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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
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Inferior epigastric vessels
lateral space
lateral space
of rectus muscle
Transversus abdominis
muscle release
Developed
(TAR)
J. Daes
Inguinal preperitoneal space Ventral hernia
Transversus abdominis
muscle release
(TAR)
Developed
Posterior aponeurosis,
extraperitoneal fat, and
peritoneum
Fig. 33.3 An extensive extraperitoneal space has been developed by dissecting both inguinal
regions (eTEP inguinal), both retrorectus spaces with division of the linea alba (eTEP RivesStoppa) and releasing the transversus abdominis muscles/internal oblique posterior fascia (eTEP
bilateral TAR)
Released middle portion
Line of Douglas
4. Tolerance to pneumoperitoneum. A larger CO2-lled surgical space withstands
better the presence of a pneumoperitoneum due to an increased tension in its
walls, rarely requiring additional measures to manage it such as the use of a
Veress needle or conversion.
5. Great ergonomics.
Indications
We use the eTEP technique to repair most inguinal hernias; however, there are cases
for which the eTEP technique is especially useful:
1. The eTEP approach is easier to learn and master for surgeons new to the tech-
nique. Most trainees in our clinical immersion courses are surgeons who have
only performed transabdominal preperitoneal (TAPP) surgeries and have no TEP
experience. Notably, in follow-up surveys, most surgeons incorporated the eTEP
technique into their practices.
2. For obese or post-bariatric patients, eTEP allows the surgeon to avoid the dif-
culties caused by the panniculus; in addition, the subcutaneous tissue is thinner
as the surgeon progresses higher in the abdomen.
3. The eTEP approach is useful when the distance between the umbilicus and pubic
tubercle is short.
33 Minimally Invasive Surgical Techniques forInguinal Hernia Repair
4. The eTEP approach is useful in patients with previous pelvic surgeries.
5. With experience, the eTEP approach can be performed for more complex cases,
such as patients with large inguinoscrotal, incarcerated, or sliding hernias.
In our experience, the more difcult hernias to repair with the eTEP approach are
those involving a previous open radical prostatectomy (especially bilateral hernias
involving a midline laparotomy), large sliding hernias, and recurrent laparoscopic
hernias. Such cases should be managed by experts.
Surgeons who perform a wide dissection in using the traditional TEP technique
may not see the difference at rst, but they may nd that the eTEP approach is an
option when considering TAPP and open approaches and may appreciate the benets derived from all procedures that have branched from the eTEP approach.
453
Preparation
We recommend administration of a rst-generation cephalosporin during the induction of anesthesia. We do not routinely use prophylactic antithrombotic medication
but instead use pneumatic compression devices in all patients. Patients should be
reexamined while standing immediately before surgery, and the physical examination ndings should be compared with the laparoscopic ndings. This is an excellent method for ensuring that hernias are not missed.
We routinely prepare the skin, drape the patient, and set up the equipment while
the patient is still awake (but sedated) so that surgery starts almost immediately after
the induction of anesthesia, thereby reducing costs and facilitating a faster recovery.
We recommend that patients void their bladder immediately before surgery, and we
administer parenteral uids conservatively. We consider the use of a urinary catheter
for difcult cases or when we foresee a long operative time. Optimal muscle relaxation is important to ensure a fast and easy procedure, and the anesthesiologist
should provide a short period of full relaxation before the start of the operation.
Technical Aspects oftheeTEP Approach
Creation oftheSpace
Creation of the extraperitoneal space is fast and easy with minimal dissection. At the
chosen location, a 12- to 15-mm incision is made, and the anterior fascia is exposed
with the help of a pediatric S retractor and incised with an inverted no. 11 blade. No
further retraction is necessary. Dissection continues bluntly with a nger introduced
through the fascia and muscle to reach the posterior fascia, which is usually thick.
The nger slides down into the retrorectus space. A lubricated balloon dissector is
carefully introduced to follow the same path, while the abdominal wall is pulled up
454
J. Daes
by the other hand to maintain an appropriate angle of insertion and avoid accidental
penetration into the abdominal cavity until the pubic spine is reached. Once the
space is created, the balloon dissector is replaced by a blunt-tip trocar or a conventional trocar of appropriate diameter. It is possible to dissect the space without a
balloon dissector, especially after the learning curve has been reached. However,
studies have suggested that the use of a balloon dissector reduces the procedure
duration and bleeding volume.
