**8.1. Operating room layout**

The opposite side of the surgical field and both legs are in closed position. In bilateral hernia repair, both arms are in closed position. The videomonitor laparoscopy tower is placed on the patient's foot, on the side to be operated. The operator can be placed on the opposite side of the area to be operated and the camera assistant can be placed on the same side or opposite side of the surgeon depending on the experience and habits of the team. We prefer the camera assistant to sit on the same side of the surgeon (**Figure 1**).

### **8.2. Surgical instruments**


### **8.3. Preparation of the patient and treatment of trocars**

A single dose of 1 g second-generation cephalosporin as prophylactic antibiotic is injected half an hour before the onset of operation. The patient should urinate before operation and preoperative fluid resuscitation should be kept to a minimum. Before the operation, the patient

**Figure 1.** Operating room: The surgeon and camera assistant placed on the opposite side of the surgical area.

**8.5. Peritoneal incision, dissection and preparation of preperitoneal area**

**Figure 3.** Trocar placement for TAPP procedure.

**8.6. Preparation, placement and detection of the mesh patch**

The preparation of the peritoneal flap starts on approximately 5 cm above the hernia canal at the level of the anterior superior crista iliaca on the upper outer side of the annulus inguinalis. The incision is advanced to the medial side of the transverse plane through the upper 5 cm of the inguinal canal's inner ring and terminated at approximately 2 cm to median ligament. The peritoneal incision can be done with endoscissors or hooks. Rest of the peritoneal flap on the inguinal canal inner ring can be easily disrupted with the help of intraabdominal CO<sup>2</sup> pressure, stretched with endograsper. Peritoneal dissection, below the inguinal canal inner ring, is a little more difficult. The lower peritoneal flap is liberated until lateral visualization of the iliopubic tract, and medial visualization of the Cooper ligament. The hernia sac is carefully dissected from the spermatic cord and elements that are attached through the lower peritoneal membrane (**Figure 4**). The peritoneal upper and lower flaps are dissected in each direction to provide large parietalization and vision of myopectineal orifice. Thus, enough space is available to lay a mesh on probable direct, indirect and femoral herniation defect sources. If bilateral hernias are present, the peritoneal incision can be extended from one side of the crista iliaca to the other side of the crista iliaca, but in the literature it is suggested that a single incision should be made and a peritoneal bridge could be released in the midline.

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Special shaped polypropylene or polyester patches prepared in size appropriate to the anatomical characteristics of the hernia of the patient are used. The patch is rolled from the outside to the inside and from top to bottom in the form of a roll with limb or without limb (**Figure 5**). It is placed into the abdomen through a 10 mm trocar. With the help of two endograspers, placed in the working ports, the roll is unfolded in the opposite direction and is laid to cover

**Figure 2.** Surgical instruments for TAPP procedure.

is scrubbed and covered in the supine position for sterility. Under general anesthesia, by Hasson technique or with Veress needle which is placed in the infraumbilical region, produces caphno pneumoperitoneum. General intraabdominal exploration is completed with a 10 mm trocar inserted in the infraumbilical region. The operating table position is kept (30° Trendelenburg and 15°–20°opposite to the operating area). Two operating ports (5 mms) are placed on the umbilical level transverse line, with the lateral sides of both rectus muscles localized and placed under direct vision. The trocars on the operative side are placed on infraumbilical transverse line, while the opposite trocar is placed 4–5 cm caudal side on this line (**Figure 3**). In bilateral hernias, it is suggested that both trocars to be placed on the transverse line at the same level.

#### **8.4. Intraabdominal inguinal exploration**

As the trocar placements are complete, the inguinal area is examined with care. The hernia type is detected and the content—if present—of the hernia is carefully reduced to origin with atraumatic clamp. If there are elements such as intestine or omentum in the hernia sac, the vitability of intestine or omentum is checked after reducement.

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**Figure 3.** Trocar placement for TAPP procedure.

is scrubbed and covered in the supine position for sterility. Under general anesthesia, by Hasson technique or with Veress needle which is placed in the infraumbilical region, produces caphno pneumoperitoneum. General intraabdominal exploration is completed with a 10 mm trocar inserted in the infraumbilical region. The operating table position is kept (30° Trendelenburg and 15°–20°opposite to the operating area). Two operating ports (5 mms) are placed on the umbilical level transverse line, with the lateral sides of both rectus muscles localized and placed under direct vision. The trocars on the operative side are placed on infraumbilical transverse line, while the opposite trocar is placed 4–5 cm caudal side on this line (**Figure 3**). In bilateral hernias, it is suggested that both trocars to be placed on the transverse

**Figure 1.** Operating room: The surgeon and camera assistant placed on the opposite side of the surgical area.

As the trocar placements are complete, the inguinal area is examined with care. The hernia type is detected and the content—if present—of the hernia is carefully reduced to origin with atraumatic clamp. If there are elements such as intestine or omentum in the hernia sac, the

line at the same level.

**8.4. Intraabdominal inguinal exploration**

**Figure 2.** Surgical instruments for TAPP procedure.

78 Hernia Surgery and Recent Developments

vitability of intestine or omentum is checked after reducement.

