What is the procedure for laparoscopic access and port placement 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

A TAPP repair for recurrent inguinal hernia is shown in the video below.

Laparoscopic repair of recurrent inguinal hernia: TAPP. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Laparoscopic access and port placement

One of the main criticisms of the TAPP procedure is the potential for intra-abdominal injuries. Accordingly, safe laparoscopic access is an essential initial step. A number of techniques, both open and closed, have been described. An excellent method of obtaining laparoscopic access at the umbilicus is the umbilical stalk technique (see the video below). [97]

Laparoscopic inguinal hernia repair: TAPP. Umbilical stalk technique for obtaining laparoscopic access.

An infraumbilical incision is made, through which the subcutaneous tissues are dissected bluntly and the umbilical stalk is grasped with Kocher clamps and retracted upward. Fascia inferior to the umbilical stalk is then grasped with a second pediatric Kocher clamp, and the fascia is incised between the two clamps in a transverse fashion with a No. 15 blade scalpel. A Kelly clamp is gently placed through the incision to ensure that the peritoneal cavity has been entered.

At this point, a 5-mm trocar is placed, and the abdomen is insufflated. A 5-mm 30° scope is then placed through the trocar, allowing the peritoneal cavity to be viewed.

Two lateral 5-mm trocars are placed at the level of the umbilicus and lateral to the rectus at approximately the midclavicular line. It is important that the lateral ports not be placed too far inferiorly; a large preperitoneal pocket must be made to place the mesh, and the peritoneal flap can be hard to visualize if the port is placed too low. Care must also be taken to avoid the epigastric vessels during the placement of these trocars. The 5-mm trocar initially placed at the umbilicus is then upsized to an 11-mm trocar to facilitate entry of a large mesh prosthesis.

After ports are established, diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. Evaluation of the pelvis should follow. It is easy to identify hernia defects and to determine whether they are direct or indirect defects.

As a rule, the operating surgeon stands opposite the side of the hernia and operates using both hands, one for the umbilical trocar and the other for the trocar on his or her side of the table (ie, the side opposite the hernia defect). The assistant places the 5-mm 30° camera through the 5-mm trocar on the side of the hernia defect. If bilateral inguinal hernias are present, the surgeon and assistant first approach one side in this manner and then switch sides to repair the contralateral hernia.

Although the approach described above is preferred by the authors, it should be kept in mind that different approaches to port placement and camera location can be employed, depending on the assistant (who may be a resident, a surgeon, or a surgical technologist assistant) and his or her ability to assist with the operation and run the camera.

Obtaining an appropriate laparoscopic view during all portions of the TAPP procedure can be very difficult for the person controlling the camera and often requires considerable skill and experience. It is important, especially during the learning curve, that the camera operator/assistant have some previous experience with using a 30° camera.


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