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Laparoscopic total extraperitoneal approach (TEP) for a left inguinal hernia

Authors

Abstract

This "live" surgery demonstrates the totally extraperitoneal (TEP) approach for a left indirect inguinal hernia repair in a young, muscular male. Some tips are offered regarding surgery in such patients.

Mots-clés

inguinal hernia, TEP

Type de vidéo

Durée

11'45''

Publication

2007-01

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Jan 2007;7(01).
URL: http://www.websurg.com/doi-vd01en2035.htm

Laparoscopic total extraperitoneal approach (TEP) for a left inguinal hernia

1. Patient presentation and port placement 00'10''

This is the case of a 26-year-old man with a left inguinal hernia, probably IIIb according to the Nyhus classification, with a past medical history of incarceration. Three ports are used. The main port is a 10mm optical port placed infraumbilically, and two 5mm ports, one at 1cm from the midline on the opposite side of the hernia, and the 3rd port (5mm) at the junction of the horizontal umbilical line and mid-axillary line. This port is about 3 fingerbreadths above the anterior iliac spine. This young man has a BMI of 22. This guy is strong. He is a Black guy from Mali, and the aponeurosis is very strong, especially in this kind of patient.. Here is the 1st plane. It is the anterior layer of the rectus muscle. We perform a horizontal incision in the anterior layer, and immediately I place a retractor under the anterior layer, and just underneath you can see the muscle. The 2nd retractor is placed laterally to push out the muscle because we have to find the posterior layer of the rectus muscle. We have to place the 1st 10mm port above the posterior layer. And you see the white sheet of the posterior layer. This way I have to introduce the 1st port. Now we start the insufflation of the extraperitoneal space with a pressure of 12mm Hg. You can see the space that is the normal aspect of the fascia propria that is the tissue in the extraperitoneal space. Now to the dissection with the scope, and I push it slowly and check on the screen that I’m going in the right way. We can perfectly open the space here. I have to place the 2nd port in this space. This port is 1cm from the midline on the opposite side of the hernia, just 1cm above the 1st port. If you are not sure to go in the correct space, the trick is to go in the direction of the 1st port and get in contact with it, then slide along this port. I have to find my 1st landmark.

2. Exposure of the extraperitoneal space 04'00''

The pubic symphysis is clearly visible here. Here is the medial line, the bladder. We don’t have to dissect too low. That’s enough 1cm above Cooper’s ligament. At this stage, watch out for the corona mortis which is the anastomosis between the epigastric pedicle and the obturator pedicle. The corona mortis is visible here. Here is the fascia. At this stage, we normally have a small vein running lateral to Cooper’s ligament. You’re working along the ligament to create the space. Then I change direction. I have to dissect the linea arcuata that is the inferior limit of the posterior sheet of the rectus muscle. If you’re not in the right plane, if you’re going up to the epigastric vessels, what would you do? You have to divide. Afterwards, you have to replace the pedicle with a stitch from outside to inside with a straight needle through the abdominal wall and fix it. Because it’s very difficult to continue the procedure with a detached pedicle. You must be very careful at this stage. It’s really the critical part of the operation. Here is the posterior layer of the rectus muscle. You must always be above the anterior layer, because it’s impossible to dissect between the posterior sheet and the peritoneum. Immediately you open the peritoneum. You can see the pedicle is here, the artery and the vein that are going into the muscle. This is the posterior layer. You have to find the inferior limit of the posterior layer that is the linea arcuata. Now we have to dissect the peritoneum from the posterior layer. I need to open this layer to increase my lateral view. Now I extend my lateral dissection. The objective now is to place the 3rd port. Medially we have the symphysis, Cooper’s ligament, fascia transversalis, epigastric pedicle, anterior right muscle, the spermatic cord, the transversus muscle, the psoas muscle behind, the posterior layer of the rectus muscle.

3. Dissection of the hernia sac 07'43''

In this case normally, you don’t have to dissect underneath the cord, you have to dissect only the peritoneum to find it. It’s important to mention that even with a small opening of the sac, you can work. The sac is opened. That is the opening of the sac. Then I can continue the procedure easily. Even with a small leak in the peritoneum, you can still work in the extraperitoneal space. The dissection is over now. The vas deferens is here, the spermatic cord there. The sac is closed now with an Endoloop. That is the ligation. Normally we don’t have to dissect very close from the nerve because I like to have some tissue over the nerve to avoid the direct contact of the mesh with the nerve. Here is the psoas muscle underneath and the nerve. I like to have this sheet to avoid the direct contact.

4. Mesh placement 09'30''

We can see the anatomy, medially the symphysis, Cooper’s ligament, the bladder, fascia transversalis, just here the triangle of Doom between the vas deferens and the spermatic vessels, with the artery and the vein, internal iliac vein; here the psoas muscle with the nerve, and the transversus muscle. Now it’s over. I have to place the mesh. Here is the shape of the mesh, the medial line, the place for the psoas muscle. I fold the mesh like an accordion and I introduce it through the 10mm port medially. That is the posterior layer. Dissection is enough for placement of the mesh here. I don’t like to go more than 1cm under Cooper’s ligament. That’s the 1st one over the pubis and the 2nd one must be placed laterally very high to avoid the nerve triangle. You have to fix the mesh during the exsufflation. Now we can proceed to the exsufflation of the space. That’s the end of the operation.

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