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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
124
F. Köckerling et al.
. Fig.11.12 Observing the landmark structures like
the pubic bone with Cooper’s ligament and the sac of a
medial hernia on the left side
11
rectus muscle) (. Fig. 11.12). In particular in
the case of older patients, displacement of the
epigastric vessels from the rectus muscle in the
dorsal direction can be avoided by appropriate
maneuvering of the balloon under direct vision.
Direct hernias are reduced almost completely by
the dissection balloon through which the whitish,
transversalis fascia overlapping Cooper’s ligament
dorsally remains visible (. Fig.11.12). e use of
the dissection balloon is, of course, optional, and
the preperitoneal dissection can also be eected
bluntly with the telescope trocar. In our opinion, however, utilization of the balloon results
in an appreciable saving of time and a reduction
in bleeding by enabling the early identication
of the epigastric vessels. In a Swedish prospective randomized study involving more than 300
patients with unilateral primary hernias operated
on utilizing the TEP approach, a signicantly
lower conversion rate and a signicantly shorter
operating time were found in the group in which
the dissection balloon was employed [16].
In the IEHS Guidelines, it is therefore recommended that balloon dissection should be
considered for extraperitoneal space creation,
especially during the learning curve, when it is
dicult to nd the correct plane in the preperitoneal space [12].
Aer removing the telescope and the deated
balloon, a 10mm blunt-Tip trocar (
. Fig.11.13) is
advanced to the posterior rectus sheath or a reusable 10mm Hasson trocar secured to the anterior
rectus sheath with sutures. With the patient in
a mild Trendelenburg position, CO
insua-
2
tion at a pressure of up to 12mmHg is initiated
(. Fig.11.14). 4–5cm caudal to the umbilicus, a
5mm blunt-tip trocar is introduced in the midline under vision (. Fig.11.15).
. Fig.11.13 A 10/12mm blunt-tip trocar is advanced to
the posterior rectus sheath (right side)
. Fig.11.14 CO2 insuation at a pressure of up to
12mmHg is initiated
e blunt dissection is then continued, singlehanded, toward lateral, with the peritoneal sac
being dissected from the transverse abdominal
muscle caudally and dorsally to the arcuate line
. Fig.11.16). e arcuate line extending far in
(
the lateral-caudal direction must be incised over a
short distance to ensure safe and adequate dissection (. Fig.11.17). If problems are encountered
with the lateral dissection, as, for example, in
patients aer appendectomy, additional placement of a 5mm trocar suprapubically in the midline is to be recommended.
e lateral, second, working trocar is inserted
under direct vision approximately 3–4 cm cranial and 1–2cm ventral to the anterior superior
iliac spine, almost on a level with the telescope
trocar (
. Fig. 11.18a, b). Instead of a 10 mm
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
125
11
a
b
. Fig.11.15 A blunt-tip 5mm trocar is introduced after
control of optimal positioning with a needle a 4–5cm
caudal to the umbilicus b
. Fig.11.16 Dissection of the arcuate line (left side)
trocar, a 5 mm port may be employed in which
case, during the further course of the operation,
the polypropylene mesh must be introduced via
the infraumbilical trocar. An adequate cranial
distance between the anterior superior iliac spine
and the lateral working trocar is necessary to
ensure the problem-free placement to wrinkled
free and 15×13 cm, it extends ventrolaterally to
the iliac spine.
e abovementioned arrangement of the
two working trocars enables a favorable 70–90°
instrument angle, while placement of both working trocars in the midline is associated with an
a
b
. Fig.11.17 Incision of the arcuate line a and the pos-
terior rectus sheath b
unfavorable working angle. Furthermore, in the
event of a large lateral hernia sac, axial tension can
be applied with the grasper via the lateral working
trocar, thus improving dissection and reduction.
In the case of bilateral hernias, a bilateral dissection balloon is employed which is introduced
into the rectus sheath on the side with the larger
hernia. e lateral working trocar cranial to the
anterior superior iliac spine is also introduced on
the side with the larger lesion, and the contralateral side is dissected via the ipsilateral ports.
