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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
462
G. Carvalho et al.
With the maturation of therapeutic laparoscopy in the last decade has come an
emphasis on making minimally invasive surgery even less invasive, almost “scarless” [4]. “Reduced port surgery” (RPS) emphasizes fewer ports, smaller diameter trocars and skin incisions, and placement of incisions in occult locations [5].
Natural orice transluminal endoscopic surgery (NOTES) and single-incision
laparoscopic surgery (SILS) are two recent examples of RPS that enjoyed brief
periods of popularity until a number of concerns, including unique procedure
risks, longer operative times, unfavorable ergonomics, and higher costs, dampened enthusiasm. Mini-laparoscopy is a RPS option that is enjoying renewed
interest.
What Is Mini-laparoscopy?
It is helpful to begin with a denition of terms [6, 7]. The term “mini-laparoscopy” (abbreviated Mini) is generally applied to laparoscopic instruments with
reduced shaft diameters ranging from 1.9 to 3.5mm (trocars of 2.2–4.2mm),
though some surgeons include instruments as large as 4mm under the same
rubric. Also, most surgeons apply the term mini-laparoscopy to procedures that
utilize one 5–10mm trocar (primarily for imaging, also for specimen extraction) as long as this site is hidden (usually intraumbilical) and as long as all
other sites utilize Mini-sized instruments. In cases where more than one nonMini trocar is used, the term “hybrid- Mini” is employed. Finally, the terms
“minilaparoscopy,” “mini-laparoscopy,” “mini laparoscopy,” “microlaparoscopy,” and “needlescopic surgery” have all been utilized, leading to some confusion. Several scientic groups and professional medical societies have recently
published consensus statements on terminology, with most settling on the term
“mini-laparoscopy” [8].
Mini-laparoscopy was pioneered about 20years ago [9–14]. Early adoption of
Mini was inhibited by the limitations of rst-generation instruments, especially
functionality and durability. Newer generation Mini instruments have recently
become available with improved effector tips, a choice of shaft diameters and
lengths, better insulation and electrosurgery capability, improved strength and rotation, more ergonomic handles, low-friction trocar options, and improved instrument
durability (Fig. 34.1). The marked improvements in Mini instrumentation have
occurred contemporaneously with the increasing desire to reduce even further the
invasiveness of standard laparoscopy, the waning enthusiasm for SILS and NOTES
platforms, and the growing concern regarding the costs of computer-assisted
(robotic) surgery. Together, these forces have contributed to somewhat of a renaissance for Mini [4, 7, 15–26].
34 Inguinal Hernia Repair withMini-laparoscopic Instruments
Fig. 34.1 Mini-laparoscopic instruments. Newer generation Mini instruments have recently
become available with improved effector tips, a choice of shaft diameters and lengths, better shaft
insulation and electrosurgery capability, improved shaft strength and rotation, more ergonomic
handles, low-friction trocar options, and improved instrument durability
463
Why Use Mini-laparoscopy?
Mini-laparoscopy is a natural evolution of conventional laparoscopy. The port
placement, instrument triangulation, and procedure conduct of standard laparoscopic procedures are preserved [27]. The optical shadow produced by Mini instruments is less than that of 5–10mm instruments, allowing the laparoscope to come
closer to the surgical target, enhancing visualization of anatomic landmarks and
structures. A surgeon procient in conventional laparoscopy can transition to minilaparoscopy with minimal learning curve.
Mini-laparoscopy is intuitively cost-effective. No large capital expenditures for
equipment purchase or maintenance are necessary. No expensive single-use, singleincision devices are required. Reusable instruments and trocars are available.
Operative times are similar to standard laparoscopy.
What are the results of Mini? The science behind mini-laparoscopy was recently
reviewed. Most of level I data on mini-laparoscopy address its use for cholecystectomy. Though there are many publications of mini-laparoscopic inguinal hernia
repair, fundoplication, appendectomy, hysterectomy, renal surgery, sympathectomy,
464
ab
Fig. 34.2 Conventional laparoscopic and mini-laparoscopic instruments. (a) The comparison of
trocars with diameters of 11, 6, and 3.5mm. (b) The low-friction Mini trocar has been designed to
precisely t the corresponding instruments, with less gap between the instrument shaft and the
trocar, allowing for a valveless, very low-friction system
G. Carvalho et al.
and other procedures, there are limited level I data regarding these procedures.
