Right inguinal hernia and intrafascial psoas hernia: TEP repair

This is a video demonstrating the laparoscopic preperitoneal approach to repair a right inguinal hernia. The Veress needle is used directly at the beginning of the procedure to create the preperitoneal space. Interestingly, a psoas herniation is also discovered during the dissection. This video is suitable for general surgeons with an interesting laparoscopic hernia surgery. The authors gain view of the pubic bone, following it to the Cooper’s ligament. Their goal is to create space with blunt dissection and gentle traction only. They proceed with caution to avoid the epigastric vessels. The hernia comes into view, but the authors remain close to the hernia sac to avoid the epigastric vessels until they discern the exact anatomy. This guides the operators to the hernia, and they then continue to develop additional lateral space.

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Right inguinal hernia and intrafascial psoas hernia: TEP repair

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

This is a video demonstrating the laparoscopic preperitoneal approach to repair a right inguinal hernia. The Veress needle is used directly at the beginning of the procedure to create the preperitoneal space. Interestingly, a psoas herniation is also discovered during the dissection. This video is suitable for general surgeons with an interesting laparoscopic hernia surgery.
The authors gain view of the pubic bone, following it to the Cooper’s ligament. Their goal is to create space with blunt dissection and gentle traction only. They proceed with caution to avoid the epigastric vessels. The hernia comes into view, but the authors remain close to the hernia sac to avoid the epigastric vessels until they discern the exact anatomy. This guides the operators to the hernia, and they then continue to develop additional lateral space.

Keywords

right inguinal hernia, intrasfascial psoas herniation, TEP repair

Media type

Surgical video

Duration

13'30''

Publication

2007-06

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E-publication

WeBSurg.com, Jun 2007;7(06).
URL: http://www.websurg.com/doi-vd01en2099.htm

Right inguinal hernia and intrafascial psoas hernia: TEP repair

1. Trocar introduction 00'15''

We’re using a direct approach to the extraperitoneal space as compared to the technique that will be demonstrated by Dr. Begin who is opening the posterior layer of the rectus muscle to get access to this preperitoneal space. It’s another way. It’s blinder. We should initially recommend for beginners the safe “Begin” approach. So I’m creating this bubble in the preperitoneal space, and I’ll try to get access to this space directly with the optical port, and I’ll come with the trocar directly and in an oblique fashion, trying to perforate the linea alba and get access to preperitoneal space. I have gas coming from the port. I’m in the right plane. I put some insufflation in the main trocar and you see the space. This woman has had a previous operation: it was an appendectomy, see the scar in the right iliac fossa, and she has had a previous hernia repair using an anterior approach, so we’ll work mostly on the right side. We don’t have to do anything on the left side. The advantage of the TEP approach is that we can observe both sides without the need of opening the peritoneum, so it’s probably a very good indication for bilateral repair. So we’re using a scope like a balloon dissector just to create this initial dissection that gives you space to insert the 1st trocar. So I’m not moving on the side because I don’t want to injure the epigastric vessels. So I need to dissect in order to identify the epigastric vessels correctly. Here I have my space. This is the midline. It’s a Step trocar, and then I need scissors for coagulation purposes. Back to the operative field now. This is the pubic bone.

2. Preperitoneal dissection 03'12''

And we will follow the line of the pubic bone towards Cooper’s ligament. I’m trying to create this space for blunt dissection this way, gentle traction only. We should avoid getting the epigastric vessels from the start. Caution is the key, and this is probably the hernia. It looks like a direct hernia because it’s inside of the epigastrics. The goal is to find this landmark with the epigastrics. I’m staying very close to the sac and to avoid the epigastrics because I don’t know yet the exact anatomy. I will try to find the plane between the sac and the abdominal wall. There are a lot of adhesions here. Now we are trying to find the lateral space, and normally the psoas muscle should be somewhere there. We have very strong adhesions. I think that I will use a 2nd trocar; usually in women you can do it with one trocar but here because of those adhesions, I have to use another one. We will place it laterally to the optical port. To place this port, I will follow the direction of the scope.

3. Hernia sac dissection 06'10''

We’re working with a zero degree scope. I try to reduce this hernia, exerting some traction on the sac. This hernia is quite difficult to reduce. Usually in women it’s very easy, but this one is not. Here it’s the end of the sac.

4. Division of hernia sac 08'00''

The round ligament is incised; here is the opening of the sac. I will divide everything. There is no bowel inside so I can divide it here. It’s like a peritoneovaginal channel. So I divide both the end of the sac and the ligament. It’s a very long sac, and I’m cutting the round ligament. We will close the sac with an Endoloop. I’ve divided the round ligament. Everything will be included with the Endoloop. We’ll work on the side. Here you see Cooper’s ligament – I won’t dissect too much, there is the small lipoma there. The bladder is down there. This is the artery. I don’t have that much space on the scar of the appendicectomy, which is here. I can try to open that a little bit. We try to take down those adhesions. We can see this scar with the appendix. During the dissection of the right psoas, we could see the nerve fibers, and we were surprised to encounter a small hernia to the sheath of the right psoas muscle.

5. Discovery of psoas herniation 11'00''

This is an unusual finding. We reduce this hernia. There was no specific treatment for that. We can imagine that if this hernia develops in a patient, it can lead to some pain. We have very few descriptions of this type of hernia in the literature. It’s quite unusual to find such a small hole in the sheath of the psoas muscle. Here you can exactly identify the hole where we found some lipoma.

6. Mesh placement 12'00''