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30 Open New Simplied Totally Extraperitoneal (ONSTEP) Technique forInguinal Hernia Repair
303
repair, because the mesh will be present both preperitoneally and between the two aponeuroses
laterally. It is, however, no problem at all to do a
recurrence repair after a previous ONSTEP. It
may preferably be done by two different
approaches, one being a simple re-ONSTEP procedure and the other by laparoscopic operation. If
doing a re-ONSTEP, then you dissect on top of
the previously placed mesh, with dissection
between the mesh and the pubic bone making a
new space for a new Onex mesh. A mesh is then
placed between the old mesh and the pubic bone
without removing any part of the old mesh. With
a laparoscopic repair, we use the transabdominal
preperitoneal (TAPP) approach; it has been easy
to take down the peritoneum from the inside, and
then simply put a standard at mesh in the preperitoneal space as a standard TAPP procedure.
30.3 Clinical Data
The rst clinical data regarding the ONSTEP
technique is a large and impressive series of
patients from two centers. The inventors presented 693 patients operated with the technique
and followed up for one year [1]. Several ndings
from this paper showed a promise of a better
open technique. Firstly, the degree of pain was
very low, and none of the patients had chronic
pain at 1-year follow-up. Secondly, only four
recurrences (0.6%) were found with three of
them being in women. This has led the inventors
to slightly modify the technique for female
patients. Thirdly, a very short duration of surgery—mean (SD), 17 (6) minutes—was found,
which can be cost-saving for a department since
it will allow for more patients to be operated in
one day. Such a large series with promising
results called for further scientic exploration of
the technique and also justied the conduction of
randomized controlled trials. Surgeons from
other countries in Europe visited the inventors,
learned the technique, and started operating at
their own centers.
The rst published results from outside
Portugal were from Denmark and included 80
patients, with follow-up by standardized questionnaires [9]. Results were good, albeit with the
use of questionnaires and not a dichotomous pain
registration some patients were found to have
pain, but at very low levels. Later, results were
presented from a series from Greece [10]. Results
were still similar, with low levels of postoperative
pain and no patients with chronic pain. A similar
report was published from the Czech Republic
[11], still with promising results (Table30.1).
The non-controlled series outside the departments of the inventors supported the promising
results but are all at risk of bias since no randomization and/or control group was added to any of
the studies. Furthermore, follow-up time and
methods were not standardized. Therefore, there
was a need for randomized clinical trials. As of
December 2015, two prospective trials can be
found on the WHO trial search portal [12]. Both
studies are from Denmark. One is the ONSTEP
versus Lichtenstein (ONLi) study, with 290
included patients and 1-year follow-up [5]. The
other, ONSTEP versus Laparoscopy (ONLap), is
nished but not published yet [6]. Both studies
are being conducted as multicenter studies with
general surgical departments, i.e., not specialized
hernia centers.
The early results from the ONLi trial demonstrated a safe implementation of the technique,
with results similar to the Lichtenstein technique
[13]. The only signicant difference found in the
early results was the duration of surgery. Patients
were followed up with several questionnaires and
at 6-month follow-up, a signicant difference
was found, favoring the ONSTEP technique in
the number of patients experiencing pain during
sexual activity [14]. Follow-up for pain at 6 and
Table 30.1 Case series
Country No Study type Persistent pain (%) Recurrence Minutes
Portugal [1] 693 Case series 0 4 (0.6) 17 (+6)
Denmark [9] 80 Case series 4.5 0 24 (13–53)
Greece [10] 33 Case series 0 0 33.28 (+11.69)
Czech [11] 72+25 Case series 0 2 18–35
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J. Rosenberg and K. Andresen
12 months showed that the number of patients
with nonsexual pain and the intensity of pain
were similar in the two groups. A noteworthy
nding was that two patients in the Lichtenstein
group experienced disabling chronic pain after
surgery. Both had the mesh surgically removed as
well as neurectomy conducted around 6months
postoperatively with complete resolving of pain
for one patient but persisting pain for the other.
No patients in the ONSTEP group experienced
these disabling symptoms.
