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. 2019 Feb 7;32(1):e1426.
doi: 10.1590/0102-672020180001e1426.

SYSTEMIZATION OF LAPAROSCOPIC INGUINAL HERNIA REPAIR (TAPP) BASED ON A NEW ANATOMICAL CONCEPT: INVERTED Y AND FIVE TRIANGLES

[Article in English, Portuguese]
Marcelo Furtado  1 , Christiano M P Claus  2 , Leandro Totti Cavazzola  3 , Flavio Malcher  4 , Alexandre Bakonyi-Neto  5 , Rogério Saad-Hossne  5
Affiliations

SYSTEMIZATION OF LAPAROSCOPIC INGUINAL HERNIA REPAIR (TAPP) BASED ON A NEW ANATOMICAL CONCEPT: INVERTED Y AND FIVE TRIANGLES

[Article in English, Portuguese]
Marcelo Furtado et al. Arq Bras Cir Dig. .

Abstract
in English, Portuguese

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.

Racional:: O reparo laparoscópico da hérnia inguinal tem se mostrado superior aos reparos abertos, com retorno mais rápido às atividades diárias e diminuição na ocorrência de dor crônica. No entanto, custos diretos mais altos e o uso obrigatório de anestesia geral são argumentos contra seu uso. Além disso, o aumento da complexidade da operação resultante de uma anatomia incomum aos cirurgiões gerais impede a ampla adoção da abordagem laparoscópica.

Objetivo:: Propor uma sistematização técnica para reparo laparoscópico transabdominal (TAPP) de hérnias inguinais com base em conceitos anatômicos.

Método:: Oferecer sistematização do reparo do TAPP baseado em pontos anatômicos bem definidos, descrevendo o conceito de “Y invertido”, identificação de cinco triângulos e três zonas de dissecação, para alcançar a “visão crítica de segurança” para o reparo de hérnia inguinal laparoscópica.

Resultados:: Desde que essa padronização foi desenvolvida há cinco anos, muitos cirurgiões foram treinados seguindo esses preceitos. A reprodutibilidade é muito alta, assim como a taxa de adoção entre cirurgiões.

Conclusão:: O conceito de “Y invertido”, dos “Cinco triângulos” e a dissecção baseada em “Três Zonas” estabelecem uma padronização efetiva e reprodutível da técnica TAPP.

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Conflict of interest statement

Conflict of interest: none

Figures

FIGURE 1
FIGURE 1. Laparoscopic view of male posterior wall, right inguinal region: A) intact peritoneum; B) dissected peritoneum.
FIGURE 2
FIGURE 2. “Inverted Y”: in red inferior epigastric vessels; in white vas deferens; in blue spermatic vessels
FIGURE 3
FIGURE 3. Division of inguinal region in medial and lateral, and anterior and posterior, from inferior epigastric vessels and iliopubic tract (in blue), respectively
FIGURE 4
FIGURE 4. Illustration of “five triangles”: A) illustration of the iliopubic tract crossing the inverted Y and formation of the five triangles; B) anatomical scheme of the inverted Y formed by inferior epigastric vessels, vas deferens and spermatic vessels. The figure also illustrates in a didactic way the representation of five triangles, clockwise: indirect hernias (I), pain (P), doom (D), femoral (F) and direct (D) hernias.
FIGURE 5
FIGURE 5. Illustration of anatomical proposal of “Inverted Y and the Five Triangles” over the laparoscopic view, posterior right inguinal floor, in male, with peritoneum still intact
FIGURE 6
FIGURE 6. Zones of dissection of pre-peritoneal space following the tactical proposal for standardization of TAPP technique
See this image and copyright information in PMC

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