Laparoscopic total extraperitoneal approach of a left inguinal hernia

This video demonstrates a case of laparoscopic total extraperitoneal repair of inguinal hernia in which the surgeon does not use a balloon to create the extraperitoneal space. A large mesh is used but not fixed to any structures. This video provides for an alternate method of performing TEP without mesh fixation.

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Laparoscopic total extraperitoneal approach of a left inguinal hernia

Authors

Abstract

This video demonstrates a case of laparoscopic total extraperitoneal repair of inguinal hernia in which the surgeon does not use a balloon to create the extraperitoneal space. A large mesh is used but not fixed to any structures.
This video provides for an alternate method of performing TEP without mesh fixation.

Catégorie

controversial cases

Mots-clés

Ingunial hernis, TEP,laparoscopic, no mesh fixation

Type de vidéo

Vidéo chirurgicale

Durée

16'00''

Publication

2005-11

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1876.htm

Laparoscopic total extraperitoneal approach of a left inguinal hernia

1. First trocar introduction 00'11''

First step, it’s a vertical 8 or 9mm infra-umbilical skin incision. Second step is the dissection of the subcutaneous plane. I have to find the anterior layer of the rectus muscle and now I perform a 10mm incision in the anterior rectal sheath. 8mm round because I have to avoid a gas leakage and so in this case I perform an 8 or 9mm skin incision. I push and I place my scissors or shears just under the anterior layer. I place the 1st retractor. You can perfectly see the rectal muscle laterally. With my 2nd retractor, I push out the rectal muscle and therefore you can see the posterior sheath perfectly. You have to place your port just between the 2 layers. This is a balloon trocar and I push it slowly between the 2 layers. That will be a CO2 sealed. I enter the port. You can see posteriorly the posterior layer up the rectal muscle. And you can see immediately the shape of the fascia propria, that is the extraperitoneal tissue. I push my scope gently and slowly and it’s like a liposuction and I create some channel in this tissue. There is no resistance. That is a good place for the placement of my 2nd port. I have the physical contact with the symphysis.

2. Second port placement 03'17''

You can see Cooper’s ligament. And now I place my 2nd port. The 2nd port is placed laterally, 2mm lateral to the midline and 2mm under the umbilical line. It’s a 5mm port. You have to place the port in the correct space. First of all, I have to coagulate this small vessel, that is the epigastric pedicle.

3. Preperitoneal dissection 04'00''

My first landmark is the symphysis pubis. This is a small vessel coming from the epigastric vessel and running to the muscle. My 1st landmarks are Cooper’s ligament and the symphysis. This is the obturator foramen with the vein on the nerve. Normally it’s the inferior limit of your dissection. The symphysis is my 1st landmark. I now find the linea arcuata which is my 2nd landmark. It’s the crossing between the epigastric vessel and the linea arcuata. This is the posterior sheath where it is finishing down laterally. That is the inferior limit of the posterior sheath. That is the key for the dissection of the space of Bogros. You can see the sheath and normally I cut it to increase the size of my pocket of dissection. You can see the very specific shape of the transversus muscle and we increase step by step the size of the dissection of your lateral pocket

4. Third trocar placement 06'00''

until you find the limit between the umbilical line and the axillary line and you can see my scissors here. This is the place for my 3rd trocar. I push it through the skin incision and this is the placement of my 2nd port.

5. Hernia sac dissection 06'25''

Posteriorly you have the psoas muscle with the nerve, which is the famous triangle of the nerve. No stapler, no fixation must be done in this area. The fascia transversalis is just here with the lateral vein coming from the epigastric pedicle. This small vein is sometimes dangerous during the fixation of the mesh. We have to be careful during the dissection. We have to reduce the small lipoma. I am just in front of the iliac artery and iliac vein. That is the pedicle with the vas deferens. Don’t injure vessels during this dissection and keep the vas deferens and the spermatic vessels together. Personally I use a split mesh but it’s not a rule. A lot of surgeons use a plain mesh without a split. I think the split mesh allows you to avoid any recurrence by overlapping on the anterior flap of the mesh. The edge of the peritoneum is here. So there is no indirect hernia. It’s important not to make a hole in this because otherwise you get the pneumoperitoneum as the CO2 in the extraperitoneal space goes into the abdomen and that tends to limit the space you can operate in. If I make a hole in the peritoneum now, it’s not really a problem because we have a good balance with intra- and extra-abdominal pressure and the peritoneum is vertical with the same intra- and extra-abdominal pressure. The problem is when you make a hole at the beginning of the dissection and afterwards it’s difficult to continue. Now it’s sufficient, I dissect until the vas deferens crosses Cooper’s ligament. You can see Doom’s triangle, a triangle that is between the vas deferens and spermatic vessels, it includes the artery, the vein and lymph nodes around. Don’t dissect this area. Here is the fascia transversalis. Now the dissection is over. Here’s a small trick: I reverse the fascia transversalis to avoid a seroma afterwards. I push from outside and I reverse this fascia and I fix it with a stapler on Cooper’s ligament. And so it’s fixed. Now I have to prepare the mesh. I use a 5mm grasper coming from the 5mm port and I push it through the 10mm lateral.

6. Mesh preparation 10'53''

First I prepare the space for Cooper’s ligament, and then I go laterally towards the psoas, then turn it vertically. The design for the space of this mesh is different according to the anatomy of the patient. The most important thing is the distance between the umbilical and pubic line. I cut the mesh in the middle since I use a split mesh. It’s my way of doing it. I then remove a small triangle of tissue, of material and so that is the internal external flaps and I cross the external on the internal flap. And therefore I reproduced exactly the shape of the inguinal area. It’s a conical shape. The cord goes through the hole but you don’t have the hole in front of the hole because it’s a kind of zigzag way that you reproduce. I fold the mesh like an accordion with my fingers very easily. I take it with my grasper and the split is up. I introduce the internal part, now I fold the external part.

7. Mesh positioning 12'58''

I introduce the mesh in the port. I push it under the cord and immediately with the memory of the tissue, the internal part is placed. Same thing for the external part. This is the external part and here is the internal part. And I cross the external on the internal. You can see the epigastric pedicle and the internal part of the split follows exactly the epigastric pedicle. When I staple in this area I am sure that I don’t staple the epigastric pedicle. The stapler is perpendicular and this is the split mesh. I don’t fix it just above because you can get a stricture of the cord but 1cm above. You can see the small triangle, I resect it and I fix it just here. I push from outside with my finger and I fix it, 2 for security and 1 above. Fix it just above the symphysis and just a stitch on Cooper’s ligament. It’s over now and you can see that the mesh is placed. That is the cord and the posterior layer with the psoas muscle and the nerve. And you can see that the mesh covers the whole hernia site, femoral direct right. I now split the mesh in order to avoid any recurrence by overlapping of the mesh. The danger is if you place the mesh on the cord. During exsufflation, you can have an overlapping of the mesh and recurrence. In this case, it’s impossible because it’s closed. Now we proceed to the exsufflation. Here’s the peritoneum.