Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_888_Библиотеки_им_академика_М_И_Перельмана
.pdf
420
E. Inga-Zapata and F. García
The goal of the TAPP technique is the creation of a wide peritoneal pocket for
mesh placement. The mesh should cover the MPO and extend to the psoas posteriorly to the rectus and transversus abdominis anteriorly and approach the anterior
superior iliac spine laterally and the midline and space of Retzius medially. Care
must be taken to prevent any peritoneum from slipping behind the mesh and being
a cause for early recurrence. Desufation and reinsufation may alert the surgeon to
this occurrence. Hemostasis is assured before placing the mesh, which is introduced
rolled in its long axis, and grasped with an atraumatic forceps with an average size
of 15cm×10cm. It is upon the surgeon to tailor the size according to patient habitus. Classic plain or knitted 3D meshes seem not to make a clinical difference and
both are good options.
Mesh Placement andFixation Aspects
The mesh is placed taking care to completely cover the myopectineal orice. Once
placed with caution not to have folds at any border, the decision of xation or not
arises. Many xation options have been proposed in the history of TAPP technique;
nonetheless, based on the available level of evidence, we can say that leaving the
mesh without xation could be reasonable too as long as the following specications are met: the defect is indirect, the defect is direct and small, or the defect is
femoral [26–28].
The xation options are invasive and noninvasive type. Invasive xation options
include tackers, staples, and stitches. Noninvasive xation options for TAPP include
vacuum suction [29] and glue-like options available today, brin and cyanoacrylate,
the latter not yet commercially available in the USA but available in other countries.
Both are suitable for TAPP repair.
One of the xation options for TAPP, staples (i.e., Endo Hernia, by Medtronic),
has mostly been abandoned by surgeons due to increased pain and risk of nerve
entrapment. Tackers are another invasive option for TAPP and are preferred by some
surgeons for mesh xation, and many use them selectively for larger hernias, specially big direct defects. If tackers are chosen, there are many design congurations
(helical and not helical) made in two types of material (permanent and absorbable)
both used with quite similar clinical success in TAPP.The safest place to tack is in
the Cooper’s ligament over the pubic bone, in its mid- to external/lateral area, avoiding the region where the corona mortis is found.
Where to re the tacker—aside from Cooper’s ligament—remains open to discussion, but never under an imaginary line below the Cooper’s ligament, and never
in the triangle of doom due to risk of neurovascular damage [30]. It is helpful to use
counterpressure on the abdominal wall against the tip of the tacking device when
applying tacks in the soft tissue (Fig.30.6).
Noninvasive xation of the mesh for TAPP includes glue-like materials. In the
USA brin glue is the most readily available (though expensive) option. In most
other countries, cyanoacrylate is the adhesive option that is available and is quite
inexpensive. Besides the fact that these glue-like materials show overall
30 MIS Techniques: Lap TAPP andrTAPP
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 30.6 Places not to
re tackers or staples
421
complications and recurrences not signicantly different in comparison to conventional tacker or suture xation, both seem to offer somehow less painful results
[31–33].
For a TAPP technique, these glue-like products are instilled through a cannula
inserted through one trocar, parallel to the trocar, or simply percutaneously drop by
drop over the points where xation is desired or through a spraying device [34].
Fixation by suturing can be done with similar considerations for safety as in the
other methods. The added effort time needed for this task is probably the main reason it is being avoided by many surgeons.
Because all invasive xation methods raise the concern of neurovascular damage, interest does exist for self-xating meshes. Some are already being used in
TAPP cases in many places worldwide. This self-xating mesh is simply placed as
a conventional mesh, with the advantage of saving time but not necessarily costs.
Long-term data is yet needed for comparison.
The nal step in the TAPP technique is the closure of peritoneal ap, and there
are several ways described in almost 25years of TAPP history: closure by conventional running suture, closure by interrupted sutures, closure by tackers, closure by
staples, and closure by glue-like products. Recent efforts have been made to nd
whether or not it is fully necessary to close the peritoneal ap in TAPP by any of the
listed means, and although preliminary results show that it may also be possible to
leave the ap without closure [35], further clinical research about this is needed,
being consequently the thorough closure of peritoneal incision and any big peritoneal tear the only real and formal recommendation [36]. Considering the recent
onset of litigation worldwide and specially in the USA regarding mesh, many now
avoid intraperitoneal mesh placement or exposure.
