We devised a method for confirming the position of mesh placed during transabdominal preperitoneal repair (TAPP) of an inguinal hernia. The preperitoneum is sufficiently detached, and the mesh is fixed in place as usual. Before completely closing the peritoneum, pressure is applied from outside the body and inside the abdominal cavity to remove as much air as possible from the detached preperitoneum ; the peritoneum is then sutured using a V-LocTM closure device so that it does not constrict. By releasing the pressure all at once, the airtightness of the preperitoneum is maintained, and the position of the mesh can be observed through the translucent peritoneum. This method, called Mesh-Airtight-Preperitoneum (MAPP), could become widely used as a simple technique for confirming mesh position in TAPP

Edagawa, Hiroshi

Goto, Masakazu

Ikeuchi, Mayumi

Kuramoto, Shunsuke

Matsuo, Yuta

Mori, Osamu

Okitsu, Hiroshi

Tani, Ryotaro

Tomibayashi, Atsushi

Yuasa, Yasuhiro

Tokushima University Institutional Repository

INTRODUCTIONThe transabdominal preperitoneal approach (TAPP) is a methodfor repairing an inguinal hernia from inside the abdominal cavityand has become widely used in recent years. The procedure in-volves making a laparoscopic incision of the peritoneum, detachingthe inguinal floor, placing mesh in the preperitoneum, and closingthe peritoneum.Initially, due to the small area of detachment, small meshes of116 cm were used (1). To prevent recurrence, mesh sizes weregradually increased (2). In Europe and the United States, meshsized 1510 cm or larger has been reported to reduce recurrencerates (3). To accommodate this, the inguinal floor must be detachedto a precise degree, and the mesh needs to be placed properly.However, proper placement of the mesh could only be confirmedafter the patient recovered from anesthesia. There is not the usefulreport and it is routine to gradually lower the pneumoperitoneumpressure while controlling mesh and is performed in forceps by alocalization method of the mesh.Here, we report a simple method termed Mesh-Airtight-Preperi-toneum (MAPP) developed by our department to confirm meshposition during TAPP.MATERIALS AND METHODSTAPPIn our department, to conduct TAPP, the surgeon stands oppo-site the affected side and creates three ports, one at the umbilicusand one each on the left and right sides of the abdomen, sized 12mm, 5 mm, and 5 mm, respectively. A 5-mm flexible scope is in-serted into the abdominal cavity from the affected side for observation(Figure 1).Regardless of the hernia’s shape or whether it is on theleft or right, an electrosurgical hook knife is used to make an inci-sion of the peritoneum from the lateral side of the inner inguinalring. After confirming the gonadal blood vessels and vas deferens(uterine round ligament) from the lateral side, the field of view isdeveloped by placing traction on the medial umbilical fold and dis-secting near its border with the abdominal wall using an electro-surgical knife.ORIGINALMesh-Airtight-Preperitoneum : a simple method for confirmingmesh placement in transabdominal preperitoneal repair ofinguinal herniaYasuhiro Yuasa, Hiroshi Okitsu, Masakazu Goto, Yuta Matsuo, Hiroshi Edagawa, Osamu Mori, Ryotaro Tani,Shunsuke Kuramoto, Mayumi Ikeuchi, and Atsushi TomibayashiTokushima Red Cross Hospital, Department of Digestive Surgery, Tokushima, JapanAbstract : We devised a method for confirming the position of mesh placed during transabdominal preperitonealrepair (TAPP) of an inguinal hernia. The preperitoneum is sufficiently detached, and the mesh is fixed in placeas usual. Before completely closing the peritoneum, pressure is applied from outside the body and inside theabdominal cavity to remove as much air as possible from the detached preperitoneum ; the peritoneum is thensutured using a V-LocTM closure device so that it does not constrict. By releasing the pressure all at once, theairtightness of the preperitoneum is maintained, and the position of the mesh can be observed through thetranslucent peritoneum. This method, called Mesh-Airtight-Preperitoneum (MAPP), could become widely usedas a simple technique for confirming mesh position in TAPP. J. Med. Invest. 