H. J. Bonatti1, H. Bonatti1 1Meritus,Surgical Specialists,Hagerstwon, MD, USA
Introduction: Transabdominal preperitoneal (TAPP) inguinal hernia repair requires a 10mm and two 5mm trocars. When using a transverse peritoneal flap, a rather long incision is required. Tacks for MESH fixation and re-approximation of the flap may be associated with pain and are costly.
Methods: A two port technique was used replacing one 5mm instrument with a Teleflex minigrasper. The peritoneal flap was created from a 5-10cm vertical incision in the infraumbilical peritoneum and re-approximated with a running suture or tacks. Dissection of the inguinal region was done in a reduced size pocket.
Results: Median age of the 17 men and five women was 64.4 (range 29.5-84.8) years; there were 16 unilateral and six bilateral inguinal hernias (including three recurrent hernias and two incarcerated hernias). Two patient had large inguinoscrotal hernias. Tacks for the flap were used in four of the first seven cases; in the last 15 suture closure was used in all patients. Various techniques to suture the flap were tried out, the V-lock turned out to be the easiest option and was made standard. In eight patient only two 5mm trocars were used, in two patients a 5mm and an 8mm trocar was inserted and in 12 patients a 5mm and a 10mm trocar was used. Progrip MESH without tacks was placed in 20 patients. TAPP was done as outpatient procedure in 50% of cases, six patients required 23 hours extended recovery; only five patients with severe co-morbid conditions required admission. Complication included seroma (n=2), bladder injury (n=1) and urinary retention (n=2); two patients with preexisting groin pain had ongoing symptoms post TAPP. No recurrence was observed during a median follow up of 722 (range 14-1299) days.
Conclusion: Creation of the peritoneal flap from a midline incision and re-approximation using a running suture is technically feasible. The created preperitoneal pocket is smaller than in conventional TAPP but still allows good exposure. TAPP can be done with two 5mm ports and the Teleflex minigrasper. The minigrasper can be used for laparoscopic suturing.