Probably worth mentioning—but not classically part of the TAPP technique—
might be the aspiration of remanent preperitoneal gas once the ap is closed, which
has been proposed as a way to reduce urinary retention and to serve as another xating mode [37]. It can be done by inserting a cannula/aspirator through the already
422
closed peritoneal opening until the remanent CO2 is aspirated and deation of the
bulged peritoneum is completed [29] which may also serve to xate the mesh in
place, as previously cited.
Finally, drains are never recommended in TAPP inguinal hernia repairs.
Hemostasis should be assured before placing the mesh and before closing the peritoneal ap.
E. Inga-Zapata and F. García
Failure oftheTAPP: Recurrence
A number of complications could arise from the TAPP technique including vascular, visceral organ, and nerve injuries. They are rare, and recurrence is the most
frequent. Early in the history of laparoscopic TAPP repair, recurrences were reported
and attributed to poor technique [38].
After 25years of the laparoscopic TAPP approach, the same reasons for failure
have been pointed out by almost every publication and surgical academic society
worldwide: inadequate size of the mesh, poor closure of the peritoneal ap, and
inadequate dissection for creation of the pocket. These are often related to an incomplete knowledge of the anatomy of the region due to insufcient training or
inexperience.
Several recommendations can be made from accumulated worldwide experience:
1. Standardize your own steps for the technique.
2. Plan to dissect until nding all the landmarks and obtaining the CVMPO.
3. Proceed with very gentle movements in order to avoid bleeding, and then you
will always have a clear view of every structure in the operative eld.
4. Use a 15×10cm mesh (minimum) to cover the MPO with broad overlap.
5. Fixate the mesh in every case of big direct hernias.
6. Meticulously close the peritoneum.
Robotic TAPP (rTAPP)
Performance of TAPP robotically (rTAPP) has been adopted by many surgeons.
Benets include tridimensional high-denition (3D HD) vision, wristed instruments with greater ease of suturing, and improved ergonomics for the surgeon.
Lower pain scores have also been reported by some as well as improved outcomes
and lower complication rates for obese patients [39]. When performed well, recurrence rates should be equivalent between open, laparoscopic, and robotic repairs.
Preoperative Considerations
Patients undergoing rTAPP should be able to undergo general anesthesia. Relative
contraindications might be prior to retropubic dissection, radiation, a history of pelvic trauma, or infections. Unlike laparoscopic TAPP technique, there is a shorter
30 MIS Techniques: Lap TAPP andrTAPP
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
423
learning curve to adoption of rTAPP, probably because surgeons utilize previously
acquired laparoscopic expertise. Familiarity with the anatomy of the groin region,
the anterior abdominal wall, and how the preperitoneal space transitions to the retroperitoneal space are critical both for low recurrence rates and avoidance of complications. Anatomy, dissection, mesh placement, and peritoneal closure have been
discussed in the preceding section.
How robotic surgery might inuence the TAPP technique becomes evident when
it comes to one of the pending issues of laparoscopic TAPP repair: what to do with
large direct defects. The skills needed to close them as in open surgery are not an
easy task by pure laparoscopy, but thanks to the 7 degree of wrist movements that
robotics offers, some now nally advocate closure of these defects with far more
precision than laparoscopy [40, 41].
Operative Setup
For inguinal hernias with both the DaVinci-Si and DaVinci-Xi systems, three arms
are typically used. For both systems the peritoneal cavity can be accessed with an
optical port, Veress technique or via an open Hasson-type entry. An 8.5mm camera
port at the umbilicus (or supraumbilical 15cm from the pubis in patients of short
stature) is common. Instrument ports are placed 8–10cm lateral and 4–6cm cephalad to the camera port bilaterally. Before docking, the patient is positioned supine
with arms tucked and in 20° Trendelenburg. A special bed (Trumpf 7000 dV) is
available for the DaVinci robot that allows for synchronized simultaneous movement of the DaVinci-Xi robotic arms with the patient table. In the absence of this,
table movement can only be done while undocked (Fig.30.7).
Numerous instruments are available for performing robotic TAPP hernia repairs.
However, each new instrument incurs a cost. Minimizing the number of instruments
results in lower cost.