In the guidelines of the IEHS, also two alternatives for the trocar placement are recommended:
two 5mm working ports in the midline and in the
midway between the camera port and the pubic
symphysis. Alternatively, the second working trocar (5 or 10mm) can be placed aer lateral dissection approximately 3–4cm superior and 1–2cm
anterior to the anterior superior iliac spine [12].
11.2.9 Dissection
If this has not yet been done, the operating table
should be tilted toward the surgeon and moved
into a mild Trendelenburg position aer placement of the trocars as described above, in order
to ensure on the one hand optimal utilization of
the preperitoneal space and on the other hand
126
F. Köckerling et al.
a b
c
11
. Fig.11.18 The lateral working trocar is inserted approximately 3–4cm cranial and 1–2cm ventral to the anterior
superior lilac spine a, b under direct vision c (left side)
relaxation of the surgeon’s shoulder. Here, in
particular the arm of the surgeon operating the
lateral working trocar should be relieved by tilting the table appropriately. e zoom should be
adjusted such that, to enable good orientation,
the maximum possible operating eld is covered.
at the light source and camera gain should be
optimally adjusted goes without saying.
Since the peritoneal sac has already been dissected from the transverse abdominal muscle to a
point 4–5cm cranial to the iliac spine to be able
to introduce the lateral working trocar, it makes
good sense to complete this dissection caudally.
. Fig.11.19 Blunt dissection of the preperitoneal
fascial structure inserted lateral to the inguinal ligament
(right side)
is can be done by bluntly pushing the peritoneal sac (. Fig.11.19) from the lateral abdominal
wall and dorsally from the psoas muscle with the
aid of two instruments. During this manoeuver,
a preperitoneal fascial structure inserted lateral
to the inguinal ligament is encountered, and this
must be divided sharply to enable subsequent
placement of the mesh (
. Fig.11.19).
e lateral femoral cutaneous nerve is usu-
ally seen beneath very thin transparent fascia
(. Fig.11.20). To avoid the subsequent development of neuralgia, this layer should be preserved,
and the course of the nerve carefully identied
before applying any electrocoagulation that might
be necessary.
e genitofemoral nerve with its genital and
femoral branches courses along the median margin of the psoas muscle and is not always visible
. Fig. 11.20). Selective exposure of the nerve
(
appears to be indicated only if electrocoagulation
is intended in this area. Since the femoral nerve
is covered by the psoas muscle, it is usually not
exposed.
To ensure correct orientation, the primary
landmarks epigastric vessels (AV epigastrica
A.,V. epigastrica inferior
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
127
11
. Fig.11.20 Lateral
femoral cutaneous nerve
(n. cutaneous femoris lateralis), genitofemoral nerve
with its genital (ramus genitalis n. genitofemoralis) and
femoral (ramus femoralis n.
genitofemoralis) branches
(right side) (a schematic,
bintraoperative)
a
R. genitalis n. genitofemoralis
M. psoas major
Tractus iliopubicus
Lig. pectineale
b
Ductus deferens
A., V. iliaca externa
N. cutaneus femoris lat.
A., V. testicularis
R. femoralis
n. genitofemoralis
11
128
F. Köckerling et al.
inferior), Cooper’s ligament (pectineal ligament),
iliopubic tract (tractus iliopubicus), and the cord
structures of the deferens duct (ductus deferens)
and testicular vessels (AV testicularis) should be
identied and, if necessary, constantly referred
to (. Fig.11.20). Medially, the preperitoneal and
prevesicular connective tissue is now bluntly
freed bimanually from the pubic bone; in the case
of unilateral hernias, dissection should be accomplished some 2cm to the other side extending the
readily recognizable symphysis. When dissecting
free the pubic bone and Cooper’s ligament, the
iliac vessels must be identied. Here, the vein is
not always readily and unequivocally identiable
because of its dorsal location (. Fig.11.20).
Cooper’s ligament should be freed of tis-
sue mainly with the lateral working hand
(. Fig.11.21), since the instrument is positioned
relatively parallel to the iliac vessels and, in contrast
to the instrument introduced via the 5mm trocar,
is not directed to the vulnerable iliac vein. If, in the
case of a medial hernia, the peritoneal sac has not
already been reduced by the dissection balloon, the
sac, which conceals the iliac vessels, must be separated, stepwise, from the transversalis fascia.