Pitfalls and Pearls
• Breaking the operating table at the level of the costal margin facilitates the intro-
duction of the balloon dissector.
• Incisions close to or lateral to the semilunar lines or close to the midline should
be avoided.
• The skin incision and the incision over the anterior fascia should be created in
the same axis to ensure easy introduction of the balloon dissector in the proper
plane.
• Creation of a subcutaneous path above the anterior fascia should be avoided.
• Placement and ination of the balloon dissector under the symphysis pubis
should be avoided to prevent bleeding and lesions in the bladder.
• In the case of an inadvertent perforation of the posterior fascia and peritoneum,
with the rent close to the skin incision, the surgeon should expose the tear with
an “S” retractor, grasp its inferior border, and slide the balloon dissector over it
to regain the correct plane. If the rent is too far distal from the skin incision, the
surgeon should return to the rst steps and create a new path medial or lateral to
the original path. In most cases, the extraperitoneal space is successfully created,
and the rent does not interfere with the procedure.
Port Setup
Port setup is very exible in the eTEP approach. There are two main port distributions: one involves the initial incision in the ank opposite the hernia side, which is
also used in bilateral cases, and the other involves an initial cutdown in the upper
quadrant on the same side as the hernia. When using the rst port distribution, the
initial incision is placed on the ank about 3cm above and 5cm lateral to the umbilicus line, which allows the dissector balloon to cross under the arcuate arch to the
other side. One 5-mm working port can be placed at or next to the umbilicus, and
the other can be placed inferior and lateral to the camera on the same inferior quadrant, thus achieving perfect triangulation (Fig. 33.4). This approach has the
Left inguinal region
Rectus muscle
33 Minimally Invasive Surgical Techniques forInguinal Hernia Repair
455
Fig. 33.4 eTEP approach established from the ank opposite the hernia side. The left working
port is at the umbilicus and the right working port is placed at right lower inferior quadrant of the
abdomen
advantages of a large surgical eld for large or complex hernias, less arcuate arch
interference, and visual triangulation. For bilateral cases, we use the same distribution but ensure that the working ports are high enough not to interfere with mesh
placement, and an additional 5-mm working port is regularly placed high on the
opposite inferior quadrant (Figs.33.5 and 33.6).
same side of the hernia, usually 4–5cm above and 5cm lateral to the umbilicus
(but sometimes higher, e.g., to avoid the panniculus in an obese or post-bariatric
surgery patient). One 5-mm working port is placed at or next to the umbilicus, and
the other is placed on the opposite lower inferior quadrant, where it is deemed
appropriate. Using this distribution, the surgeon works with the camera at his or
her side (Fig.33.7).
Trocar placement
at umbilicus
Peritoneum and
extraperitoneal fat
Linea alba
Posterior aponeurosis
dissected from
right rectus muscle
Douglas line
Camera
In the second setup, the initial incision is placed in the upper quadrant on the
456
Inguinal hernia
at umbilicus
Inguinal hernia
at umbilicus
Fig. 33.5 eTEP approach
for a bilateral case. For the
repair of the right-side
hernia, the camera port is
on the left, the right
working port is at the
umbilicus, and the left
working port is high in the
left inferior quadrant; in
visual triangulation, the
surgeon and camera
operator are opposite the
hernia side
J. Daes
Camera
Trocar placement
Camera
Trocar placement
Fig. 33.6 eTEP approach for a bilateral case. For the repair of the left-side hernia, camera stays
at the left ank, the port at the umbilicus now becomes the left working port, and an additional
right working port is added high in the right lower quadrant to become the right working port. The
surgical team is now working with a side camera. The surgeon and camera operator are opposite
the hernia side
Left inguinal region
Rectus muscle
33 Minimally Invasive Surgical Techniques forInguinal Hernia Repair
Trocar placement
at umbilicus
Linea alba
Douglas line
457
Camera
Fig. 33.7 eTEP approach for a left unilateral hernia. The initial incision/camera is at the upper
lateral quadrant on the same side as the hernia. The left working port is at the umbilicus (it can be
lateral to the right side), and the right working port is at the right lower quadrant
Posterior aponeurosis
dissected from
left rectus muscle
Peritoneum and
extraperitoneal fat
Pitfalls and Pearls
• The surgeon and camera operator work on the same side of the patient, opposite
the side of the hernia. Thus, the anesthesia equipment is set accordingly, and an
ether screen is not used.
