Total extraperitoneal approach for hernia repair

The description of the total extraperitoneal approach for hernia repair covers all aspects of the surgical procedure used for the management of inguinal hernia. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: creating the plane, dissecting balloon, 1st and 2nd trocars, dissection and 3rd trocar, clearing the internal ring, dangers, types of hernia, contralateral side, the mesh. Consequently, this operating technique is well standardized for the management of this condition.

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Total   extraperitoneal   approach   for   hernia   repair

Authors
M Bailey, D Fölscher, G Slater
Abstract
The description of the total extraperitoneal approach for hernia repair covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: creating the plane, dissecting balloon, 1st and 2nd trocars, dissection and 3rd trocar, clearing the internal ring, dangers, types of hernia, contralateral side, the mesh.
Consequently, this operating technique is well standardized for the management of this condition.
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Publication
2001-03
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E-publication
WeBSurg.com, Mar 2001;1(03).
URL: http://www.websurg.com/doi-ot02en195.htm

Total   extraperitoneal   approach   for   hernia   repair

1. Introduction
The endoscopic totally extraperitoneal approach is our preferred method of inguinal hernia repair. It provides for the placement of a large preperitoneal mesh with the following advantages:
- repair of bilateral hernias require minimal further dissection;
- no need for a pneumoperitoneum and its consequent complications;
- rapid return to normal activity after repair;
- exceptional cosmesis;
- excellent long-term results for both primary and recurrent hernias.
2. Inguinal anatomy
• Anatomical landmarks
The inferior epigastric vessels constitute the main landmark.
The position of the iliac vessels should be noted to avoid injury.
1. Pectineal ligament
2. Rectus abdominis muscle
3. Epigastric vessels
4. Internal ring
5. Iliopubic tract
6. Cutaneous nerves on psoas muscle
7. Urogenital fascia
8. Reflected peritoneum
• Hernia site
• Direct hernia
- a direct hernia occurs through a weakness in the transversalis fascia in the inguinal triangle.
- medial to the inferior epigastric vessels, often attenuating the vessels.
1. Hernia site
2. Inferior epigastric vessels
3. Testicular vessels
4. Ductus deferens
• Indirect hernia
- an indirect hernia occurs through the internal ring, often a long sac. Lateral to the inferior epigastric vessels.
1. Inferior epigastric vessels
2. Hernia site
3. Hernia sac entering the inguinal canal
• Femoral hernia
- a femoral hernia occurs inferior to the inguinal ligament, medial to the femoral vein.
1. Inguinal ligament
2. Hernia site
3. Femoral vein
• Recurrent hernia
- a recurrent hernia is usually medial to the inferior epigastric vessels, i.e. direct hernia.
- a recurrent hernia can be indirect if peritoneal reflection was not properly dissected back.
- unusual recurrences may be observed.
1. Inferior epigastric vessels
2. Recurrence medial to inferior epigastric vessels
• Danger areas
1. The Triangle of Pain: Potential for nerve injury or entrapment.
2. The Triangle of Doom: Potential injury to the great vessels.
3. Femoral vessels
4. Cutaneous nerves
3. Abdominal wall anatomy
• Anatomical landmarks
1. Skin
2. Fatty tissue
3. Linea alba
4. Pubic symphysis
5. Urinary bladder
6. Internal ring
7. Muscles of the abdominal wall:
a) External oblique muscle
b) Internal oblique muscle
c) Transversus abdominis muscle
• Anterior abdominal wall
• At umbilicus level
The abdominal wall anatomy is different above and below the umbilicus. This variation creates the preperitoneal space and makes it easier for the surgeon to find the space.
1. Linea alba
2. Rectus abdominis muscle
3. Anterior layer of rectus sheath
4. Posterior layer of rectus sheath
5. Transversalis fascia
6. Peritoneum
• Below umbilicus
1. Linea alba
2. Posterior layer of rectus sheath
3. Peritoneum and fascia transversalis
4. Arcuate line
• Arcuate line
The arcuate line is the border of the posterior rectus sheath.
From here downwards, the peritoneum is directly below the rectus muscle, creating the potential preperitoneal space.
