WeBSurg.com, May 2005;5(05).
1. Trocar placement 00'09''This patient is 40 years old and presents with a right hernia. We only see a small skin incision done for a previous appendectomy. In this case, the skin incision is high. I use 3 ports, two 10mm and one 5mm. The first 10mm is infra-umbilical. We have to find the right access for the 1st port, just between the 2 layers of the rectus muscle, the anterior and the posterior layer. We must absolutely avoid port placement between the peritoneum of the posterior layer because we don’t find enough space for the dissection this way. The 2nd port is a 5mm one, which is about 2 fingerbreadths from the midline and 2 fingerbreadths under the 10mm port. The 3rd port is a 10mm lateral one just at the junction of the umbilical line and the mid-axillary line. I use a 10mm port because I use a 10mm stapler. I perform a vertical skin incision, which is better than a circular one because anatomically you’re exactly in the fold of the umbilicus and we have to dissect the subcutaneous plane to find the anterior layer of the rectus muscle. I always use a 30 degree scope. It must be absolutely clear to find this way, the wedge-shaped of the anterior layer. You have to perform your incision laterally until you find the color of the rectus muscle. This way, you find the posterior sheath. You can see the posterior layer of the rectus muscle. We have to place the port exactly between the 2 shapes. Now I use a 10mm port, a blind trocar and you slowly push in the space. Insufflate the space with a pressure of 10mm. I use the scope for the dissection.
2. First trocar introduction 03'00''Other surgeons use a balloon. Here is the skin and the posterior layer of the rectus muscle. When I turn my scope, you can see the rectus muscle laterally. I am into the space and you can see an important landmark, which is the linea arcuata that is the inferior limit of the posterior layer. This layer switches to a special tissue of the extraperitoneal space. You can push your scope in this space. With my scope, I have the contact with the pubic bone. Here you can see the linea arcuata. It is essential to dissect this way.
3. Dissection of peritoneum 04'16''This is a key point in the dissection of the extraperitoneal space. The pubis is here, you can see the bone. I have enough space for the placement of my port. We now push the 5mm port in and I use scissors for the dissection of the space. You don’t have to cut, but only to retract the tissue very smoothly. That is the bone. You don’t need to have too large a dissection, only 1cm above the pubis is enough. You don’t have to dissect lower. If you place too large a piece of mesh, the dissection is very difficult and you have to be careful for the bladder. At this level, you have the posterior sheath behind you. You have to find the linear arcuata since it is key for the dissection of the iliac fossa. This way, you avoid opening of the peritoneum because you are above the posterior layer of the rectus muscle. Step by step, you can dissect laterally. I am just on the skin incision of the appendectomy. The transversus muscle is up here. The problem is that you never know if the patient has had a bad appendicitis or not and whether it’s going to be very adherent. Indeed, yes. The peritoneum is here. Don’t open it. This way, when you follow the linea arcuata, I think that you can avoid opening the peritoneum. It’s easy to dissect laterally. The transversus muscle is just here and that’s the linear arcuata. You have to cut it to increase the space laterally. Now you have to push the peritoneum up in the space until the umbilical line. It may be helpful to put the patient in a Trendelenburg position. We dissect the space and we always find this plane, which divides the extraperitoneal space in the iliac fossa into 2 spaces. Now we can place the third port. You can see the relief of my device just here. Now I have to perform my skin incision under visual control, and now we can dissect the midline. This is a direct hernia. The transversalis fascia is just here. That is the reflection line. The pubis is here and the transversalis fascia is just here. I push it.
4. Sac dissection 09'00''We haven’t seen the inferior epigastric vessels because they are up. You’ll see them in a moment as he dissects more laterally from where he is now. You can see the iliac vein just underneath and that is the direct hernia with the transversalis fascia. This is the cord. The inferior epigastric vessels are just there in the fat, just between the transversalis fascia and the cord. You have to dissect this lipoma. Sometimes they come back and think that they have another hernia. Personally I use a split mesh. In this case, you have to dissect all around the cord. This is the right way under the cord. That is the vas deferens. Don’t take it with your grasper. Here’s the reflection line of the peritoneum. You have to dissect over 6cm. The fat is around the spermatic vessel. I stop here otherwise there is a risk of injuring the vessel. There is a lymph node around the artery and the vein. Don’t dissect it. Laterally you can see the nerve triangle. Here are the femoral nerves. Here is the psoas muscle. I keep the fat on to avoid contact of the mesh directly with the nerve. Now the dissection is over. Here are a few anatomical landmarks: the midline with the pubis, Cooper’s ligament, transversalis fascia with the direct hernia, epigastric vessels in the fat, the cord, the reflection line of the peritoneum, and the iliac fossa laterally. The dissection is over. Here’s a small trick to avoid the formation of a seroma, I revert the fascia, I take only a small piece, I don’t take the vas deferens, now you can place the scope laterally, it’s much easier because we’re in a good axis for the placement of your stapler. We can see the 5mm port. Here’s the sac. And we can fix it. We can place the scope medially just before I show you how to place the mesh. I push my grasper in the lateral 10mm port. Now I prepare the mesh. This is a non-woven polypropylene mesh, 15 by 17cm. This is the internal part of the mesh, this is the place for Cooper’s ligament, for the lateral port, and for the psoas muscle. Now I cut it in the midline, 7cm and I remove a small triangle of tissue and now the crossing of the 2 parts of the mesh. If you place the mesh this way, you will place the hole by the hole, the external part crosses the internal part. So you’ll reproduce the shape of the inguinal region. This is the cord, and this forms a kind of ‘zig-zag’ and so the pressure is on the external part and you don’t replace the hole by another one.
5. Mesh positioning 15'00''I fold the mesh like an accordion. I take it with my grasper and we introduce the mesh and push it under the cord. Pull it! And immediately thanks to the memory of the tissue, the internal part of the mesh is placed. And I remove the external part and it’s open. I use 2 graspers and now you can fold the 2 parts of the mesh. And now the internal part crosses the external part. You avoid injuries to the epigastric vessels with your stapler. I fix the mesh laterally and internally. I place the scope laterally and I introduce the stapler medially. You don’t fix it here because you can injure the cord. So I fix the first 1cm above. I put one on Cooper’s ligament. That’s the distance between the cord and the vessel when you split the mesh, you can avoid any recurrence. It’s the overlapping. It’s the internal ring and you so cover perfectly this area with the mesh. We place the scope medially. Laterally you can see the mesh, the psoas muscle, the cord, Cooper’s ligament – don’t fix the mesh in this area, not too lower down to avoid the lateral surface of the bladder. Never staple lateral to avoid the nerve! The stapler must be in the internal plane of the epigastric vessels and never outside. That’s a very dangerous area as the triangle of Doom is here with the vessel and that is the nerve triangle. Now we have to exsufflate the space and you can see the placement of the peritoneum. And it’s over.