Left inguinal hernia TEP

The extraperitoneal technique for inguinal hernia repair is now well defined. In this video, Dr. Begin describes the various key points.

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Left inguinal hernia TEP

Authors

Abstract

The extraperitoneal technique for inguinal hernia repair is now well defined. In this video, Dr. Begin describes the various key points.

Mots-clés

hernias,operation,groin hernia,total extraperitoneal

Type de vidéo

Vidéo chirurgicale

Durée

11'00''

Publication

2002-06

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jun 2002;2(06).
URL: http://www.websurg.com/doi-vd01en1298e.htm

Left inguinal hernia TEP

1. First trocar introduction and creation of the space 00'08''

Today, we’d like to demonstrate a totally extraperitoneal approach to a pair of a left inguinal hernia in a young male patient. The first point is the placement of the 1st trocar. You have to find the anterior layer of the rectus sheath. The plane of dissection is between the anterior and posterior rectus sheaths you can see here in an illustration. You can see here the white layer of the fascia. At this point, you make it a 10mm transverse incision in the fascia. Immediately you can see the rectus muscle under your incision. You now have to push the rectus muscle laterally to find the posterior fascia of the rectus sheath. The trocar should be positioned between the anterior and posterior layers of the rectus sheath. And at this point, we will begin the insufflation of the extraperitoneal space. Pressure should be 12mm Hg. I use a 30 degree scope and push it directly and repeatedly into the areolar tissue to create a working space. And so you can dissect very smoothly the extraperitoneal space and you have a nice view here: the rectus muscle is here, extraperitoneal space, and Cooper’s ligament is just here.

2. Second trocar introduction and dissection 02'27''

You can see the trocar has been inserted here. We are now medial. You can see the symphysis, laterally is Cooper’s ligament. Be careful in this area because the corona mortis vein can be here, which is an anastomosis between the inferior epigastric and obturator veins. In this direction, you are in the iliac fossa. The anterior iliac spine is just here and if I push on the abdomen, you can see this is the anterior superior iliac spine. I open progressively in this direction. With the external view, you can see that my dissection goes 3 fingers above the anterior superior iliac spine.

3. Third trocar introduction and spermatic cord dissection 03'45''

And then, I can introduce a 2nd working trocar. It can be difficult to introduce the mesh through a 5mm port. You can see here the inferior epigastric vessels and the internal ring is just here. The sac is just here. You can see the edge. And now I’m in the so-called triangle of Doom, which contains the cord and the iliac vessels. Laterally is the triangle of pain, which contains the nerves, and more medially is the triangle of Doom, which contains the vessels and the cord. Here you can see the area for a direct hernia and this is the transversalis fascia. I will go under the cord. The vas deferens is here. This technique allows you to dissect the very big hernia because there’s plenty of space.

4. Hernia sac dissection 05'06''

This is an illustration of the sac. So the sac is just here. The obvious danger is opening the peritoneum so you have to be careful. If you perform this kind of surgery under local anesthesia like George Fresley for example, this is the most difficult portion that is dissection of the sac because the patient can have a lot of pain, with tension and manipulation of the sac. The dissection is carried about 6 to 7cm from the internal ring. And this is the internal ring here. This is the transversalis fascia just here. This is the femoral ring. This is the ligament and this small vessel is the corona mortis. You can see the anatomy perfectly and it’s good to visualize before placement of the mesh. The iliopubic tract is just here, the internal ring, the cord is here, the peritoneum is here, inferior epigastric vessels come from here, the transversalis fascia is here and Hesselbach’s triangle between Cooper’s ligament, the inferior epigastric vessels, and the border of the rectus muscle. Here’s the symphysis and the bladder, the nerves run along the belly of the psoas muscles, which is just here. The region where they run is the triangle of pain.

5. Mesh preparation 07'32''

The mesh we use is a 15 by 15cm Prolene sheet. The first cut is for Cooper’s ligament. I come laterally around the corner and this helps obtain good landmarks in this space. You can see the mesh; it’s for Cooper’s ligament and this is for the psoas. I’ll cut the mesh just in the middle, about 7cm length. I remove a small triangle of mesh because normally the shape of the mesh in the abdomen is that of a cone like so. The external flap comes over the internal flap to create the cone shape. I fold my mesh like an accordion and introduce the first flap, the internal flap into the trocar first. My assistant folds the external flap like an accordion and now I introduce the mesh into the port.

6. Mesh placement 08'50''

I push my port under the cord and take the mesh, which will now open automatically because I have folded it like an accordion, due to its memory. Placement is atraumatic as you can see. You can see the mesh, the cord, and now I have to insert the stapler. One thing is important: don’t staple immediately over the cord because you can cause stricture of the cord. Another point: the epigastric vessels are just here, so it’s easy to get a vascular injury if you put a stapler near here. The 1st staple must be 1cm above the cord, which is just here, and the 2nd one above it, and you can put another staple here to stabilize the mesh if you like. The last one is for Cooper’s ligament. You must be perpendicular to the mesh to get adequate fixation, not here but 1cm above just here. And now you push from outside the abdominal wall to push the tissue onto the stapler, 1st one, second one is for security, and a 3rd one here. Last one is for Cooper’s ligament. Be careful of the corona mortis, which you can see here. Never staple in this area. You can get a nerve injury if you place staples in this region. Laterally this is the anterior superior iliac spine, Cooper’s ligament and the nerves and never ever staple this area, or this area: this is the triangle of Doom. One danger of this technique is the potential for the mesh to fall on itself with desufflation. It causes immediate recurrence of the hernia. With this style of split mesh, we don’t really have this possibility. And now, I will exsufflate to show how the mesh lays.