12.2. Hernia: Port Placement Arrangements
David S. Thoman, M.D.
Edward H. Phillips, M.D.
A. Transabdominal Preperitoneal (TAPP) Repair
1. The optical port (5–10 mm) is placed just below the umbilicus in the midline.
2. Place two additional 10-mm working ports lateral to the rectus sheath on either side at the level of the umbilicus. (Figure 12.2.1). These may be used to pass the mesh into the abdomen and to accommodate the hernia stapler.
3. Alternatively, a 5-mm helical tacker may be used, allowing for 5-mm lateral ports. The mesh can then be passed blindly through the 10-mm optical port. There are also data to support not fixing the mesh, although migration has been observed.
B. Near-Total Preperitoneal Repair
1. Pneumoperitoneum is established with the Veress needle technique, and an optical port (5–10 mm) is placed at the umbilicus.
2. A 10-mm incision is made just superior to McBurney’s point on the right side of the abdomen. This point corresponds to the site of a preperitoneal fat pad commonly located in this position (Figure 12.2.2).
3. A Kelly clamp is then used to dissect through the oblique muscles until the peritoneum is reached.
4. A large mayo clamp is then used to develop this preperitoneal space, creating a pathway for a blunt-tipped 10-mm trocar.
5. A blunt grasper and CO2are used to develop the preperitoneal space toward the internal ring.
6. The procedure is duplicated on the left side at the mirror-image location.
7. The optical port is then repositioned into the preperitoneal space under direct vision, while the pneumoperitoneum is released.
5 or 10 mm5 or 10 mm5 or 10 mm5 or 10 mm5 or 10 mm
5 or 10 mm5 or 10 mm5 or 10 mm5 or 10 mm Figure 12.2.1.Port arrangement for transabdominal preperitoneal repair (TAPP).
10 mm5 or 10 mm10 mm 10 mm
5 or 10 mm5 or 10 mm10 mm10 mm 10 mm Figure 12.2.2.Port placement scheme for near-total preperitoneal repair (note that lateral ports are more caudally located than in the scheme depicted in Figure 12.2.1).
Figure 12.2.3A. Port placement scheme for total extraperitoneal repair.
A
C. Totally Extraperitoneal Repair
1. The initial incision is made infraumbilically to accommodate a 10-mm port. The anterior rectus sheath is opened on the ipsilateral side and the muscle is retracted laterally to expose the posterior sheath. Stay sutures may be placed in the anterior fascia to secure the port and limit CO2leakage.
2. Dissection is carried toward the symphysis pubis, opening the space between the peritoneum and the transversalis fascia. This may be done with a dissecting balloon or manually.
3. Once the preperitoneal space is insufflated, two additional work- ing ports are placed under direct vision in one of the following arrangements.
i. A 5-mm port is placed one fingerbreadth above the symphysis pubis in the midline and a 5- or 10-mm working port is inserted midway between the 5-mm port and the umbilicus (depending on the size of the fixating stapler or tacker to be used).
ii. A 5- or 10-mm working port is placed midway between the sym- physis pubis and the umbilicus (Figure 12.2.3A) (depending on the size of the fixating stapler or tacker to be used), and a 5-mm port placed lateral to the rectus on the ipsilateral side (Figure 12.2.3B).
4. As mentioned, a 5-mm helical tacker may be used, or the mesh simply not anchored or fixed, reducing the minimum number of 10-mm ports to one.
Figure 12.2.3B.Continued
B
Brief Operative Description of Inguinal Hernia Repair
Regardless of the approach, laparoscopic repair includes the following steps.
1. After access to the preperitoneal space, the preperitoneal space is developed to a large enough area to accommodate a sizeable piece of mesh.
2. The preperitoneal dissection includes reduction of the space (direct, indirect, or femoral).
3. The dissection must include exposure of midline between the rectus abdominus muscles, Cooper’s ligament, the direct space, the internal inguinal ring, the gonadal vessels, and either the vas deferens or the round ligament, and enough space lateral, superior, and inferior to the internal ring to place mesh.
4. The peritoneum must be dissected away from the gonadal vessels sufficiently proximal for the mesh to fit posterior and inferior to the peritoneum.
5. The mesh is introduced into the preperitoneal space through one of the 10-mm ports.
6. The mesh is often, but not always, fixed with tacks or staples, depend- ing on surgeon preference.
7. The peritoneum is either closed or allowed to roll up onto the mesh as desufflation occurs.
D. Ventral Hernia Repair Port Placement 1
1. The site farthest from the edge of the hernia defect is found on the right or left lateral abdominal wall. The open Hasson technique is used to place a lateral 10-mm port midway between costal margin and the iliac crest. (Figure 12.2.4).
2. On the same side, under direct visualization, two 5-mm ports are placed, one as far superior and lateral as possible and one inferior and lateral.
3. Rarely, a fourth 5-mm port is required on the contralateral side.
Port Placement 2
1. A site for entry is chosen as far lateral and superior as possible (Figure 12.2.5). Either the Veress needle technique or Hasson technique may be used. This may be a 5- or 10-mm port, depending on the size of the laparoscope to be used.
Figure 12.2.4.Port placement scheme for ventral hernia repair.
Figure 12.2.5.Alternate port scheme for ventral hernia repair.
2. With laparoscopic visualization, another 5-mm port is placed laterally and inferior to the defect.
3. After adhesiolysis, two mirror-image ports are placed on the opposite side of the abdomen, as far lateral to the defect as possible.
4. One of the four ports must be changed to a 10- or 12-mm port for introduction of the prosthesis. However, the other three ports may be 5 mm if the laparoscope is 5 mm.
5. This placement allows the use of the camera and tacker on the same side for tacking the opposite side of the mesh.
Brief Operative Description
1. After establishing laparoscopic access and placing ports, the first portion of the operation is to complete adhesiolysis between the viscera and the parietal peritoneum. This step includes reduction of all contents of the hernia sac.
2. The edges of the defect(s) are identified and marked on the abdomi- nal wall. The combined size of all the defects is measured and the size of the mesh is chosen and cut, if necessary.
3. Sutures are placed at 5- to 6-cm intervals around the periphery of the mesh.
4. The mesh is rolled and placed into the abdominal cavity through the largest port.
5. The sutures are pulled through the abdominal wall muscles and tied over a bridge of muscle and fascia (through multiple 1- to 2-mm stab wounds in the skin).
6. The circumference of the mesh is tacked or stapled to the abdominal wall at 1-cm intervals between the sutures.
E. Selected References
Crawford DL, Phillips EH. Totally extraperitoneal laparoscopic herniorrhaphy. In: Zucker KA, ed Surgical Laparoscopy. Philadelphia: Lippincott Williams & Wilkins, 2001:571–584.
Fallas MJ, Phillips EH. Laparoscopic near-total preperitoneal hernia repair. In: Phillips EH, Rosenthal RJ, eds. Operative Strategies in Laparoscopic Surgery. New York:
Springer-Verlag, 1995:88–94.
Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000;190(6):645–650.
Memon MA, Fitzgibbons RJ. Laparoscopic inguinal hernia repair: transabdominal preperi- toneal (TAPP) and totally extraperitoneal (TEP). In: Scott-Conner CEH, ed. The SAGES Manual. New York: Springer-Verlag, 1999:364–378.
