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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, andeTEP Approaches
https://t.me/med1917
astric
essels
Median
unbilical
fold
Fig. 1 Right indirect inguinal hernia
Fig. 2 Peritoneal incision
411
Indir
hernia
sac
lateral extent of this incision, the incision is curved inferiorly to just below the level
of the defect and beyond the anterior superior iliac spine (ASIS) (Fig.2).
2.1.3 Dissection
Dissection begins in the indirect space where the testicular vessels and vas deferens
are identied and dissected off the underlying peritoneum (Fig.3a, b). In the female
patient, the round ligament is generally quite adherent to the peritoneum and in
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a
esticular
esticular
Her
sac
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Hernia
sac
A. T. Lucy and M. N. Mustian
Vas
deferens
T
vessels
b
Vas
deferens
T
nia
Fig. 3 (a) Testicular vessels are seen dissected off the peritoneum while vas deferens are still
attached. (b) Both testicular vessels and vas deferens are mobilized off the peritoneum
order to avoid peritoneal tears and to place the mesh against a at surface, the round
ligament can be divided with minimal risk. The preperitoneal space is dissected
along the medial portion of our incision. The bladder is mobilized in the space of
Retzius and separated from Cooper’s ligament for a distance for 2cm (Fig.4).
Direct defects will be found in this location and should be reduced by removing the
preperitoneal fat off of the overlying transversalis fascia. Indirect hernia sacs should
then be reduced and separated from the vas deferens and testicular vessels (Fig.5).
s
’s
es
He
sac
Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, andeTEP Approaches
https://t.me/med1917
Pubic
ymphysis
Fig. 4 Bladder mobilization to expose the pubic symphysis and Cooper’s ligaments
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Cooper
ligament
Cord
rnia
Fig. 5 Reduction of an indirect hernia sac
structur
Once the hernia sac has been completely reduced, adequate space must be created in order to accommodate the mesh. Careful dissection along the iliac vessels is
performed in an avascular plane to expose the femoral space and create adequate
room for mesh reinforcement. Care should be taken to avoid vessels in this area
such as the obturator vein and corona mortis as it traverses Cooper’s ligament. The
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s
ic
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Direct
space
Pubic
ymphysis
A. T. Lucy and M. N. Mustian
Epigastr
vessels
Indirect
space
Cooper’s
ligament
Fig. 6 Completed dissection
Testicular
vessels
completed dissection is seen in Fig.6 and dissection should include the myopectineal orice, with skeletonized cord structures and bladder separation more than 2cm
away to accommodate mesh placement. Care should be taken to preserve the investing fascia of the lateral abdominal wall nerves. All cord lipomas should be reduced
as well. The critical view of the myopectineal orice should be achieved prior to
mesh placement regardless of approach (TAPP, TEP, eTEP) (Table1) [4].
2.1.4 Mesh Placement
Proper mesh placement should focus on covering the entire myopectineal orice
with wide 2cm overlap in all directions as described above. We use an anatomically shaped polypropylene mesh which can be inserted through the 8mm robotic
trocar or the 12mm laparoscopic trocar and extends medially to at least the pubic
symphysis and most commonly to the contralateral side (Fig.7). Mesh should be at
least 10×15cm and may require larger mesh to fully cover the myopectineal orice. Fixation is not generally required for unilateral hernias but can be performed
with large defects or bilateral hernias. If xation is desired, the mesh can be secured
with sutures to Cooper’s ligament or the rectus muscles and laterally above the
level of the iliopubic tract. Great care must be taken not to xate below Cooper’s
ligament medially or the iliopubic tract laterally as vascular or nerve injuries
could occur.
Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, andeTEP Approaches
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Table 1 Nine steps to achieve the critical view of the myopectineal orice [4]
1 Identify and dissect the pubic tubercle across the midline and Cooper ligament (CL). For
large, direct hernias, extend the dissection to the contralateral CL.
2 Rule out a direct hernia. Remove unusual fat in the Hasselbach triangle.
3 Dissect at least 2cm between CL and the bladder to facilitate at placement of the
medial and inferior edge of mesh toward the space of Retzius, thereby avoiding mesh
displacement caused by bladder distention.
4 Dissect between CL and the iliac vein to identify the femoral orice and rule out a
femoral hernia.
5 Dissect the indirect sac and peritoneum sufciently to parietalize the cord’s elements.
This step is often not completed, especially in a small surgical eld. To ensure
compliance with this requirement, continue to dissect until the cord’s elements lie at.
Then, visualize the psoas muscle and iliac vessels, pull the sac and peritoneum upward
without triggering movement of the cord’s elements, and dissect between the cord’s
elements to avoid missing a tail of the sac.
