Hernia surgery has evolved remarkably with the introduction of laparoscopy, offering patients quicker recovery, less postoperative pain, and lower recurrence rates compared to open approaches. Among laparoscopic methods, Transabdominal Preperitoneal (TAPP) repair is one of the most widely practiced techniques for inguinal hernia repair. While routine hernias can be managed with relative ease, large sac hernias present a unique surgical challenge due to their size, dissection difficulties, and risk of complications. Mastery of laparoscopic anatomy, precise dissection, and mesh placement are critical in ensuring successful outcomes.

Understanding Large Sac Hernias

A large sac hernia refers to an inguinal hernia with a voluminous peritoneal sac, often extending significantly into the scrotum in men or labia in women. These hernias may be indirect inguinal hernias with a long sac that follows the spermatic cord, or they may coexist with direct hernias. Key challenges with large sacs include:

Difficulty in mobilization and complete reduction.

Higher risk of injury to cord structures or vessels.

Potential for seroma or hydrocele formation.

Increased operative time compared to smaller hernias.

Principles of TAPP Repair

The TAPP technique involves entering the abdominal cavity laparoscopically, creating a peritoneal flap, dissecting the preperitoneal space, and placing a prosthetic mesh to cover all potential hernia sites. In large sac cases, meticulous handling of the sac is vital.

The fundamental principles include:

Complete reduction of the sac or adequate transection if reduction is not possible.

Wide preperitoneal dissection to expose the myopectineal orifice.

Proper mesh placement to cover direct, indirect, and femoral spaces.

Secure closure of peritoneum to avoid mesh exposure to bowel.

Step-by-Step Technique for Large Sac TAPP Repair
Patient Positioning and Port Placement

The patient is placed supine under general anesthesia.

A 10-mm camera port is inserted at the umbilicus.

Two 5-mm working ports are placed in the lower abdomen lateral to the rectus sheath.

Creation of Peritoneal Flap

A curvilinear incision is made in the peritoneum about 2–3 cm above the hernia defect.

The flap is carefully raised to expose the preperitoneal space.

Identification of Key Landmarks

Inferior epigastric vessels medially.

Vas deferens and spermatic vessels in males.

Cooper’s ligament, pubic bone, and iliac vessels to ensure proper orientation.

Management of the Large Sac

This is the most critical step:

Gentle dissection of the sac from cord structures is done, taking care not to damage the vas deferens or testicular vessels.

If the sac extends deep into the scrotum and cannot be completely mobilized, the surgeon may transect the sac high at the internal ring, leaving the distal sac in situ to avoid testicular complications.

Adequate reduction of the proximal sac is ensured to allow tension-free mesh placement.

Mesh Placement

A large, flat polypropylene or composite mesh (minimum 12 x 15 cm) is placed in the preperitoneal space.

The mesh covers the entire myopectineal orifice, including the direct, indirect, and femoral spaces.

Fixation can be done using absorbable tacks, glue, or in some cases, no fixation depending on surgeon preference.

Peritoneal Closure

The peritoneal flap is closed with continuous sutures or tacks, ensuring the mesh is completely separated from intra-abdominal contents.

Proper closure prevents adhesions or bowel obstruction.

Challenges in Large Sac TAPP Repair

Extended operative time due to careful sac dissection.

Risk of injury to vas deferens, testicular vessels, or epigastric vessels.

Incomplete reduction may lead to recurrence.

Seroma formation is more common in large sacs, sometimes requiring aspiration postoperatively.

Postoperative Considerations

Patients usually recover quickly with early ambulation and discharge within 24 hours.

Analgesia requirements are minimal compared to open repair.

Complications may include seroma, hematoma, or testicular discomfort, particularly if distal sac is left behind.

Recurrence rates are low when the procedure is performed meticulously.

Advantages of TAPP in Large Sac Hernias

Magnified laparoscopic view allows precise dissection of sac and cord structures.

Comprehensive coverage of all potential hernia defects with mesh.

Lower postoperative pain compared to open repair.

Faster return to work and normal activities.

Ability to detect and repair bilateral hernias during the same procedure.

Conclusion

Laparoscopic TAPP repair for large sac inguinal hernias is a technically demanding yet highly effective procedure. The critical step is the careful dissection and management of the large hernia sac to prevent injury to cord structures and ensure durable repair. With proper technique, adequate mesh placement, and meticulous peritoneal closure, TAPP offers excellent outcomes, even in challenging large sac cases. Surgeons must be familiar with pelvic and inguinal anatomy, laparoscopic ergonomics, and strategies for sac management to perform this surgery safely and effectively.