#### **8.5. Peritoneal incision, dissection and preparation of preperitoneal area**

The preparation of the peritoneal flap starts on approximately 5 cm above the hernia canal at the level of the anterior superior crista iliaca on the upper outer side of the annulus inguinalis. The incision is advanced to the medial side of the transverse plane through the upper 5 cm of the inguinal canal's inner ring and terminated at approximately 2 cm to median ligament.

The peritoneal incision can be done with endoscissors or hooks. Rest of the peritoneal flap on the inguinal canal inner ring can be easily disrupted with the help of intraabdominal CO<sup>2</sup> pressure, stretched with endograsper. Peritoneal dissection, below the inguinal canal inner ring, is a little more difficult. The lower peritoneal flap is liberated until lateral visualization of the iliopubic tract, and medial visualization of the Cooper ligament. The hernia sac is carefully dissected from the spermatic cord and elements that are attached through the lower peritoneal membrane (**Figure 4**). The peritoneal upper and lower flaps are dissected in each direction to provide large parietalization and vision of myopectineal orifice. Thus, enough space is available to lay a mesh on probable direct, indirect and femoral herniation defect sources. If bilateral hernias are present, the peritoneal incision can be extended from one side of the crista iliaca to the other side of the crista iliaca, but in the literature it is suggested that a single incision should be made and a peritoneal bridge could be released in the midline.

#### **8.6. Preparation, placement and detection of the mesh patch**

Special shaped polypropylene or polyester patches prepared in size appropriate to the anatomical characteristics of the hernia of the patient are used. The patch is rolled from the outside to the inside and from top to bottom in the form of a roll with limb or without limb (**Figure 5**). It is placed into the abdomen through a 10 mm trocar. With the help of two endograspers, placed in the working ports, the roll is unfolded in the opposite direction and is laid to cover

**Figure 4.** Anatomic details of left inguinal region after peritoneal flap preparation.

**8.7. Closure of peritoneum over mesh**

**Figure 6.** After mesh fixation in TAPP procedure.

vision and the operation is terminated.

**8.8. Postoperative care**

After the integration of fixation, the upper and lower leaves of the peritoneum are covered on the patch and the opposite edges are closed with either continuous stitches or with clips. Closing the peritoneum with stitches is more convenient but requires more time and experience. The hernia sac, which is usually left in the lower peritoneal sheet and reduced into the peritoneum, can be left if it is small, also the larger sacs can be partially resected before closing the peritoneal leaves. According to experience and preference, a drain can be placed behind the peritoneal flap. After the peritoneum is closed, 5 mm ports are removed under direct

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Oral intake can be started a few hours after surgery and the patient is mobilized the same evening. The following day the patient can be discharged by removal of the drain. There is no

Despite discussions about the use of laparoscopy in the repair of primary unilateral groin hernias, the superiority of TEP in bilateral or recurrent hernias is accepted. The major advantages of this method are that it is extraperitoneal and there is no break in peritoneum. The

need to regulate postoperative medical treatment other than oral analgesics.

**9. Laparoscopic total extraperitonal approach**

**Figure 5.** Mesh preparation.

the existing hernia defect and potential hernia sources. Also, it must be ensured that the patch is placed with a proper tension. When a limb patch is applied the lower limb is passed under the spermatic cord and it is wrapped in a tie and is joined laterally with the upper limb again. The location and number of staples is very important for the immobilization of the mesh patch. The basic rule—with different suggestions about this—is that the staples must be placed on the ileo-pubic tract. We prefer to fix it with two absorbable staples totally, one medially to the Cooper ligament and one to the back of the transverse fascia (**Figure 6**). Tissue adhesives or absorbable suture materials may also be used for detection.

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**Figure 6.** After mesh fixation in TAPP procedure.

#### **8.7. Closure of peritoneum over mesh**

After the integration of fixation, the upper and lower leaves of the peritoneum are covered on the patch and the opposite edges are closed with either continuous stitches or with clips. Closing the peritoneum with stitches is more convenient but requires more time and experience. The hernia sac, which is usually left in the lower peritoneal sheet and reduced into the peritoneum, can be left if it is small, also the larger sacs can be partially resected before closing the peritoneal leaves. According to experience and preference, a drain can be placed behind the peritoneal flap. After the peritoneum is closed, 5 mm ports are removed under direct vision and the operation is terminated.

#### **8.8. Postoperative care**

the existing hernia defect and potential hernia sources. Also, it must be ensured that the patch is placed with a proper tension. When a limb patch is applied the lower limb is passed under the spermatic cord and it is wrapped in a tie and is joined laterally with the upper limb again. The location and number of staples is very important for the immobilization of the mesh patch. The basic rule—with different suggestions about this—is that the staples must be placed on the ileo-pubic tract. We prefer to fix it with two absorbable staples totally, one medially to the Cooper ligament and one to the back of the transverse fascia (**Figure 6**). Tissue

adhesives or absorbable suture materials may also be used for detection.

**Figure 4.** Anatomic details of left inguinal region after peritoneal flap preparation.

**Figure 5.** Mesh preparation.

80 Hernia Surgery and Recent Developments

Oral intake can be started a few hours after surgery and the patient is mobilized the same evening. The following day the patient can be discharged by removal of the drain. There is no need to regulate postoperative medical treatment other than oral analgesics.