Focusing on the best quality data that we have at this time, the review of the science
behind Mini concluded that “when applied to elective laparoscopic cholecystectomy, the use of mini-laparoscopic instruments results in a marginally longer operative time (3–5min), slightly less early postoperative pain (in the rst 24h), and a
better initial cosmetic result, with no other apparent signicant differences” [6].
Notably, there were no apparent negative outcomes when Mini was compared to
conventional laparoscopy.
One recent instrument development may advance the results of Mini: the
development of a very low-friction trocar for use with Mini instruments. Current
commercialized Mini trocars are miniaturized versions of traditional laparoscopic
trocars which typically incorporate two seals to minimize CO
loss: a rubber cap
2
and an internal mechanical valve. In order to improve the precision of movement
with Mini instruments, a low-friction Mini trocar was precisely engineered (with
narrow tolerances), allowing for the use of a valveless trocar [28, 29]. As compared to standard trocars, these low-friction, valveless Mini trocars are longer,
have thinner walls, and have minimal gap between the trocar and the instruments
(Fig.34.2). This provides both minimal friction (instrument on trocar friction of
0.13N vs 4.3N) and minimal CO
loss (<0.1L/min). They also have a long taper-
2
ing conical blunt-tip obturator (Fig.34.1) to minimize tissue damage during trocar
insertion [30, 31] (Figs.34.3 and 34.4). Studies have shown that the abdominal
ab
cd
34 Inguinal Hernia Repair withMini-laparoscopic Instruments
465
Fig. 34.3 Low-friction Mini trocar insertion. (a) Pinpoint skin incision is made with a scalpel. (b)
Skin incision is dilated and the trocar with conical blunt-tip obturator is inserted. (c) With the funnel cap attached to the trocar inlet, instrument insertion is facilitated. (d) The trocar may be used
without the cap, though instrument exchange may be slightly more difcult
wall tissue injury caused by different trocar sizes is proportional to the square of
radius of the trocar (Table34.1, Fig.34.5). A 10mm trocar generates approximately 5 times more tissue damage than a 5mm trocar and about 25 times more
damage than a 2mm trocar. Mini instruments and low-friction Mini trocars have
been evaluated in a variety of preclinical bench studies, including surgical simulators. Studies of surgical tasks being performed by medical students and surgical
residents revealed improved instrument precision, particularly during dynamic
and delicate tasks, with lower muscle effort and higher efcacy of movement
(p<0.001). Initial clinical studies of these newer, low-friction trocars are limited
but encouraging ([32–35]).
Regarding Mini for inguinal hernia surgery, early adopters of the low-friction
Mini trocars have noted improved surgical precision during dynamic tasks (e.g.,
Hernia sac dissection), lower surgeon stress, higher efciency of movement, and
fewer trocar dislocations and reinsertions [28, 29].
466
ab
cd
Fig. 34.4 Mini trocar insertion. Image sequence (a–d) shows insertion of the low-friction Mini
trocar with conical blunt dilating tip
G. Carvalho et al.
Table 34.1 Surgical access technique and parietal injury
Technique
NOTES Pure—no skin incision ~0
Hybrid NOTES (3.5mm×2) 612
Hybrid NOTES (6mm×1) 900
LESS (single port) (28mm) 19,600
LESS (single port) (36mm) 32,419
Mini-laparoscopy (11mm×1+3.5mm×3) 3945
Std laparoscopy (11mm×2+6mm×2) 7854
Incisions
Parietal injury volume (π · r2 · h)
Mini-laparoscopy: Helpful forTAPP or TEP?
For laparoscopic repair of inguinal hernias, the two techniques most often employed
are the totally extraperitoneal (TEP) and the transabdominal preperitoneal (TAPP)
techniques. Both are proven with similar safety and effectiveness [36]. The decision for TAPP vs. TEP approach is subject to a surgeon’s personal experience and
preference [37].