The ONLap study is designed to show noninferiority between the ONSTEP and the laparoscopic technique (TAPP), i.e., similar levels of
postoperative pain. The rationale is that the
ONSTEP technique has some advantages compared to laparoscopy, and therefore, if non-inferiority can be demonstrated regarding pain, other
advantages will justify it as a valid alternative.
The advantages are that the ONSTEP technique
has a shorter duration of surgery, it does not
require the same expensive equipment as laparoscopic repair, and it is likely to have a much
shorter learning curve.
30.4 Learning, Training,
andImplementation
The ONSTEP procedure has a shorter duration of
surgery than a standard Lichtenstein or laparoscopic repair, and surgeons learning the technique nd it easy to learn. To our knowledge, it
has primarily been learned by surgeons already
familiar with hernia repair, and therefore, experience is lacking as to how well younger surgeons
in training can pick up the technique. We believe
that it will be easier to learn than the Lichtenstein
repair, but solid data are missing to support this.
It is very likely easier to learn the ONSTEP technique compared to the laparoscopic techniques
(TEP or TAPP), since no endoscopic skills are
needed.
Implementation of the ONSTEP technique
can be done if surgeons with experience are willing to learn the technique. It has been suggested
that the optimal way of learning the technique
and subsequent implementation is when the
training is done as proctoring [15]. When training
surgeons in the ONSTEP technique, some concerns and difculties need to be addressed, such
as fear of the preperitoneal space [16].
30.5 Health Economics
A formal health economics analysis comparing
the ONSTEP method with laparoscopic and
Lichtenstein repair has not been conducted yet,
but it is planned to use the data from the ONLi
and ONLap randomized trials [5, 13] for such an
analysis. It is expected that the ONSTEP method
will prove to be cost-saving compared to the laparoscopic techniques and comparable or maybe
even cost-saving compared to the Lichtenstein
technique.
Compared to the laparoscopic technique, the
Lichtenstein technique has been demonstrated to
result in lower costs [17], mainly due to the cost
of equipment, sterilization, and time in the operating room. The level of pain, minor complications,
and sick leave are expected to be similar between
the laparoscopic and the ONSTEP technique, so
the cost from sick leave will probably be equal in
the two groups. The laparoscopic technique
results in a low, albeit increased risk of serious
complications that can result in increased costs.
Compared to Lichtenstein, the costs of conducting the ONSTEP are more or less comparable but with a more expensive mesh. However,
the price of the mesh might be justied by the
shorter duration of surgery, which in some healthcare systems is an important economic factor.
However, it is well known that the Lichtenstein
technique carries a risk of serious disabling
chronic pain that results in a tremendous cost for
the society because of resulting unemployment,
for the employer because of long sick leave, and
for the insurance, be it public or private, because
of unemployment benets. The development of
disabling chronic pain seems so far to be avoided
with the use of the ONSTEP technique.
Furthermore, if the assumptions regarding a
shorter learning curve are true, younger surgeons
will not need the same amount of supervision,
which can free hands in the surgical department
30 Open New Simplied Totally Extraperitoneal (ONSTEP) Technique forInguinal Hernia Repair
305
and thereby be cost-saving, compared to training
surgeons for the Lichtenstein or laparoscopic
repairs.
Firm conclusions regarding the health economics aspect of the ONSTEP technique can
only be made when results from the ongoing trials are combined and analyzed.
30.6 Perspectives
If data with the ONSTEP procedure continue to
be robust and shown by different research groups
to produce distinctly low levels of severe disabling chronic pain and comparable levels of
acute pain and recurrences, then there may be a
place for the ONSTEP procedure in the routine
surgical armamentarium for repair of inguinal
hernias. The procedure is fast and easy to learn,
as well as advantageous compared with both the
Lichtenstein and the laparoscopic procedure.
Thus, ONSTEP may be rst choice for primary
inguinal hernias in men. In women it may be different since the operative procedure is different
and technically more difcult than in men.
It could therefore be argued, that the laparoscopic procedure should still be rst choice for
women, as recommended in previous guidelines
[18, 19].
