Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva's maneuver. We decide to perform a totally extraperitoneal laparoscopic approach.

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Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

Authors

B Dallemagne, F Costantino, J Marescaux

Abstract

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva's maneuver. We decide to perform a totally extraperitoneal laparoscopic approach.

Classification

basic techniques

Keywords

Laparoscopic TEP repair, recurrent inguinal hernia after anterior plug hernioplasty

Media type

Surgical video

Duration

06'47''

Publication

2010-02

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E-publication

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2685.htm

Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

1. Introduction 00'09''

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva maneuver. We decide to perform a totally extraperitoneal laparoscopic approach. A small arciform incision is performed under the umbilicus. The posterior aponeurosis of the rectus sheath is identified and the first laparoscopic port is slid along the posterior aponeurosis.

2. Creation of pre-pneumoperitoneum 00'42''

Once this aponeurosis is identified, the insufflator is switched on, allowing to gradually create the pre-pneumoperitoneum. The dissection is carried out blindly to start off with, towards the pubis, in order to create a working zone in which the initial landmarks can be found.

3. Ports introduction 01'21''

Two ports are then introduced; these are placed under the umbilicus and on the opposite side to the hernia, and the totally extraperitoneal dissection is continued.

4. Identification of recurrent hernia 01'30''

In this patient, the hernia recurrence can be immediately identified. It is probably a direct hernia due its position in relation to the epigastric vessels.

5. Hernia reduction 01'56''

The first part of the procedure consists in reducing the hernia, or at least the resulting adhesions, as we can easily identify a Plug in this extraperitoneal space. Laterally, the dissection is continued in order to identify the various anatomical landmarks. The hernia is apparently direct, and seems to encapsulate part of the Plug and the latter does not seem to fill the orifices of the traditional hernias, direct or indirect. In this type of re-intervention and especially after this technique, the hardest is to dissect the elements in relation to the epigastric vessels as they are usually partially included in the prosthesis.

6. Plug partial resection 02'38''

In this patient, we decide to resect part of the Plug as it is partially herniating. The adhesions related to the epigastric vessels make the procedure difficult, but it does seem essential to diminish the patient’s pain. A complete resection of the plug is impossible, so we decide to resect part of it to diminish the prosthetic mass. Dividing the prosthesis is usually difficult, so we advise the use of a monopolar hook as it is quite efficient with this type of material. On this picture, the epigastric vessels are clearly identifiable, along with the closeness of the prosthesis. According to the Plug’s position, the patient seems to have been treated for an indirect hernia; the Plug did not stay in place and moved medially. Behind the Plug, a small indirect hernia is visible, which must have been the first hernia presented by the patient. We use monopolar cautery to diminish the prosthetic mass. All the hernia orifices will then be covered by a classic polypropylene laparoscopic mesh. The hernia treatment is continued by dissecting the various elements surrounding the cord in order to create enough space for the placement of the prosthesis. The peritoneal reflection sac is brought away and dissected off the elements of the inguinal cord. The vessel and the deferens duct are identified and preserved.

7. Mesh positioning 05'51''

The space is now sufficient and can accommodate a large mesh, usually measuring 13 by 10cm, that will cover the indirect and direct orifices. In extraperitoneal treatments of hernias, the prosthesis does not usually need to be fixed, but in the context of a recurrence, we systematically use surgical staplers to stabilize the prosthesis during the first few postoperative days. At the end of the procedure, the residual prosthesis is placed in an Endo-bag in order to extract it through the umbilical orifice. No drain is introduced. During desufflation, it is essential to check that the peritoneum unfolds properly in order to avoid prosthetic folds. To do so, an instrument is left in the preperitoneal space, thus maintaining the prosthesis in the best position.