Laparoscopic total extraperitoneal approach (TEP) in a male patient for a right inguinal hernia

WeBSurg est une université virtuelle accessible mondialement sur Internet. Notre objectif est de fournir aux chirurgiens, aux sociétés savantes et au secteur médical un enseignement médico-chirurgical de pointe en ligne en chirurgie mini-invasive et toute information concernant les dernières avancées en chirurgie laparoscopique, dont notamment la Chirurgie Endoscopique Transluminale par les Voies Naturelles (NOTES) et la chirurgie assistée par robot.

Naviguez dans
l'Université Virtuelle
Français ▼

Laparoscopic   total   extraperitoneal   approach   (TEP)   in   a   male   patient   for   a   right   inguinal   hernia

Authors
GF Bégin
Mots-clés
TEP, hernie inguinale, coelioscopie, laparoscopy, treatment of inguinal hernia, mesh
Type de vidéo
Durée
14'00''
Publication
2006-06
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Jun 2006;6(06).
URL: http://www.websurg.com/doi-vd01en1962.htm

Laparoscopic   total   extraperitoneal   approach   (TEP)   in   a   male   patient   for   a   right   inguinal   hernia

3. Start of procedure 01'39''
That is the subcutaneous plane here and you can see a white layer here that is the anterior layer of the rectus muscle. This is a 10mm incision on the side of the hernia, which means that my incision is laterally, and underneath you can see the right muscle. You have to place your first port just under the anterior layer and the second port pushes out the rectus muscle. You can see the posterior layer of the rectus muscle. I place the port between the anterior layer and the posterior layer of the rectus muscle. Now we can start the insufflation of the extraperitoneal space with a pressure of 10 to 12mm Hg. The second port is a 5mm port, laterally and in this case I use a very long trocar because this is a fatty patient. You have to imagine where the ball of gas is and push your trocar in there. It’s a small piece of intellectual work for the placement of this port. Now you have to dissect medially and your second landmark is now is a symphysis, Cooper’s symphysis. That is exactly the fascia transversalis, the Cooper’s ligament is here and the limit of the dissection at this point is the obturator nerve and vein. Now I have to find my landmark, it must be the linea arcuata, you can see here the epigastric vessel, that is the vein, and you have to go underneath and not above. The epigastric vessels are just here, and you have to dissect just between the epigastric vessel and the cord. Just here is the cord and here are the epigastric vessels. On my way, is laterally, in the fossa iliaca until I find the relief of the transversus muscle. The psoas muscle is here and you have to push up the peritoneum. We are in the extraperitoneal space. It is an obese patient so we have a lot of fat. At this point, especially if the patient has had an appendectomy before, you must be very careful; open the peritoneum because sometimes the peritoneum is fixed to the abdominal wall and you can open it very easily at this point. So you push up the peritoneum until you reach the place of the third trocar. I place a port; again, the epigastric vessels are just here, you have to be careful at this step for the dissection.
4. Dissection of sac 06'29''
Sometimes the situation is a little confused at the beginning; I show you the internal ring, just here. You have to be careful not to injure the vas deferens. There’s a big lipoma just here. I am using a 30 degree scope. I use a split mesh, so in my situation I have to dissect under the cord; If you don’t use a split mesh, if you use an anatomical mesh, you don’t need this kind of dissection, you only need to parietalize the cord. I use this type of mesh because I think I can reduce the rate of recurrence with a split mesh; one way for recurrence to occur is the overlapping of the mesh. I always use this method. The vas deferens is here. Step by step you have to dissect the sac, and that is the sac here. You don’t need to open the sac so you need to be very careful. I always dissect the sac completely. Here there is the spermatic vessel and just here is the vas deferens and the rest is the sac. You can see the limit of the sac. You need to be very careful not to injure the vessel and dissect very gently. It is different here as you pull on the sac which is thickened, whereas if you had a direct hernia you have to be very careful otherwise it is very easy to make a hole in the peritoneum. I’ll show you the internal ring, it is just here. The limit of the dissection is the crossing of the vas deferens with the Cooper’s ligament. Now we need to place the mesh, because the dissection is over. Under the cord structure you have the famous Doom triangle. The Doom triangle is normally made by the vas deferens laterally and the spermatic vessel outside. In this triangle is the iliac vessel, just here, and you have lymph nodes all around it: Don’t dissect it, that is the protection for me between the mesh and the vessel. Laterally you have the psoas muscle and you can see the nerve just here. That is the nerve triangle. Never place a stapler or a fixation in this area.