Systemization of Laparoscopic Inguinal Hernia Repair (Tapp) Based on a New Anatomical Concept: Inverted Y and Five Triangles

Abstract

Background: Laparoscopic inguinal hernia repair has been shown to be superior than open repairs with faster return to daily activities and decrease in the occurrence of chronic pain. However, higher direct costs and mandatory use of general anesthesia are arguments against their use. In addition, increased complexity of surgery resulting from an anatomy that is unusual to general surgeons prevents the widespread adoption of laparoscopic approach. Aim:To propose a technical systematization for transabdominal laparoscopic repair (TAPP) of inguinal hernias based on anatomical concepts. Method:To offer a systematization of TAPP repair based on well defined anatomic landmarks, describing the concept of “inverted Y”, identification of five triangles and three zones of dissection, to achieve the “critical view of safety” for laparoscopic inguinal hernia repair. Results:Since this standardization was developed five years ago, many surgeons were trained following these precepts. Reproducibility is high, as far as, it´s rate of adoption among surgeons. Conclusion: The concept of the “inverted Y”, “Five triangles” and the dissection based in “Three Zones” establish an effective and reproducible standardization of the TAPP technique.

Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide

“…In order to apply the proper steps of an MIS inguinal hernia repair, a surgeon must understand the anatomy of Myopectineal Orifice. By using the inverted Y concept and the 5 triangles published by Furtado et al [14] (Fig. 1), the anatomical landmarks of dissection are defined and should provide a roadmap for a safe and proper MIS inguinal hernia repair, following the critical view and surgical steps published by Daes and Felix [13].…”

“…Crucial to a proper posterior approach, however, is understanding the anatomy. A recent publication by Furtado et al has developed a new way to understand this sometimes confusing posterior view of the anatomy of the groin [14]. With the identification of basic anatomical landmarks and triangular areas, it becomes possible to easily define the essential zones of dissection.…”

Update of the nomenclature of the myopectineal orifice in the endoscopic repair of hernias in the inguinal region

“…Ambos aspectos han sido profundamente valorados. La descripción de la Y invertida, los conceptos de la visión crítica de seguridad y las diez reglas de oro constituyen en resumen el sendero por el que debemos transitar [5][6][7][8] .…”

Evaluation of early post-operative pain and seroma formation in transabdominal pre-peritoneal (TAPP) repair of groin hernias with light weight mesh placement.

“…Throughout the world more than 20 million patients in a year undergo inguinal hernia repair surgery, making hernia repair surgery as one of the most commonly performed surgery. [1][2][3] Incidence of inguinal hernia, visceral protrusions or adipose tissue protrusions through the inguinal or femoral canal is 27-43% in men and 3-6% in women. 1 Definitive and the only treatment of groin hernias is surgery for which multiple approaches and techniques are applied.…”

“…Another difficulty faced by surgeons related to laparoscopic approach is the internal anatomy of inguinal canal to which general surgeons are not familiar. 3,5 In our setup, we mostly use Transabdominal pre-peritoneal approach for groin hernias, with placement of synthetic mesh in pre peritoneal space. [5][6][7] This concept of posterior approach to groin hernias was first introduced by Stoppa in 1975.…”