If the patient has a recurrent hernia, then an
ONSTEP procedure may be used after previous
ONSTEP or after previous laparoscopic repair. If
the patient has a previous Lichtenstein repair, then
a laparoscopic approach will probably be the easiest technically to perform. The main goal of
changing strategy for choice of operation for
inguinal hernia repair will be to avoid the
Lichtenstein procedure because of the well-known
production of severe disabling chronic pain in
some patients. A new strategy could therefore be
as shown in Table30.2. This, however, has to be
supported by trial data from other research groups
conrming the current available results, as well as
a health economics analysis showing advantages
for the ONSTEP procedure compared to the
Lichtenstein as well the laparoscopic approach.
Table 30.2 Suggested treatment strategies of inguinal
hernias
Current hernia
Male primary
hernia
Male,
recurrent
hernia
Female,
primary hernia
Female,
recurrent
hernia
Male, special
cases (prostate
cancer,
extensive
surgery, etc.)
This could become effective if other research groups can
reproduce the ndings, and the health economics analysis
supports use of the ONSTEP technique
Conclusion
Previous
operation
– ONSTEP
Lichtenstein
Laparoscopic
repair
ONSTEP
– Laparoscopic repair
Open procedure
laparoscopic
repair
– ONSTEP or
Recommended
procedure
Laparoscopic repair
ONSTEP
Laparoscopic repair
or ONSTEP
Laparoscopic repair
Lichtenstein
Lichtenstein
The ONSTEP procedure was introduced by
two surgeons from Portugal and has been
used in the inventors’ clinics with great success. It thereafter spread to several European
countries by proctoring initially at the clinic
in Porto and after that also through local
training in other countries. Randomized trials
have been performed, and until now they have
shown advantages for the ONSTEP procedure compared with Lichtenstein regarding
sexual dysfunction after operation. Another
very interesting feature of the ONSTEP procedure is that until now, after thousands of
procedures, not a single patient with severe
disabling chronic pain has been produced.
This is in contrast to the Lichtenstein procedure where it is well-known that some patients
will develop severe disabling chronic pain.
Overall, the ONSTEP procedure seems to be
very promising and will probably nd its
place in routine inguinal hernia repair in the
near future.
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J. Rosenberg and K. Andresen
References
1. Lourenço A, da Costa RS.The ONSTEP inguinal her-
nia repair technique: initial clinical experience of 693
patients, in two institutions. Hernia. 2013;17:357–64.
2. Sevonius D, Montgomery A, Smedberg S, Sandblom
G.Chronic groin pain, discomfort and physical disability after recurrent groin hernia repair: impact
of anterior and posterior mesh repair. Hernia.
2016;20:43–53.
3. Pélissier EP, Ngo P, Gayet B.Transinguinal preperi-
toneal patch (TIPP) under local anesthesia with sedation. Am Surg. 2011;77:1681–4.
4. Lange JF, Lange MM, Voropai DA, et al. Trans rec-
tus sheath extra-peritoneal procedure (TREPP) for
inguinal hernia: the rst 1,000 patients. World J Surg.
2014;38:1922–8.
5. Andresen K, Burcharth J, Rosenberg J.Lichtenstein
versus Onstep for inguinal hernia repair: protocol
for a double-blinded randomised trial. Dan Med J.
2013;60:A4729.
6. Andresen K, Burcharth J, Rosenberg J.Onstep versus
laparoscopy for inguinal hernia repair. A protocol for a
randomized clinical trial. Dan Med J. 2015;62:A5169.
7. Öberg S, Andresen K, Hauge D, Rosenberg
J.Recurrence mechanisms after inguinal hernia repair
by the Onstep technique—a case series. Hernia.
2016;20(5):681–5.
8. Öberg S, Andresen K, Rosenberg J.How to surgically
remove the permanent mesh ring after the Onstep procedure for alleviation of chronic pain following inguinal hernia repair. Case Rep Surg. 2016;2016. article
ID 5209095.
9. Andresen K, Burcharth J, Rosenberg J. The initial
experience of introducing the Onstep technique for
inguinal hernia repair in a general surgical department. Scand J Surg. 2015;104:61–5.