Some frequently used instruments include a grasper (Cadiere forceps, fenestrated bipolar, or ProGrasp), cautery (hot scissors or hook bovie), and a sewing
instrument, large needle driver, or mega suture cut. Surgeon experience and preference will guide choice. For the DaVinci-Si system, more time and attention has to
be paid to the table used and to patient cart positioning and docking. For unilateral
hernias the patient cart can be docked 45° over the side of the hernia, and this can
also be used for bilateral hernias. However, for bilateral hernias some surgeons prefer pelvic docking which can also improve arm reach for very obese patients.
TAPP withother Surgical Robots
It is important to note that this brief reference to the rTAPP technique is based on
the DaVinci robot (Intuitive Surgical, Inc.). There is another surgical robot used in
Europe (Senhance, by TransEnterix, Inc.), which has recently gotten FDA clearance
for the American market and similar allowance in some Asian countries as well.
This new robot has different features and technical considerations when compared
424
E. Inga-Zapata and F. García
Fig. 30.7 Robotic TAPP setup (DaVinci-Si)
to the DaVinci robot models, essentially technically conceptualized in conventional
laparoscopy. The rTAPP procedure has been successfully accomplished with the
Senhance robot in Europe, but no large series has yet formally been reported to date.
Other robotic platforms, multiport, and some of them single port will be soon available. It remains to be seen how robotic surgery evolves.
Conclusion
After a quarter century, the TAPP technique has kept its essence: tackling the
problem posteriorly, at its origin. The evolution of the TAPP technique has led to
technical recommendations to reduce complication and recurrence rates. While
data from the Americas Hernia Society Quality Collaborative accrues, the bene-
ts of laparoscopic vs. robotic TAPP will be better dened for both patients and
surgeons, never forgetting that robotic costs need to approximate laparoscopic
costs to foster wider adoption of robotic TAPP.
30 MIS Techniques: Lap TAPP andrTAPP
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
425
References
1. Dulucq JL, Wintringer P, Mahajna A. Laparoscopic totally extraperitoneal inguinal hernia
repair: lessons learned from 3,100 hernia repairs over 15 years. Surg Endosc. 2009;23(3):482–6.
2. Hussain A, Nicholls J, El-Hasani S.Technical tips following more than 2000 transabdomi-
nal preperitoneal (TAPP) repair of the groin hernia. Surg Laparosc Endosc Percutan Tech.
2010;20(6):384–8.
3. Foro Hernia SoHAH (Sociedad Hispanoamericana de Hernia) https://www.facebook.com/
groups/388472254649712/
4. IHC—International Hernia Collaboration https://www.facebook.com/groups/herniacollab/.
5. Witzel K, Weitzendorfer M.If time matters: a multicenter review of minimally-invasive hernia
repair in 7176 cases. Minerva Chir. 2017;72(5):365–7.
6. Bracale U, Sciuto A, Andreuccetti J, Merola G, Pecchia L, Melillo P, Pignata G.Laparoscopic
recurrent inguinal hernia repair during the learning curve: it can be done? Ann Ital Chir.
2017;88:62–6.
7. Bökeler U, Schwarz J, Bittner R, Zacheja S, Smaxwil C.Teaching and training in laparoscopic
inguinal hernia repair (TAPP): impact of the learning curve on patient outcome. Surg Endosc.
2013;27(8):2886–93.
8. Carvalho GL, Loureiro MP, Bonin EA, Claus CP, Silva FW, Cury AM, Fernandes
FA.Minilaparoscopic technique for inguinal hernia repair combining transabdominal preperitoneal and totally extraperitoneal approaches. JSLS. 2012;16(4):569–75.
9. Mizota T, Watanabe Y, Madani A, Takemoto N, Yamada H, Poudel S, Miyasaka Y, Kurashima
Y.Liquid-injection for preperitoneal dissection of transabdominal preperitoneal (TAPP) inguinal [corrected] hernia repair. Surg Endosc. 2015;29(3):516–20.
10. Tong YS, Wu CC, Bai CH, Lee HC, Liang HH, Kuo LJ, Wei PL, Tam KW.Effect of extra-
peritoneal bupivacaine analgesia in laparoscopic inguinal hernia repair: a meta-analysis of
randomized controlled trials. Hernia. 2014;18(2):177–83.
