Laparoscopic bilateral hernia with single mesh TEP

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Laparoscopic bilateral hernia with single mesh TEP

Authors

Mots-clés

hernias,operation,mesh,inguinal hernia,total extraperitoneal approach,bilateral

Type de vidéo

Vidéo chirurgicale

Durée

10'16''

Publication

2002-06

Popularité

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Sous-titres

E-publication

WeBSurg.com, Jun 2002;2(06).
URL: http://www.websurg.com/doi-vd01en1299e.htm

Laparoscopic bilateral hernia with single mesh TEP

1. Creation of preperitoneal space 00'23''

The first operative step is the creation of an operative space. The procedure begins with a 10mm transverse incision inferior to the umbilicus. A space is created posterior to the rectus muscle and a 10mm trocar is introduced in this space. CO2 is insufflated at this moment, which creates an initial operative field. The laparoscope can then be inserted in that space and the areolar tissues are taken down first centrally in the space of Retzius where the bladder is completely freed and laterally where 2 other 5mm trocars are introduced. The anatomical structures of the posterior surface of the anterior abdominal wall can be identified: the rectus abdominis muscles, the inferior epigastric vessels and the neck of indirect or direct hernias can be searched for.

2. Right hernia dissection 01'34''

This procedure begins with a right hernia. Dissection is progressively carried on medially in the prevesical space, then laterally. The transversalis fascia can be easily identified in the weakened area over the direct inguinal hernia defect. The Cooper’s ligament is identified. The hernia sac and the spermatic cord including the vas deferens and vessels of the spermatic cord adherent to the peritoneum are dissected. This careful dissection must be performed step by step in direct contact with the peritoneum. With a careful use of coagulation, the elements of the cord and fibers of the cremaster muscle are progressively dissected away from the sac. The intersection between the umbilical ligament and the vas deferens constitutes the limit of the dissection medially. Elements are gently swept away from the peritoneum. Laterally dissection continues until all vessels of the spermatic cord have been completely parietalized. This careful dissection also aims at avoiding any tears of the peritoneum. We usually perform parietalization of the cord followed with placement of a mesh covering the spermatic cord. Thus the peritoneum must be completely peeled off from the lateral wing of the spermatic sheath until it can be retracted easily.

3. Left hernia dissection 04'03''

We can see the completed area of dissection with Cooper’s ligament. We now shift to the left side of dissection. The hernia sac will also be dissected medially, then laterally. It begins with mobilization of the bladder, and the hernia orifice will be progressively freed. A lipoma is dissected out of the hernia and the sac is freed by sharp division and coagulation from the elements of the cord. The spermatic cord is identified. Dissection must not take place too laterally. It must be performed in contact with the hernia sac and lipoma. The hernia defect is slowly dissected. The hernia sac and the lipoma are dissected sharply and separated from the fibrous structures. This allows for total isolation of the hernia sac. As performed on the right side, dissection of the fibrous adhesions is performed in close contact with the hernia sac with coagulation of all capillaries and small vessels to avoid bleeding that will lead to postoperative hematoma. The elements of the cord are swept away progressively. Some fibers of the cremaster muscles are cut to allow for complete dissection of the vas deferens. By totally extraperitoneal approach, freeing of the vas deferens medially, and of the vascular elements of the cord laterally can be performed. If the lipoma is not devascularized, it is simply left in the space of Retzius and is not resected. In all cases, the hernia lipoma must be pulled out of the inguinal canal to avoid the presence of a postoperative inguinal mass mimicking recurrence of a hernia. As was done on the right side, the vas deferens is freed from relatively dense adhesions until the level of the umbilical ligament allowing for a complete parietalization of the cord. The dissection of Cooper’s ligament can be performed at that moment. Care must be taken not to injure the corona mortis, a vascular anastomosis between the obturator and epigastric vessels. Injury to this vessel can cause severe hemorrhage, which may be difficult to control. The length of dissection of the hernia sac must be sufficient to allow for a good laying of the mesh in a preperitoneal position. This allows for pediculization of the vascular elements and vas deferens 6 to 7cm away from the hernia defect and avoids recurrences. Adhesions are completely freed and the sac is now completely separated from the cord and spermatic sheath.

4. Mesh placement 08'34''

The bilateral hernias are treated by the placement of a polypropylene mesh of 28 by 13cm. The mesh is rolled, secured with a suture, and inserted in the preperitoneal space. The mesh is stapled on the anterior abdominal wall, then the stay sutures are cut and the mesh is unrolled down like a curtain. The mesh is carefully placed to cover all orifices and is tacked near the anterior superior iliac spine to avoid mesh displacement, then tacked to the Cooper’s ligament on the left and right sides. Desufflation of the CO2 is performed under vision. No drainage is required. The procedure is completed.