Infraumbilical Incision

• Make a 1-2 cm Infraumbilical Incision
• Dissect Down to the Rectus Sheath
• Incise the Anterior Rectus Sheath Off Midline
• Bluntly Retract or Split the Rectus Muscle to Access the Posterior Rectus Sheath

Preperitoneal Exposure and Dissection

• Develop the Preperitoneal Space Posterior to the Rectus Muscle
  • Can Use Finger Dissection or a Balloon Dissector (Inflates to Spread and Open the Space)
• Insert a 10-12 mm Camera Port Through the Incision into the Preperitoneal Space (Larger to Later Insert the Mesh Through)
• Insufflate the Preperitoneal Space
• Place Two Additional 5-mm Ports Under Direct Visualization Inferiorly Along the Midline
  • First ~ 5 cm Below the Camera Port
  • Second ~ 5 cm Below the Other (Usually Just Above the Pubis)
• 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

Caution: Avoid Inadvertent Violation of the Peritoneal Cavity Which Can Cause Pneumoperitoneum and Loss of the Preperitoneal Working Space – May Consider Veress Needle to Decompress or a Conversion to a TAPP Repair

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
• Close Any Inadvertent Peritoneal Tears

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

• Desufflate Under Direct Visualization While Maintaining Mesh Position
• Remove Ports
• Close the Fascial Defect at the 10-12 mm Port Site
• Close Skin