11. D’Hondt M, Nuytens F, Yoshihara E, Adriaens E, Vansteenkiste F, Pottel H.Totally extraperi-
toneal laparoscopic inguinal hernia repair using a self-expanding nitinol framed hernia repair
device: a prospective case series. Int J Surg. 2017;40:139–44.
12. Zacharoulis D, Fafoulakis F, Baloyiannis I, Sioka E, Georgopoulou S, Pratsas C, Hantzi E,
Tzovaras G.Laparoscopic transabdominal preperitoneal repair of inguinal hernia under spinal
anesthesia: a pilot study. Am J Surg. 2009;198(3):456–9.
13. Tzovaras G, Symeonidis D, Koukoulis G, Baloyiannis I, Georgopoulou S, Pratsas C,
Zacharoulis D. Long-term results after laparoscopic transabdominal preperitoneal (TAPP)
inguinal hernia repair under spinal anesthesia. Hernia. 2012;16(6):641–5.
14. Frezza EE, Ferzli G. Local and general anesthesia in the laparoscopic preperitoneal hernia
repair. JSLS. 2000;4(3):221–4.
15. Soper N.Mastery of endoscopic and laparoscopic surgery. Philadelphia: Lippincott Williams
& Wilkins; 2009.
16. Memon MA, Fitzgibbons RJ. Laparoscopic inguinal hernia repair: transabdominal preperi-
toneal (TAPP) and totally extraperitoneal (TEP). In: Scott-Conner CE, editor. The SAGES
manual. NewYork: Springer; 2006.
17. Talar Tejirian (International Hernia Collaboration—Poll): “Never use a Foley because it’s sim-
ply not necessary so long as patient voids pre-op” and “Selectively use a foley for large incarcerated hernias or redo hernias”. 23 Oct 2017, 11:10 am. IHC—Facebook Post.
18. Shabino PJ, Greenberg JA. Laparoscopic inguinal hernia repair: transabdominal preperito-
neal (TAPP) approach. In: Chen H, editor. Illustrative handbook of general surgery. Cham:
Springer; 2016.
19. Inga-Zapata, Edmundo (International Hernia Collaboration—Closed Group): “Humidied
gauzes are way more effective than dry gauzes when it comes to clear the tissue planes in
TAPP”. 03 Nov 2017 21:02 hrs—Facebook Post.
.
426
20. Inga-Zapata, Edmundo (Foro Hernia SoHah—Closed Group): “La gasa húmeda funciona
muchísimo mejor que una gasa seca cuando se trata de aclarar la visión para ver bien los planos de tejido y las estructuras”. 03 Nov 2017 21:14 hrs—Facebook Post.
21. Leroy J. Laparoscopic TAPP inguinal hernia repair. [ONLINE]. 2003. http://www.websurg.
com/doi-vd01en1247e.htm. Accessed 1 Sept 2017.
22. Strasberg SM.A perspective on the critical view of safety in laparoscopic cholecystectomy.
Ann Laparosc Endosc Surg. 2017;2:91.
23. Daes J, Felix E.Critical view of the myopectineal orice. Ann Surg. 2017;266(1):e1–2.
24. Ates M, Kinaci E, Kose E, Soyer V, Sarici B, Cuglan S, Korkmaz F, Dirican A.Corona mortis:
invivo anatomical knowledge and the risk of injury in totally extraperitoneal inguinal hernia
repair. Hernia. 2016;20(5):659–65.
25. Kinaci E, Ates M, Dirican A, Ozgor D. Low pressure is necessary to view and to protect
corona mortis during totally extraperitoneal hernia repair. J Laparoendosc Adv Surg Tech A.
2016;26(12):978–84.
26. Taylor C, Layani L, Liew V, Ghusn M, Crampton N, White S.Laparoscopic inguinal hernia
repair without mesh xation, early results of a large randomised clinical trial. Surg Endosc.
2008;22(3):757–62.
27. Meyer A, Dulucq JL, Mahajna A. Laparoscopic hernia repair: nonxation mesh is feasibly?
Arq Bras Cir Dig. 2013;26(1):27–30.
28. Mayer F, Niebuhr H, Lechner M, Dinnewitzer A, Köhler G, Hukauf M, Fortelny RH, Bittner R,
Köckerling F.When is mesh xation in TAPP-repair of primary inguinal hernia repair necessary? The register-based analysis of 11,230 cases. Surg Endosc. 2016;30(10):4363–71.
