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G. Carvalho et al.
Fig. 34.8 Pelvic anatomy for Mini TEP right inguinal hernia repair. Intraoperative photos of the left and right groin anatomy
pain and faster recovery [2, 9, 15, 42]. Although advantageous in these ways, TEP has not been widely adopted because it is regarded as a more complex procedure, especially with respect to creating the preperitoneal space and understanding its anatomy. In addition, TEP does not allow intraperitoneal inspection, which is cru­cial for treating incarcerated hernias [2, 9, 15, 42]. By combining the advantages of TEP (no peritoneal ap and no mesh xation), the advantages of TAPP (visualiza­tion), and the precision and cosmesis of Mini, a new technique was recently devel­oped [28, 29].
In this combined Mini-TAPP-TEP technique, initial intraperitoneal laparoscopy (TAPP) works as a TEP facilitator. TAPP is immediately followed by TEP, and in this particular combined technique, TAPP is not being used selectively for incarcerated hernias but routinely for its specic advantages in the combined approach [48, 49]. The addition of mini-laparoscopy allows easy exchange of trocar position between the intra- and extraperitoneal spaces, which increases the versatility of this tech­nique. Besides facilitating creation of the preperitoneal space under direct view, this
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34 Inguinal Hernia Repair withMini-laparoscopic Instruments
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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Fig. 34.9 Initial trocar insertion utilizing a direct trocar entry technique at the umbilicus. (a) Administration of intraumbilical anesthesia. (b) The intraumbilical area is exposed and skin inci­sion is made at a hidden umbilical fold. (c, d) Blunt dilation of aponeurosis with a needle holder
combined approach also provides a number of benets over straight TEP.Laparoscopy allows adequate evaluation of all the anatomic elements involved in hernia repair, which allows good planning of what needs to be done in the preperitoneal space. It becomes especially useful in unusual situations such as underestimated hernia size, direct coalescing bilateral hernias, displaced epigastric vessels, and abdominal con­tents within the hernia sac. This anatomic preview may decrease perioperative com­plications, which, although infrequent, are potentially serious. By facilitating TEP, this combined technique can also potentially lessen the learning curve of TEP.
The procedure starts with the author’s standard laparoscopic access which is an open access. After local anesthesia inltration (20mL of bupivacaine 0.25%), a vertical transumbilical incision (more prominent for the infraumbilical direction) is performed (Fig.34.9). Careful dilation of the aponeurotic umbilical orice is made by the tip of a needle holder. A 10 mm trocar with a blunt dilating tip is gently inserted after proper dilation of this aponeurotic orice (Fig.34.10). The patient undergoes pneumoperitoneum using a CO
pressure ranging from 8 to 12mmHg.
2
Then, a 30° laparoscope is used for the entire procedure. Veress needle and 3mm scope are not used here.
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Fig. 34.10 Direct insertion of blunt-tip trocar at the umbilicus. (a, b) Sequence showing how dilation of the umbilical orice is achieved by inserting a blunt-tip trocar. (c, d) Through the inci­sion previously placed in a hidden umbilical fold, a blunt-tip trocar is inserted into the peritoneal cavity. No Veress needle or sutures are used
G. Carvalho et al.
After completing the initial setup, an inspection of the abdominal cavity is car­ried out before starting the herniorrhaphy procedure. Potentially complicated cases are immediately converted to conventional laparoscopy by using 5mm conventional laparoscopic trocars instead of Mini trocars. Incarcerated hernias can be reduced at this moment, after proper evaluation of the bowel, and they usually don’t require conversion (Fig.34.11).
After abdominal cavity inspection, the rst 3.5mm trocar is inserted, with trans­peritoneal visual control, medial to the epigastric vessels, almost at the midline, using the atraumatic 3mm blunt dilating tip obturator and avoiding peritoneal per­foration (Fig.34.12a, b). Through this Mini trocar, dissection is made with small sideway movements between the peritoneum and the musculoaponeurotic planes under transabdominal laparoscopic vision. After removing the Mini trocar obtura­tor, the CO
tubing is disconnected from the 11mm umbilical trocar and relocated
2
to the Mini trocar with the appropriately placed Luer lock. The preperitoneal insuf­ation begins at the same moment that the 11mm intraperitoneal umbilical trocar valve is opened halfway. At this point, we directly visualize the CO the preperitoneal space (Fig.34.12c, d)
ination into
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Fig. 34.11 (a-d) Reduction of incarcerated inguinal hernia. Under laparoscopic (TAPP) vision, external compression maneuvers are gently performed, and bowel can generally be reduced
Fig. 34.12 Combined Mini-TAPP-TEP procedure. Creation of the preperitoneal space under lapa­roscopic view for a right inguinal hernia repair (a) intial view; (b) blunt dissection with the Mini trocar; (c, d) preperitonial insuation under direct view
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G. Carvalho et al.