1. Linea alba
2. Posterior layer of rectus sheath
3. Arcuate line
4. Rectus abdominis muscle
5. Peritoneum
6. Epigastric vessels
4. Operating room set-up
• Patient
- dorsal decubitus, table horizontal;
- both arms at side;
- drapes wide exposing iliac crests.
• Team
• Left-sided hernia
1. The surgeon sees TV1.
2. The assistant sees TV2.
3. The scrub nurse is always on the left of the patient.
4. The anesthesiologist.
• Right-sided hernia
1. Surgeon now on left side.
For a bilateral hernia, the surgeon changes sides or stays on the left of the patient.
2. The assistant sees TV1.
3. The scrub nurse is always on the left of the patient.
4. The anesthesiologist.
• Variation
Left-sided hernia:
Alternatively the cameraman can be on the same side as the surgeon.
1. The surgeon sees TV1.
2. The assistant sees TV1.
3. The anesthesiologist.
• Equipment
- two monitors at foot of bed;
- all cables in one bundle, except diathermy lead;
- always a 0° laparoscope.
1. Anesthetic unit
2. Instrument table
3. Diathermy
4. Laparoscopic unit
5. Two monitors
5. Trocar placement
• Right-sided hernia
• 10 mm trocars
The two 10 mm trocars are always in the same position.
1. 10 mm 0° scope optical trocar, in subumbilical position
2. 10 mm operating trocar
• 5 mm trocar
The 5 mm trocar is above the superior iliac spine contralateral to the hernia.
1. 5 mm operating trocar
• Left-sided hernia
• 10 mm trocars
The two 10 mm trocars arealways in the same position.
1. 10 mm 0° scope optical trocar, in subumbilical position
2. 10 mm operating trocar
• 5 mm trocar
The 5 mm trocar is above the superior iliac spine contralateral to the hernia.
1. 5 mm operating trocar
• Bilateral hernia
• Option 1
The 5 mm trocar is placed opposite the largest hernia.
1. Largest hernia
• Option 2
It can also be placed opposite an indirect hernia.
1. Indirect hernia
6. Instruments
• Optical device
1. 0° laparoscope
• Operating devices
1. Grasper
2. Fine dissector
3. Suction-irrigation device
4. Scissors
5. Curved dissector
6. Finger dissector
7. Creating the plane
• Landmarks
1. Incised anterior layer of rectus sheath
2. Posterior layer of rectus sheath
3. Arcuate line
4. Peritoneum
• Incision
• Step 1
15 mm skin incision inferior to the umbilicus, slightly towards the side of the hernia.
1. Midline
2. Hernia
• Step 2
Expose linea alba and anterior sheath on hernia side.
1. Midline
2. Hernia
3. Umbilicus
4. Anterior layer of rectus sheath
• Creating the plane
• Step 1
Incise anterior sheath, extending 10 mm to hernia side.
1. Midline
2. Hernia
• Step 2
Expose and retract ipsilateral rectus muscle laterally.
1. Midline
2. Hernia
3. Anterior rectus sheath
• Step 3
Create canal between linea alba, rectus muscle and posterior sheath.
1. Midline
2. Hernia
3. Anterior rectus sheath
8. Dissecting balloon
• Insertion
• Step 1
Balloon in midline aimed at pubic symphysis
1. Balloon insertion
• Step 2
Tip just posterior to anterior edge of pubic symphysis
• Step 3
Remove trocar
• Inflation
• Step 1
Laparoscope tip in trocar
• Step 2
Inflate balloon under vision with bulb (25-30 puffs)
Advance scope into balloon as it opens up
• Step 3
Left hand directs balloon inflation
1. The surgeon’s left hand guides the balloon into position.
• Deflation
- remove bulb once dissection completed;
- deflate balloon slowly;
- remove balloon and laparoscope.
If the balloon is deflated too quickly, bleeding may occur from the anterior abdominal wall.
9. 1st and 2nd trocars
• Balloon-tipped trocar
Different trocars can be utilized, eg cone with sutures, but the balloon trocar ensures an adequate seal while also enlarging the working space to a maximum.
• Camera
• Step 1
Balloon trocar inserted to full length and inflated.
Pulled back, hooking arcuate line upwards.
Locked in place.
Check with the scope before inflation to ensure that the trocar is in the correct space.
• Step 2
Laparoscope inserted, space inflated with CO2, under vision.
• Second 10 mm trocar
The second 10 mm trocar is inserted:
- midline, as high as possible;
- under direct vision;
- through the linea alba.
There is a danger of entering the peritoneal cavity by pushing this trocar through the posterior sheath. It must be inserted under continuous vision.
1. Place trocar on midline through linea alba
10. Dissection and 3rd trocar
• Internal view
Internal view after balloon removal
