Transabdominal Preperitoneal (TAPP) Repair

David Ray Velez, MD

Definition

Definition: A Minimally Invasive Posterior Mesh Repair Performed by Entering the Peritoneal Cavity, Creating a Peritoneal Flap, and Placing a Mesh in the Preperitoneal Space

Become the Most Common Technique for Robotic Inguinal Hernia Repair

Repairs Both Inguinal Hernias and Femoral Hernias

Inguinal Anatomy/Laparoscopic Triangles: *See Abdominal Wall: Anatomy

Technique

Establish Pneumoperitoneum and Place Ports

10-12 mm at Umbilicus (Camera Port)
5 mm (x2) 8-10 cm Lateral to Umbilicus on Either Side (Working Ports)

Preperitoneal Exposure and Dissection

Create a Transverse Peritoneal Flap
- Extend from the Medial Umbilical Ligament to the ASIS
- Begin ≥ 4 cm Above the Deep Inguinal Ring
Develop the Space of Retzius Medially – Between the Pubic Symphysis and Bladder
Develop the Space of Bogros Laterally – Lateral from the Inferior Epigastric Vessels to the ASIS
Obtain the Critical View of the Myopectineal Orifice (MPO)
- *See Below

Repair

Completely Reduce the Hernia Sac
Parietalize the Spermatic Cord Structures – Completely Separate the Peritoneum from the Vas Deferens and Gonadal Vessels
Place a Large Mesh Over the Myopectineal Orifice (MPO)
- Ensure Adequate Circumferential Overlap
- Mesh May Be Left Unfixed or Secured with Tacks, Glue, or Self-Fixating Mesh Depending on Surgeon Preference

Caution: Identify and Avoid Tacks or Sutures within the “Triangles of Danger” (Inferior to the Inguinal Ligament and Lateral to the Vas Deferens)

*See Abdominal Wall: Anatomy

Closure

Close the Peritoneal Flap to Completely Reperitonealize the Mesh
- Commonly Use a Running Absorbable Barbed Suture
Desufflate Under Direct Visualization While Maintaining Mesh Position
Remove Ports
Close the Fascial Defect at the 10-12 mm Port Site
Close Skin

Port Placement

Laparoscopic View of the Inguinal Triangles ¹

Laparoscopic Inguinal Triangles

Critical View of the Myopectineal Orifice (MPO)

Definition: Complete Exposure of the Myopectineal Orifice (Anatomical Area Viewed) Prior to Mesh Placement During Minimally Invasive Hernia Repair

Similar Concept to the Critical View of Safety in Laparoscopic Cholecystectomy – Although Not Universally Adopted in the Same Way

General Requirements:

Expose the Pubic Tubercle and Cooper’s Ligament Across the Midline
Develop the Spaces of Retzius (Medially) and Bogros (Laterally)
Reduce All Hernia Sacs – Direct, Indirect, Femoral, and Obturator
Completely Parietalize the Cord Structures
Reduce Any Cord Lipoma
Visualize the Psoas Muscle and Iliac Vessels Laterally
Achieve Complete Hemostasis
Place a Large Flat Mesh to Cover the Entire Myopectineal Orifice Without Folds or Creases

9 Steps to Establish

Step 1: Expose the Pubic Tubercle and Cooper’s Ligament Across the Midline
Step 2: Rule Out a Direct Hernia
- Visualize the Entire Hasselbach Triangle
Step 3: Develop the Space of Retzius Medially
- Dissect at Least 2 cm Between Cooper’s Ligament and the Bladder
- Facilitates Flat Placement of the Medial Mesh to Avoid Mesh Displacement Caused by Bladder Distention
Step 4: Rule Out a Femoral Hernia
- Visualize the Femoral Canal Between Cooper’s Ligament and the Iliac Vein
Step 5: Parietalize the Cord’s Elements
- Completely Separate the Peritoneum from the Cord Structures Until the Cord’s Elements Lie Flat and No Movement of the Cord is Triggered by Pulling the Sac and Peritoneum Upward
Step 6: Reduce Any Cord Lipomas
Step 7: Develop the Space of Bogros Laterally
- Extend Beyond the Anterior Superior Iliac Spine (ASIS)
Step 8: Ensure the Mesh and Any Fixation Lie Above the Inter-ASIS Line
- Avoids Recurrence and Nerve Injury
Step 9: Place a Large Flat Mesh Only After Complete Dissection and Hemostasis
- Typically ≥ 15 x 10 cm
- Ensure No Creases or Folds

References

Carter J, Duh QY. Laparoscopic repair of inguinal hernias. World J Surg. 2011 Jul;35(7):1519-25. (License: CC BY-ND-4.0)