The TAPP approach allows the surgeon to operate in a larger working space as
compared to TEP. Advantages of TAPP include routine evaluation of intra- abdominal
34 Inguinal Hernia Repair withMini-laparoscopic Instruments
Fig. 34.5 The volume of abdominal wall tissue injury is a nonlinear function of trocar size.
Because tissue injury is related to the square of the radius of the trocar, small differences in trocar
diameter result in larger differences in tissue injury
467
organs, diagnosis and treatment of incidentally detected contralateral hernias, and
evaluation of bowel viability in incarcerated hernias [38]. Disadvantages of TAPP
include possible increased costs and longer procedure durations due to mesh xation and closure of the peritoneal ap [39]. Mesh xation has been described with
staples, tacks, sutures, brin, and cyanoacrylate [40, 41].
Advantages of the TEP approach include simplicity and speed of execution
(omitting mesh xation saves time), possibly lower cost, and no need for opening
and closing the peritoneum [38, 39, 42]. Disadvantages of TEP include a small
working space with increased technical demands and an increased level of difculty
identifying anatomic landmarks [28, 29].
Almost all reports of mini-laparoscopic inguinal hernia repair refer to TEP procedures. In TAPP procedures, the surgeon uses wider movements of dissection than
in TEP procedures. This may generate greater forces on the Mini instruments,
increasing the potential for instrument damage, particularly with the early generation instruments. Also, because the visual space in TAPP is much larger than that in
TEP, the advantage of reduced instrument size to improve visual eld is less relevant. In addition, because most surgeons choose to xate the mesh in TAPP procedures using a 5mm diameter tacker, the use of Mini instruments in TAPP is restricted
in most cases to the replacement of one 5mm port with one 3mm port. Thus, the
advantages of a mini-laparoscopic approach for TAPP seem less than for TEP.Both
options though are presented here for the reader to consider.
468
G. Carvalho et al.
Mini-laparoscopic TAPP
The author’s preferred technique for performing a Mini TAPP utilizes a 45°, 10mm
lens in the umbilicus and two 3.5mm low-friction Mini trocars in the lower quadrants. This approach exploits the following advantages: (1) no need for those already
familiar with TAPP to learn a new surgical technique, since it is fundamentally the
same procedure as a traditional TAPP; (2) precise surgical maneuvers due to the
low-friction Mini trocars, particularly helpful for hernia sac dissection and for
suture closure of the peritoneum; (3) enhanced visualization due to smaller instruments casting a smaller optical shadow; and (4) good cosmetic outcome.
For Mini TAPP technique, patients are subjected to balanced general anesthesia
and operated in supine position with upper extremities well-padded and tucked.
Chlorhexidine is utilized for skin preparation. Incision site is routinely inltrated
with ropivacaine. The author’s preference for establishment of pneumoperitoneum
is an open direct trocar entry technique through the umbilicus with an 11mm blunttipped trocar (Kii Balloon Blunt Tip
maintained at 12–15mmHg. A 45°, 10mm laparoscope is utilized to perform a full
abdominal cavity exploration as part of the routine protocol. Two 3.5 mm lowfriction “Carvalho Mini trocars” (Storz) are inserted under direct visualization and
with transillumination of the abdominal wall to avoid injury to the inferior epigastric vessels. These are placed at the border of the rectus abdominis muscle, at level
of the umbilicus on each side of the patient. The operating table is tilted to 15°
Trendelenburg and 15° airplane with the hernia side up. Using a mini-laparoscopic
scissor, the peritoneal ap is developed from a point 1cm medial and superior to the
anterior superior iliac spine to the medial umbilical ligament in a hockey-stick fashion. A complete anatomical dissection of the extraperitoneal pelvic oor is performed, parietalizing the cord structures. The extent of dissection reaches medially
1cm beyond the symphysis pubis, cranially 3cm above the transversalis arch or any
direct hernia defect, laterally to anterior superior iliac spine, and caudally 1 cm
below the pubic bone. The complete retraction of indirect sacs is important, always
avoiding critical structures and having control of hemostasis. In female patients, the
round ligament is divided using a 3mm bipolar device (Gyrus
forceps®, Olympus). Mesh selection depends on surgeon preference and hospital
