4DDOME® right indirect inguinal hernia repair

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4DDOME® right indirect inguinal hernia repair

Authors

J Leroy, D Mutter, M Vix, J Marescaux

Keywords

hernie indirecte droite, prothèse 4DDOME®

Media type

Surgical video

Duration

08'10''

Publication

2006-03

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E-publication

WeBSurg.com, Mar 2006;6(03).
URL: http://www.websurg.com/doi-vd01en1903.htm

4DDOME® right indirect inguinal hernia repair

1. Infiltration of anesthetics 00'19''

4DDOME® inguinal hernia repair under local anesthetic. Local anesthetic is firstly infiltrated to block the ilio-inguinal nerve. Then it is infiltrated into the area where the incision will be made.

2. Skin incision 00'36''

The incision is deepened through subcutaneous tissues and fat. A number of small vessels will be encountered here and hemostasis needs to be ensured. The external oblique is now coming into view.

3. Opening of aponeurosis 00'58''

This is opened using a scalpel and following enlargement of this incision, a local anesthetic is infiltrated into the inguinal canal and the spermatic cord. The external oblique is reflected superiorly and the spermatic cord is then identified ensuring at all time to preserve the nerve associated around this area.

4. Dissection of spermatic cord 01'26''

A right angle is passed behind the spermatic cord and then a tape is passed posteriorly utilizing the right angle in order to aid retraction. Further local anesthetic is infiltrated into the spermatic cord.

5. Identification of hernia sac 01'52''

The hernia sac is identified and is dissected free from the cord structures using gentle retraction and coagulation diathermy. At all times careful attention is placed on hemostasis. The sac is now almost completely free from the structures of the spermatic cord. The large defect in the posterior wall of the canal is demonstrated and the contents are reduced into the abdominal cavity. By asking the patient to cough, it is obvious where the defect is.

6. Opening of the sac 02'52''

The sac is then opened. It is plicated at its neck and divided distally. The sac is reduced; however, there remains a large defect in the posterior wall of the inguinal canal. It is this defect that is going to be obliterated using the DOME as is demonstrated in this diagram. The DOME is picked up using a no-touch technique and it is introduced into the defect posteriorly. It is very important to secure the DOME as can be seen in this diagram.

7. Positioning of 4DDOME® 03'49''

This is done using an absorbable suture which is placed north south east and west to secure the DOME to the posterior wall of the inguinal canal.

8. Mesh positioning 04'45''

Once the final sutures secure the DOME in place, attention can the move to cutting the mesh that will be used to secure, then to bolster the posterior wall of the inguinal canal. The mesh is cut to size and then it is introduced into the inguinal canal. The tails of the mesh are the placed either side of the spermatic cord. They are then secured in place using interrupted non-absorbable sutures. The next stage of the procedure is to secure the mesh to the posterior wall of the inguinal canal. This starts medially with a suture from the area of the pubic tubercle through the mesh. Once the mesh has been secured medially, a suture can then be used to run along the inferior surface of the mesh to secure it to the inguinal ligament. This can be seen being done here. When suturing occurs in the region of where the DOME is being placed, the DOME is also incorporated into this inferior suture. The suture is continued lateral to the deep inguinal ring before it is tied. The superior aspect of the mesh is secured using interrupted sutures. The final results can be seen here.

9. Closure of external oblique aponeurosis 07'46''

The external oblique is now closed with a continuous suture. At all times, careful attention is placed on hemostasis. This is to ensure that hematoma does not incur as this can predispose to infection and to pain.

10. End of procedure 08'20''

The final incision is only just over 6cm long.