TAPP into our Inguinal Hernia Repair Simulation
by Brie Eteson, Medical Communications, Digital Surgery
A new procedure has landed on the Touch Surgery™ app and it’s on the most common type of abdominal wall hernia, inguinal hernias.1 These are more common in men, with a lifetime risk around 27%, compared with around 3% in women.2,3,4 This one-module simulation sets out the steps of an inguinal hernia repair to ensure you understand the key surgical objectives, alongside the contraindications, and complications when performing this procedure.
This simulation focuses specifically on a laparoscopic transabdominal preperitoneal repair of an indirect inguinal hernia — that’s TAPP for those of you who don’t like syllables. The module demonstrates the appropriate port insertion sites and how to allow access and dissection of the inguinal region. To facilitate reduction of the inguinal hernia, the patient is positioned in Trendelenburg.
Identification should then be made to appropriately determine the hernia type based on its location. This procedure demands knowledge of the anatomy using the inverted-Y concept.5
Getting to grips with the inverted-Y concept and the Triangles of Doom and Pain are a must for hernia repairs. This ensures you can identify these landmarks that create a roadmap for safe surgery. We’ve included a snapshot of one of the steps that may help you familiarize yourself with the anatomy.
The so-called Triangles of Doom and Pain were named by laparoscopic hernia surgeons and refer to anatomical sites to avoid due to potential neurovascular damage, which subsequently cause pain.5
Triangles of Pain and Doom
The following steps guide you through the remainder of the hernia repair procedure:
- Preperitoneal space dissection
- Hernia resolution to carefully dissect the hernia sac from the cord structures
- Preparation for mesh fixation and insertion
- Peritoneal flap closure
- Port removal and closure
Let’s get down to some of the need-to-knows of hernia repairs. There are two approaches to repair inguinal hernias, which we will briefly discuss.
Hernia repairs can be performed as a laparoscopic (as demonstrated in this new simulation) robotic or open procedure. Each one has its advantages. As with any laparoscopic procedure, some aims are to improve recovery time and lower infection rate, despite the longer surgical time.6,7 Two approaches can also be taken, either transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP). As you may have concluded from the title, this simulation focuses on the TAPP approach.
What’s the Difference?
TAPP is performed by accessing the peritoneal cavity, creating a peritoneal incision, and then placing a mesh through that incision to cover all potential hernia sites.8 The site is then closed, with the mesh remaining between the preperitoneal tissues and abdominal wall.8 This is the approach demonstrated in the simulation.
TEP is performed by using the mesh to seal the hernia from outside the peritoneum.8 Generally, this approach is considered more technically difficult than TAPP.
Types of Inguinal Hernia
Indirect inguinal hernias can develop due to incomplete obliteration of the processus vaginalis, and therefore may be congenital. The hernia may appear in the scrotum in males or the opening of the vagina in females.
Direct inguinal hernias may occur due to weakness in the abdominal muscles. This can cause fatty tissue and sometimes the bowel to push through this defect and enter the inguinal canal.
This simulation was produced with Medtronic to showcase devices used for this procedure. The products recommended in this simulation are linked below:
Port insertion for laparoscopic TAPP hernia repair
That’s the whistlestop tour of the Laparoscopic TAPP indirect inguinal hernia repair simulation. Get started with the full module in the Touch Surgery™ app and start your training.
1. Dabbas N, Adams K, Pearson K, Royle G. Frequency of abdominal wall hernias: is classical teaching out of date?. JRSM Short Rep. 2011;2(1):1–6.
2. Jenkins JT, O’Dwyner PJ. Inguinal hernias. BMJ. 2008;336(7638):269–272.
3. Kingsnorth A, LeBlanc K. Hernias: inguinal and incisional. Lancet. 2003;362(9395):1561–1571.
4. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and emergency surgery, readmission and mortality. Int J Epidemiol. 1996;25(4):835–839.
5. Furtado M, Claus CMP, Cavazzola LT, Malcher F, Bakonyi-Neto A, Saad-Hossne R. Systemization of laparoscopic inguinal hernia repair (TAPP) based on a new anatomical concept: inverted y and five triangles. Arq Bras Cir Dig. 2019;32(1).
6. National Institute for Clinical Excellence. Laparoscopic surgery for inguinal hernia repair. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/ta83. Published Sep. 22 2004. Accessed Jun. 16 2020.
7. McCormack K, Wake B, Perez J, et al. Laparoscopic surgery for inguinal hernia repair: systematic review of effectiveness and economic evaluation. Health Technol Assess. 2005;9(14).
8. McCormack K, Wake BL, Fraser C, Vale L, Perez J, Grant A. Transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) laparoscopic techniques for inguinal hernia repair: a systematic review. Hernia. 2005;9(2):109–114.