1. Inferior epigastric vessels
2. Rectus abdominis muscle
3. Pubic symphysis
4. Urinary bladder
5. Collapsed peritoneum
• The finger dissector
- made for sweeping tissues atraumatically;
- serrated tip for catching and pulling on fascia;
- inserted through second midline trocar (10 mm).
• Midline
- pubic symphysis felt;
- bladder swept down bluntly;
- inferior edge of pubis cleared for approximately 2 cm.
Some authors do not dissect the pubic bone clear as this could interfere with a future suprapubic prostatectomy.
• Lateral
- then go directly lateral and superior to the internal ring;
- no dissection of the internal ring at this stage;
- sweep cranially, identifying and dissecting the peritoneal edge down dorsally;
- expose the transversus abdominis muscle medial to the superior iliac spine. This creates space for inserting the third trocar;
- repeat on the other side.
1. Internal ring
• Third trocar
• Placement
- 5 mm trocar inserted under vision;
- contralateral to biggest or indirect hernia;
- as high as possible, to allow space for the mesh in bilateral hernias.
1. Largest hernia
2. 5 mm trocar
• Danger
Initial dissection and the third trocar: lateral dissection
Injudicious dissection or tearing of tissues can cause peritoneal damage, with pneumoperitoneum. This is especially true if there are adhesions from previous surgery, e.g. appendicectomy.
If adhesions exist laterally, usually from previous appendicectomy, the trocar can be placed more medial, but still as cranial as possible.
11. Clearing the internal ring
• Landmarks
1. Hernia sac
2. Peritoneal edge
• Peritoneal edge
Finding the peritoneal edge:
- bimanual dissection utilising graspers, finger dissector and scissors;
- dissection lateral and superior to the internal ring until the psoas muscle comes into view;
- no attempt at this stage to identify the internal ring or cord structures;
- the aim is to find the peritoneal edge and dissect it downwards, exposing the psoas muscle.
1. Recurrent hernia medial to the epigastric vessels
2. Transversus abdominis muscle
3. Psoas muscle
4. Peritoneal edge
• To the internal ring
Following it to the internal ring:
- strands of tissue divided with diathermy and scissors;
- the peritoneal edge is followed to the internal ring and dissected down, leading to the important landmarks:
1. Cutaneous nerves
2. Genital branch of genitofemoral nerve
3. Peritoneum followed from lateral to internal ring
4. Peritoneum has been dissected down
5. Inguinal triangle
6. Internal ring
7. Femoral vessels in the Triangle of Doom
8. Cutaneous nerves in the Triangle of Pain
• Indirect sac
Dissecting out an indirect sac:
- follow the peritoneal edge from its lateral side to the internal ring;
- retract the peritoneum and the hernia sac cranially in line with the inguinal canal;
- free strands towards the internal ring with the other hand;
- diathermy small bleeders;
- frequently change the retracting grip, do not let go completely of the sac.
1. Hernia sac
2. Internal ring
• Retracting the peritoneum
Do not attempt to actively identify the ductus deferens or testicular vessels;
These come into view as dissection progresses;
Dissection continues until the edge of the sac comes into view.
1. Edge of the sac
2. Internal ring
12. Dangers
• Landmarks
- the Triangle of Pain: potential for nerve injury or entrapment;
- the Triangle of Doom: potential injury to the great vessels.
1. Cutaneous nerves
2. Femoral vessels
3. DOOM
4. PAIN
• Peritoneal edge
Finding the peritoneal edge:
- do not grasp the peritoneal fold itself, as this will cause tearing;
- do not dissect with diathermy too closely onto the psoas muscle laterally, as this may cause nerve damage.
1. Recurrent hernia medial to the epigastric vessels
2. Transversus abdominis muscle
3. Psoas muscle
4. Peritoneal edge
• To the internal ring
Following it to the internal ring:
- do not grasp the peritoneal fold itself, as this will cause tearing;
- do not dissect with diathermy too closely onto the psoas muscle laterally, as this may cause nerve damage.
1. Inguinal triangle
2. Internal ring
3. Femoral vessels in the Triangle of Doom
4. Cutaneous nerves in the Triangle of Pain
• Indirect sac
Dissecting out an indirect sac:
Not ensuring adequate hemostasis while retracting allows small bleeders to disappear into the canal. This might cause seromas and hematomas.