. Fig.11.21 Dissection of Cooper’s ligament with a
blunt instrument via the lateral working trocar (right side)
. Fig.11.22 Dissection of the indirect hernia sac with
the use of the electrocautery hook (right side)
. Fig.11.23 Blunt dissection of the indirect hernia sac
from the deferens duct and testicular vessels (right side)
On completing the creation of the preperitoneal space laterally and medially, the hernia is dissected out (
. Fig.11.22) with exposure of the vas
deferens and the testicular vessels (. Fig. 11.23)
and round ligament and exposure of Hesselbach’s
triangle, the internal ring, and the potential femoral hernia orice. Direct grasping of the vas deferens should be avoided. e peritoneum must be
separated from the retroperitoneal structures dorsally from the internal ring in the cranial direction
for at least 5cm in order to provide an adequate
margin for secure implantation of the prosthetic
mesh. An indirect hernia sac is drawn out of the
inguinal canal by grasping its ventrolateral margin with a laterally introduced atraumatic grasper
and separated from the spermatic cord, stepwise,
using a bimanual technique (. Fig.11.23).
In the IEHS Guidelines, the statements advised
that the dissection should extend superiorly up to
the subumbilical area, inferiorly to the space of
Retzius, inferolaterally to the psoas muscle and
Bogros space until anterior superior iliac spine is
reached, and medially beyond the midline [12].
e landmarks to be visualized are the pubic
bone, Cooper’s ligament (pectineal ligament),
inferior epigastric vessels (AV epigastrica inferior), cord structures (testicular vessels,AV testicularis; deferens duct, ductus deferens), the
myopectineal orice boundaries, and the fascia
over psoas muscle [12] (
. Fig.11.24).
Complete parietalization of the vas deferens
and the testicular vessels needs to be performed
[12] (. Fig.11.24b). Complete dissection of the
whole pelvic oor (anatomical) should be done
for at placement of the mesh to cover the entire
myopectineal orice and prevent its folding [12].
In the case of an open vaginal process or very
large non-reducible lateral hernia sacs (scrotal
hernias), transection of the peritoneum can be
A., V. epigastrica inferior
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
129
11
. Fig.11.24 Extent of
dissection: superiorly up
to the subumbilical area,
inferiorly to the space of
Retzius, inferolaterally
to the psoas muscle and
the Bogros space until
the anterior superior iliac
spine, and medially beyond
the midline (a schematic,
bintraoperative)
a
R. genitalis n. genitofemoralis
M. psoas major
Tractus iliopubicus
Lig. pectineale
Ductus deferens
b
A., V. iliaca externa
N. cutaneus femoris lat.
A., V. testicularis
R. femoralis
n. genitofemoralis
11
130
F. Köckerling et al.
performed, the distal portion remaining unclosed.
e proximal opening is closed with a continuous
endoclip suture.
e updated guidelines on laparoscopic
(TAPP) and endoscopic (TEP) treatment of
inguinal hernia of the International Endohernia
Society (IEHS) state that transection of a large
indirect sac does not lead to signicant dierences
in postoperative pain, length of hospital stay, and
recurrence, but does result in a signicant higher
seroma rate.
e recommendation in the IEHS Guidelines
is that a large indirect sac may be ligated proximally and divided distally without the risk of a
higher postoperative pain and recurrence rate, but
with an increased postoperative seroma rate [13].
e presence of a peritoneal lipoma in the
internal ring must always be excluded, since
lipomas le in situ in the inguinal canal present
postoperatively as a pseudorecurrence and also
carry a risk of necrosis and abscess formation
(. Fig.11.25). If the lipoma can be separated from
the peritoneal hernia sac, it should be drawn out
of the preperitoneal space in toto. When dissecting preperitoneal lipomas, it is important to avoid
injuring vessels and postoperative lymphoceles
through confusion with the lymph vessel-rich
perivascular fat of the pelvic vessels.
e IEHS Guidelines recommend that lipomas of spermatic cord/round ligament and the
preperitoneal lipomas of direct and femoral sacs
should be removed [12].