• A diagnostic intraperitoneal laparoscopic evaluation may be used at the rst step
to conrm a diagnosis or reduce and evaluate incarcerated hernias.
• Working ports are always placed under vision with the help of irrigation from a
syringe and needle.
• In very complex cases in which we foresee difculties placing the working ports,
the ports may be placed through the inated balloon under guidance of the cam-
era and its illumination. Of course, the balloon is rendered useless.
• For bilateral cases involving midline scars in which we suspect the preperitoneal
spaces to be separated, it is possible to dissect each retrorectus space indepen-
dently and develop individual preperitoneal spaces from a single midline incision
458
at the epigastrium or with two separate incisions at each respective upper lateral
quadrant.
• Laparoscopic intraperitoneal evaluation at the end of the procedure is recom-
mended when the peritoneum has been violated during trocar placement.
J. Daes
Division oftheArcuate Arch
The arcuate arch of Douglas usually extends half of the distance between the umbilicus and the pubic tubercle. Its division may be required if it interferes with visualization of the space, which is more frequent when using the camera high in the
upper quadrant. When using a 10-mm camera, the arcuate line is divided with a
scissors coming from the lower working port. Visualization of the scissors tip
through the transparent posterior fascia indicates the appropriate extension for safe
division and helps to prevent division of the peritoneum. A small cut is usually
enough to substantially improve visibility. Division should take place laterally
because the posterior sheath and peritoneum are sealed at the midline. When using
a 5-mm camera, dissection and division of the arcuate arch and posterior sheath can
be undertaken under vision. The camera is introduced through the lowest 5-mm
working trocar, and the other working port is used to bluntly dissect posterior fascia
free from the peritoneum from lateral to medial and then divide the arcuate arch
medial to the semilunar line. This is the same maneuver performed routinely today
in the eTEP-TAR’s bottom-up division of the posterior fascia.
Pitfalls and Pearls
• In many cases, the peritoneum is accidentally torn during this and other maneu-
vers, resulting in pneumoperitoneum. This is not a problem during eTEP repair
as long as a wide dissection is undertaken and no air escapes from the preperito-
neal space, usually from the ports. Ensuring that the trocars are airtight is essen-
tial to avoid intermittent oscillatory movement of the peritoneum, which occurs
when air escapes from the preperitoneal space and is replaced by the insufator
pump in waves.
Video 33.1 shows the detailed technical aspects of space creation, port setup, and
division of the arcuate arch during the two most common eTEP arrangements.
Hernia Repair: Critical View oftheMyopectineal Orifice
(CV oftheMPO)
No laparoscopic technique replaces the need for a thorough knowledge of the laparoscopic inguinal hernia anatomy and advanced laparoscopic skills. A detailed
description of hernia repair is beyond the scope of this chapter; however, the dissection steps are common to any laparoscopic or robotic repair and are consolidated
33 Minimally Invasive Surgical Techniques forInguinal Hernia Repair
459
under the concept of the CV of the MPO.The CV of the MPO is a novel concept
derived from the International Hernia Collaboration (IHC) Facebook Group, to help
standardize a growing variety of techniques, technology, materials, and equipment
used for minimally invasive inguinal hernia repair [12]. The CV of the MPO technique is characterized by proper exposure of the anatomical area that must be
attained before placing a mesh regardless of the approach, by following a list of
steps. These steps, taught separately for years, are based on studies that have shown
fewer complications and recurrences. The steps we follow in repairing inguinal hernias with the TEP, eTEP, and TAPP techniques are as follows [12]:
1. Identify and dissect the pubic tubercle across the midline and Cooper’s ligament
(CL). For large, direct hernias, extend the dissection to the contralateral CL.
