Laparoscopic transabdominal preperitoneal access for inguinal hernia

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Laparoscopic transabdominal preperitoneal access for inguinal hernia

Authors

J Leroy, J Marescaux

Keywords

hernia,crura,mesh

Media type

Surgical video

Duration

15'00''

Publication

2005-11

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E-publication

WeBSurg.com, Nov 2005;5(11).
URL: http://www.websurg.com/doi-vd01en1867.htm

Laparoscopic transabdominal preperitoneal access for inguinal hernia

1. Trocar placement 00'13''

I have drawn on the abdominal wall the landmarks of the left and right anterior superior iliac spine, the pubis bone and the symphysis, the umbilicus, the midline, the left and right mid-clavicular line, the left and right anterior axillary line and finally the horizontal line through the umbilicus. I use 3 trocars, one 10-12mm trocar, the 12mm one is the optical trocar and two 5mm trocars. It is also the trocar where I’ll introduce the mesh. I always introduce above the umbilicus to place the trocars in an arc circle with the centre on the hernia site.

2. Exposure/Exploration 01'24''

In this case, we have a type IIIb indirect hernia according to the Nyhus classification because the inguinal canal is destroyed and we can conclude that the internal and external rings are in the same axis so it is as a direct hernia. To the right, this is the umbilical ligament. Here is the urinary bladder, we don’t put a urinary catheter to do this surgery. To the right, the landmarks are as follows: here is the spermatic cord that crosses the umbilical artery. Remember this because when I’ll do the anterior dissection, I’ll do the dissection of the preperitoneal space until I reach this landmark, the triangle between the spermatic cord and the spermatic vessels. This is the triangle of Doom where you have the external iliac vessel. I’ll do an external taxis medial to the anterior superior iliac spine on the left and I’ll do a tattoo, a landmark like this to be sure I’ll reach this area.

3. Incision of peritoneum 02'55''

I do an incision very high on the horizontal line of the anterior superior iliac spine. I don’t dissect the hernia sac immediately, it’s a big error, it’s a trap too. I don’t hesitate to do a large incision to see the space very well.

4. Preperitoneal dissection 03'34''

With regards to the anterior dissection, because I’m a right-handed surgeon, we have to dissect staying not far from the peritoneum. Don’t do a trauma of the nerves which are more anterior. We’ll find the anatomical embryological plane more easily. We use traction counter-traction and we can use scissors to open this. The bladder is visible on the right. Here is the pelvic bone, the symphysis. We don’t dissect the sac immediately. See when we’re in the right plane, laterally we have the spermatic vessels, we have to find the spermatic sheath.

5. Hernia sac dissection 05'30''

We have not dissected the inside of the sac. If it is too long, we’ll divide it. My left hand is exerting traction on the sac. There is a small lipoma. See we’re pulling the sac. Finally we do the parietalization, what Stoppa called the parietalization of the spermatic cord. The sac is not completely freed from the cord. You see that it’s coming back into the inguinal canal. We can use the Harmonic scalpel but I use the monopolar. Most of the surgeons doing hernia repair surgery use monopolar, sometimes bipolar. These are the spermatic vessels after parietalization and dissection. This is the vas deferens, the cord, the hernia sac is behind. We have the pubic symphysis, the iliopubic branch with Cooper’s ligament, the epigastric vessels with Hesselbach’s ligament, the triangle, the internal ring of the inguinal canal. Can you show us where the psoas muscle is, all the nerves come on the psoas?

6. Mesh preparation 08'21''

The psoas muscle and the nerves are running here. Don’t put staples in this area. What kind of mesh are you going to use? We’ll use a multifilament polyester mesh. Imagine the lateral, medial sides. This will be positioned this way with spermatic vessels underneath and the cord too. I will roll from lateral to medial, this is uneasy because it’s a bit rigid. And then from anterior to posterior, I will roll it. Introduce the mesh into the suprapubic trocar and I push it.

7. Mesh placement 09'35''

What size is the mesh? 15cm large, 12cm superior medial, and 8cm lateral.

8. Fixing the mesh 10'10''

I’ll put staples on the superior edge of the mesh avoiding the epigastric vessels, another stitch on Cooper’s ligament and it’s complete.

9. Closing the peritoneum 11'10''

Now for closure, we will do an overlapping of the mesh but also in TAPP, in TEP, when we have a defect like this, we don’t close. This can occur also when we dissect anteriorly. When the patient has had a previous surgery, there is more risk of injury to the bladder, and this is more recognized when using TAPP than with TEP, and immediately treated with TAPP. It’s more complicated to handle hernia using laparoscopy than with open surgery. You’ve seen a minimum of manipulation, injury of the epigastric vessels, there are a lot reported in the literature. I’ll close now. We have a big needle and a small trocar. We need to modify the shape of the needle. I introduce the 5mm needle holder into the trocar, I pull the trocar, put your finger to obturate, I catch the sutures, not the needle and I push the needle and suture into the hole. And I push the trocar around. And you can introduce big needles this way. It takes 1 or 2 seconds to do it. Sometimes bleeding occurs when you introduce your trocar, so always check the trocar site. First introduce an instrument into the trocar and pull the trocar outside to make sure there is no bleeding and you can push back the trocar around your instrument. Same on the left. On the other side, you can see that we have a sleeve, we can do the same with a sleeve, we remove it and check around the sleeve and we can push the trocar back inside. Finally, we’ll do the exsufflation and we’ll remove trocars at the end after exsufflation because there’s a risk of incarceration of omentum or bowel through big holes.