Laparoscopic TEP repair for right direct inguinal hernia

In this video, we present the technique of a TEP approach for the management of an inguinal hernia in a male patient. The technique is meticulously explained, emphasizing on the main anatomical landmarks, the key steps of the procedure and the potential injuries to be avoided.

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Laparoscopic   TEP   repair   for   right   direct   inguinal   hernia

Authors
B Dallemagne, J Marescaux
Abstract
In this video, we present the technique of a TEP approach for the management of an inguinal hernia in a male patient. The technique is meticulously explained, emphasizing on the main anatomical landmarks, the key steps of the procedure and the potential injuries to be avoided.
Classification
routine cases
Keywords
Laparoscopic TEP repair, right direct inguinal hernia
Media type
Duration
16'20''
Publication
2009-01
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2531.htm

Laparoscopic   TEP   repair   for   right   direct   inguinal   hernia

3. Placement of the umbilical trocar 01'08''
You can see that we are working into the umbilicus and we have already made a small arciform incision below the umbilicus so it’s a very thin patient. It’s a very small incision so regarding the cosmetic results, it’ll probably be good but it’s not the main issue of this operation. We have dissected the subcutaneous tissues to get access to the fascia, the aponeurosis of the rectus muscle on the right side because this patient has a right inguinal hernia and you can see that we have made a small vertical incision of the anterior aponeurosis of the rectus muscle. And then I will try to retract the muscle to open the posterior sheath and I’ll introduce my 1st trocar alongside this posterior sheath. I’m used to doing it with a direct approach so usually I’m creating a pre-pneumoperitoneum by insufflation above the pubic tuberculum and go directly with the trocar. I think that people who want to start with this operation, it’s better to do this step by step approach from the umbilicus. This is a trocar with some serrations and sometimes it’s dangerous for the peritoneum when you have a very slim patient. I’m using a 0 degree scope, and then I’ll check inside to see if I’m in the right plane. I think I am. Then and only then, I will inflate. My 1st direction is the pubis so I’m trying to get access and I’m moving towards the pubic tubercle. Of course initially the view is not very clear because we are in the tissues. You see I have the contact with the pubis so it’s quite a nice view here. One of the main problems with the TEP is that when we’re starting, sometimes it’s difficult to find the right plane.
4. Placement of the suprapubic and left side trocar 04'04''
I’m just opening a small window in the preperitoneal space and I have the pubis as a 1st landmark. I will introduce a 2nd 5mm trocar that is placed about 2 to 3 fingers above the pubic bone. Of course we are controlling the entrance of this trocar. Then in my left hand, I will have the scissors with some cautery and in my right hand I have the camera. This is the pubic bone. We will just dissect bluntly initially to get the other landmarks. I know I have to move from the pubic bone so we use gentle blunt dissection and I’m looking for an important landmark: the epigastric vessels. I’m not moving or dividing anything before seeing the epigastric vessels. Here I’m enlarging a little bit. Probably when we see this, I don’t see the epigastrics. So this is a hernia that is inside of the epigastrics if I’m right so probably it’s a direct hernia. The idea is to stay very closely in contact with the sac. I’m not working in this direction because these are the epigastrics and if I’m going this way, I’ll move above the epigastrics. So you see that the 1st step is really to look for the epigastrics staying in close contact with the hernia sac. We know that the hernia is somewhere here so I’m staying very close to that and probably the epigastrics are here as you see. I don’t know if there’s a direct hernia. You see the epigastrics and maybe some indirect part of it. You see on this side. I don’t know if there’s a hernia there. Probably the main part is a direct one and that is quite strange for a young guy. I know where the epigastrics are so I continue the dissection on the side. I always keep an eye on the epigastrics. So I’m staying in close contact with the peritoneum. The idea now is to try to find my plane laterally between the abdominal wall and the peritoneum. And if I can work with one hand, as I do now, I’ll try to use only one