63 : 270-273, August, 2016Keywords : Inguinal hernia, laparoscopy, transabdominal preperitoneal approach, surgical meshReceived for publication May 31, 2016 ; accepted June 23, 2016.Address correspondence and reprint requests to Yasuhiro Yuasa, Irinokuchi103, Komatsushimacho, Komatsushima, Tokushima Prefecture, 773-0001 Japan, and Fax : +81-885-32 -6350.Figure 1. Port positions. The ports of 12 mm, 5 mm, and 5 mm areplaced such that they form a triangle with the hernia at the apex. Note thatthe figure is for a right -sided inguinal hernia.The Journal of Medical Investigation Vol. 63 2016270To fully reconstruct the myopectineal orifice, the range for de-tachment should be at least 3 cm larger than the hernia orifice(Figure 2) (4, 5). A 1510 or 139-cm mesh is then fixed in place(Figure 3a), the peritoneum is closed, and the procedure is finished(Figure 3b).MAPPHere, we describe the technique we devised to easily confirmmesh position. To prepare, first the peritoneum is closed as usualusing V-LocTM, but this is done with only enough tightness so theperitoneum does not constrict or by not completing the last stitch.Air is then removed by placing pressure on the preexisting herniafrom outside the body (Figure 4a) and using gauze to apply gentlepressure on the preperitoneum from inside the abdominal cavity(Figure 4b). Air is fully eliminated by temporarily reducing ab-dominal air pressure to around 4 mmHg. While maintaining pres-sure, abdominal air pressure is returned to normal, and then byreleasing manual pressure at the same time (Figure 4c), airtight-ness of the preperitoneum were preserved and causes the lateralperitoneum to become convex. The position of the mesh can thenbe observed through the translucent peritoneum (Figure 4d).RESULTSThe patients’ characteristics were summarized in Table 1. Twentysix patients, who underwent TAPP by the same surgeon Y. Y. wereretrospectively analyzed from February to September,2014. Meshcovered the peritoneum, and completely exfoliated in all cases anddid not need the labor in particular. However it was not alwayscompletely visible. The success of this surgical procedure hadtendency in large existing hernias, but may not be as successful inwomen or with smaller hernias.DISCUSSIONTAPP is a method of repairing inguinal hernia via the abdominalcavity that has become widely used in recent years. The procedureinvolves fully detaching the inguinal floor from inside the abdomi-nal cavity, then placing the mesh in a suitable position.This method was first reported in 1982. Initially, the hernia ori-fice was closed using clips (6). The surgical style currently in useis based on a 1992 report by Arregui et al. (1). In Japan, it wasstarted after Matsumoto et al. reported laparoscopically openingand fixing mesh in the preperitoneum (7). In 1994, TAPP was cov-ered under insurance, which led to a temporary increase in its use ;however, an anterior approach that was developed later becamethe mainstream method. However, recent improvements in imagequality and standardization of manipulations in laparoscopic sur-gery have resulted in a reconsideration of the usefulness of TAPP.In 2012, a survey by the Japan Society for Endoscopic Surgeryfound that over 20% of inguinal hernia cases were repaired laparo-scopically (8).For the sake of preventing recurrence, the size of the mesh hasgradually increased since the initial report ; recently, mesh of atleast 1510 cm has been recommended (9). In addition, it has be-come important to ensure the preperitoneum is detached neithertoo much nor too little and to place the mesh in an appropriate posi-tion. Normally, after placing the mesh and closing the peritoneum,the detached peritoneum forms a convex shape in the abdominalFigure 2. Range of preperitoneal detachment. The detachment is atleast 3 cm larger than the hernia orifice. Note that the figure is for a right -sided internal inguinal hernia.a bFigure 3.a : The mesh is fixed in preperitoneum.b : Immediately after suturing the peritoneum, the peritoneum is convex to the abdominal cavity.The Journal of Medical Investigation Vol. 63 August 2016 271cavity, making it difficult to confirm the position of the mesh, in-cluding whether it has folded, which can lead to recurrence. Apply-ing pressure to the abdomen to release abdominal air is thought tocause the mesh to adhere closely the detached peritoneum as wellas to cause tissue to permeate the mesh. However, this cannot beconfirmed until the patient recovers from anesthesia.There is not the useful report and it is routine to gradually lowerthe pneumoperitoneum pressure while controlling mesh and isperformed in forceps by a localization method of the mesh so far.We devised MAPP to address the lack of a method for confirmingthe position of mesh during surgery after suturing the peritoneum.The keys to MAPP are having a sufficient range of