6 Identify and reduce cord lipomas (which may appear small and unimportant until
reduced). Usually lateral to the cord’s elements, they should not be confused with lymph
nodes (which are generally spared). Most lipomas do not require removal, but should be
placed above the mesh to help prevent mesh rolling upward.
7 Dissect peritoneum lateral to the cord’s elements laterally beyond the anterosuperior iliac
spine (ASIS), sweeping it back inferiorly well behind the mesh’s inferior border.
8 Perform the dissection, provide mesh coverage, and ensure that mesh and mechanical
xation are placed well above an imaginary inter-ASIS line and any defects, thereby
avoiding recurrence and nerve injury, especially to the ilioinguinal nerve.
9 Place the mesh only when items 1 to 8 are completed and hemostasis has been veried.
Mesh size should be at least 15×10 cm, although a larger piece of mesh is sometimes
required to cover the MPO.Preferably, choose mesh that adapts to the contour of the
space and the cord’s elements. It should not have undue memory. Place it without creases
or folds. Avoid splitting the mesh. Ensure that its lateroinferior corner lies deep against
the wall and does not roll up during space deation (use glue or careful suturing if
necessary).
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Fig. 7 Mesh placement
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Fig. 8 Peritoneal closure
2.1.5 Peritoneal Closure
The peritoneal defect needs to be closed over the mesh to prevent bowel exposure to
the mesh and minimize adhesions. This may be completed with a variety of methods. We prefer to suture the defect with a continuous running barbed slowly absorbable suture (Fig.8). Alternatively, tacks may be used for peritoneal closure. With the
peritoneal defect closed, the trocars are removed, the abdomen is desufated. If a
12mm trocar is utilized, the fascial defect is closed with interrupted absorbable
suture. Generally the 8 mm robotic trocars may not need fascial closures unless
open Hasson technique is employed. Skin sites are closed with 4-0 monocryl and
sealed with skin glue. The scrotum is inspected following the procedure to ensure
both testicles are present.
A. T. Lucy and M. N. Mustian
3 Minimally Invasive Totally Extraperitoneal
Approach (TEP)
A variety of approaches to inguinal hernia repair are available to surgeons. The
laparoscopic totally extraperitoneal (TEP) approach allows for mesh placement
within the preperitoneal space without entering the abdominal cavity, thereby avoiding the incision and closure of the peritoneum required of the TAPP approach. Some
have suggested that TEP avoids the potential for intraabdominal complications.
However, TEP and TAPP repair have been shown to have comparable length of stay,
cost, rates of postoperative hernia recurrence, post operative complications, sexual
function and chronic pain [5–7]. Given the conicting or equivocal data, we recommend that the choice of the technique should be based on the surgeon’s skills, education, and experience. We will describe our typical TEP approach below.
Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, andeTEP Approaches
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4 Preoperative Setup
Similar to the laparoscopic TAPP approach, the surgeon and assistant should position themselves optimally for operating in the inferior abdomen and pelvis. The
room and equipment should be organized to allow clear line of sight to a single
monitor which is placed at the patients feet.
4.1 Entry andPort Placement
Initial incision is made just lateral and below the umbilicus on the contralateral side
of the hernia, avoiding the midline where the anterior and posterior rectus sheaths
merge. Dissection is carried to the anterior rectus fascia and is incised longitudinally and the rectus muscle retracted laterally to expose the posterior fascia.
Dissection starts between the rectus muscle and posterior fascia with a nger or
blunt dissecting instrument such as a balloon tipped trochar. A 5mm optical viewing trocar is advanced through the rectus muscle and directed into the retromuscular
space towards the pubic symphysis. Avoid over-aggressive insertion posterior to the
symphysis due to the risk of bladder injury. This space is developed enough to
accommodate additional ports, a 12mm midline and two 5mm lower abdominal
ports, one approximately one nger breadth above the symphysis, the other halfway
between the two previously placed trocars. The pubis and Cooper’s ligaments
should be seen bilaterally, the rectus bers and inferior epigastric vessels anteriorly
and the urinary bladder posteriorly (Figs.9 and 10).
Unreduced direct hernias should be carefully reduced, clearing Cooper’s ligament and allowing for visualization of lateral structures (Figs.11 and 12). Prior to
lateral dissection, the position of the inferior epigastric vessels should be identied.
It is important that lateral peritoneal dissection occur posterior to the plane of the
epigastric vessels. In rare circumstances, the epigastric vessels may be clipped and
divided should they dissect free from the rectus bed.
