Left Spiegelian and left retrofunicular inguinal hernias: laparoscopic TAPP repair

This video demonstrates how a Spiegelian hernia repair may be included by expanding the standard TAPP inguinal hernia repair.

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Left Spiegelian and left retrofunicular inguinal hernias: laparoscopic TAPP repair

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates how a Spiegelian hernia repair may be included by expanding the standard TAPP inguinal hernia repair.

Keywords

left Spiegelian, left retrofunicular inguinal hernia, laparoscopy, TAPP repair

Media type

Surgical video

Duration

11'39''

Publication

2008-05

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E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2339.htm

Left Spiegelian and left retrofunicular inguinal hernias: laparoscopic TAPP repair

1. Trocar positioning 00'23''

When I do a TAPP inguinal hernia repair, I use three trocars, one is 12mm trocar for the optic introduced just above the umbilicus, and two 5mm trocars placed on the umbilical line at the crossing with the mid-clavicular line on the left and the right. These are to manipulate with my left hand and to cut with scissors with my right hand. This patient had a previous surgery on the right side; it was a TAPP repair with a polyester mesh.

2. Demonstration of inguinal and Spiegelian anatomy 01'08''

We are impressed by the importance of the shrinkage due to the polyester, it is not rigid enough when the mesh is fixed. We do a panoramic exploration and we diagnose a hernia. As you see, we have the sigmoid, the umbilical ligament to the left, it seems to be no hernia. At this level, the spermatic vessels, spermatic cord is not far, probably there. What we do see is this, I think it is a Spiegelian hernia, you see the defect, and it is located at the anterior superior iliac spine line. The anterior superior iliac is there and we are exactly here.

3. Operation begins with peritoneal dissection (TAPP repair) 02'22''

We will do the treatment of this, using the same approach, TAPP approach. I’ll do an opening of the peritoneum very high, of the anterior superior iliac spine, it is where we have the adhesion with the transversalis fascia, I don’t like mesh only because I have seen some complications with meshes inside the abdomen, only preperitoneal mesh. When you put on only mesh, you will double the peritoneum but you will not treat the hernia because shortly or a little later afterwards, you will see the mesh sliding with the peritoneum inside the hole. This is the transversalis fascia with the Douglas’ arch. This is a beautiful lipoma. I will do the same dissection I usually do for hernias because I will put a big mesh. I am dissecting the preperitoneal space, this is Cooper’s ligament to the left, the iliopubic branch. We have freed the hernia from the hernia sac. I think it is not only a hernia sac but a lipoma that I am dissecting. Do you like to remove the lipomas for inguinal hernias as well, do you think that is important? When there is a big lipoma, we remove it because a lipoma is more anterior, in this case, it’ll be posterior, because it simulates postoperative recurrence. I am now dissecting the peritoneum from the spermatic cord, this is the internal ring of the inguinal canal. With the examination of the patient, we had the impression it was an inguinal hernia when it probably is just a lipoma. Had you done a TEP repair, you might have missed that small Spiegelian hernia? Yes perhaps.

4. Inguinal anatomy after peritoneal dissection 05'36''

I have now finished dissecting, this is the vas deferens, the duct, these are the spermatic vessels, this with vascular and spermatic sheet covering all the elements of the spermatic cord, this is the peritoneum. I am doing the lateral freeing, just above there we have the defect, perhaps I will also remove these other two lipomas. There’s a lipoma inside the inguinal canal. I will close the hole with a suture.

5. Suture repair of Spiegelian hernial orifice 06'31''

I think it is better to close the hole a little if we can. We will place the mesh, I will place Protack and sutures.

6. Placement of mesh 07'23''

We will modify the shape a little, shorter on the lateral side, and 15cm on the middle side, so 15 by 15. This will be lateral, this will be medial, and I roll from lateral to medial and anterior to posterior. The mesh is pushed into the preperitoneal space; to come back to your question, if we put the mesh only for the Spiegel hernia, we don’t treat the inguinal hernia. The clinical examination is very important because we thought there was an inguinal hernia, we discovered another thing intraoperatively that proves perhaps there are both. This is the Douglas’ arch, this is the limit you see it very well.

7. Fixation of mesh 08'55''

I close with sutures, I will close the peritoneum now, I have finished fixing the mesh. We can use mixed sutures, external/internal, to facilitate, I use absorbable monofilament sutures.

8. Closure of peritoneum 09'19''

I begin on this side because I am a right-handed surgeon. Do the sutures with large stitches, you begin lower, wide because you see I don’t need to manipulate the peritoneum while I’m doing that. I can do it all inside but I am showing how you can do it from an external situation. I will put a stitch between, it is not necessary when we use monofilament to pull immediately. This is good, I have finished there. This is a monofilament, I pull and it’s OK. Before using staples, I did that regularly. If you want to fix the mesh with sutures, first I use an extracorporeal knot to fix on Cooper’s ligament, next I keep a part of the sutures with the needle and I do a running suture on the superior edge of the mesh and I take another suture to close the peritoneum as you see now.