Recorded live laparoscopic TAPP approach for bilateral hernia with single mesh and absorbable tacker

Laparoscopic hernia repair has become one of the most common laparoscopic operations. Several studies have demonstrated a definite advantage over open repair with regard to reduced postoperative pain and earlier return to work and normal activities, especially when treating bilateral hernias. This video shows the TAPP treatment of a bilateral direct hernia.

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Recorded live laparoscopic TAPP approach for bilateral hernia with single mesh and absorbable tacker

Authors

J Leroy, J Marescaux

Abstract

Laparoscopic hernia repair has become one of the most common laparoscopic operations. Several studies have demonstrated a definite advantage over open repair with regard to reduced postoperative pain and earlier return to work and normal activities, especially when treating bilateral hernias. This video shows the TAPP treatment of a bilateral direct hernia.

Catégorie

live recorded

Mots-clés

Live laparoscopic TAPP approach, bilateral hernia, single mesh, absorbable tacker

Type de vidéo

Vidéo chirurgicale

Durée

17'00''

Publication

2010-07

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en3000.htm

Recorded live laparoscopic TAPP approach for bilateral hernia with single mesh and absorbable tacker

1. Description of external landmarks 00'19''

When we do surgery, we have to speak about landmarks. As you see, we have the pubic symphysis, right and left anterior iliac spine, the rib and the external limit, the anterior axillary line on the left and on the right, the midline, the mid-clavicular line before insufflation and the horizontal line through the umbilicus.

2. Umbilical access and optical trocar insertion 00'53''

See I begin just above the umbilicus. I do a large incision, particularly for beginners. I recommend to do as I’m doing now. See the aponeurosis, I fix the aponeurosis like this with 2 stitches. With experience, I use my forceps but for you, you can do that like this, with Kelly forceps. Scissors. We will take scissors to incise better and I have opened the peritoneum this way. See? We introduce a particular trocar: this is a trocar with a sleeve; we push a bigger trocar in and we connect the tap. We don’t open. I’m introducing the scope. This is a zero degree scope.

3. Bilateral direct hernia identification 02'18''

We are inside the abdominal cavity and at this moment, we can insufflate slowly controlling the insufflation and you see we have a big defect medial to the epigastric vessels: this is a direct hernia; on the other side, we also have a direct hernia. This is a weakness of both inguinal areas. This is a good indication of repair using a posterior mesh laparoscopically. This is the position of the trocar crossing between mid-clavicular and horizontal line on the right and on the left. I will begin on the right. This is the urachus, the urinary bladder with some urine. This is the umbilical ligament on the right, on the left, and the vas deferens is crossing the umbilical ligament, we can define it better if we do a traction, it is there.

4. Right side dissection 03'41''

Right side: epigastric vessels, one artery, two veins, umbilical ligament, vas deferens, spermatic vessels, the triangle shaped by both structures, this is the triangle of Doom where we have the iliac vessels, artery and vein, and lateral to the spermatic vessels and under the inguinal ligament, we will see better. Remember, I have the anterior iliac spine, I do a taxis the find this landmark, and using a posterior traction, I’m opening and I’m dividing, we see the limit with the plication of the peritoneum. See this is the horizontal incision and vertical incision there. I’ll do the same on the other side later. We use traction, counter-traction, if we respect the anatomy, it is an avascular plane; these are the spermatic vessels, this is the lateral wing of the spermatic cord.

5. Medial dissection 05'08''

Opening of the preperitoneal space medially, not far from the Retzius’ space. We’re going to the pubic symphysis there, there’s a small lipoma in front of the hernia sac we are removing and we see now the Cooper’s ligament and we have now the transversalis fascia, the white structures, see, with the peritoneum visible by traction. Now we free the peritoneum because there is no hernia sac from the spermatic structures. Medially, we have the vas deferens there; we have to complete medially.

6. Removal of hernia lipoma 06'15''

This is the lipoma of the hernia we will remove. I want to do a complete mobilization. This is the vas deferens as I said that is crossing the umbilical artery. We stop when we have reached this crossing. This is the limit.

