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194 Moldovanu R.Jurnalul de Chirurgie (Iaşi), 2013, Vol. 9, Nr. 2ANESTHESIA AND OPERATIVEROOM SET-UP; INSTRUMENTSGeneral anesthesia is mandatory. Thepatient is placed in supine position, in a 15ºTrendelenburg tilt with both arms inadduction along the body; the laparoscopictower is placed to the feet of the patient asthe display to be located on the hernia’s site[5,6]. The surgeon operates from theopposite side of the hernia near the patient’sshoulder, and the assistant stands opposite tothe surgeon [5,6].Three trocars are used: one of 10 mmand two of 5 mm. Common laparoscopicinstruments (fenestrated graspers, scissors,hook, needle holder etc.) are necessary. The30º laparoscope is preferable [5].SURGICAL PROCEDURE:Usually the pneumoperitoneum isperformed using a Veress needle [5]. Theopen technique is used in patients withprevious abdominal surgery and/or umbilicalhernia. The 5 mm trocars are inserted underlaparoscopic view control, laterally from theepigastric vessels to improve the ergonomicsand triangulation [5].The procedure starts by a carefulexploration of the abdomen identifying thesuperficial anatomical landmarks (urachus,umbilical folds, epigastric vessels, spermaticvessels, vas deferens or uterine roundligament) and the site and type of hernia [7].Then a large opening of theperitoneum is performed, from the anterosuperioriliac spine until the lateral umbilicalligament (umbilical artery cord) 2 to 3 cmbeyond the parietal defect [1,3-6,8].The dissection starts in Retzius space,in contact with abdominal rectus muscles, fromlaterally to medial and from cranial tocaudal, “targeting” the pubic bone, dividingthe fine conjunctive fibers (“angel hair”)[1,5]. Then, the dissection is conducted frommedial to lateral into the Bogros space, fromepigastric vessels to spermatic vessels [5]. Inthe same time we start the dissection ofhernia sac. The hernia sac is completelydissected using traction contra-tractionmaneuvers, sharp and blunt dissection andfine coagulation; it is mandatory to find theavascular plan to preserve the spermaticfascia and to protect the fragile parietalstructures (vas deferens, vessels and nerves)[1,5,8]. The dissection has to be conductedin obturator fossa to identify theoccult obturator hernias (type I obturatorhernia) [5]. The dissection is completedwhen all the deep anatomic landmarks(Cooper, Gimbernat ligaments, coronamortis and external iliac vein) are wellexposed and the pre peritoneal space is wideopened (at least 12 x 15 cm) to allow thecorrect mesh deployment and parietalization[1,5,8].It is important to search, dissect andremove the cord or pre peritoneal lipoma,because the overlooked lipomas couldbe misdiagnosed as recurrent hernia orseroma [9].Afterwards, a large (12 x 15 cm) lightweight mesh is deployed in pre peritonealspace, positioning to cover all the parietaldefects and fixed in appropriate positionusing absorbable staples [1-3,6,8]. Forthe bilateral hernia two overlapping meshare used, stapled together on themidline [1-3,6,8].In case of large hernia or after difficultdissection or in patients with risk ofhemorrhage a suction drain is inserted inRetzius space [10]; it will be removed after12 to 24 hours postoperatively.The peritoneum is then carefullyclosed using continuous non absorbablesuture secured with an extracorporeal knot;the closure using staples or barbed sutures isalso possible [5]. The closure has to be“waterproof” to avoid small bowelherniation [2,3].The trocars are then removed underlaparoscopic control view. Usually the trocarsites are infiltrated using ropivacaine, underlaparoscopic view [5]. The pneumoperitoneumis then exsufflated and thetrocars wounds are closed [5].POSTOPERATIVE PERIODThe usual postoperative analgesictherapy consists in anti inflammatory non