1. Hernia sac
2. Internal ring
• Retracting the peritoneum
- do not grasp the ductus deferens, as this can cause fertility problems;
- overzealous dissection of the cord structures and genital branch of the genitofemoral nerve probably contributes to postoperative neuralgia;
- do not dissect medially in the triangle of Doom.
Some surgeons isolate and circumcise the sac, without dissecting it completely out of the inguinal canal.
1. Edge of sac
2. Internal ring
13. Types of hernia
• Landmarks
1. Inguinal falx (conjoint tendon)
2. Inferior epigastric vessels
3. Inguinal ligament
Inguinal falx, inferior epigastric vessels and inguinal ligament forming the inguinal triangle
4. Internal ring
• Direct hernia
Strip extraperitoneal fat from the transversalis fascia.
Define the margins of the direct defect.
The femoral vessels lie inferior to the hernial defect, so avoid dissecting inferiorly.
1. Superior pubic ramus
2. Direct hernia
3. Inferior epigastric vessels
4. Testicular vessels
5. Ductus deferens
• Recurrent hernia
This is usually a small direct defect.
Reduction is easy and identical to managing a direct hernia.
Strip extraperitoneal fat from the transversalis fascia.
Define the margins of the defect.
Large direct or recurrent defects can be reinforced with a second smaller mesh.
1. Inguinal triangle
2. Recurrent defect in transversalis fascia
3. Epigastric vessels
• Variation
Variation in direct and recurrent hernias: tacking an inverted sac to the superior pubic ramus
The empty transversalis sac can be inverted and stapled to the pubic bone to stop a hematoma or a seroma from forming in it.
14. Contralateral side
Occult contralateral hernias
Inspect the contralateral side for evidence of a direct or indirect hernia.
If present ensure that the peritoneum is sufficiently retracted for placement of a second mesh.
1. Occult weakness
2. Inferior epigastric vessels
15. The mesh
• Preparation
- polypropylene mesh (Prolene);
- mesh must be at least 15 by 13cm;
- 2 meshes are needed for bilateral hernias;
- a horizontal line is drawn on the mesh with a sterile marker pen to aid orientation.
• Insertion
The mesh is grasped on the side which will lie closest to the third trocar at the level of the marked line.
The mesh is inserted through the 10 mm trocar under direct vision.
In bilateral hernias, place the mesh furthest from the third trocar first.
• Positioning
- correct position;
- manual manipulation;
- peritoneum must lie below the inferior edge of the mesh.
1. The midline
2. Internal ring
3. Testicular vessels and ductus deferens
4. Peritoneum
5. Site of a direct hernia
• Securing
• Stapling
- stapling to the superior pubic ramus;
- do not staple in the triangle of Doom superior or lateral to the internal ring, otherwise a nerve entrapment with chronic pain may occur.
• Glue
Currently there is no licence for internal use of glue.
• No fixation
- unsecured mesh;
- particularly with large hernias, mesh migration could cause a recurrence.
• Variation
Securing the mesh: helical stapler
Do not staple in the triangle of Doom superior or lateral to the internal ring, otherwise a nerve entrapment with chronic pain may occur.
16. End of procedure
• Deflation
- hold the mesh in position with the instruments;
- slow deflation of the extraperitoneal space.
1. Peritoneum
• Closure
- sheath closed with interrupted vicryl sutures;
- subcuticular skin closure;
- sterile adhesive strips.
17. Postop period
Routine
- no driving for one week;
- return to normal activities and work as able.

Complications
Infection:
- occasional slight wound infection;
- routine antibiotic prophylaxis used;
- mesh infection rare.

Urinary retention:
- occurs in <1% of cases;
- easily managed by catheterization.

Seroma:
- usually asymptomatic;
- conservative management is the rule, as most disappear quickly;
- sterile aspiration if symptomatic or persistent.

Persistent pain:
- usually related to the ilio-inguinal, genitofemoral or lateral femoral cutaneous nerves;
- majority of neuralgias will disappear with time;
- local nerve blocks in extreme cases.

Recurrence:
Probably related to technical failure:
- incomplete lateral dissection;
- incomplete dissection of peritoneal fold at internal ring;
- using too small a mesh;
- not fixing the mesh.
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