Editing Inguinal hernia (section)

=== '''TAPP''' ===

* First performed 1990 by Schultz
* Supine, GA, prep, drape, Abx
* Hasson entry at umbilicus with 10mm port, then two 5mm ports bilaterally in a horizontal plane with the umbilicus
* Landmarks - umbilical ligaments, bladder, inferior epigastrics, vas def, spermatic cord, iliac vessels, hernia defects.
* Incise peritoneum from lateral edge of median umbilical ligament (at level of ASIS bilaterally) and extend 8-10cm laterally, to about 2cm medial to ASIS. Allow enough room above hernia for mesh placement! Need 2-3cm!
* '''Zone 1:''' First work laterally to IEVs, pushing transversalis and fat away from the peritoneum, which allows nerves to retain their fascial coverings (thin peritoneal flap)
* '''Zone 2:''' Then move medially to IEVs, and dissect directly on the posterior rectus sheath, with fat being pushed down with the peritoneum, which avoids damage to bladder or peri-vesical structures (thick peritoneal flap). Continue the dissection 2cm below pubic symphysis, and 2cm across midline to the contralateral side.
* '''Zone 3:''' Then dissect out around the IEVs, and triangle of doom
* Continue dissection until 'critical view of safety' is obtained
* Reduce hernia with gentle traction
* Insert mesh (e.g. Bard 3D Max ideally large) to cover the entire myopectineal orifice and fix in place with sutures/tacks (don’t use self-fixating mesh). 5-6 tacks is usually enough to fix it. Don't tack to bone. Often use fibrin glue on posterior aspect of mesh in triangles of doom and pain.
* Close peritoneum
* Close fascia, skin
** The 'inverted Y': inferior epigastrics (red), vas deferens (white), spermatic vessels (blue).
** Iliopubic tract in blue
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