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Value of a TEP approach for a bilateral direct inguinal hernia repair

The laparoscopic inguinal herniorrhaphy has become an established approach to groin hernia. The use of a totally extraperitoneal (TEP) approach, allows a preperitoneal approach with potentially less discomfort and morbidity than do conventional repairs. We present a stepwise approach for the surgical repair of a bilateral inguinal hernia.

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Value of a TEP approach for a bilateral direct inguinal hernia repair

作者群

B Dallemagne, J Marescaux

摘要

The laparoscopic inguinal herniorrhaphy has become an established approach to groin hernia. The use of a totally extraperitoneal (TEP) approach, allows a preperitoneal approach with potentially less discomfort and morbidity than do conventional repairs. We present a stepwise approach for the surgical repair of a bilateral inguinal hernia.

分類

routine cases

關鍵字

TEP, bilateral direct inguinal hernia repair

媒體類型

手術影片

期間

06'47''

刊物

2008-11

普通的

最愛

Favorites Media

音訊

副標題

數位出版

WeBSurg.com, Nov 2008;8(11).
URL: http://www.websurg.com/doi-vd01en2379.htm

Value of a TEP approach for a bilateral direct inguinal hernia repair

1. Direct access to the preperitoneal space 00'15''

The totally extraperitoneal procedure is probably the best choice to repair a bilateral inguinal hernia when compared to the trans-abdominal preperitoneal repair. To get access to this preperitoneal space, there are different techniques; the one shown in this video is a direct access to this preperitoneal space. We begin by inflating this preperitoneal space, then insert a trocar at the level of the umbilicus. This trocar is inserted through the pubis and then is placed in the space that has been created by the pre-pneumoperitoneum. The scope is then directed towards the pubis, when you feel that it has come into contact with the pubic bone and then you know that you are in the right plane. The initial view is sometimes difficult but after reduction and preparation with the laparoscope, you can get a nice view.

2. Trocars and landmarks 01'16''

It is very important when dissecting the peritoneal sac to identify the exact position of the epigastric vessels because if you go too low, there will be a problem with it as the dissection will pass over the vessels. As soon as this access is prepared, you can insert a second port at the level of the superior iliac spine. With a two-hand technique, the dissection is continued. The usual goal of this dissection is to prepare a large space that will accommodate a large preperitoneal mesh and it is important to dissect the peritoneal sac from the vas in order to create this large space. Dissection is usually performed with scissors but there is no need for extensive cautery.

3. Hernia sac dissection 02'23''

The different structures, the vas and the vessels are clearly identified and gently dissected from the peritoneal sac. In this picture, we can see on the right side the large direct orifice; this patient has a bilateral direct hernia, and getting access on both sides is one of the major advantages of the preperitoneal approach. Moreover, we discover in this patient a small femoral hernia that was also reduced. There was just a lipoma, and reduction is very easy and the prosthesis will cover all the orifices, direct and indirect, and of course the femoral one. We can also see a large corona mortis, which is a very important vessel that can bleed sometimes and has to be preserved. On the psoas muscles, the different nervous fibres are clearly identified and as you see, this large space is prepared for the mesh.

4. Contralateral dissection of inguinal region 03'41''

The left side is now finished, and by moving on to the right side of the patient, a large direct orifice can be seen. Again, it is important, almost crucial to identify the epigastric vessels to start the dissection just below the vessel.

5. Hernia sac dissection 04'06''

The same technique is applied on the right side, with progressive reduction and dissection of the peritoneal sac in order to clear the vas deferens and the vessels. We also want to get enough space for a large prosthesis. The vas is cleared from the peritoneal recess with gentle dissection with not too much grasping or manipulation of the vas. Again, the anatomy with this corona mortis, the iliac vein, the iliac artery, these are very important structures that delimitate the triangle of Doom and no question about stapling in this place.

6. Mesh insertion and placement 05'09''

A prosthesis of 15 by 12cm is prepared; it is rolled and introduced through the 10mm umbilical trocar. It is then deployed in the preperitoneal space covering all the different hernia orifices. Usually, in some indirect hernias, there is no need for fixation, but usually for large direct hernias and because of the risk of slippage of the mesh within this orifice, we recommend prosthesis fixation to the medial side. As mentioned earlier, no prosthesis in the triangle of Doom or the triangle of pain, no tackers, no fixations. Another mesh is deployed on the left side of the patient using the same rules, fixations because it is a large direct orifice, but none in the triangle of doom nor pain. We know that when we are deflating the patient, the pneumoperitoneum will come and push on the mesh and we will fix the mesh on the posterior abdominal wall. At the end of the operation, it is important to control the position of the mesh while deflating in order to avoid any misplacement.