In TAPP, How to Manage Small for Size Mesh

In laparoscopic groin hernia repair, the mesh should ideally measure about 10 × 15 cm to adequately cover the Myopectineal Orifice and overlap all potential hernia sites (direct, indirect, femoral, obturator). Small-for-size mesh during Transabdominal Preperitoneal Repair (TAPP) for Inguinal Hernia is a recognized intraoperative problem when the available mesh is smaller than the recommended coverage of the myopectineal orifice. Management options when the mesh is small are:

1. Maximize medial fixation and placement: Ensure adequate medial overlap over the pubic tubercle (2–3 cm), Fix the mesh securely to the Cooper’s Ligament, this prevents recurrence of direct hernia.

2. Prioritize coverage of the myopectineal orifice, even with a small mesh, make sure it covers: Direct space, Indirect space, Femoral canal. These structures lie within the Myopectineal Orifice.

3. Lateral positioning without fixation: Laterally, the mesh should extend toward the Anterior Superior Iliac Spine, but avoid fixation in the region of the Triangle of Pain and Triangle of Doom.

4. Increase effective coverage by: Unfold and stretch the mesh properly, Create a slit for the cord structures if necessary, Flatten the mesh widely before peritoneal closure

5. Use a second mesh (if available): If the defect is large, it is safer to add another mesh or replace with a larger mesh rather than relying on a very small one.

When the mesh is borderline small: Medial overlap is the most critical point, Ensure fixation to Cooper’s Ligament and coverage of the direct space, because recurrence commonly occurs there.

NB:

Recurrence after Transabdominal Preperitoneal Repair (TAPP) is usually due to insufficient mesh size or poor overlap, not failure of fixation.