In the event of a direct hernia, dissection of the
hernia sac from the enlarged transversalis fascia
leaves a space ventral to the mesh (. Fig.11.26).
To prevent hematomas/seromas in this space
formerly lled with hernia sac or a lipoma, we
consider tension-free gathering and securement
. Fig.11.25 Lateral inguinal hernia with an additional
lipoma in the inguinal canal (right side)
. Fig.11.26 Large direct inguinal hernia (left side)
of the extended transversalis fascia to Cooper’s
ligament to be indicated. is is accomplished
with a nonabsorbable suture (2.0) knotted extracorporeally on a straight needle (
. Fig.11.27a–e).
As additional eect of this procedure in the case
of large medial hernia defects is optimization of
mesh placement with prevention of recurrences.
e IEHS Guidelines recommended in
voluminous direct hernias that the extended
transversalis fascia should be inverted [12]. e
direct sac should be inverted and anchored to
Cooper’s ligament to decrease the risk of seroma
and external hematoma formation [12].
Any peritoneal tear occurring during dissection should– with the exception of defects smaller
than 5mm– be closed with a continuous suture,
in order to prevent adhesions between bowel and
prosthesis and the incarceration of small bowel
loops. Apart from the training eect, the rigorous
closure policy also increases safety since peritoneal lesions appear smaller optically than they
actually are on instrumental exposure. According
to the IEHS Guidelines, it is recommended that
peritoneal tears should be closed whenever feasible to prevent adhesions [12].
Although the round ligament corresponds
embryologically to the vas deferens, it is more
rmly fused with the peritoneum, and in the case
of young women, the latter must be dissected free
with the scissors.
Here, again, care must be taken to ensure subsequent peritoneal closure. In older women, severance of the round ligament aer placement of
absorbable clips has proven valuable for avoiding
peritoneal lesions.
Oen, a femoral hernia is found to be an irreducible peritoneal lipoma. Here, to avoid avulsion
of the lipoma, the hernia ring should be enlarged
ventromedially with the aid of a hook scissors.
ab
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
131
11
c
e
. Fig.11.27 Reduction of the large direct sac (left side)
with grasping the extended fascia transversalis a, complete inversion of the sac b and xation accomplished by a
d
nonabsorbable suture (2.0) with a straight needle c, xed
to Cooper’s ligament d and knotted extracorporeally e
. Fig.11.28 Parietalization of the spermatic cord . Fig.11.29 Exposure of the internal ring
11.2.10 Mesh Placement
Hesselbach’s triangle, and the femoral canal,
a careful inspection to ensure the absence of
Aer reducing the hernia sac, parietalization of
the spermatic cord (. Fig.11.28) or the round ligament, and exposure of all true or potential hernia
orices as well as the internal ring (. Fig.11.29),
remaining bleeding is made (
a 10 × 15 cm polypropylene mesh introduced
(. Fig. 11.31) and placed (. Fig. 11.32). If the
defect size is more than 4cm in diameter, the size
. Fig. 11.30) and
132
a
F. Köckerling et al.
. Fig.11.30 Careful inspection of the preperitoneal
space for remaining bleeding with the use of a small
compress
b
11
. Fig.11.31 Introduction of a polypropylene mesh
(TiMesh light) 15×10cm via the lateral 10mm trocar
right trocar (right side)
of the mesh must be matched accordingly – for
example, 13×15cm, 15×15cm, or 12×17cm.
e IEHS Guidelines recommend a mesh of at
least 10×15cm and the use of a bigger mesh (i.e.,
12 × 17cm or greater) for large hernias (direct
>3–4cm, indirect >4–5cm) [12].
. Fig.11.32 Mesh placement overlapping all potential
hernia defects (a schematic, b intraoperative). Mesh type:
TiMesh light (right side)
e mesh is folded concertina-like and then
introduced into the preperitoneal space via the
10mm trocar (. Fig.11.31).
