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Stepwise approach for a typical inguinal hernia repair using the 4DDOME®

Authors

Abstract

In this video, the standardized technique for the treatment of an indirect inguinal hernia is presented. Each step is precisely described and leads to the final hernia repair with placement of a 4DDOME® mesh (that is a semi-absorbable mesh).

Classification

basic techniques

Keywords

stepwise approach, typical inguinal hernia repair, 4DDOME® mesh, prosthesis

Media type

Duration

16'00''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2394.htm

Stepwise approach for a typical inguinal hernia repair using the 4DDOME®

1. Introduction 00'10''

This video shows the surgical treatment via anterior herniorrhaphy of a right direct inguinal hernia according to the 4DDOME® technique.

2. Skin incision and dissection of the aponeurosis 00'18''

Following the anatomical exploration, a 5cm incision is made symmetrical to the inguinal canal. The dissection is continued plane after plane and an orthostatic retractor is introduced. The dissection continues until the aponeurosis of the external oblique muscle is identified. It will be divided in the same direction as the fibres run with the aid of monopolar coagulation. Traction is applied at the level of the superior leaflet of the aponeurosis of the external oblique muscle with the help of 2 Kocher clamps. A peanut swab mounted on a forceps allows to perform a large dissection at the level of the superior surface of the falx inguinalis, also called conjoined tendon. The same maneuver is performed at the level of the inferior inguinal canal, thus freeing its anterior and inferior walls in a blunt fashion.

3. Extenal inguinal ring dissection 02'02''

The dissection is continued atraumatically: the external inguinal ring is dissected. At the inferior part of the plane of dissection, the pubic symphysis can be seen and it is the inferior limit of our dissection plane. The cord is entirely fired with the help of a right-angled grasper that will allow a loop to pass around the elements of the inguinal canal.

4. Skeletonization of the elements in the inguinal canal 04'00''

The cord is gradually dissected using monopolar coagulation. The cremaster muscle is divided in the same direction as the fibres of the internal inguinal ring run towards the external inguinal ring. Once the cremaster’s fibres have been partially divided, traction is applied with the help of graspers in order to skeletonize the elements of the inguinal canal. The indirect inguinal hernia is then properly identified. Monopolar coagulation allows to perfectly dissect the cremaster muscle. The vas deferens is controlled in the inferior portion of the cord in transparence. The skeletonization of the elements of the inguinal canal continues: scissors are used to perform its dissection, which is continued towards the internal inguinal ring with the dissection of the vas deferens and of the gonadal vessels. Using graspers, the triangulation allows to complete the dissection of the internal inguinal ring and allows to recognize the pre-hernial lipoma, in front of which the hernia sac is identified. The sac is dissected with the help of monopolar coagulation, always towards the internal inguinal ring, by skeletonizing the funicular structures. The cremaster muscle is divided at the level of the internal inguinal ring. The lipoma and the hernia sac are re-introduced into the internal inguinal ring.

5. Prosthesis insertion and fixation 07'32''

A 4DDOME® prosthesis is used to obstruct the defect of the inguinal ring, at the site of the hernia. Its ideal positioning is controlled. It is fixed by 3 stitches of non-absorbable monofilament 3/0 wire. Its position is adjusted to the inguinal ring. The next step is the introduction of the prosthesis. It is grasped at the level of its inferior part with a grasper placed posterior to the spermatic cord. The internal inguinal ring is calibrated thanks to the suturing of the 2 arms of the mesh before it is fixed at the level of the pubic symphysis. This is performed by 2 interrupted stitches of non-absorbable monofilament suture. The mesh is then positioned at the level of its inferior portion, then at the level of the pubic symphysis. Then the mesh is spread out inferior to the aponeurosis of the external oblique muscle, its superior component is passed anterior to the spermatic cord. The fixation of the mesh is continued with a suture of absorbable or non-absorbable monofilament material. The suture starts at the pubic symphysis. Then the inferior component of the mesh is fixed at the inferior internal border of the inguinal canal. Here you can see that interrupted sutures are used, sometimes allowing for a better adjustment in the positioning of the mesh. It is not always necessary to fix it at the level of the falx inguinalis, also called conjoined tendon. The final positioning of the mesh is adequate. The next step is the re-approximation of the aponeurosis of the external oblique muscle using an absorbable 3/0 running suture extending from the internal inguinal ring proximal to the pubic symphysis, thus allowing for the reconstruction of the external inguinal ring. The surgical procedure ends with the closure of the subcutaneous tissue planes using absorbable Vicryl 3/0 stitches and an intradermal skin running suture.

6. Second case presentation 12'22''

Another technique of positioning of the 4DDOME® mesh for the treatment of a direct inguinal hernia is demonstrated. Three mesh sizes are available. The size of the mesh can be chosen depending on the type of parietal defect, whether direct or indirect. In the present case, a weakness of the transversalis fascia and the presence of a direct inguinal hernia can be observed. This direct hernia can be clearly identified when a Valsalva’s maneuver is performed, namely when the patient is asked to cough. The size of the hernial defect is precisely assessed and then measured. A 4DDOME® mesh is fixed all around the transversalis fascia using a running suture of non-absorbable monofilament 3/0. The mesh is positioned similarly to the previously described case. In all cases, it is preferable to calibrate the internal inguinal ring before fixing the mesh.

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