2. Rule out a direct hernia. Visualize the anatomy through the inated balloon dur-
ing TEP and eTEP repairs to detect a direct hernia before dissection. Remove
unusual fat in the Hesselbach’s triangle.
3. Dissect at least 2cm between the CL and bladder to facilitate at placement of
the medial and inferior edge of the mesh toward the space of Retzius, thereby
avoiding mesh displacement caused by bladder distention.
4. Dissect between the CL and 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 ele-
ments. This step is often not completed, especially in a small surgical eld. To
ensure compliance with this requirement, continue dissection 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 con-
fused with lymph nodes (which are generally spared). Most lipomas do not
require removal but should be placed above the mesh to help prevent the mesh
from rolling upward.
7. Dissect the peritoneum lateral to the cord’s elements laterally beyond the ante-
rior superior iliac spine, sweeping it back inferiorly well behind the mesh’s infe-
rior border.
8. Perform the dissection, provide mesh coverage, and ensure that mesh and
mechanical xation are placed well above an imaginary inter-anterior superior
iliac spine line and any defects. This avoids recurrence and nerve injury, espe-
cially to the ilioinguinal nerve.
9. Place the mesh only when items 1–8 are completed and hemostasis has been
veried. The mesh size should be at least 15–10cm, 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 lateral-inferior corner lies deep against the wall and does not roll
up during space deation (use glue or careful suturing if necessary).
460
J. Daes
Video 33.2 shows a very detailed step-by-step dissection of the space following
the concept of the CV of the MPO. Implementing the CV concept through education and urging its documentation will help to standardize minimally invasive inguinal hernia repair, facilitate teaching and evaluation of techniques, reduce
complications and recurrences, and ultimately improve patient care.
Conclusion
The eTEP approach is more a concept than a technique. It introduces the notion
that the extraperitoneal space is limitless once the conuence of the arcuate line
and semilunar line is taken down. The eTEP approach for inguinal hernia repair
facilitates the performance of an anatomical and sound TEP repair, compliant
with the concept of CV of the MPO, especially for residents and surgeons early
in their experience. The eTEP approach also allows extension of the indications
for the extraperitoneal technique to patients with a difcult body habitus, a short
umbilicus-pubis distance, previous pelvic surgeries, and more complex condi-
tions. Many procedures have branched out of the eTEP concept. Finally, the
eTEP approach has a place in the armamentarium of hernia surgeons.
References
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Inguinal Hernia Repair with
Mini- laparoscopic Instruments
GustavoCarvalho, MarceloLoureiro, MiguelNacul,
FlavioMalcher, EduardoMorenoPaquentin,
andPhillipShadduck
Introduction
Surgical treatment of groin hernias has dramatically improved over the past
century. The importance of inguinal oor repair was recognized in the 1880s, and
polymer mesh repairs were introduced in the 1980s.The tension-free hernioplasty
described by Lichtenstein in 1989 is now widely considered the “gold standard”
to which other repairs should be compared [1]. Laparoscopic repair of inguinal
hernias was established in the 1990s, and totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repairs remain the most widely utilized laparoscopic techniques [2]. Current TAPP/TEP techniques yield good outcomes in
terms of postoperative pain, time to recovery, hernia recurrence rates, and longterm pain rates [2, 3].
34
G. Carvalho
Department of Surgery—University of Pernambuco, Hospital Universitario Oswaldo Cruz,
Recife, PE, Brazil
M. Loureiro
Department of General Surgery, INC Curitiba Positivo University, Curitiba, Parana, Brazil
e-mail: loureiro@up.edu.br
M. Nacul
Institute of Education and Research, Moinhos de Vento Hospital,
Porto Alegre, Rio Grande do Sul, Brazil
F. Malcher (
Department of Surgery, Monteore Medical Center, Bronx, NY, USA
E. M. Paquentin
Department of General and Laparoscopic Surgery, Hospital Centro Medico ABC Santa Fe,
Mexico City, Mexico
P. Shadduck
Department of Surgery, Duke University Medical Center, Durham, NC, USA
© 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_34
*)
461