TEP approach for inguinal hernia repair: live comments

Authors

Abstract

This is a live video recorded during an intensive IRCAD laparoscopic general surgery course. In this video, a TEP approach for inguinal hernia is presented. Live comments help understand the different aspects of this procedure.

Classification

live recorded

Keywords

TEP, inguinal hernia, laparoscopy, mesh, tacker

Media type

Duration

14'50''

Publication

2010-09

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Audio

Subtitles

E-publication

WeBSurg.com, Sept 2010;10(09).
URL: http://www.websurg.com/doi-vd01en2829.htm

TEP approach for inguinal hernia repair: live comments

1. Introduction 00'19''

The idea of the TEP is not to enter the peritoneal cavity but to work only in the extraperitoneal space. The rationale for this is that we are working on the posterior aspect of the abdominal wall and it is difficult to understand why we have to enter the peritoneal cavity. So this is the rationale for the TEP.

2. Patient position 00'46''

The patient is placed in a supine position. The two arms are alongside the body. This is the pubis of the patient. It is an 18-year-old slim patient. We are probably going to discover a persisting peritoneovaginal canal.

3. Umbilical incision 01'10''

This is the umbilicus and you see that the first thing that we have done is to make a small arciform incision in the lower part of the umbilicus. We have just exposed the anterior layer of the rectus muscle on the right side, because we are working on a right-sided hernia. There are different techniques to create the pneumoperitoneum: sometimes you do a direct insufflation that we will try to show you.

4. Anterior aponeurosis dissection 01'46''

So the idea is to dissect the anterior aponeurosis of the right rectus muscle and you see it. You see that we have opened the anterior sheath of the right rectus muscle. The idea is to retract the body of the muscle to get access to the posterior sheath of the muscle. On this posterior sheath, we will insert a trocar and find our way towards the pubis and the preperitoneal space.

5. Trocar insertion and insufflation 02'26''

So I use a blunt trocar. Then I insert it just a little, not all the trocar within the incision, just to check the position of my port. The idea is to look if I am in the right plane on the posterior muscle. So I am coming with the camera. Now we connect the insufflation and I progressively insert my trocar keeping the view. You see I’m following the rectus muscle. I have my left hand on the pubic bone. I am trying to give the direction to my optical system. See the pubis bone? OK. What pressure are you using for insufflation?

6. Second trocar insertion 03'37''

This time is 12 mmHg. You see the pubic bone and I am touching the anterior abdominal wall and approximately three fingers above the pubic bone, I will insert a second trocar on the midline. So I have to control on the main screen the introduction of my trocar with the camera. I have the camera in my right hand. In my left hand, I have my instruments. I am not cutting or coagulating anything because I want to clear progressively my landmarks.

7. Landmarks identification 04'28''

My first landmark will probably be the epigastric vessels, so probably you see the vein there. This guy is so slim that there is a good demonstration of the anatomy. This is the pubic tubercle. This is probably the Cooper’s ligament, the vein, the symphysis. So now you see I have cleared this little space of work. Because of these strong tissues, I will introduce a second port in this patient, because I know that it is not a direct hernia. You see the epigastrics there, the pubis, probably the cord somewhere here, the epigastrics. I need probably a second trocar to dissect this cord. You see? I am just working close to the epigastrics. I am not working above but just close to the epigastrics because I know that probably there I will find my sac. This is the peritoneum. We have to find the cleavage plane between the peritoneum (you see this plane is probably here) and the abdominal wall. So probably it will be easier to work with two hands to perform this dissection. It is very difficult because the space is so small. I am looking at the light of the camera and again going in the direction of the pubis. I am coming with a second port. Just a question, it looks like when we were using the balloon, we dissected both spaces, left and right, to get to the right. Here you are just going to stick to dissecting only the side of the hernia. Yes, that is right, because this patient had a previous left inguinal repair, so there is no justification to work on the other side. Your question is quite interesting, because I do not know which technique was used initially on the left side, but we can imagine that if you have adhesions, etc., on the left side, coming with the balloon would create some problems when creating the cleavage plane. If it was just a primary hernia on the right side, would you still do it laparoscopically? That is the first question. Ok. First is the question regarding the patient. It is a very young guy. Usually hernias in these young patients are congenital hernias, so it is not a defect of the abdominal wall. There is room for discussion regarding the best approach for this congenital hernia. The second point is that is it logical to use prosthetic reinforcement in a young patient like this with a congenital hernia? I think this is probably more the subject of discussion than the approach in this precise patient. Should we reinforce the abdominal wall when treating this kind of congenital hernias? That is my question.

