Nyhus IIIb right inguinal hernia: a stepwise TAPP approach

This is the case of a patient presenting with a Nyhus IIIb right inguinal hernia. The surgical technique is explained live in a stepwise fashion starting from the introduction of the first port until closure of the peritoneum. The major anatomical landmarks are highlighted. The dissection technique as well as the positioning of the Parietene® mesh fixed by absorbable staples (AbsorbaTack™) is demonstrated.

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Nyhus IIIb right inguinal hernia: a stepwise TAPP approach

Authors

J Leroy, J Marescaux

Abstract

This is the case of a patient presenting with a Nyhus IIIb right inguinal hernia. The surgical technique is explained live in a stepwise fashion starting from the introduction of the first port until closure of the peritoneum. The major anatomical landmarks are highlighted. The dissection technique as well as the positioning of the Parietene® mesh fixed by absorbable staples (AbsorbaTack™) is demonstrated.

Catégorie

live recorded

Mots-clés

right indirect inguinal hernia, Nyhus IIIb, TAPP approach, laparoscopy

Type de vidéo

Vidéo chirurgicale

Durée

21'28''

Publication

2011-11

Popularité

Favoris

Favorites Media

Audio

E-publication

WeBSurg.com, Nov 2011;11(11).
URL: http://www.websurg.com/doi-vd01en3491.htm

Nyhus IIIb right inguinal hernia: a stepwise TAPP approach

1. First trocar insertion 00'18''

I am dissecting until I reach the aponeurosis as you see now. And I will incise the aponeurosis, not too much though, just above the peritoneum, and I will perforate the peritoneum with my forceps. I am now inside the abdomen. You can see the opening. We introduce inside the abdominal cavity under the optical vision. I’m pushing the trocar in the sleeve or you push a conical trocar, and I’m connecting the insufflation. Now we can insufflate. We use hot water to warm the scope. I’m always beginning with a large view.

2. Exploration of abdominal cavity 01'37''

So we have done a panoramic exploration of the abdominal cavity as you see, and we have seen only a defect on the right side. I’ll go into details after I have exposed the anatomy.

3. Insertion of operative ports 01'56''

I introduce 2 other trocars: one on the left, on the mid-clavicular line under the umbilicus, horizontal line, I will show you later. See we introduce this Step-trocar. The other one is introduced on the side of the hernia on the mid-clavicular line above the horizontal line of the umbilicus. See we have on the left side, right side. Now I’m exposing the anatomy. We can see a lot of structures, which are well visible because it is a slim patient with a BMI of 22.

4. Identification of anatomical structures 02'49''

Some structures are vertical. We have first on the midline, this is the urinary bladder, which is not empty. Normally at the summit of the urinary bladder, we have the urachus, probably at this level but it’s atrophic. We have 2 other structures not completely vertical but oblique and vertical: these are the umbilical ligament or artery, left, right, and we see them very well on the right and on the left. Other vertical structures: this is Hesselbach’s triangle in which we will find the epigastric vessels with the artery in the center and lateral we normally have 2 veins: one is lateral. See we have 3 vertical structures, artery and 2 veins, on the left, on the right, we have the same at this level. Spermatic vessels on the left, on the right, we have the same. We also have another structure, white coming from the back of the urinary bladder and from the prostate area. This is the vas deferens duct, which is crossing the umbilical ligament on the back. This is the posterior limit of our dissection. This is the vas deferens duct. We have virtual structures we don’t see. It is the structure between. I’ve the anterior superior iliac spine at this level, and watch just behind, we have a nerve running. In front of the peritoneum, we will see better after the dissection. We have the anterior superior iliac spine and the pubic bone and the symphysis. This line is the line of the inguinal ligament. All these structures will determine different areas. First, laterally to the Hesselbach’s ligament and triangle and the epigastric vessels, and above the inguinal ligament we see in transparency, it’s a white structure, we have the external inguinal area. Between the epigastric vessels and the umbilical ligament, we have the mid-inguinal area. Between the urachus here and the umbilical ligament, we have the internal inguinal area. We have other areas, a triangle formed by the spermatic vessels and the vas deferens duct, this is a triangle with the base there, this is the triangle of Doom. In this triangle, we have some dangerous or delicate structures we have to respect: the external iliac vessels, you can see the artery and you can see the vein behind. This is the area where we will not put staples. We also have another triangle determined by the spermatic vessels and the inguinal ligament we can see very well there. This huge ligament is the triangle of pain. Its name is related to the danger of injury of the nerve running and we see one very well but we have some other ones, and sensitive nerves. It is where if you dissect too deeply, if you injure the nerve by dissection or by sutures or stapling, you will have chronic postoperative pain.

5. Indirect inguinal hernia 07'50''

And this is the case of an indirect inguinal hernia. If we see with a scope introduced in the umbilicus the internal and external ring, you see, external ring of the inguinal canal, we have the internal ring—this one, the external ring is there. This is a zero degree scope and we can see the internal and external ring, which means that the obliquity of the inguinal canal does not exist. It is a type IIIb inguinal hernia in the Nyhus classification. There is a high risk of recurrence, higher than Nyhus type I or type II. I’m using only 2 working trocars to determine– and I do a taxis, the external limit of my incision.

