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Laparoscopic TEP repair for left inguinal hernia: a stepwise approach to the preperitoneal space

Authors

GF Bégin, J Marescaux

Abstract

This video carefully demonstrates each of the technical steps of the TEP method for inguinal hernia repair.

Keywords

laparoscopy TEP repair, left inguinal hernia, stepwise approach, preperitoneal space

Media type

Duration

18'22''

Publication

2008-05

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Subtitles

E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2338.htm

Laparoscopic TEP repair for left inguinal hernia: a stepwise approach to the preperitoneal space

1. Surface anatomy 00'25''

Today, we are operating a 52-year-old patient with a left inguinal hernia. For this procedure, I use three ports;

2. Rectus sheath exposure and incision 00'35''

on this line, I will place my trocars, the hernia is just here. You have to know the different landmarks before starting, the first one is Cooper’s ligament just here, symphysis is here. The second landmark is the linea arcuata or Douglas’s arcade, that is the inferior limit of the posterior layer of the rectus muscle, which starts at the umbilicus and normally finishes with a round line. In 50% of the cases, the linea arcuata is inserted very laterally. In 25% of the cases, the round line is found medially and can be a problem at the beginning of your dissection. You must keep in mind the variation of the linea arcuata. The third landmark is the epigastric vessel in this direction. I put some local anesthesia. We can show you the anterior layer. You can see here the white plane of the anterior layer of the rectus muscle. Now we do a 10mm lateral incision in this layer at the same side as the hernia. I put my first retractor under this layer and I push up; with the second layer, I retract the rectus muscle laterally so we can create a channel. You are exposing the posterior part of the sheath. You can see the posterior layer between the muscles. That is my direction, just between the 2 layers.

3. Insertion of 1st trocar 02'56''

We can now insert the first trocar, it is a 10mm port, importantly it should be a blunt trocar, and we push it very gently. Can you us the level at which it goes with the scope? You said it goes behind the rectus sheath. Yes, within the sheath, just in front of the posterior part of the sheath, and as it goes down, the posterior part of the sheath becomes deficient and that is the arcuate ligament, so then behind the scope will be peritoneum, and in front the rectus. That is the whole principle of the operation. He does not use the spacemaker, he always does it this way. I do not use a spacemaker because my scope is a perfect dissector, I push very slowly and search for contact with Cooper’s ligament, it is very easy and you don’t have any vessels in this area. I have perfect contact, that is the symphysis and you can see Cooper’s ligament. Straight away, I have to search laterally the inferior limit of the posterior layer also called the linea arcuata. When the insertion of the linea arcuata is very medial, it can be more difficult. Yes, it’s true in 25% of the cases. You can see the limit, this is it, that is the end of the posterior sheath.

4. Anatomy of preperitoneal space 04'55''

My first landmark here is Cooper’s ligament, second is the linea arcuata and the muscle. I can now insert my second port in this space. It is a 5mm port, be careful not to place your 2nd trocar too laterally.

5. Insertion of 2nd trocar 05'18''

You have to place it just medially, one finger away. Push exactly in the right space. Now I can insert scissors. I increase the space medially. The bladder is posterior to you, just there, pubic bone just ahead of you. The bladder is here, be careful, this is the symphysis, Cooper’s ligament is here, we have to search for the linea arcuata. That is my second step. We have to search for where the epigastric vessels are, they are just here, that is the beginning of the epigastric vessels. So that’s your next landmark.

6. Inferior epigastric vessels 06'48''

You follow the epigastric vessel and now I follow exactly the linea arcuata, you can see this round line, that is the key for a good exposure of the extraperitoneal space. This will bring him down to the internal ring. In a young patient, this line is very strong; in old patients, it is easier. You use your scissors under the line to create a space, because if you are cutting now with the peritoneum, it is very close and you can open the peritoneum, be careful at this stage. I increase the distance between the epigastric vessel and the linea arcuata.

7. Lateral dissection 07'50''

I don’t try now to see the medial part, I approach the lateral dissection and so I increase the space. You can see the beginning of the dissection in the Bogros’ space; behind here will be the psoas muscle. Now I search for the relief of the transverse muscle. Push up the peritoneum with your scissors until you have created enough space for the placement of your third port.

8. Ilioinguinal nerve 08'57''

I check with my finger. You can see the nerve on the psoas muscle just here, be careful as this is the most important step, don’t injure the nerve. You see these very well in thinner patients, you don’t see those often in the more obese patients. Normally, I always keep some fat around the nerve, so I am sure that the mesh is not directly in contact with the nerve. Sometimes you can have a fibrosis so difficult to treat afterwards. You can see here the relief of the transverse muscle. I think that my dissection is good now, with my finger I can check. So that is above the anterior superior spine?

9. Insertion of 3rd trocar 10'02''

Yes, in this case around 4 fingerbreadths away. The scope I am using is a 30 degree. You can see the placement of the port in the space.

10. Demonstration of operative landmarks 10'30''

The first landmark is Cooper’s ligament here, second is the linea arcuata just here, the third one is the epigastric vessel just here and the psoas with the nerve. Here, the famous nerve triangle. Just between this triangle and the vas deferens is the Doom triangle with the artery.

11. Reduction of hernia 11'14''

Now you can start with the dissection of the medial part. I think you can see the lateral vein and artery just here, be careful not to injure it. Now you can see the reflection line of the transversalis fascia. This may well be a direct hernia. We can push it, that is a reduction of the hernia. Just here is the femoral, I have seen some lymph nodes just here, the iliopubic tract is just here. Do not go underneath, you don’t need to. You have to keep some fat around the vein and the artery, so you have to go very slowly for the dissection of the fat around the cord. If you don’t dissect enough of the fat around the epigastric vessel, it might be difficult to place the mesh correctly afterwards. Be careful not to take the vas deferens with your grasper because it can create some pain afterwards. We can see a lipoma. Placement of the mesh is easier with a split mesh but it is not absolutely necessary for a lot of surgeons. We can see the vas deferens and the spermatic cord and vessel are here. I’ll show you the limit of the peritoneum. It is important to bring the peritoneum back. Yes, about 7cm; for me, the limit of my dissection is when the vas deferens turns and goes towards the bladder. You can see the reflection line. That is enough in my case because I use a split mesh. I you use a plain mesh, you have to dissect a little more. Here is the internal ring, and you can see my grasper with the fascia.

12. Preparation of mesh 14'43''

The psoas is here with the nerve. Now I have to prepare the mesh. The mesh is 15 by 10cm, it is a polypropylene mesh. I prepare the mesh for Cooper’s ligament because the overlapping under Cooper’s ligament must not be more than 1cm because if you are a urologist and have to operate the patient, it will be better for him. That is the lateral placement along the psoas muscle. Now I split my mesh and remove a small triangle of tissue for the placement of the mesh across the external part that comes over the internal part. In this way, I recreate the shape of the inguinal area, it is a contour. I fold the external part of the mesh, push it through the 10mm trocar.

13. Placement of mesh 16'37''

That is the external part and I have to place the triangle at this point. The dissection is good. I place the split mesh just along the vessel and I cross the external part like this. The aim is to avoid the injury of the vessel during the fixation of the mesh. If you use a stronger mesh, at the beginning it may be easier. Now I fix the mesh with tackers. 3 here and one on the medial line, that is all.

14. Fixation of mesh 18'00''

These are absorbable. The medial line one is not absolutely needed. Never put the stapler in this area because you can see that the nerves are just here.

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