10. Marinis A, Psimitis I. The open new simplied
totally extra-peritoneal (ONSTEP) inguinal hernia
repair: initial experience with a novel technique. Hell
Cheirourgike. 2014;86:362–7.
11. Kohoutek L, Musil J, Plechâcovâ P, Gryga A.Operace
tfïselné kyly technikou ONTEP [The ONSTEP
inguinal hernia repair technique]. Rozhl Chir.
2015;94:152–5.
12. World Health Organization. International Clinical
Trials Registry Platform.
search
13. Andresen K, Burcharth J, Fonnes S, etal. Short-term
outcome after Onstep versus Lichtenstein technique
for inguinal hernia repair: results from a randomized
clinical trial. Hernia. 2015;19:871–7.
14. Andresen K, Burcharth J, Fonnes S, et al. Sexual
dysfunction after inguinal hernia repair with Onstep
versus Lichtenstein technique: a randomized clinical
trial. Hernia. 2016;161(6):1690–5.
15. Rosenberg J, Andresen K, Laursen J.Team training
(training at own facility) versus individual surgeon’s
training (training at trainer’s facility) when implementing a new surgical technique: example from
the ONSTEP inguinal hernia repair. Surg Res Pract.
2014;2014:762761.
16. Andresen K, Laursen J, Rosenberg J.Difculties and
problematic steps in teaching the Onstep technique
for inguinal hernia repair- results from a focus group
interview. Surg Res Pract. 2016;2016:4787648.
17. Medical Research Council Laparoscopic Groin Hernia
Trial Group. Cost-utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre
randomized clinical trial. Br J Surg. 2001;88:653–61.
18. Rosenberg J, Bisgaard T, Kehlet H, et al. Danish
Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan
Med Bull. 2011;58:C4243.
19. Miserez M, Peeters E, Aufenacker T, et al. Update
with level 1 studies of the European Hernia Society
guidelines on the treatment of inguinal hernia in adult
patients. Hernia. 2014;18:151–63.
http://apps.who.int/trial-
Transinguinal Preperitoneal (TIPP)
Inguinal Hernia Repair Using
aTotally Extraperitoneal,
Parietalized, Memory-Ring Patch
Jean-FrançoisGillion andEdouardPelissier
31
31.1 Introduction
Since introduction of the prosthetic repair of
inguinal hernia reduced the recurrence rate to
1–2%, nowadays, chronic pain is the principal
concern for hernia surgeons. This complication is
indeed very common (10–12%) and can be debilitating in 0.5–6% of the cases [1]. The principal
causes of chronic pain related to the surgical technique are nerve injury, chronic irritation by the
brotic reaction induced by the patch, and damage to the spermatic cord or testicular vessels.
The Lichtenstein technique is the most commonly used because it is technically simple and
easy to reproduce, but it entails some of the risk
factors of chronic pain, namely, (1) extended dissection of the inguinal canal required to deploy
the patch on the inguinal wall; (2) mesh xation
to prevent the patch breaking away, by the effect
of intra-abdominal pressure; and (3) chronic irritation of the nerves by the broplastic reaction
induced by the patch.
Most of the technical attempts to minimize
these drawbacks failed to solve the problem.
Identication of the three nerves is not always possible, and it is not associated with a reduced risk of
chronic pain [2], which can even be increased by
neurolysis [3]. Nerve resection can contribute to
reduce the incidence of chronic pain according to
a meta-analysis [4], but it failed to induce signi-
J.-F. Gillion (*) · E. Pelissier
Hôpital Privé d’Antony, 1, rue Velpeau,
92160 Antony, France
cant effect according to another one [5], and in
both instances it resulted in sensory trouble. Fibrin
sealant and synthetic glue were tried to minimize
the risk of nerve entrapment by sutures, but on ve
meta-analyses, only two showed a reduction of
chronic pain [6, 7], though one of them underlined
the poor quality of the trials [6] and three concluded negatively [8–10]. Self-adhesive patches
did not do better. Indeed, a recent large RCT as
well as meta-analyses concluded that the self-gripping mesh could reduce early postoperative pain,
but not chronic pain [11–13].
