Indications and contraindications for rTAPP

In general, indications for rTAPP are similar to open and laparoscopic approaches and include symptomatic hernias. rTAPP is preferred over open repair in the setting of hernia recurrence following open repair and in the setting of bilateral hernias. Furthermore, in the setting of incarceration or suspected strangulation, a transabdominal approach allows for intraabdominal assessment of bowel viability following reduction.

Absolute contraindication to rTAPP includes patients unable to undergo general anesthesia or tolerate pneumoperitoneum, coagulopathy, and known intraabdominal infection. Relative contraindications include history of extensive abdominal/pelvic operations, including prior TAPP hernia repair, TEP hernia repair, as well as prior gynecologic and prostate procedures. The presence of a large scrotal component may prove difficult to reduce from a robotic or laparoscopic technique. In this case, open technique may be required; otherwise, if the sac is partially reduced and transected, this will almost certainly result in postoperative seroma.

Preoperative assessment

Preoperative assessment should begin with a thorough history and physical examination. Key components of the history include duration of symptoms, history of incarceration, and presence or absence of obstructing symptoms. Surgical history focusing on prior surgeries, including all abdominal or pelvic procedures and prior inguinal/femoral hernia surgeries, may alter the operative approach. Finally, a careful history of the patient’s comorbidities including cardiopulmonary status, use of anticoagulant medications, as well as conditions that predispose to recurrence such as constipation, chronic cough, obstructed urination, obesity, and diabetes, which may aid in further optimization prior to repair.

Physical exam includes a thorough inspection of the bilateral groins in all patients, as well as the presence and position of the testicles in males. The clinical presentation of a hernia varies and ranges from a large scrotal hernia that is unable to be fully reduced to a fully reduced hernia sac which only provides impulse to the examiner’s finger within the canal on cough or Valsalva. If a bulge is present, it is important to note its relative location to the inguinal ligament, as femoral hernias reside inferior to the inguinal ligament. The skin should be examined for evidence of prior surgical scars.

Regarding imaging, the diagnosis of inguinal hernias remains a clinical diagnosis. Imaging, such as computed tomography or ultrasonography, is not routinely performed unless there is uncertainty regarding the diagnosis. Ultrasound can be particularly helpful in diagnosing testicular and scrotal pathology as well as inguinal lymphadenopathy.

Patient preparation and positioning

After induction of general anesthesia, a Foley catheter is placed in a sterile fashion, prior to positioning the patient in supine position with arms tucked. All pressure points are carefully padded, and the patient is secured to the operating table at the level of the chest and/or hips using a designated belt or tape. We use a commercially available Trendelenburg positioning pad, as the surgical table is ultimately positioned in a steep Trendelenburg position. Clipping of hair, skin preparation, and draping are performed as usual. Preoperative antibiotics are administered prior to incision.

Stages of the procedure

Mesh placement and peritoneal closure

Following adequate exposure of the MPO, it is important to choose appropriate size mesh that covers the entire MPO without being too large, causing impedance to peritoneal closure or curling with peritoneal closure (clam shell). The monopolar scissors are then exchanged for a needle driver. We prefer a 3-point fixation with 2-0 silk suture at the pubic tubercle medially ( Fig. 56.5 ), a second medially to the inferior epigastric vessels, and a third lateral to the inferior epigastric vessels. Once the mesh is secured, the peritoneal flap is closed with a running 3-0 barbed suture ( Fig. 56.6 ). Defects in the peritoneal flap can be closed primarily with silk sutures. Each of the working ports is removed under direct visualization, the abdomen is desufflated, and the umbilical facia is closed in a standard fashion.

Medial Fixation of Mesh.

Using a 2-0 silk suture, the medial aspect of the mesh is secured to the pubic tubercle.

Peritoneal Flap Closure.

The peritoneal flap is closed in a running fashion, using 3-0 barbed suture.

Postoperative care

Immediately following the operation, the Foley catheter is removed prior to transition to the postoperative anesthesia care unit. The patient is given a regular diet in the postoperative care unit. Pain control, ambulation, and ability to void are all discharge requirements. Most patients are discharged on the day of surgery. We prefer the use of multimodal analgesia regimen including NSAIDs, acetaminophen, and methocarbamol, with judicious use of narcotics. Early and frequent ambulation is encouraged at discharge. Heavy lifting (>10 kg) is discouraged for the first 2 to 4 weeks postoperatively. The patient follows up in clinic to track progression in 1 to 2 weeks postoperatively.

Complications

The overall complication rate of rTAPP ranges 0.6% to 7%; intraoperative complications including significant vascular injury (e.g., inferior epigastric vessels, femoral vessels) or visceral injury (e.g., bowel or bladder) are rare. Postoperative procedure specific complications include urinary retention, seroma formation, inguinal neuralgia, wound infections, and recurrence. To date, only one randomized control trial comparing minimally invasive laparoscopic versus robotic approaches has been conducted and demonstrates no differences regarding postoperative complications such as pain, wound infection, or readmissions. More information regarding long-term outcomes is needed.