8. Hernia identification 08'05''

You see this type of hernia. So it is a long indirect sac. It’s a personal feeling: in a young age, with indirect inguinal hernia, I would really go in correct the deficiency and forget, even if it is a direct approach, about putting a tension-free repair, since there is nothing to repair. That includes the mesh. Therefore, go correct the hernia, do the herniotomy like in children, and get out of there, you do not a need a mesh. I am just taking your seat just to show you the anatomy, the vessels and the deferens duct there, you see? I always check before dividing anything—see here I have the cord-- so I can go further and go to the testicle, but does this make sense? No.

9. Sac division and closure 09'02''

So I am going to divide the sac and leave this little part, because I know that if I try to do more, probably the risk is to get the testes inside the cavity. I will use an Endoloop to close this sac. I have a special “Leroy-made” Endoloop. I will try to manipulate that properly. It is a very nice system. I have closed the sac. I am just preparing the place for the mesh. What is your limit for the dissection? At this point, I am at the level of the superior iliac spine, and I am checking in fact in the abdominal wall of the patient and I can see the light of the endoscope. There is a very good view of the nerve in this very thin young man on the psoas muscle that you mustn’t damage. In this patient, the demonstration of the anatomy is very nice. That’s the psoas muscle behind. Here you have the external view. You see the light. This is the iliac spine. And you see the light of the scope at the level of the iliac spine. I have quite good room for the prosthesis.

10. Mesh preparation and insertion 11'01''

I am preparing the mesh. This guy is very slim, so I am starting with a 15 by 15. so I probably do a 13 by 10 or something like that. You have to adapt a little bit the size of the mesh to the size of the patient. Is this a polypropylene mesh? Yes, because, when you are working with a polyester mesh, it is very difficult in TEP. You need a mesh with some memory. The one that Professor Leroy is using is the Parietex® mesh. Michael, I do not know if you prefer the polypropylene? If I may ask, I just notice that you roll the mesh lengthwise instead of widthwise, exactly the opposite of the TAPP. Is there a reason for it? Because usually I want to place the mesh immediately on the psoas muscle laterally. So the idea is to initially try to place the mesh in the lower part, because I know that in the upper part, I will have some problems with my trocars. So very important to have it quite high on the top, and not going too deep. This is a bladder, obturator hole. So I don’t want to go too deep in this space. I am just checking the coverage of all the ring on the side. In this patient, it is good to have the internal ring in the middle of the mesh. Yes, that is right. So I am going to fix probably in this patient because he’s quite slim. I’d say that in half of the patients, I do not use any tacker. Usually, the fatty tissues help a little bit to fix the mesh, which is not the case here. This is why I will probably fix it a little bit. A lot of people still do fix the mesh. It’s slightly reassuring. Yes, that is right. But this it is not necessary. People we worked with sometime ago were surprised to have higher recurrence rate with fixation.

11. Mesh fixation 13'34''

So I am checking the position of the mesh. Probably one tacker, but as I have a device, I will use a second one, which is not very useful, but just to fix it there. I remove the suprapubic trocar. I will just check the position of the mesh when the pneumoperitoneum is released. The second port seems incredibly close to the optical port and does not quite support the triangulation that we normally use. I am using the suprapubic trocar three fingers above the pubis. You can insert it on the midline, but you will have a loss of triangulation at all times. The other solution is to dissect and place the second port in the iliac spine, but sometimes the position of the operator is a little bit difficult. That is the positioning I use when doing bilateral repair, because I can work on the right and on the left sides. Usually, for single unilateral repair, I place it just two fingers away from the main umbilical trocar. What you have to know is that there is so little space in the TEP that, even if you try to create triangulation, you still have problems with space, so you have to adapt a little bit on that.

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