7. Transversalis fascia fixation 06'46''

At the end of the dissection, we have the internal ring of the inguinal canal with the spermatic cord, some of the spermatic vessels and vas deferens, the triangle of Doom, in which you have the external iliac vessels; this is the artery and the vein corona mortis, the anastomosis between epigastric and obturator vessels and the defect (it’s not totally visible), see this is the defect and we have the weakness of the transversalis fascia, and we will fix this posteriorly to have a tension of the transversalis fascia to avoid recurrence postoperatively due to seromas we can have and this is a trick we use in direct hernias. So I have finished on the right, I will do on the left.

8. Left side dissection 07'58''

I will reproduce what we did. We have the anterior superior iliac spine as a landmark. I do a taxis. I’m a right-hand surgeon. To be sure that I’m on the horizontal line, I can do a new taxis there to do a horizontal incision. Why? It’s because when we do the incision, there’s a trend to do an oblique and not a horizontal incision. See I’m not cutting completely. I can complete to avoid the curtain effect by horizontal incision, I’m always beginning up and going down because it’s easier to cut from up to down. And I can begin the dissection by a medial approach. The problem is not to be too anterior and to dissect anterior to the Douglas’ arch and the transversalis fascia. We have to stay back to the aponeurosis. See we have found the plane we have dissected using a right approach. I complete the lateral dissection of the spermatic cord, dissecting the Bogros’ space until I reach the spermatic vessels and the lateral wing of the spermatic cord, and I do a parietalization well described by Stoppa, putting the retroperitoneal structures on the back of the space. See these are the spermatic vessels, this is the spermatic cord and we will have soon the vas deferens there. This is the vas deferens. Now I’m reducing. This is the transversalis fascia. Bigger weakness as you see.

9. Hernia sac dissection 10'54''

We are detaching the hernia sac we reverse and the transversalis fascia is pushed now and we free back to the iliopubic branch. But as on the right side, we have big vessels, corona mortis, anastomosis between epigastric vessels and obturator vessels. See the pelvic floor. Move back. So we have freed enough. So we have finished. The defect is there. AbsorbaTack™. The hernia sac is reduced but we still have the defect. I will fix using AbsorbaTack™. This is a risk. I don’t have to fix within vessels. We have another possibility to fix back to the rectus muscles. It’s enough. We’ll do the same on this side. Other possibility is to do, as proposed by Wantz, a posterior fixation to the rectus muscles like this. As I said, it’s not the treatment. This is the urinary bladder, pubic symphysis, and all the structures. Now it’s time to put a mesh.

10. Double size mesh insertion 12'40''

We put a double size, one piece mesh. Why? Because we save time, and it’s easier. I’m rolling the mesh from down to up, and from anterior to posterior. And I will fix with 2 sutures the rolled part. The mesh is rolled with 2 sutures we will remove afterwards. To summarize, we have rolled the mesh, except 1cm—the superior part. Now I’m doing a plication like this and grasp in the middle. So we introduce the mesh inside the trocar and push it inside the abdomen. We now have to position the mesh inside the preperitoneal space and remember, I don’t roll the upper part. We will position on the white line between the 2 rectus muscles.

11. Mesh fixation 14'12''

I’m using as you have seen AbsorbaTack™. I’m not putting too much on the other side. Don’t fix in the triangle of Pain. Now I’m cutting the sutures, unroll the mesh to be positioned. Size of the mesh: 27 large, see it’s 12mm high on the mid-part and 8 lateral. We can now fix the mesh on the Cooper’s ligament. Move in. It’s not perfectly fixed. There, you see and on the mid-part too. I don’t have to fix on the inferior part to save time. I don’t have to fix in the epigastric vessels. Now as I said, when we have a big sac, don’t try to dissect the sac completely. It’s not really necessary. You will get more risks of hematoma, of injury to the spermatic cord, and ischemia of the testicles. You have to remove the sac but it’s not necessary, the only problem you will have is hydrocele, but it is in 10% of cases; but you can use only sutures, it’s a little longer but we can do a demonstration with sutures only. So I want to show you when we remove trocars. It’s always necessary to verify that there is no bleeding and thanks to the type of trocars we are using, we remove the trocar not the sleeve, and we have a view on the trocar site and we can remove the sleeve when we are finished. And we will close.