On the contrary, the preperitoneal patch does
not involve these drawbacks: (1) the patch applied
to the abdominal wall by intra-abdominal pressure requires minimal or no xation at all; (2) the
patch does not contact the nerves in the inguinal
canal; (3) it is no more in contact with the nerves
in the preperitoneal space, since before they
reach the inguinal canal, the ilioinguinal and iliohypogastric nerves run between the internal
oblique and transverse muscles (thus they are
separated from the patch by the transverse muscle) and the genitofemoral nerve runs on the
psoas muscle covered by the fascia iliaca [14].
Meta-analyses have shown that laparoscopic
techniques provide less postoperative pain,
shorter time to resume activity and work, less
numbness, and less chronic pain than open techniques [15–17]. By contrast, a recent meta-analysis by Koning etal. comparing TEP to Lichtenstein
concluded that the advantage of TEP is not really
established, due to the huge heterogeneity and
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_31
307
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J.-F. Gillion and E. Pelissier
insufcient quality of some RCTs [18].
Nevertheless, three RCTs with low risk of bias
[19–22] showed that the TEP provided less postoperative pain, earlier return to activity and to
work, and less chronic pain than the Lichtenstein.
Westin etal. concluded that TEP is the procedure
of choice in the surgical treatment of primary
inguinal hernias [22], and Langeveld etal. concluded that TEP could be recommended as the
optimal technique in experienced hands [19].
Reference to the surgeon’s skills is important,
because of the limitations and drawbacks of laparoscopic techniques. Laparoscopy is indeed more
demanding than the Lichtenstein technique, the
learning curve is longer [23], and it can result in
rare but severe complications [15].
The limits of laparoscopic repair justify the
introduction of minimally invasive open techniques. The trans-inguinal preperitoneal (TIPP)
repair consists of placing the patch in the preperitoneal space by inguinal approach. It was originally introduced by Rives in France [24] and by
Schumpelick in Germany who coined the term
TIPP [25]. These techniques were not simple and
involved long opening of the transversalis fascia,
extended preperitoneal dissection, and transmuscular sutures to x the patch.
The modern TIPP concept consists of a short
inguinal incision; limited dissection; introduction
and deployment of the patch through the hernia
orice, without any other damage to the abdominal wall; and no xation. This is enabled by the
use of the special memory-ring patch Polysoft.
In his initial experience, Pelissier [26] used to
split the patch in most cases of indirect hernias, to
accommodate the spermatic cord, but he soon
switched to parietalizing the cord and not splitting the patch [27]. We describe the current technique based on cord parietalization, without
splitting the patch.
geal mask, completed with a TAP block performed under ultrasound control [28]. The
complete recovery is very fast allowing a quick
return home, which is especially interesting for
those patients operated on even late in the afternoon. This way TIPP is perfectly tted with the D
case surgery.
31.3 Operative Technique:
Lateral Hernia
31.3.1 First Step: Skin Incision
Contrary to some other open preperitoneal
repairs, TIPP uses the inguinal route well known
by every surgeon. A short skin crease incision
(3–5 cm depending on the panniculus adiposus
thickness) is carried out at the level of the deep
inguinal orice (Fig.31.1).
31.3.2 Second Step: Nerve
Preservation
1. Ilioinguinal Nerve.
The external oblique aponeurosis is
incised. A careful attempt to identify and preserve the ilioinguinal nerve (II), running just
behind this aponeurosis, is carried out. It is
easier when done at the beginning of the procedure (Fig.31.2).
2. Ilio-hypogastric Nerve.
31.2 Anesthesia
Contrary to TEP, TIPP does not require a deep
general anesthesia with myorelaxants. TIPP can
be achieved either under local anesthesia [27] or
under a “light” general anesthesia with a laryn-
Fig. 31.1 Short inguinal incision (right inguinal hernia)
31 TIPP Repair Using a Totally Extraperitoneal, Parietalized, Memory-Ring Patch
vessels (lesser cord) and both the internal
spermatic vessel and the vas deferens (proper
cord) [29].
