Lap hernia steps of operation (TAPP – trans abdomen pre peritoneal)
As seen in video
@www.youtube.com/generalsurgery
Preparation
• Ask patient to empty the bladder
• GA
• Position supine – head down may be needed
• WHO time out
Ports
• 10mm umbilical port open technique – camera
• Two 5mm working ports at the level of umbilicus just lateral to the mid clavicular line
Steps
• Peritoneal incision from the level of anterior superior iliac spine to medially in a lazy S fashion (last part of the incision should run anteriorly and medially)
• Raise peritoneal flap – make sure you stay in the correct plane – just anterior to the peritoneum (will bleed if you are not on correct plane)
• Expose pubis bone medially
• Dissect the sac – this may be difficult if indirect – separate video included
• Make sure the vas is exposed and protected. The vas is medial going towards prostate and testicular vessels lateral going towards aorta form the deep ring
• Recognise and anticipate anatomy – triangle of pain (inverted V shaped space bounded anteriorly by iliopubic tract/inguinal ligament and posteriorly by testicular vessels, where nerves are present lateral to testicular vessels) and triangle of Doom (between vas and testicular vessels posteriorly, where major vessels are present). Do not put any tackers in these triangles.
• Insert 10X15 cm mesh and fix this using tacking instrument (eg sorbafix, securestrap etc) starting at pubis medially tacking superiorly only
• Cover mesh with peritoneum and either tack or suture this together
• Close umbilical fascia using 1/0 vicryl or PDS
• Close skin
• Infiltrate local
HOW TO DISSECT SAC WHILE DOING HERNIA SURGERY
