Removal of mesh plug and TEP repair of a recurrent left inguinal hernia in a 72-year-old man

This video demonstrates in great detail the laparoscopic TEP approach to recurrent hernia. The previously placed mesh plug is carefully dissected and removed. The preperitoneal space is thus created in order to place a mesh in the correct position. This video is suitable for experienced laparoscopic hernia surgeons. The author begins the dissection lateral to the inferior epigastric vessels, then uses sharp dissection to take down the adhesions. This step requires caution because of the proximity of major vessels. The author then continues with sharp and blunt dissection to further develop the lateral peritoneal space. A few clean sweeps of the scissors or blunt forceps downward make adequate space lateral to the inferior epigastric vessels for mesh placement.

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Removal   of   mesh   plug   and   TEP   repair   of   a   recurrent   left   inguinal   hernia   in   a   72-year-old   man

Authors
P Arora
Abstract
This video demonstrates in great detail the laparoscopic TEP approach to recurrent hernia. The previously placed mesh plug is carefully dissected and removed. The preperitoneal space is thus created in order to place a mesh in the correct position. This video is suitable for experienced laparoscopic hernia surgeons.
The author begins the dissection lateral to the inferior epigastric vessels, then uses sharp dissection to take down the adhesions. This step requires caution because of the proximity of major vessels. The author then continues with sharp and blunt dissection to further develop the lateral peritoneal space. A few clean sweeps of the scissors or blunt forceps downward make adequate space lateral to the inferior epigastric vessels for mesh placement.
Mots-clés
Removal, mesh plug, TEP repair, recurrent left inguinal hernia, peritoneal space
Type de vidéo
Durée
11'34''
Publication
2007-06
Popularité
Favoris
Favorites Media
Audio
en es tw
Sous-titres
en
E-publication
WeBSurg.com, Jun 2007;7(06).
URL: http://www.websurg.com/doi-vd01en2137.htm

Removal   of   mesh   plug   and   TEP   repair   of   a   recurrent   left   inguinal   hernia   in   a   72-year-old   man

1. Creation of preperitoneal space 00'16''
This video shows a TEP approach for the repair of a left-sided recurrent inguinal hernia after a previous plug hernioplasty. This video particularly emphasizes the nature of the dissection and the removal of a mesh plug. It is the case of a 72-year old gentleman who had a repair done 2 years previously. Since that repair, he has had continuous pain in the groin and has recently detected a recurrence of his original hernia. He is in good health; he likes to play sport and to walk a lot, and he has not been able to do this because of the symptoms he has had from his recurrent hernia. So we placed the patient in a supine position on the operating table. We use a 10 mm subumbilical optical port and two 5 mm midline infraumbilical ports. We use a balloon to prepare the preperitoneal space. The dissection here begins lateral to the inferior epigastric vessels. We find that there are adhesions bounding the peritoneum. These need to be taken down with the help of sharp dissection. One must proceed very gently and cautiously as there are major vessels in this area. Once these adhesions are divided, we continue the combination of sharp and blunt dissection in order to further develop the lateral peritoneal space of Bogros. As you can see, it is quite easy to develop the lateral peritoneal space, especially if there have been no previous operations. A few clean sweeps of the scissors or blunt forceps downwards, adequate space lateral to the inferior epigastric vessels is made to place a mesh. Once the lateral space is developed, we find our field, look at the anatomy by pointing to the posterior part of the pubic symphysis, Hesselbach’s triangle, the inferior epigastric vessels, lateral space, preperitoneal process going towards the inferior epigastric vessels and getting there, the mesh plug which is easily palpable in between the peritoneum and the iliac vessels beneath.
2. Dissection of mesh plug 03'03''
For this reason, it is very important to be extremely careful and cautious while dissecting this mesh plug. We proceed slowly and cautiously with the combination of blunt and sharp dissection using diathermy and trying to separate the mesh from the adjoining fibrous areolar tissue. We realize that there are some suture materials which are keeping the mesh plug down and therefore, this needs to be removed. The suture is divided and it is taken out. We try then to dissect the peritoneum away from the mesh. While we are doing this, we soon realize that in fact there is a small hole through the peritoneum. Initially this looks like it might be some loose areolar tissue that would give a good plane of dissection if we enlarge this hole. Fairly soon, we realize that this is not a hole in the loose areolar tissue. Rather the peritoneum is very flimsy where it has been attached to the previous mesh and therefore we have a fair-sized hole in the peritoneum. Fortunately the peritoneum although the carbon dioxide is going into the peritoneum it’s not compromising the amount of space in the retroperitoneal area; therefore, it’s not causing much deflation with respect to this space and we can continue without dissection. We then try to dissect the peritoneum away from the mesh plug but the adhesions are dense in this area and as the peritoneum is flimsy, this is technically challenging. After some time of dissection and once it is appreciated that this plane cannot be adequately developed an alternative method of dissection is employed. We pick up the peritoneum over the mesh and divide it very cautiously, close to the mesh plug making sure that there is no vessel nearby. Extreme caution is recommended at this stage while freeing this posterior aspect of the mesh. As you can see so far, the testicular vessel has not been seen and neither is the vas and it is thought that these are hidden behind the mesh plug. At all times the dissection proceeds gently and cautiously identifying the tissues with a combination of sharp and blunt dissection and diathermy in order to minimize any problems or potential problems with bleeding. By the use of traction and counter-traction, the tissues can be placed on tension so they divide easily and safely. You encounter a small amount of bleeding as we try to separate the peritoneum from the mesh and this can be taken care of with the use of diathermy scissors. Now it seems that we are about half-way through now separating the mesh from the peritoneum. However, a fair amount of dissection still remains. And at this stage the concern is that there must be branches of the inferior epigastric vessels close to where the mesh is applied and hence the possibility of further bleeding. Therefore, it is important to take the dissection slowly and steadily. And bit by bit we free up two of the three sides of the mesh and it does give the impression that the Prolene mesh is simply being folded down rather than extended into the preperitoneal space. Perhaps it never opened properly after the repair; therefore we recommend at this point that if one has to use a plug in the deep ring, then one must try and use the preformed mesh plug rather than to construct one from a flat piece of Prolene mesh. Recurrent hernias are certainly easier if the previous repair is a Lichtenstein-type of mesh rather than a plug through the deep ring. Therefore, we recommend that a plug repair should not be taken lightly and perhaps only done if absolutely necessary because it makes any subsequent repair, particularly a TEP repair, but TAPP also, quite difficult. Of course the ideal thing is to avoid any recurrence in the first place. At all times we try to stay as close to the mesh to minimize the risk of bleeding. At this stage the mesh is closely applied to the inferior epigastric vessels; therefore by staying very close to the mesh, we can ensure and do everything possible to prevent damage to the structures. In fact, dissection was close to the mesh because it was better to leave part of the mesh behind rather than making a hole through the inferior epigastric vessels. There is a painstaking dissection through the dense fibrous tissue that is associated with both the placement of mesh and also recurrent hernias. By ensuring that the tension is maintained both on the mesh and on the surrounding tissue those fibers can be divided gently and slowly deliberately making sure that always it is under direct vision and it is controlled by the surgeon. Despite the hole in the peritoneum you can see that there is ample space for working which enables us to have good vision and to perform the dissection carefully and safely. There are now a few fibrous strands which are holding the mesh on. By using diathermy as well as the scissors this can be safely removed from the mesh. At all times, we have ensured that we taken time to make sure that the mesh is removed safely and carefully. The last bit of dissection shows the vas and a little bit of bleeding from the artery of the vas. This is not usually brisk bleeding; therefore there is no need to cause too much concern.