4. Femoral Branch of the Genitofemoral Nerve.
As we will see further, the preperitoneal dissec-
tion is done in the visceral compartment close
to the peritoneum and not in the lateral compartment where runs the genitofemoral nerve
(GF) and caudally its femoral branch (FBGF).
309
Fig. 31.2 Identication and preservation of the ilioingui-
nal nerve
Fig. 31.3 Dissection between the proper cord and the
lesser cord avoid any further traction on the genital branch
of the genitofemoral nerve
Contrary to what is required in the
Lichtenstein repair, no extensive dissection
between the external oblique aponeurosis and
the internal oblique muscle is necessary; therefore, the ilio-hypogastric nerve (IH) is protected,
left in its bed far from the TIPP dissection.
3. Genital Branch of the Genitofemoral Nerve.
Unlike in the Lichtenstein procedure, the
inguinal oor (anterior aspect of the transversalis fascia) has not to be cleaned up.
The genital branch of the genitofemoral
nerve (GBGF) is left in place alongside the
external spermatic vein, called the Amid’s
“blue line” [29] which helps to nd the nerve.
If the cord is lifted, in order to facilitate the
parietalization of the cord constituents, attention is paid to avoid any direct or indirect traction on the GBGF leaving in place the external
spermatic vessels. This is achieved (Fig.31.3)
by passing through the window between these
31.3.3 Third Step: Treatment
oftheHernia Sac
In lateral (indirect) hernia, the cremaster muscle
is not resected, just longitudinally incised; the sac
is dissected free, not resected and will be further
reduced in the preperitoneal space through the
internal orice. Should you want to resect the
sac, it is useful to postpone that because tensioning the sac helps both the dissection and the
parietalization.
31.3.4 Fourth Step: Dissecting
thePreperitoneal Space
Completely different from the Lichtenstein
repair, the prosthesis will be inserted posteriorly
to the transversalis fascia.
Completely different from the on-step technique, the prosthesis will be totally inserted in the
preperitoneal space, exactly as in TEP.
The preperitoneal space is entered through
the herniated inguinal ring following the inner
aspect of the deferens, laterally and cranially to
the epigastric vessels (Fig.31.4). These vessels
are a landmark to properly enter the preperitoneal space. They are preserved and gently
retracted. The dissection starts just behind the
transversalis fascia (Fig. 31.5), goes to the
Cooper ligament (Fig. 31.6) and the posterior
aspect of the pubicum, and comes back posteriorly to the rectus muscle and to the conjoint tendon. Provided the dissection keeps contact with
the inner part of the abdominal wall, the plane is
totally avascular.
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Fig. 31.4 Epigastric vessels, the door for the preperito-
neal space
J.-F. Gillion and E. Pelissier
31.3.5 Fifth Step: Parietalization
oftheCord Elements
The inguinal ring, muscular, can be easily
enlarged. Two Langenbeck’s retractors are introduced. The second gauze is then introduced and
kept in place with the retractor. That helps to
expose the peritoneum being separated from the
vas deferens and the spermatic vessels.
It is actually difcult to imagine how much
this minimal approach can provide a sufcient
exposure onto the preperitoneal structures
(Fig.31.7). This approach allows a complete dissection, under a permanent visual control (blunt
but not blind dissection) of the peritoneum, the
vas deferens, and the anterior aspect of the internal spermatic vessels (Fig.31.8).
Fig. 31.5 Dissection of the Bogros space and right part
of the Retzius space
Fig. 31.6. Cooper’s ligament
A rst large gauze is inserted in the Bogros
space, acting as an auto-static retractor.
Fig. 31.7 Preperitoneal view during the parietalization
(C cord; P peritoneum; R gauze in the Retzius space)
Fig. 31.8 External view of the laparoscopic “doom tri-
angle” (C cord; D vas deferens; P gauze covering the peritoneum; SV internal spermatic vessels)
31 TIPP Repair Using a Totally Extraperitoneal, Parietalized, Memory-Ring Patch
tice, the length of the index nger in the direction
of the pubis, and in the direction of iliac spine as
well as the same in width, is adequate.
