classification, laparoscopic classification, exposure and exploration, incision of peritoneum, preperitoneal dissection, hernia sac dissection, preperitoneal space, the mesh, mesh placement, fixing the mesh, closing the peritoneum.
Consequently, this operating technique is well standardized for the management of this condition.