Thread by @DrJonnys

10⁦ ➡️⁩ rules:) for TAPP for inguinal hernia.📚⁦👨🏻‍⚕️⁩⁦👩🏻‍⚕️⁩⁦👇🏻⁩⁦↘️⁩⁦⤵️⁩⁦
#SoMe4IQLatAm #SoMe4Surgery

Rule 1:) Beginning of Surgery⁦⁦↘️⁩⁦⤵️⁩
💠TAPP: Start Flap 4 cm above Deep Ring, Continue from ASIS to Medial Umbilical Ligament
💠TEP: Blunt Telescopic Dissection or Balloon Dissection

Rule 2:) Dissection Should Follow the Peritoneal Plane
💠Keep Fatty Tissue with the Muscle of the Inguinal Floor
💠Avoid Exposing Muscle to Preserve Nerves in Zone 1 and Inferior Epigastric Vessels in Zone 3
💠Don't Overdissect Nerves
💠Zone 3 Dissection is Left for Last⤴️⤴️

Rule 3: Medial Extent of Dissection
💠Pubic Symphysis Medially
💠At Least 2 cm below pubis at Zone 2
💠Overlap Direct and Femoral Triangle by 3 - 4 cm
💠Prevents Lifting by Distending Bladder
💠Reduce Direct Hernia...👇🏻👇🏻

💠May Plicate TF for Seromas but Don't Close Defect
💠Decompress Bladder Preop⤴️

Rule 4:) External lliac Vein Should be Visible
💠Avoid Missing a Femoral Hernia (Zone 3)⤵️⤵️📚
💠Lymph Nodes Should be Differentiated From Preperitoneal Fat

Rule 5:) Extent of Cord Parietalization
💠Extent of Inferior Peritoneum Dissected
💠Vas Crossing External Iliac Vein (Zone 3)
💠lliopsoas Muscle Identified

💠Indirect Sac Dissection is the Most Challenging, Separate Sac from Cord
💠In Women, Round Ligament can be transected 1 cm proximal to Deep Ring

Rule 6:) Management of Indirect Sac
💠In Large or Inguinoscrotal Hernias, it is recommended to transect and.....⤵️⤵️👇🏻

.....abandon the distal sac in the scrotum
💠Only feasible after identifying all aspects of the cord
💠Avoids excess traction and cord/ testicle injury, hematoma, ischemic orchitis
💠May form pseudo-hydrocele, easier to manage

Rule 7:) Explore the Deep Inguinal Canal For Cord Lipoma
💠Extension of Retroperitoneal Fat
💠Lateral to Cord Elements
💠Major Cause of Recurrence
💠Visualized lliopubic Tract Confirms No Lipoma
💠Differentiate Cord Lipoma From Nodes or Fatty Cord↘️⤵️

Rule 8:) Mesh Size and Choice
Large Mesh at Least 10 x 15 cm
💠Cover MPO Completely
💠Overlap all spaces 3 - 4 cm
💠Should Reach Symphysis Medially and ASIS/ Psoas Laterally
💠Extend 1- 2 cm below Pubis between pubic bone and bladder↘️⤵️

💠Edge of peritoneum must be below mesh to prevent folding⤴️⤴️

Rule 9:) Mesh Fixation
💠Not Necessary in most MIS Cases
💠Recommended in Large Direct M3 Hernias
💠Tack Recommendations: Medially Avoid Pubic Bone (Use Cooper's) Laterally Above IPT (2 cm), Avoid InferiEpigastrics⁦

💠5 - 6 Tacks Maximum
💠External Palpation with Tack Firing
💠Consider Gluel / Self-Gripping
💠Fixation Cannot Fix Inadequate Dissection

Nerves at Risk in MIS Inguinal Hernia Repair: No Fixation
💠Genital Branch of Genitofemoral Nerve
💠Femoral Branch of Genitofemoral Nerve

💠Lateral Femoral Cutaneous Nerve

Rule 10:) Deflate Under Direct Visualization
💠Prevent Peritoneum Folding or Rolling Mesh
💠Prevents Meshoma and Clamshelling

💠If Mesh Lifts, Need Wider Dissection
💠Suture Instead of Tacking Peritoneal Flap is Recommended
💠Closure of Gaps is Recommended