Totally extrafascial laparoscopic large indirect right inguinal hernia repair (TAPP approach)

This video demonstrates the dissection of a large direct inguinal hernia through a transabdominal preperitoneal approach. The video does not demonstrate the mesh fixation, which has been shown in other videos.

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Totally   extrafascial   laparoscopic   large   indirect   right   inguinal   hernia   repair   (TAPP   approach)

Authors
D Fölscher, J Leroy
Abstract
This video demonstrates the dissection of a large direct inguinal hernia through a transabdominal preperitoneal approach. The video does not demonstrate the mesh fixation, which has been shown in other videos.

Catégorie
basic techniques
Mots-clés
indirect hernias,operation,transabdominal preperitoneal dissection, TAPP,right inguinal hernia
Type de vidéo
Durée
07'00''
Publication
2005-05
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en0058e.htm

Totally   extrafascial   laparoscopic   large   indirect   right   inguinal   hernia   repair   (TAPP   approach)

1. Case presentation 00'15''
Laparoscopic hernia repair has met a renewed interest in the anatomy of the preperitoneal space, and specifically of the fascial planes. The urogenital fascia and its extension around the structures of the spermatic cord to the spermatic sheath has been well described by René Stoppa and this is indeed the basis for a safe extraperitoneal placement of mesh. We will demonstrate this in the trans-abdominal preperitoneal right inguinal hernia repair. This is a patient with a large indirect right inguinal hernia and the peritoneum is opened as normal in a horizontal line above the structures of the cord and above the inguinal hernia. Dissection will commence laterally in the space of Bogros and thereafter move to the medial side above the bladder in the space of Retzius. One is tempted to dissect in the loose areolar tissue opening up as one pulls the peritoneum away but this is indeed not the right plane. There is a completely bloodless extrafascial plane between peritoneum and the preperitoneal fascia as is demonstrated here. Dissection can be done bluntly with very little use of scissors and diathermy as there are no important structures and no blood vessels in this plane. It is very easy to continue dissection in this plane once it has been opened and there is indeed a white line visible that guides further dissection. As is evident here, it is mostly done by blunt dissection and just pushing the tissues away from the underlying peritoneum. As one nears the structures of the cord, it is very important because it keeps one from invading the spermatic sheath and makes it possible to do an extrafascial dissection of even this large sac of the cord structures. The hole of the lateral space can be cleared in this way and one can see the spermatic sheath and the cord structures becoming visible on the left-hand side of this picture while all structures are safely enveloped in a protective sleeve. It is clear that the spermatic sheath extends laterally to a lesser or a greater extent in all patients as is shown here. This is a different patient just to illustrate this point that one should actually attempt to stay in the correct plane even lateral to the sheath. Now it’s tempting to dissect in this plane shown here where space is opening up and inviting one to dissect but further examination shows that this is actually the lateral wing and one should stay between that and the peritoneum and work it away. Later on in the dissection, if one stays to this in this plane, it is clear that this helps one in doing an extrafascial dissection with minimal bleeding and gets the peritoneum off the spermatic sheath and off the structures of the cord without endangering them at all. Returning to the initial patient, this is now in the medial space of Retzius and once again, when one pulls the peritoneum away, a loose areolar tissue invites one to dissect; on the medial side, this is indeed the correct plane. The only structures of importance in this space are the inferior epigastric vessels before they enter through the transversalis fascia and one can safely dissect once again almost bluntly the space. Once the medial and lateral aspects have been dissected, the sac structures and the peritoneum attached to the spermatic sheath are remaining in the medial aspect. These can now be dissected safely off the structures of the cord without endangering either the vessels or the vas deferens. Once again, it is clear that this plane is bloodless and very little sharp dissection is needed to clear this very large sac off these structures. This is only loose connective tissue attached to the peritoneum and the cord structures are safely enveloped in their little protective sheaths. The very large hernia visible there, attenuated inferior epigastric vessels and there the cord structures and the white line showing the preperitoneal plane is still visible and one continues dissection in this plane. From this area, the whole medial aspect of the potential hernia defect can be cleared and the site of a direct hernia can be freed and any direct hernias, if they are there or even just preperitoneal fat herniation can be dissected back without any danger to the underlying large vessels or nerves. Structures are worked back from the site of the direct herniation, which in this case does not appear to be evident and on inspection of the structures of the spermatic cord, it is clear that they are still safely enveloped in the spermatic sheath and there is no danger of damaging any of these structures either by dissection or by the use of a mesh, which will be placed in this space later.