We consider it to be unnecessary to slit the
mesh, since with adequate preperitoneal dissection,
placement of the mesh between the peritoneal sac
and abdominal wall poses no problem. Since there
is no technical need to slit the mesh, it should be
le undone, so as to avoid potential postoperative
irritation of the vas deferens or testicular vessels.
e IEHS Guidelines recommend not cutting
a slit in the mesh.
e polypropylene mesh is placed parallel
to the inguinal ligament, overlaps the symphysis by approximately 2 cm in the contralateral
direction, and extends laterally to the anterior
superior iliac spine. It covers the medial, lateral,
and femoral hernia orice and should be placed
such that the pathological orice is relatively cen-
. Fig.11.32). It is important to ensure that
tral (
the dorsal margin of the mesh is everywhere in
contact and runs mediolaterally from dorsal to
the pubis over the vas deferens, iliac vessels, and
psoas muscle to the transverse abdominal muscle
(. Fig.11.32). is margin should be about 5cm
distant from the center of the internal ring. e
lightweight large pore polypropylene mesh used
can be modeled to the abdominal wall and folds.
anks to the lightweight and large pores, the
mesh adheres well to the tissue. Securement of
the mesh with absorbable tacks or glue is technically not necessary and should not be done so as
to avoid potential nerve injuries. Only when adequate covering of the hernia orice, for example,
in previously operated patients or large medial
Technique Total Extraperitoneal Patch Plasty (TEP): Standard Technique andSpecic Risks
133
11
. Fig.11.33 Introduction of a Redon drain via the 5mm
trocar placed in the Retzius space (right side)
hernias, cannot be achieved by adaptation of the
mesh dimensions do we use glue for securement.
e IEHS Guidelines recommended, if TAPP or
TEP techniques are used, non-xation could be considered in types LI, II and MI, II hernias. For TAPP
and TEP repair of big direct defects (LIII, MIII), the
mesh should be xed; however, xation does not
compensate for inadequate mesh size or overlap [12].
For xation, brin glue should be considered
to minimize the risk of postoperative acute and
chronic pain [12].
On completion of mesh placement, a drain
is introduced via the 5 mm port placed in the
Retzius space (. Fig. 11.33). With the drain in
place, the mesh must be checked for correct positioning, in particular laterally.
We consider routine drainage to be necessary
for the following reasons:
1. Aer removal of the trocars, it enables complete desuation of the preperitoneal space
and thus complete readaptation of the tissue
layers with the mesh in between.
2. Despite careful hemostasis with highfrequency diathermy, the release of the CO
2
pressure of 12mmHg might result in an
unpredictable accumulation of blood escaping from microscopic vessels in the relatively
large preperitoneal wound. Even when the
area appears to be completely dry intraoperatively, up to 50ml of uid may accumulate
which, in the worst case, may lead to displacement of the mesh.
3. Postoperative preperitoneal hematomas/
seromas may result in an increase in mesh
infection rates.
In the update of guidelines on laparoscopic (TAPP)
and endoscopic (TEP) treatment of inguinal hernia
of the International Endohernia Society, a statement
. Fig.11.34 Via the drain in the midline, the CO2 pres-
sure can be released stepwise (right side)
. Fig.11.35 “Grounding” of the peritoneal sac on the
mesh (right side)
is given that a drain aer TEP signicantly reduces
the incidence of seroma formation without
increasing the risk of infection or recurrence [13].
erefore it is recommended that a closed-suction
drain can be used to reduce the risk of seroma formation without increased risk of infection.
For the critical phase of desuation regarding
vision, CO
pressure and anesthesia management
2
and optimal intraoperative conditions must be
reestablished. Via the drain in the midline, the CO2
pressure can be released stepwise (. Fig.11.34) aer
switching o the insuator. During this process, in
particular the inferior margin of the mesh, which
in the midline pressed against the pelvic bone by
the bladder and prevesicular fat, must be observed.
Laterally in the region of the psoas muscle, the
appropriate “grounding” of the peritoneal sac on the
. Fig.11.35) should be clearly observed to
mesh (
avoid any displacement. In some patients foot-down
positioning may be helpful. If appropriate visualization is not unequivocally possible, the maneuver
must be repeated with the operating table in another
position and/or the position of the mesh corrected.
If the peritoneal sac causes kinking folding of the
mesh, a repeat dissection might become necessary,
which can be done aer removal of the drain and