Laparoscopic inguinal hernia repair: TEP approach without fixation of the mesh

The most common laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. In TAPP, the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over potential hernia sites. TEP is different in that the peritoneal cavity is not entered and the mesh is used to seal the hernia from outside the peritoneum. This approach is considered to be more difficult than TAPP but may have fewer complications. This video demonstrates a laparoscopic TEP inguinal hernia repair without fixation of the mesh.

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Laparoscopic inguinal hernia repair: TEP approach without fixation of the mesh

Authors

B Dallemagne, J Marescaux

Abstract

The most common laparoscopic techniques for inguinal hernia repair are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. In TAPP, the surgeon goes into the peritoneal cavity and places a mesh through a peritoneal incision over potential hernia sites. TEP is different in that the peritoneal cavity is not entered and the mesh is used to seal the hernia from outside the peritoneum. This approach is considered to be more difficult than TAPP but may have fewer complications. This video demonstrates a laparoscopic TEP inguinal hernia repair without fixation of the mesh.

Classification

live recorded

Keywords

Laparoscopic inguinal hernia repair, TEP approach, mesh

Media type

Surgical video

Duration

17'54''

Publication

2011-06

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E-publication

WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3329.htm

Laparoscopic inguinal hernia repair: TEP approach without fixation of the mesh

1. Patient position 00'19''

We will perform another type of operation for inguinal repair because we will use this totally extraperitoneal repair. As you mentioned, we will have time to discuss about the rationale for both of these operations. We start only with the abdominal incision. The head of the patient is here. This is the pubic bone. You have it here. This is the umbilicus.

2. Umbilical incision 00'56''

We made a small arciform incision at the lower part of the umbilicus. We are looking for the rectus muscle.

3. Port insertion 01'10''

It is a left hernia so we will look for the left rectus muscle sheath. We will look at the posterior sheath, and then Dr. Jacopo D’Agostino will introduce the first port on the posterior sheath. He will direct his trocar towards the pubic bone.

4. Pubic bone identification 01'40''

First, we will check with the camera just to be sure that we are in the right cleavage plane. You see the muscle on the left side. We will then connect the inflation. I always check before just to be sure that we are on the right spot. I’m going towards the pubic bone. I will try to feel the pubic bone. That’s the way to create the preperitoneal space, which is not too expensive. The problem with this technique is that you have always some problems with the camera. Here I feel the bone. See the bone there? Then I will create a little bit of space. As soon as I’m ready with my little space, I’ll wash a little bit the camera just to get a nice view for you. I am using the 0-degree scope. When I started with that, there was no balloon on the market so I got used to that. Initially, I always used a direct approach to create the pre-pneumoperitoneum with a direct insufflation with the needle going straight with the trocar. But for teaching purposes, I switch a little bit to this approach on the posterior sheath of the muscle.

5. Blunt dissection 03'52''

I enlarge a little bit the space. You see that I’m working mostly with blunt dissection because this is an anatomical dissection, so you don’t have to use a lot of cautery because the problem in the preperitoneal space is that if you coagulate too much, you get a lot of smoke. And because of this very small area, you can’t clear the smoke easily because you will immediately lose your space. At this point, when we’re working on this extraperitoneal space, the critical part is to find the right entrance in this space.

6. Identification of the epigastric vessels 04'44''

The landmark is the epigastric vessels because we know if we try to find the landmark here, the risk is to go above the epigastric vessels. You see if you go there, that’s not a good option. I know that my cleavage plane is just below the epigastric vessels, and we can already see quite well the indirect sac of the hernia. I’m staying quite close to the sac just below the epigastric vessels. I will try to initiate the dissection towards the left side of the patient. At this point, we have two options, either you can create easily your cleavage plane only with one hand, so in fact I have the scope in my left hand and I’m working with my right hand, so I’m directing the dissection by myself, or you have some problems when trying to find this cleavage plane and then you can introduce a second port on the midline to help you while dissecting this area. You get the experience with the TAPP for example, and then you can move to the TEP because you know a little bit more about the different landmarks. That’s very important. Now I will use my scope to help my dissection laterally. So you see I’m on the latero-abdominal wall, and I will use my scope to help in the dissection. We have increased the space, and probably I will introduce a second trocar laterally approximately at the level of the iliac spine to follow the light of the laparoscope, just to see that we are progressing very high laterally. That’s very important.

7. Landmarks 07'00''

Again you see the anatomy: pubic bone, pubic symphysis, hernia, hernia sac, and then the lateral dissection with the psoas muscle.

8. Insertion of the second port 07'12''

Now I will introduce a second 5mm trocar on the iliac spine. I will try to retract a little bit the cord because you have to go very precisely because you can imagine how dangerous can the lateral introduction of this trocar be, as you have all the important structures there. So it’s very important to control visually the introduction of this trocar.

9. Reduction of hernia sac and lipoma 07'47''

At this point, I can work with two hands. My left hand is on the lateral side of the patient, and my right hand is in the middle. I will try to dissect this cord. I keep on trying to reduce this sac lipoma. There’s a little bit more adhesions there so I have to clear a little bit more medially. Personally, for hernias, I always use monopolar cautery. But when I’m doing more complex procedures, I usually switch to more sophisticated technology such as ultrasonic systems or the bipolar coagulation device by Covidien. But for basic operations, I usually just use monopolar cautery. I have to find the right cleavage plane there because we have to be careful as there is a scar there. Dr. D’Agostino is telling me that this patient had some episodes of hernia incarceration so it’s related to that. I’m just trying to find the right plane there. I have to check the position of the vessels. I try to cut this. On this side, it’s free, very strong. We’re finished. It was a well stuck hernia. Here you have the internal view. We’ve finished the dissection of this cord. You see here the indirect ring, quite large. So we\'ve have to fight a little bit with this hernia because there were many lipomas on the cord. Here you see some of them. So we have dissected all the hernia. Here we have the vessels and the vas. It was really stuck on the cord. Again, in terms of anatomy, you know this view: pubic symphysis, epigastric vessels —I showed you at the beginning that you can’t dissect this way but just below—, the ring, the cord. Here you have a nice view on the psoas muscle with all the structures. We’re going very far laterally.

10. Mesh preparation and insertion 12'39''

Now I will introduce the mesh, so I’ll leave the trocar in a good position. I’ve already prepared the polypropylene mesh, which is quite the same size as Prof. Joel Leroy’s. I will roll it. I’ve introduced the prosthesis inside. I prefer the polypropylene mesh compared to the polyester mesh, because I have a little bit more of memory with the polypropylene mesh, and for the TEP it’s quite useful. Sometimes I fight with the polyester mesh because you can’t immediately get the right positioning. So I prefer to use the polypropylene one. It’s really a matter of manipulation. You see that the polypropylene mesh is a little bit better or easier to manipulate. Now I’m covering, and I look at the position of my lipoma because if it is below the mesh, then I have a high risk of recurrence. So it’s very important to control the position of the lipoma and the peritoneal sac just above the mesh. Here you see I probably won’t fix this mesh because I have a very nice placement laterally up. Now we will remove the lateral port, and I will control during deflation the position of the mesh. One of the advantages of the TEP is that you don’t use any tackers.