detachment andavoiding tight closure of the peritoneum such that applying pres-sure does not eliminate the air and temporarily reduce the abdomi-nal air pressure, so air is fairly eliminated from the preperitoneum.With larger existing hernias, the airtightness of the preperitoneumis maintained when pressure is released, which, I think, makes theperitoneum and mesh fit better and makes confirmation easier.CONCLUSIONWe reported on MAPP, a method for confirming the position ofmesh placed during TAPP. This method does not require speciala bc dFigure 4.a : Eliminating air from the preperitoneum. Pressure is manually applied on the hernia from outside the body. This reduces abdominal air pressureto about 4 mm Hg.b : Eliminating air from the preperitoneum. Simultaneous to the manipulation in Figure 4a, pressure is applied using gauze from inside the abdominalcavity.c : Releasing the pressure. The hand that had been applying pressure is removed when abdominal air pressure returns to normal.d : Mesh-Airtight -Preperitoneum is completed. The mesh is visible through the peritoneum.272 Y. Yuasa, et al. Mesh position confirmation in TAPPequipment, is not time-consuming, and is simple, so it can be usedwidely.CONFLICT OF INTEREST STATEMENTThe authors report no conflict of interest.REFERENCES1. Arregui ME, Davis CJ, Yucel O, Nagan RF : Laparoscopicmesh repair of inguinal hernia using a preperitoneal approach :a preliminary report. Surg Laparosc Endosc 2 : 53-58, 19922. Deans GT, Wilson MS, Royston CM, Brough WA : Recurrentinguinal hernia after laparoscopic repair : possible cause andprevention. Br J Surg 82 : 539-41, 19953. Kapiris SA, Brough WA, Royston CM, O’Boyle C, SedmanPC : Laparoscopic transabdominal preperitoneal (TAPP) her-nia repair. A 7-year two-center experience in 3017 patients.Surg Endosc 15 : 972-5, 20014. Fruchaud H : Anatomie chirurgicale des hernies de l’aine.Doin, Paris, 19565. Knook MT, van Rosmalen AC, Yoder BE, Kleinrensink GJ,Snijders CJ, Looman CW, van Steensel CJ : Optimal mesh sizefor endoscopic inguinal hernia repair : a study in a porcinemodel. Surg Endosc 15 : 1471-7, 20016. Ger R : The management of certain abdominal herniae byintra-abdominal closure of the neck of the sac. Preliminarycommunication. Ann R Coll Surg Engl 64 : 342-344, 19827. Matsumoto S, Kawabe N, Mori K, Suzuki H, Miyata S, TasakaO, Ooshima R, kobayashi K, Matsumoto K, Yoshida Y, BannoT, Kimura T, Nagai K, Kanemaki T, Funabiki T : Experienceof laparoscopic inguinal hernioplasty. The Japanese Journalof Gastroenterological Surgery 26 : 2429-2432, 19938. 12th Nationwide Survey of Endoscopic Surgery in Japan. Jour-nal of the Japan Society for Endoscopic Surgery 19 : 520-524,20149. Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS,Fitzgibbons RJ, Fortelny RH, Klinge U, Kockerling F, KuhryE, Kukleta J, Lomanto D, Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J, Sauerland S, Schug-PassC, Singh K, Timoney M, Weyhe D, Chowbey P : Guidelinesfor laparoscopic (TAPP) and endoscopic (TEP) treatment ofinguinal Hernia [International Endohernia Society (IEHS)]Surg Endosc 25 : 2773-2843, 2011Table 1. patients’ characteristics who underwent “MAPP”patient diseased side hernia type* gender age hernia size (cm) mesh size (cm) MAPP1 right 1 male 77 15 1510 success2 right 1 male 49 7 139 success3 right 1 male 80 4 139 success4 right 1 male 63 4 1510 success5 right 1 male 51 3 1510 success6 right 1 male 26 4 1510 success7 right 1 male 61 5 1510 success8 right 1 male 58 4 139 failure9 right 1 male 65 7 1510 success10 right 1 male 54 3 1510 success11 right 1 female 55 3 1510 success12 right 1 male 71 3 1510 success13 right 2 male 38 4 1510 success14 right 2 male 82 6 1510 success15 left 1 male 66 3 1510 success16 left 1 male 72 4 1510 success17 left 1 female 33 2 1510 failure18 left 1 male 78 6 1510 success19 left 1 male 64 2 1510 failure20 left 1 male 71 4 1510 failure21 left 2 male 62 4 1510 success22 left 2 male 62 6 1510 success23 left 2 male 79 7 1510 failure24 left 2 male 77 4 1510 failure25 left 2 male 66 4 1510 success26 left 2 male 64 2 1510 failure*JHSclassificationThe Journal of Medical Investigation Vol. 63 August 2016 273

Mesh-Airtight-Preperitoneum : a simple method for confirming mesh placement in transabdominal preperitoneal repair of inguinal hernia

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Mesh-Airtight-Preperitoneum : a simple method for confirming mesh placement in transabdominal preperitoneal repair of inguinal hernia

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