purchasing contracts. A large pore, 15×15cm polypropylene mesh (Prolene mesh®,
Ethicon), trimmed to t the dissection space, is one common alternative. A heavyweight polypropylene precut mesh (3DMax
ene mesh (3DMax Light®, Bard®) can also be utilized. The author prefers mesh
xation with a limited number of absorbable tacks to Cooper’s ligament, rectus
abdominis muscle, and transverse abdominis aponeurotic arch. In order to use a
5mm tacker and still preserve the bilateral lower quadrant Mini trocars, the 10mm
lens is switched to a 2.7mm laparoscope that is then introduced through one of the
Mini trocars in order to free the 11 mm port for the tacker. Alternatively, after
switching to the 2.7 mm lens and freeing the 11 mm port, a tube applicator for
“brin sealant” can be utilized instead of tacks. Self-xating mesh (ProGrip
Medtronic) with no xation represents another alternative. The peritoneal ap is
closed using a Mini needle holder to create a continuous closure with absorbable
®
, Applied Medical). Pneumoperitoneum is
®
PK Molly Bipolar
®
, Bard®) or a lightweight polypropyl-
®
,
34 Inguinal Hernia Repair withMini-laparoscopic Instruments
469
suture (Vicryl® 2-0, Ethicon; V Loc® 90 device, Medtronic). In order to close the
peritoneal ap, the pneumoperitoneum is reduced to 8mmHg. Extraction of working ports is always done under direct visualization. The fascia at the umbilical trocar
®
site is closed with interrupted #0 nonabsorbable suture (Ethibond
, Ethicon). The
skin incisions are closed with topical skin adhesive (2-octyl cyanoacrylate,
Dermabond®, Ethicon).
The author reported his initial 25 hernia learning curve experiences with this
technique [43]. Average operative time was 48min per hernia. Mean hospital stay
was 26h. There was no conversion to standard laparoscopy or open surgery. There
were no major surgical complications. Only one patient required the use of opioids
in addition to ketorolac. One week post-op, no patients were taking analgesics.
What are the published data for Mini TAPP? Wada and colleagues reviewed
their experience with 352 Mini TAPP procedures in 317 patients from 1996 to
2011 [44]. They performed Mini TAPP in 89% of patients presenting with inguinal
hernia. They utilized a 5mm laparoscope at the umbilicus, and surgical instruments were inserted through 5mm and 3mm trocars. After reduction of the hernia
sac and dissection of the preperitoneal space, they placed either polyester mesh or
polypropylene soft mesh with tack xation. The peritoneum was closed with interrupted 3-0 silk sutures. The mean operative time was 103min for unilateral hernias
and 156min for bilateral hernias. There was no conversion to open repair. Fortythree patients (13.6%) used postoperative analgesics (mean frequency of use 0.5).
The authors observed one bladder injury (0.3%) and no bowel or major vessel
injuries. Postoperative complications occurred in 32 patients (10.1%). One patient
with a retained cord lipoma required reoperation. There was no reported chronic
pain or mesh infection. The operative time for experienced surgeons (≥20 repairs)
was signicantly shorter than that for inexperienced surgeons (<20 repairs;
p<0.05). The authors concluded that Mini TAPP may have more advantages than
conventional TAPP.
Chan and Hollinsky retrospectively reviewed their community hospital experience, evaluating the extent of abdominal wall surgical trauma and postoperative
consequences for Mini TAPP (n=50) and single-port sTAPP (n=35). Intraoperative
data, including length of umbilical skin incision and operative time, were recorded.
A follow-up evaluation included investigation of hernia recurrence, postoperative
pain, abdominal wall mobility, cosmetic satisfaction, and period of sick leave. The
mean umbilical skin incision length was 13±4mm in Mini TAPP vs. 27±3mm in
sTAPP (p < 0.001). The Mini TAPP procedure required less operating time
(54.8±16.9min vs. 85.9±19.7min; p<0.001). The mean immediate postoperative
pain score on the visual analog scale was lower in the Mini TAPP patients (2.7±2.1
vs. 4.4±1.9; p=0.016). Patients who underwent Mini TAPP had a shorter period
of sick leave (11.2±8.4days vs. 24.1±20.1days; p=0.02). Follow-up evaluation
after approximately 30months revealed no hernia recurrences and equal abdominal
wall mobility and cosmetic satisfaction in both groups. The authors concluded that
in patients with uncomplicated inguinal hernia, the Mini TAPP procedure resulted
in less surgical trauma, had a shorter operating time, and had distinct advantages
regarding immediate postoperative pain and sick leave time compared to singleincision laparoscopic repair.