TAPP – How to do it 195Jurnalul de Chirurgie (Iaşi), 2013, Vol. 9, Nr. 2steroid drugs (Paracetamol and Ketoprofen).Usually the patients are discharged in thesame day or in first postoperative day [5]. Tofurther control the pain, all the patientsreceived a prescription with Paracetamol 500mg x 3/day and Ketoprofen 100 mg x 2/dayfor the first 7 days [5]. A routine thromboembolicdisease prophylaxis with lightweightheparin therapy for 7 days for all thepatients, is usually performed even thesubject is controversy [2,3,5].COMPLICATIONSDifferent postoperative complicationsare noted in the literature: seroma,hematoma, chronic pain, ischemic orchitis ortesticular atrophy, infertility.Seroma is the most frequentcomplication of TAPP repair [2,3]; in myexperience, I noted a 6% rate, [11] close tothe rate reported in literature (5.7%) [2,3];furthermore I noted a decreasing rate ofseroma after the use of suction drains.Hematoma is less frequent inendoscopic hernia repair than in openrepairs, with a rate of about 8% [2,3]; in myexperience, hematoma was noted in only1.8% cases [11].Chronic pain, defined as persistence ofpain 3 months after the operation [12], is lessfrequent in endocopic techniques, andespecially after TAPP, than in open herniarepair [2,3]; it was noted in 0.6% in aprevious work [11].Several other complications afterTAPP were reported in the literature with anincidence rate of 1% or less: wound / meshinfection, urinary retention, bladder damage,mesh migration, bowel obstruction, ischemicorchitis / testicular atrophy [2,3].The recurrence rate varies between 0.4to 4.8% [2,3,13]; I noted a 0.6% rate ofrecurrence and open anterior approach(Lichtenstein repair) has performed [11].CONCLUSIONSTAPP is valuable procedure for thecure of groin hernia; is associated with lowrate of postoperative morbidity andrecurrence. Both superficial and deepanatomic landmarks are easily recognizable.The laparoscopic exploration allows thetreatment of incarcerated / strangulatedhernias and the intra operative diagnosis ofoccult hernias. The procedure is suitable forday surgery.CONFLICT OF INTERESTSNone to declareREFERENCES1. Collaboration EH. Laparoscopic comparedwith open methods of groin hernia repair:systematic review of randomized controlledtrials. Br J Surg. 2000; 87(7): 860-867.2. Simons MP, Aufenacker T, Bay-Nielsen M, etal. European Hernia Society guidelines on thetreatment of inguinal hernia in adult patients.Hernia. 2009; 13(4): 343-403.3. Bittner R, Arregui ME, Bisgaard T, et al.Guidelines for laparoscopic (TAPP) andendoscopic (TEP) treatment of inguinal Hernia[International Endohernia Society (IEHS)]Surg Endosc. 2011; 25: 2773-2843.4. Tanner J, Moncaster K, Woodings D.Preoperative hair removal: a systematicreview. J Perioper Pract. 2007; 17: 118–121,124–132.5. Moldovanu R, Pavy G. Laparoscopictransabdominal pre-peritoneal (TAPP) forbilateral inguinal hernia. Jurnalul de chirurgie(Iaşi). 2010; 6(3): 373-382.6. Leroy J. Transabdominal preperitonealapproach (TAPP). E-publication:WeBSurg.com, Mar 2001; 1(3).[available online at http://www.websurg.com/ref/doi-ot02en194.htm]7. Târcoveanu E, Bradea C, Moldovanu R.Anatomia laparoscopică a regiunii inghinale.Jurnalul de chirurgie (Iaşi); 2006; 1(4): 436-446.8. Bittner R, Leibl BJ, Jager C, Kraft B, UlrichM, Schwarz J. TAPP - Stuttgart technique andresult of a large single center series. Journal ofMinimally Access Surgery. 2006; 2(3): 155-159.9. Nasr AO, Tormey S, Walsh TN. Lipoma of thecord and round ligament: an overlookeddiagnosis? Hernia. 2005; 9: 245-247.10. Tamme C, Scheidbach H, Hampe C, SchneiderC, Kockerling F. Totally extraperitonealendoscopic inguinal hernia repair. Results of5203 hernia repairs. Surg Endosc. 2003; 17:192–195.11. Moldovanu R, Pavy G. Transabdominalpreperitoneal (TAPP) laparoscopic inguinalhernia operation – a learning curve analysis.Chirurgia. 2012; 107(Suppl 1): S373.
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Page 64 and 65: 162 Constantin C. et al.Jurnalul de
Page 70 and 71: 168 Timişescu L. et al.Jurnalul de
Page 76 and 77: 174 Lucaciu OR. et al.Jurnalul de C
Page 82 and 83: 180 Motaş C. et al.Jurnalul de Chi
Page 88 and 89: 186 Kumar S. et al.Jurnalul de Chir
Page 90 and 91: 188 Kumar S. et al.Jurnalul de Chir
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