Laparoscopic TEP repair of a Nyhus type II left inguinal hernia in a male patient

Authors

Abstract

This video shows the technical details of a laparoscopic TEP repair of a Nyhus type II left inguinal hernia in a male patient performed during an IRCAD-EITS course in Strasbourg.

Classification

routine cases

Keywords

Laparoscopic TEP repair, Nyhus type II left inguinal hernia, male patient

Media type

Duration

14'10''

Publication

2009-09

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E-publication

WeBSurg.com, Sept 2009;9(09).
URL: http://www.websurg.com/doi-vd01en2682.htm

Laparoscopic TEP repair of a Nyhus type II left inguinal hernia in a male patient

1. Introduction 00'18''

It is a left-sided hernia, the bladder should be empty and we are using a little bit of Trendelenburg position in order to increase the space between the pubic symphysis. We are using a 0-degree scope. This is the head of the patient. I am coming to the umbilicus, then to the subcutaneous tissue and I expose the aponeurosis of the right rectus muscle. In white, we can see the aponeurosis and we can see the body of the muscle.

2. Scope introduction 01'09''

The idea is to try and get into this space with my first trocar and then I will come with my trocar and insert it alongside the rectus muscle. My assistant is inside, he will focus a little bit and you see that we are on the posterior sheet, I have not used the insufflation yet. Now we will connect the insufflation because I am sure that we are in the right dissection plane. I have my left hand on the pubis and the first step is to try and get contact with the pubic bone, I have contact, I can feel it.

3. First port introduction 02'03''

This is the symphysis, from outside now I will check on the suprapubic midline, not too low because I know that my prosthesis has to come a little bit on the back of the anterior wall and I will insert a second port, which is a 5mm. I am just on the midline and under visual control I will insert my second port. Now I am working with the scope in my left hand and the trocar in my right hand. We already have the space created, if I work a little bit this way we will come to the Cooper’s ligament, which is on the side. As soon as I am here, see the view, I am working on the left side.

4. Identification of epigastric vessels 03'00''

A very important landmark when we are doing TEP is to find the epigastric vessels. Usually when people start with TEP, they want to go there because they want to stay close to the pubis and they go in this direction, but in fact if you see in this patient, you are going above the epigastric, which is not good. You have to stay very close to the peritoneal sac and be as close as possible to the epigastrics. Here we have a very nice view on the epigastrics, which is the important landmark for the TEP technique. You see that I am using a lot of blunt dissection. I am trying to do a small hole in this lateral opening, and you’ll see that at this point I can see the lateral wall and I will go inside with my scope because I know that I am in the right cleavage plane. By moving the scope laterally just a bit, I will increase the space a little. Anatomically speaking, I have my hernia, which is here, you see the peritoneum going into the external ring.

5. Second port introduction 04'16''

I am now going to try and insert my second port on this side and if you have the external view you can see that we are at the level of the iliac spine. We check from inside and I have my second port inside. We can see the ring so maybe I can increase a little bit the space there. Now the idea is to try to get the cleavage plane between the different elements of the cord and the sac. We can imagine that the structures of the cord are here and that there should be a cleavage plane there between the cord and the hernia.

6. Hernia sac and lipoma identification 05'11''

So there is a sac plus a lipoma, you see the vas. It is quite similar to open surgery, sometimes it’s easy for a long-standing hernia, sometimes the planes are a little bit more difficult. In case of a huge sac fixed deeply, do you always try to remove the sac or only sometimes? I would say that sometimes when there is a very long sac, we can cut it and lift part of it in the canal. Nice persistence of peritoneovaginal canal. Sometimes you have to look on the other side because then you can find the plane easily. So this is the lipoma, do you always remove and why? Yes, because if you don’t remove this, the patient will think that he still has a hernia.

7. Sac dissection 06'58''

You have to work on both sides. You see the white structure is the sac. He is trying to free the sac from the surrounding tissues that are the spermatic cord. So you see that it is a very old hernia, so the guy was probably born with this hernia. The idea is to really get one cleavage plane and then I can surround the sac, then I can decide if I continue my dissection towards the scrotum or if I cut the sac, that’s the general idea. I am just checking if I have all the elements. I have the vessels. As we were discussing yesterday, probably the best indication for someone who wants to start with TEP is to start with a direct hernia. It is probably the same as well for TAPP because you don’t have this amount of dissection on the cord. And less danger of injuring the spermatic structures. How far do you have to free proximally? We have to free till the point where the vas is going away from the vessels, so I try to stay in contact with the peritoneum, you can see the limit of the sac here. Of course, in this sort of hernia there are a lot of adhesions. If you have this sort of congenital hernia, the chance of having it on the other side is quite high, so I will have a look on the other side. So here’s the cord we still have to dissect a little bit. The femoral nerve is lateral to the vessels. Why is it necessary to dissect so much? You have to free the peritoneum more to peritonize more? Yes, you see now my prosthesis can go down to the Cooper’s ligament much more easily. You see, we have prepared the corona mortis, it is there. I think that we are almost done with our dissection. I will just check various things. Laterally I am OK, you see the psoas muscle there, so I have a good place for my prosthesis. I don’t dissect too much there because you have the nerves. We have seen that this is not a lipoma but the spermatic vessels, so I can dissect them. We have retracted the lipoma up, it is over there. The pubic tubercle as Joel said, the corona mortis, Cooper’s ligament. We have the obturator nerve bottom left. So going to the obturator hole, we have the vas and we have all this dissection. So you see that we will place a prosthesis that goes up to here, covers the indirect hernia, covers the direct hernia, and sometimes if needed, it can cover of course the femoral hernia.

8. Mesh preparation and positioning 11'26''

So I will prepare the prosthesis. I am using a Parietex mesh, 13 by 15 rectangular mesh. It is important to use quite a big one so as to cover well the different inguinal rings. The main problem in the TEP is always to manage the space. You unroll from up to down, it is easier than the opposite. I will try to deploy this mesh on the side on the psoas muscle, I will check from inside medially. This kind of mesh is not too soft for you? It is. I prefer to work with polypropylene in fact. As Joel Leroy said, I am using the Stoppa concept, so parietalization of the cord. This is why we have dissected that much the cord proximally in order to be able to apply the mesh. Because the ring is there, so you see the distance between the lower part of the mesh and the ring, so when I will finish, I will check that the peritoneum unrolls here. When you don’t use any tackers, it is very important to check that the peritoneum is going to lay in this surface and that nothing goes below the mesh. I am just checking that the peritoneum is covering the mesh there and checking that the mesh is in the right position in this place. Are you sure that this will not move? I think so, because I will release the pressure and as soon as the patient will recover, he will push and the mesh will be stuck to the posterior abdominal wall. If I have a very large direct hernia, a very big hole, then I will put a tacker because the risk of having the mesh getting in the hole is quite high. So that is probably the only condition in which I will leave a tacker. And that’s finished. So don\'t you fix it? No.

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