470
G. Carvalho et al.
Mini-laparoscopic TEP
TEP is technically more demanding than TAPP, performed inside a smaller working
space with the laparoscope nearer the working instruments. Any developments that
make TEP easier and that enhance visualization are welcome. Using needlescopic
instruments for TEP is one very good use of mini-laparoscopy.
General anesthesia is used. The preperitoneal access begins by a periumbilical
incision, ipsilateral to the hernia. After exposing the anterior rectus sheath, 1.5cm
of the sheath is opened. After dissection of the rectus muscular bers and visualization of the posterior rectus sheath, an 11mm reusable trocar is positioned with a U
suture using #0 polypropylene. Through the 11mm trocar, a 30° 10mm optic is
used to access the preperitoneal space. That space is progressively created by blunt
telescope dissection and CO
disposable trocar or dissecting balloon is needed. Alternatively, the extraperitoneal
space can be obtained by suprapubic puncture with a Veress needle and injection of
in the space of Retzius, as described by Dulucq [38]. This technique obviates
CO
2
the use of dissecting balloon as well. The 10mm trocar for the rigid endoscope is
then inserted into the previously distended preperitoneal space. Thereafter, under
direct view, two mini-laparoscopic trocars are placed 4cm inferior to and 4cm lateral to the 10mm periumbilical trocar, thereby respecting the triangulation principle (Figs.34.6 and 34.7). Special care is taken not to injure the epigastric vessels.
insufation at a continuous pressure of 12mmHg. No
2
Fig. 34.6 Operating room setup and trocar positions for right and left mini-laparoscopic
hernioplasty
34 Inguinal Hernia Repair withMini-laparoscopic Instruments
Fig. 34.7 Trocar
placement for minilaparoscopic left inguinal
hernia repair. The use of a
low- friction trocar reduces
inadvertent trocar
dislocation because
undesired trocar
movements during surgery
are minimal
471
Another alternative is to place both working Mini trocars in the infraumbilical midline, a setup that allows bilateral inguinal repair with the same trocars. The dissection of direct and indirect hernias is performed in the standard fashion. Scrotal
hernias are technically more difcult and sometimes require transection of the hernia sac. Once the anatomic elements are properly identied (Fig.34.8), including
dissection of the peritoneum covering the oor of the anterior pelvic wall, a
15×11cm polypropylene mesh is placed without xation, and the CO
is removed
2
under vision to ensure that there are no wrinkles in the mesh.
Loureiro and colleagues reported their experience with Mini TEP in 60 patients
(70 hernias) with an average operative time of 54min, no intraoperative complications, peritoneum perforation in six patients (10%), and one conversion to open
surgery due to technical difculty (lack of proper working space) in a recurrent
hernia [45]. Seroma formation was observed in ten patients (16%), and there were
no immediate recurrences during the 4-week follow-up period.
With the hypothesis that combining the established advantages of TEP with the
delicacy, precision, and increased visualization of Mini instruments in narrow
spaces is better, Malcher etal. compared 58 patients randomized between standard
5mm TEP and Mini 3mm TEP (both groups without dissection balloon or mesh
xation). The authors found shorter operative time and less immediate post-op pain
(at 6h) in the Mini group [46]. Opening the extraperitoneal space without using a
dissecting balloon and avoiding mesh xation also allowed this surgical approach to
be more competitive in terms of hospital costs and less likely to cause chronic pain.
Technique Combining Mini-laparoscopy, TAPP, andTEP
Laparoscopic TAPP and TEP techniques are both well established, though TEP has
proven to be somewhat better than TAPP [2, 47]. Its main advantages rely on avoid-
ing a peritoneal ap and avoiding mesh xation, resulting in less postoperative