31.3.7 Seventh Step: Positioning
theMesh
At the end of the dissection, the gauzes are
removed before proceeding to placement of the
patch. The size of the Polysoft® patch (medium
or large) is chosen according to anatomy. The
Fig. 31.9 The forceps shows the urogenital sheath in
between the vas deferens (D) and the internal spermatic
vessels (SV)
The vas deferens and the internal spermatic
vessels are ensheathed in the urogenital fascia,
well seen here in between them (Fig. 31.9),
sheath or fascia described by Stoppa etal. [30,
31], and others. They are both gently separated
from the peritoneum as far as needed (angulus of
the deferens); psoas segment of the internal spermatic vessels visualizing the same “lamda” as in
laparoscopic procedures (Fig.31.8). The dissection, close to the peritoneum (Fig.31.9), is conducted in the visceral compartment at the inner
aspect of the sheath, exactly like in TEP and not
in the lateral compartment where run the nerves,
in particular the genitofemoral and caudally its
femoral branch [32].
Its genital branch enters the inguinal canal laterally, at the very external edge of the deep inguinal ring and joins the external spermatic vein, the
so-called “blue line” landmark [29].
medial half of the patch (widest side) is introduced rst in direction of the pubic bone. To do
so, one retractor lifts the epigastric vessels, and a
blade retractor (Fig. 31.10) reclines the peritoneum medially, so as the Cooper ligament
becomes visible. The widest end of the patch,
grasped with the Kelly clamp, is introduced in the
direction of the pubis (Fig. 31.11). Then, the
clamp and retractors are removed.
To introduce the lateral part of the patch, two
retractors lift the lateral edge of the internal orice made up by the internal oblique muscle, and,
using a clamp in one hand and a toothless forceps
in the other, the surgeon manages to gently introduce the lateral half of the patch in the preperitoneal space. Then the lateral part of the ring is
inserted between the parietalized elements and
the peritoneum and the internal part of the ring
behind to the conjoin tendon (Fig.31.12). Then,
311
31.3.6 Sixth Step: Anterolateral
Release ofthePeritoneum
Anteriorly and laterally the peritoneum is separated from the posterior aspect of the arch of the
conjoin tendon. If the hernia sac has to be
removed, remove it at this step.
The extent of dissection must be sufcient to
accommodate the patch, but more extensive dissection is neither necessary nor useful. In prac-
Fig. 31.10 A blade retractor helps for inserting the mesh
in the preperitoneal space through the hernia orice itself
(no additional incision of neither the transversalis fascia
nor the epigastric vessels)
312
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J.-F. Gillion and E. Pelissier
Fig. 31.11 Inserting the memory-ring polypropylene
prosthesis in the preperitoneal space through the hernia
orice itself
Fig. 31.12 Inserting the cranial part of the mesh behind
the arch of the conjoin tendon
the retractors are removed, and deployment of the
patch is achieved (and checked) with the nger
by pushing on the memory-ring (Fig.31.13).
The counterpressure exerted by the patient,
especially under local or locoregional anesthesia,
can facilitate and check a correct deployment
(Fig.31.14).
If the mesh does not correctly t the space,
and/or if the cranial part of the mesh remains
unfold and sharp, consider that the dissection has
not been wide enough. Remove the mesh, complete the dissection, and reinsert the mesh.
No xation (Fig. 31.14) is performed, the
mesh being rmly applied by the abdominal
pressure to the deep aspect of the previously preserved inguinal oor (epigastric vessels not transected and transversalis fascia not open in case
Fig. 31.13 Check the correct positioning of the mesh in
between the peritoneum and the abdominal wall (c cord,
D vas deferens, EV epigastric vessels, M mesh, SV internal
spermatic vessels, TF transversalis fascia)
Fig. 31.14 Not any xation is required
Fig. 31.15 While removing the retractors, the deep
inguinal ring retracts
of lateral hernias, sutured in case of medial
ones).
While removing the retractors, the deep inguinal ring retracts (Fig. 31.15), leaving the mesh
totally retro-parietal (Fig.31.16).
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