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Fig. 34.13 Combined Mini-TAPP-TEP procedure. Image sequence shows how to transition from the intraperitoneal space (TAPP portion of the procedure) to the preperitoneal space (TEP portion of the procedure). (a) Umbilical skin incision. (b) Foley catheter is inserted intraperitoneal. (c) Subcutaneous tunnel 4cm long is created with a blunt Kelly forceps. (d, e) Pyramidal sharp trocar is gently advanced into the subcutaneous tunnel to access the preperitoneal space 3–4cm lower than the umbilical fascial incision. (f) The 10mm scope is utilized to bluntly enlarge the preperi­toneal space
After proper preperitoneal ination, the tip of an 18–20Fr Foley catheter is placed inside the abdomen through the umbilicus to vent any intraperitoneal CO2 that may develop either by diffusion or damage to the peritoneum during hernia sac dissection (Fig.34.13). The 10mm trocar is reintroduced through the umbilical skin incision and passed along a subcutaneous tunnel entering the fascia 3–4cm below and directed in a 45° angle toward the preperitoneal space recently created, which already has enough size to start the preperitoneal dissection. It is not necessary to use a balloon dissector because the proper workspace is progressively established with the laparoscope tip and 3mm dissection instruments introduced via the 3.5mm trocar. At this moment, a second 3.5mm trocar is inserted, in a good triangular posi­tion, to facilitate dissection of the preperitoneal space, now by bimanual technique. At the end of the setup, there will be (1) an umbilical transperitoneal hole, kept open by a Foley catheter; (2) an 11mm trocar passing through the same umbilical skin incision, through a separate hole in the posterior rectus sheath, and into the preperi­toneal space; and (3) two 3.5mm Mini working trocars.
The TEP part of the procedure then proceeds under direct preperitoneal view. After acquiring adequate preperitoneal space to fully identify the inguinal anatomy using bimanual dissection, the hernia sac is properly dissected, and the preperito­neal space is expanded to accommodate a 15 × 13 cm medium or heavyweight polypropylene mesh with rounded corners (Fig.34.14). At this point, the hernia
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34 Inguinal Hernia Repair withMini-laparoscopic Instruments
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 34.14 Combined Mini-TAPP-TEP procedure. The image sequence shows adequate exposure of the preperitoneal space, which is performed by bimanual Mini dissection (a, b). Following proper identication of the hernia sac, it is progressively separated from the spermatic cord and oor structures by meticulous blunt dissection (c) and cautious use of electrocautery (d)
477
orice and the inguinal anatomic landmarks (the iliopubic tract, vas deferens, gonadal vessels, epigastric vessels, urinary bladder, and Cooper’s ligament) must have been well identied (Fig.34.8).
The polypropylene mesh is tightly rolled, grasped with a 5 mm forceps, and gently and blindly inserted through the 11mm trocar into the preperitoneal space (Fig.34.15a). It is unrolled and positioned, completely covering the entire inguinal region, and it is usually not xed (Fig.34.15b). Selected large direct hernia defects should cause consideration for mesh xation. Preperitoneal CO2 is released allow­ing the peritoneum to compress the mesh, keeping it in place and exempting the need for mesh xation in most cases. After correct mesh positioning, the 11mm trocar is removed from the preperitoneal space and reintroduced again into the abdominal cavity, via the hole that was containing the Foley catheter. This allows the mesh to be examined from its inner aspect, conrming that it is correctly placed and without folds (Fig.34.15c, d). If better positioning of the mesh is necessary, it can be accomplished by introducing one 3.5mm trocar by the same skin hole into the peritoneal cavity. Subsequently, intraperitoneal CO2 is fully evacuated. The pro­cedure is nished by performing closure of the fascial defect at the umbilicus using a purse-string suture. The 3.5mm skin incisions will heal without suture, being covered with surgical tape or topical skin adhesive (Fig.34.16).
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G. Carvalho et al.
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Fig. 34.15 Combined Mini-TAPP-TEP procedure. (a) The rolled polypropylene mesh is gently and blindly inserted through the 11mm trocar, aiming toward the pubis. (b) Care is taken while spreading out the mesh completely in the preperitoneal space until it covers the entire inguinal- crural region and ts the individual anatomy. (c) Preperitoneal CO compress the mesh and keep it in place. After reinsertion of the 11mm trocar intraperineally, it is possible to inspect the inner aspect of mesh. The surface of the mesh should give a smooth appear­ance without any signs of wrinkles. Note the oppiness of the well-mobilized hernia sac. (d) Proper implantation of the mesh is conrmed after some minor wrinkles have been smoothed out with the aid of a 3mm forceps introduced into the peritoneal space for this purpose
is gradually released allowing the peritoneum to
2
Fig. 34.16 Appearance of mini-laparoscopic skin incisions on postoperative day 5. (a) Mini repair of a recurrent right inguinal hernia, following two prior open repairs. (b) Mini repair of a left inguinal hernia
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34 Inguinal Hernia Repair withMini-laparoscopic Instruments
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Conclusion
Mini-laparoscopy can be regarded as a natural progression and renement of
standard multiport laparoscopy. It preserves the principles of port placement,
instrument triangulation, and procedure conduct. Also, if the surgeon adopts the
use of low- friction Mini trocars and current generation mini instruments,
increased surgical precision can be achieved. Mini requires no expensive capital
expenditures, maintenance contracts, or single-use devices, an advantage over
other reduced port surgery options. These factors are driving the renaissance of
mini-laparoscopy.
Regarding inguinal hernia repair, mini-laparoscopy can be somewhat helpful for TAPP.It is especially helpful for TEP because TEP is executed in a con­strained space. A recently developed combined Mini-TAPP-TEP technique blends together advantages of each approach, and this may become a useful option for performing almost scarless laparoscopic inguinal hernia repair, though further study is needed.
The study of mini-laparoscopy is most mature regarding its use for cholecys­tectomy, where level I data reveal that Mini results in less immediate postopera­tive pain, better short-term cosmetic outcomes, and no apparent increase in complications compared to conventional laparoscopy. While the published expe­rience regarding mini-laparoscopy for inguinal hernia repair is less mature, the early ndings appear similar—comparable safety, comparable effectiveness, and mildly improved post-op pain and cosmesis. With respect to cost, avoiding sin­gle-use disposable devices and omitting mesh xation appear to improve cost-effectiveness.
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