6. Peritoneal dissection 08'53''

This is just medial to the anterior superior iliac spine, and I’m doing a small hole you see, and traction of the peritoneum. Then I’ll do a horizontal incision. If I don’t know how to do a horizontal incision, I can determine by external taxis. The danger is to be too low and having an oblique incision. Thanks to traction and to pneumodissection, I’m completing this by traction on the peritoneum medially, and a vertical incision in order to avoid the curtain effect—that means to hide the operative field with the superior flap of the peritoneum. I want to complete lower, and we complete slowly the dissection of Bogros’ space and you can see that if you are in the right plane, it’s only necessary to do traction, counter-traction, and we progressively reach laterally the lateral wing of the spermatic vessels. See they are there. So we have to complete higher. It is possible to see. We prefer to have more fat because it’s easier to find the plane. Because you see that we are really close to the peritoneum. We continue to free. We’ll do the parietalization further later. Medially, it is easier to open the plane as you will see. We don’t dissect the hernia immediately, the hernia sac.

7. Retzius\' space opening 11'28''

We will open Retzius’ space now. It is more risky in a TEP approach when we do too anterior a dissection, we have greater risks to injure the epigastric vessels. I’m opening Retzius’ space, and we will soon see the pubic symphysis. We can see it coming. It is the iliopubic branch, the pubic symphysis is at this level. So this is the left iliopubic branch, and we’re completing the dissection.

8. Parietalization of spermatic cord 12'18''

We now have to complete the parietalization of the spermatic cord, the vessels laterally and the vas deferens medially.

9. Sac dissection and reduction 12'32''

We will see better and better. And we have to revert the hernia sac that is fixed to the inguinal canal and to the spermatic structures. We see progressively the sac coming. Normally in a young patient, it is not so difficult. As previously said, in slim patients like this, there is sometimes some difficulty because the sac is directly against the spermatic structures. In adipose patients, we have some fat between. When it is a huge inguinoscrotal hernia, it is not necessary to remove the sac completely. We can keep the deep part to limit the risk of injury of the spermatic vessels and vas deferens duct, and the risk of seroma. This is perhaps a small lipoma or beginning of a lipoma here. We now complete like this and we have to do a complete parietalization of the spermatic structures. This is probably a small nerve. Remember the femoral nerve is just behind and lateral to the iliac artery. Normally we don’t see it but sometimes we do. Remember that I have to do the dissection posteriorly until the vas deferens duct is crossing the umbilical artery. It is the posterior limit, not easy to see because we have some bleeding. We have a dangerous structure, called the corona mortis. This is the artery, anastomosis between the epigastric and obturator vessels and if we dissect more, we will see the obturator vessels and obturator nerve going through the obturator foramen. I now want to complete this to have a good positioning of the mesh and to have a mesh that perfectly envelops the peritoneum. When we do a TEP, it is approximately the same dissection, not with the same approach however. Let’s take a look at the product now, the type of mesh we use. It is a Parietene mesh from Parietex®, Covidien. It’s a polypropylene, light mesh, not too rigid, 15 by 10cm.

10. Mesh insertion 16'40''

You were using a polyester mesh. No like you, I prefer to use a polypropylene mesh. I have used polyester but I don’t like it. It’s not easy to use, particularly for beginners. It doesn’t have enough memory, enough rigidity. And you see it’s not rigid polypropylene. I don’t know the weight. Normally, a classical Prolene, is 80 grams per square meter. This one is probably, I’d say about 50 grams, it’s very light. See the shape on the right side. We will have the vessels, this is lateral, this is medial, 15 by 10, and I’m rolling the mesh from lateral to medial and anterior to posterior like this. And I’m grasping. See I have positioned exactly the mesh in Retzius’ space. Now I’m unrolling the mesh and see the memory of the mesh facilitates the positioning. Do you think the same, Bernard? I think that for the TEP approach at least. It’s more important perhaps for the TEP indeed. See the mesh is positioned. I think that if you don’t cover enough medially, the recurrence is usually a direct hernia. As you see, the mesh seems smaller than you imagine but I am on the line of the anterior superior iliac spine, it’s very high.

11. Mesh fixation 18'48''

Now I will fix the mesh. Give me AbsorbaTack™. This is Cooper’s ligament see. Remember that there is the corona mortis just behind there. And I will fix the mesh on Cooper’s ligament. Normally one is enough. So I put the tacker there and I will go on the lateral side to recreate the inguinal ligament. Under this line, no tacker in the triangle of pain, triangle of Doom. I can now complete like this, not in the epigastric vessels. These are absorbable tackers. In the past, we used non-absorbable ones without any problems. But it’s interesting to use this kind of tackers. You see I have parietalized all the spermatic structures. I have reduced the hernia sac. I have dissected all the space. I have repaired putting the mesh. It’s a tension-free repair, we don’t close the defect with a suture, and now I will close the peritoneal incision.

12. Peritoneal closure 20'30''

My assistant is doing a counter-pressure. I’m using an overlapping. I’m covering with the inferior flap the superior flap of the peritoneum. At this moment of the operation, do you reduce the pneumoperitoneum? No. I never reduce it. I have now finished.