Minimally Invasive Approach to Supra-pubic and Non-Midline Lower Abdominal Ventral Hernia - An Extended Indication of TAPE Technique

Abstract

Repair of lower abdominal incisional hernia is always a surgical challenge. TAPE technique has been described for the repair of supra-pubic midline incisional hernia with satisfactory outcome. Its indication can be extended for treatment of non-midline lower abdominal hernia. Peritoneal incision is created just below the hernia defect with pre-peritoneal dissection to expose supra-pubic preperitoneal space with Cooper's ligament exposed. Non-adhesive mesh then placed over preperitoneal space and partially intra-peritoneally, and cover the whole extra-peritoneal space prepared to ensure enough overlapping. Mesh is fixed by tackers for intra-peritoneal part, most inferior fixation points were at peritoneal incision line. Extra-peritoneal part of meshes is fixed at the safety zone and covered up by the peritoneal flap to avoid mesh migration. Fixation of the meshes at the lateral aspects were facilitated by the peritoneal flap and subsequent fibrosis and adhesion to the extra-peritoneal structures in cases of lateral lower abdominal hernia. Repair of midline and lateral lower abdominal incisional hernia with this novel modified technique with prosthetic mesh is safe and effective. A larger case series and longer follow-up is required for validation of this technique.

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

“…(2) erect position; and (3) the fact that this area represents the weakest point of the abdominal wall (1,9,13). In our study, the recurrence rate was 2.9% (2/68 cases) with no statistical significance between the two groups seen through follow-up investigations.…”

“…Based on these factors, the optimization of approaches to hernial procedures have become a hot topic in the surgical field. Previous reports have indicated that the TAPE technique significantly reduces the recurrence rate and mesh-induced complications of suprapubic incisional hernia (13)(14)(15). However, closing the peritoneal flap during TAPE prolongs the operative time.…”

“…Recurrence is always the principal problem in lower abdominal marginal hernia. The main reasons for the high rate of recurrence involve the anatomical location and body position with three critical considerations (1,9,13,15,39): (1) the anatomical location including the iliac vessels and bladder;…”

“…This technique allows surgeons better visualization of the hernial defect, and also permits improved mesh overlap ( 11 , 12 ). Laparoscopy provides several key advantages to avoid recurrence, freeing the peritoneal flap, exposing the pubic comb ligament, and fixing the inferior edge of the mesh to the bony structure of the lower edge of the abdomen ( 13 ). In 2011, Sharma et al ( 14 ) first described the trans-abdominal partial extra-peritoneal (TAPE) technique, a laparoscopic approach for the treatment of the suprapubic hernia where the hernia defect was closed and repaired with mesh partially covered by the free peritoneal flap.…”

“…In 2011, Sharma et al ( 14 ) first described the trans-abdominal partial extra-peritoneal (TAPE) technique, a laparoscopic approach for the treatment of the suprapubic hernia where the hernia defect was closed and repaired with mesh partially covered by the free peritoneal flap. This technique was subsequently adopted and reported by other surgeons ( 13 , 15 ). However, closing the free peritoneal flap requires skilled surgical technique, and previous research reports when using barrier-coated mesh, there is no need to re-approximate the free peritoneal flap ( 16 ).…”