29. Zhang G, Zhang X, Zhan H, Sanyuan H. Vacuum suction xation versus staple xation in
TAPP laparoscopic hernia repair: introduction of a new technique for mesh xation. Surg
Endosc. 2016;30:114.
30. Eubanks S, Newman L, Goehring L, Lucas GW, Adams CP, Mason E, Duncan T.Meralgia
paresthetica: a complication of laparoscopic herniorrhaphy. Surg Laparosc Endosc.
1993;3(5):381–5. (ISSN: 1051-7200).
31. Subwongcharoen S, Ruksakul K. A randomized controlled trial of staple xation versus
N-butyl-2-cyanoacrylate xation in laparoscopic inguinal hernia repair. J Med Assoc Thai.
2013;96(Suppl 3):S8–13.
32. Antoniou SA, Köhler G, Antoniou GA, Muysoms FE, Pointner R, Granderath FA. Meta-
analysis of randomized trials comparing nonpenetrating vs mechanical mesh xation in laparoscopic inguinal hernia repair. Am J Surg. 2016;211(1):239–249.e2.
33. Shen YM, Liu YT, Chen J, Sun L.Efcacy and safety of NBCA (n-butyl-2-cyanoacrylate)
medical adhesive for patch xation in totally extraperitoneal prosthesis (TEP): a prospective,
randomized, controlled trial. Eur Rev Med Pharmacol Sci. 2017;21(4):680–6.
34. Li J, Ji Z, Zhang W.Staple xation against adhesive xation in laparoscopic inguinal hernia
repair: a meta-analysis of randomized controlled trials. Surg Laparosc Endosc Percutan Tech.
2015;25(6):471–7.
35. Kane ED, Leduc M, Schlosser K, Parentela N, Wilson D, Romanelli JR.Comparison of perito-
neal closure versus non-closure in laparoscopic trans-abdominal preperitoneal inguinal hernia
repair with coated mesh. Surg Endosc. 2018;32(2):627–37.
36. Bittner R, Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, Buhck H, Dudai
M, Ferzli GS, Fitzgibbons RJ, Fortelny RH, Grimes KL, Klinge U, Koeckerling F, Kumar
S, Kukleta J, Lomanto D, Misra MC, Morales-Conde S, Reinpold W, Rosenberg J, Singh K,
Timoney M, Weyhe D, Chowbey P.Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc.
2015;29(2):289–321.
37. Shen Q, Yao Q. Technical points of the laparoscopic transabdominal preperitoneal (TAPP)
approach in inguinal hernia repair. Ann Laparosc Endosc Surg. 2017;2:11.
38. Felix E, Scott S, Crafton B, Geis P, Duncan T, Sewell R, McKernan B.Causes of recurrence
after laparoscopic hernioplasty. A multicenter study. Surg Endosc. 1998;12(3):226–31.
E. Inga-Zapata and F. García
30 MIS Techniques: Lap TAPP andrTAPP
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
427
39. Kolachalam R, Dickens E, D’Amico L, Richardson C, Rabaza J, Gamagami R, Gonzalez
A. Early outcomes of robotic-assisted inguinal hernia repair in obese patients: a multiinstitutional, retrospective study. Surg Endosc. 2018;32(1):229–35.
40. Li J, Zhang W.Closure of a direct inguinal hernia defect in laparoscopic repair with barbed
suture: a simple method to prevent seroma formation? Surg Endosc. 2018;32(2):1082–6.
41. Waite KE, Herman MA, Doyle PJ.Comparison of robotic versus laparoscopic transabdominal
preperitoneal (TAPP) inguinal hernia repair. J Robot Surg. 2016;10(3):239–44.