lateral trocar, which will be placed approximately at the level of the iliac spine. So just bluntly we are progressing, trying to move up the peritoneum. Initially we are trying to avoid incision of the peritoneum because it’s much more comfortable if you don’t have a pneumoperitoneum but the systematic question when we’re doing this peritoneal repair is that if you have a hole in the peritoneum, what happens? And in fact, we know that we can continue the operation. Michael Bailey, I know that you’re using the balloon. Yes, not always, but we do use it because it’s very quick. It’s more expensive though. You can see that here I can use also my scope to open these different spaces; I’m still working with one hand trying to retract the peritoneum. I want to go up to the iliac spine to insert my 2nd trocar. You see that I’m approaching the lateral side. We can see the psoas muscle behind that. I’m just checking from outside, the light of the scope just on the iliac spine, which is there. I’ll control the introduction of my 2nd trocar because we know that if we’re going too far, that can be quite dangerous. So we’re moving back there in the middle.
5. Identification of the hernia and hernia sac dissection 09'31''
So the 1st thing to do is to retract this hernia to see what happens there. You can see the transversalis fascia there. See when I’m reducing, so it’s mostly a lipoma. In a young patient, it’s quite unusual. So just traction and usually it should come. There’s no need for cautery, it’s just blunt retraction. I’m continuing a bit the dissection towards Cooper’s ligament. This is the corona mortis. The other point when you’re using a lot of coagulation, you have a very obscure field, so I like to have only blunt. This is the cord; we can see the vas. In fact, in this position, I have no room to place my prosthesis. So even if there’s no indirect hernia, I need to increase a little bit the space. The idea is to dissect and retract the peritoneum. Sometimes it can be very thin in thin patients, and this is where you can make a hole if you’re not careful. So very gentle maneuver, mostly blunt. It’s not necessary fundamentally but it’s just to get enough room to place a large prosthesis and to avoid the mesh being lifted up when you let out the CO2. See again the peritoneum here so I’m trying to increase again the space. We can see the vessels there. That’s why we have to be quite careful in this area because you see the vein and when you’re dissecting, it’s very important to take care of your movements and not to be too aggressive with the different dissection planes. Probably my feeling is that people who are doing a TEP approach are more advanced in these inguinal laparoscopic repairs. Now I think I’m ready with the dissection. I just want to show a bit more of the anatomy. See the psoas muscle there, the lateral trocar, which is on the spine, the cord. You see I’m trying not to dissect too much in this patient because of this direct hernia.
6. Insertion and placement of the mesh 12'55''
This patient is in a normal shape so I will probably use a 15cm by 12 or 13cm mesh. I roll the mesh like a cigarette and I’ll go through the 10mm port. I have used one of the lightest ones, the one that is reinforced with titanium. It’s like T-mesh or something of the kind. It’s very light and sometimes it’s quite tough to place it because it’s so thin. It’s like cigarette paper. And sometimes it’s very difficult to place it. Meshes that are heavier are sometimes easier to place. There was a paper that showed that the mixed meshed with the Vicryl, there was a higher recurrence rate in the early ones. The idea is to cover medially more. Maybe I’m a bit too lateral so I like to have a very important coverage from the medial side for a direct hernia. I’m just displacing the mesh a bit and that’s probably one of the advantages of this TEP approach: you can go on the middle line quite easily as compared to the TAPP when sometimes you have to increase the space. Of course if at this point, you’re tacking the mesh, that’s easier. But as I don’t like the tackers, I’m just trying to hold this mesh without any fixation and that’s why it’s a little bit more difficult to keep it in the right position. I’m using the scope and controlling the mesh on the psoas side and I will hold my mesh while I’m deflating the patient. When the patient gets a full bladder, is that going to lift the mesh up? No, it will apply the mesh on the abdominal wall. See I’m releasing the pneumoperitoneum and it’s very important to control the position of the mesh. I don’t think the bladder could lift the mesh. Yes, I agree.