Fig. 9 View through
dissecting balloon. Note
pubis and Cooper’s
ligament bilaterally
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Fig. 10 View through
dissecting balloon showing
left inferior epigastric
vessels and direct hernia
Fig. 11 Attenuated
transversalis fascia of left
direct hernia, medial to
inferior epigastric vessels
A. T. Lucy and M. N. Mustian
Fig. 12 Left direct
inguinal hernia fully
reduced
4.1.1 Dissection
Lateral peritoneal blunt dissection will expose the arcuate line anteriorly and the
psoas muscle posteriorly. The three cutaneous nerves, ilioinguinal, genitofemoral
and lateral femoral cutaneous, lay on the psoas muscle and should be avoided during dissection and mesh xation. Lateral dissection will expose the lateral aspect of
an indirect hernia sac. This sac should be reduced from the internal ring. Spermatic
cord structures are skeletonized and carefully preserved, exposing the iliopubic
Minimally Invasive Inguinal Hernia Repair: TAPP, TEP, andeTEP Approaches
https://t.me/med1917
Fig. 13 Left side view of
spermatic cord vessels
lateral and vas deferens
medial. Peritoneum
dissected in cephalad
direction to a point where
the vas deferens courses
inferomedially toward
bladder
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tract. The indirect sac should be dissected in a cephalad direction to the point at
which the vas deferens turns inferiorly toward the bladder (Fig.13). The internal
ring should be examined for evidence of a lipoma and dissected away if present. All
hernias are reduced and separated from the bladder for a distance of 2cm away from
Cooper’s ligament to accommodate the mesh placement as described above in the
TAPP approach (Table1).
4.1.2 Mesh Placement andClosure
There are a variety of mesh products that may be used for the repair. Precontoured
polypropylene mesh measuring at least 10×15cm are commonly employed. Mesh
is inserted through the larger port and positioned over the inguinal oor, covering
direct, indirect, femoral and obturator spaces. It is essential that the mesh cover these
spaces widely, while avoiding peritoneal migration beneath the posterior aspect of
the mesh. As described in the TAPP approach, mesh xation may be utilized routinely or selectively (direct hernias, large indirect hernias) with suture. Fixation
should occur in three areas: Cooper’s ligament, anteromedial and anterolateral.
Posterolateral xation is to be avoided due to risk to the cutaneous nerves. For bilateral hernias, either two separate overlapping pieces or one large mesh can be used.
Ports are removed as the space is de-sufated and all gas is evacuated. The anterior fascia is then closed with a 2-0 PDS and all skin incisions were closed with 4-0
Monocryl and skin glue.
4.2 Laparoscopic Extended Totally Extraperitoneal
Approach; eTEP
Minimally invasive techniques can be tailored to t specic patient needs.
Anatomically the inguinal extraperitoneal space can be reached from different
points on the abdomen. The TEP has a few drawbacks, namely, cramped port placement into a conned dissection space that can result in difculties with mesh
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A. T. Lucy and M. N. Mustian
placement. The TEP approach also has a steeper learning curve and longer operative
times for young hernia surgeons which can limit its use. Given these limitations, the
extended totally extra peritoneal repair (eTEP) was developed. In eTEP, ports are
placed further away from the myopectineal orice, creating a large extraperitoneal
space which further allow different options for working port placement and eases
tissue dissection. Pneumoperitoneum settles better in the larger spaces, with very
little extravasation into the peritoneal cavity or subcutaneous area. It provides better
ergonomics and also eases in maintaining triangulation of ports.
The eTEP technique utilizes three modications compared to TEP:
1. Higher placement of the optic trochar
2. More exible distribution of trochars
3. Division of the arcuate line
4.2.1 Entry
Initial incision is made higher in the upper quadrant of the contralateral side of the
inguinal hernia, or on either side if there are bilateral inguinal hernias. Incision
should be made 5cm lateral to the umbilicus and 2cm cephalad.
4.2.2 Dissection totheRetrorectus Space
Dissection into the retrorectus space can be carried out in a few ways. One approach
is via open blunt dissection to the anterior rectus fascia and incising the anterior
fascia longitudinally. The rectus muscle is retracted laterally to expose the posterior
fascia, which will be thicker at this level of the abdominal wall. Conversely, retrorectus space can be entered with Optiview technique via a 5mm port. Slight lateral
movements will dissect this space and allow for insufation to 12mmHg pressure.
Using the camera or balloon, blunt dissection to below the umbilicus is achieved
for safe placement of a periumbilical 12mm trochar near the midline. An additional
5mm trochar is inserted under direct visualization into the retrorectus space in ipsilateral lower quadrant of the hernia.
If repairing the inguinal hernias robotically, 8mm trocars are used. The robot is
then docked.
4.2.3 Arcuate Line Release
Scissors are then introduced into the lowest trochar and the arcuate line is cut from
the underlying peritoneum laterally, but medial to the semilunar line. This is done
easily laterally as the two layers tend to fuse at the midline. The surgical eld
obtained with this approach is larger that the usual TEP approach.
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