MIS vs. Open Inguinal Hernia
forUncomplicated Unilateral Hernia
FadiBalla andAnkitD.Patel
Introduction
An inguinal hernia is one of the most commonly encountered general surgical
pathologies in the world. Approximately 27% of males and 3% of females will
develop one in their lifetime [1]. The surgical treatment for inguinal hernias continues to evolve, with open herniorrhaphy with tension-free mesh repair (TFR) as the
current gold standard across the world. With laparoscopy and now robotic surgery,
minimally invasive methods have been accepted as suitable alternatives to the open
repair. However, in the past, these minimally invasive methods were primarily
reserved for recurrent hernias and bilateral hernias since they offered two unique
benets—working in previously unviolated anatomic planes and visualization of
both inguinal areas in the same procedure. Unfortunately, more expensive equipment is needed for minimally invasive methods and may not be universally available. As a result, debate continues over the optimal repair method for uncomplicated
unilateral inguinal hernias. In experienced hands, recurrence rates are similar in
both open and laparoscopic repair (<2%) [2]. Therefore, the decision-making process has shifted toward consideration of other post-procedural outcomes such as
postoperative pain, time to return to daily activities, and early and late complications. Previous studies have shown that inexperience with laparoscopic inguinal
hernia repair was associated with higher rates of postoperative complications [3, 4].
We aim to evaluate these factors and provide recommendations for the practicing
general surgeon based on current and practical data.
31
F. Balla
Department of Surgery, Emory School of Medicine, Atlanta, GA, USA
A. D. Patel (
Division of General and GI Surgery, Emory University School of Medicine, Emory Bariatric
Center, Emory Saint Joseph Hospital, Atlanta, GA, USA
e-mail: Apatel7@emory.edu
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_31
*)
429
430
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
F. Balla and A. D. Patel
Open Repair
Inguinal hernias have been recognized in medical writings as early as 1550 BC in
the Papyrus Ebers. These writings describe both the appearance of inguinal hernia
as well as rudimentary treatments. Greco-Roman scholars, including most notably
Galen, began to lay the foundation for understanding the pathogenesis and treatment of hernia. Galen described the origin of hernias as rupture of the peritoneum
and overstretching of the overlying fascia and muscles. These ancient scholars
understood and described the importance of hernia sac ligation, preservation of the
testis, and hemostasis which essentially laid the foundation of modern hernia repair
concepts [5]. Edoardo Bassini is generally recognized as the rst of many pioneers
in modern hernia repair in the late 1800s. He was the rst surgeon to prospectively
follow his patients for postoperative outcomes including recurrence and infection.
Over 5years, he was able to prospectively gather data on 216 total patients [5].
Using the Bassini technique of “triple layer” closure (transversalis fascia, transversus abdominis muscle, and internal oblique muscle) to the inguinal ligament, he was
able to achieve historically low recurrence rates (4%) and infection rates (5%). Over
the next 100years, several other methods of inguinal hernia repair were pioneered,
but all were founded on the basis of tension-free repair using natural tissue planes.
In the late 1980s and early 1990s, the advent of synthetic mesh changed the world
of hernia repair immensely. Lichtenstein and colleagues popularized the routine use
of mesh for tension-free repair of both complicated and uncomplicated hernias [6].
This has been shown in numerous studies to be superior to tissue repair with regard
to most measurable data. It should be noted, however, that tissue repair at specialty
centers such as the Shouldice Institute may offer similar recurrence rates to TFR [7].
The Lichtenstein repair is considered the gold standard TFR.A 5–6cm skin incision starting from the pubic tubercle extending laterally following Langer’s line
should provide adequate exposure to both the pubic tubercle and internal ring. Sharp
dissection is carried down through Scarpa’s fascia to the external oblique aponeurosis. The external oblique aponeurosis is opened along the direction of its bers and
divided through the external inguinal ring. The hernia sac is then identied, separated from the cord structures (in the case of an indirect hernia), and reduced into
the abdominal cavity along with its contents. Usually a polypropylene mesh is
trimmed to cover the oor of the inguinal oor, covering both indirect and direct
hernia defects. The mesh is sutured to the anterior rectus sheath 2cm medial to the
pubic tubercle, and this suture is then continued laterally securing the caudal edge
of the prosthesis to either side of the pubic tubercle and the inguinal ligament to the
level of the internal ring. A slit is then made at the lateral end of the mesh creating
two tails. The tails are passed around the spermatic cord recreating the internal ring.
The tails are sewn together allowing for adequate space for the passage of the spermatic cord. The external oblique aponeurosis is then closed in a running fashion,
followed by the subcutaneous tissue.
Multiple other TFR techniques are described with excellent results and are
described in detail elsewhere in this manual. For the purposes of this chapter, we
will consider all TFR mesh-based repairs together when compared to minimally
invasive techniques.
Соседние файлы в папке Библиотека им академика М.И. Перельмана