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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1047_Библиотеки_им_академика_М_И_Перельмана.pdf
120
P. Chowbey
9.1.1 Indications ofTEP
The indications for performing a laparoscopic
hernia repair are essentially the same as repairing
• A thorough medical history of the patient
the hernia conventionally. However, the endoscopic approach may offer denite benet over
its open counterpart to the patients suffering from
bilateral inguinal hernias and recurrent inguinal
hernias.
Surgeons during their early experience
should preferably operate on the following
patients:
• Small, direct, uncomplicated hernias.
• Apart from the routine blood and urine inves-
• Incomplete, indirect reducible hernia.
• Thin patients.
• Fit for general anaesthesia.
• Patients who can safely withstand a longer
duration of surgery.
• A pre-anaesthetic check-up must be done to
• The patient is given a light dinner and kept
9.1.2 Contraindications ofTEP
• In male patients with an inguinal hernia, the
• Strangulated hernia
• Massive scrotal hernia
• Previous history of pelvic lymph node
resection
• Non-reducible, incarcerated inguinal hernia
• Previous history of laparoscopic
herniorrhaphy
• Patients unt for general anaesthesia
• A catheter may be introduced when the sur-
• An antibiotic prophylaxis is administered
of conversion to open surgery if technical difculties are envisaged, or in the interest of the
patient’s safety and well-being.
must be taken. Special measures must be taken
if the patient is on drugs such as anticoagulants (due to hypertension and coronary artery
disease); if the patient is on acetyl salicylic
acid and related drugs (these must be discontinued at least a week before surgery); and if
the patient is on oral warfarin (should be
placed on heparin or its long-acting
derivatives).
tigations, a coagulation prole must always be
performed, as an intractable coagulopathy is
an absolute contraindication for endoscopic
surgery.
get clearance for surgery.
fasting overnight.
operative area from the umbilicus to the pubic
bone and laterally to the anterior superior iliac
spine is shaved and prepared (Fig.9.1).
gery is expected to be of longer duration.
before anaesthesia.
9.1.3 Pre-operative Preparation
• Patient should be explained the basic mecha-
nism of herniation, exact disease process, and
its treatment.
• Patient should be briefed about the post-
operative sequelae of post-operative pain, pos-
sible temporary discoloration of the groin and
scrotum, and seroma formation within the rst
few post-operative days.
• Patient has to be explained the various avail-
able modalities of treatment with their poten-
tial benets and material risks.
• A written consent is mandatory after explain-
ing to the patient and relatives the possibility
Fig. 9.1 The prepared abdomen
a
9 Total Extraperitoneal Repair ofGroin Hernias
121
• After induction, complete reduction of the
contents of the hernial sac is done by manual
manipulation, if possible.
• Patients need to be explained about the occur-
rence of seromas post-operatively and their
person) on the same side as the hernia
(Fig.9.2a, b).
3. In bilateral repairs, the positions are switched
between the surgeon and assistant to repair the
contralateral side.
resemblance to recurrent hernia.
9.1.5 Surgical Technique
9.1.4 Operation Theatre Layout
• Extraperitoneal access
1. The patient is placed in the Trendelenburg
position with both the arms secured by the
sides.
2. The monitor is positioned at the foot end of
the patient. The surgeon stands on the side
opposite the hernia with the assistant (camera-
Fig. 9.2 (a) OT layout
for the repair of
right-sided inguinal
hernia; and (b) a patient
in the OT
An infraumblical, transverse 12mm incision
is made to expose the anterior rectus sheath.
(Fig.9.3a).
To avoid inadvertent opening of the peritoneum, a transverse incision is made on anterior rectus sheath to one side of midline
b
122
a b c
Fig. 9.3 (a) Subumbilical skin incision; (b) transverse incision on the rectus sheath; and (c) stay sutures
P. Chowbey
(Fig.9.3b). The margins of incised sheath are
held with stay sutures using vicryl 1-0
(Fig.9.3c).
• Balloon dissection of the extraperitoneal
space
Balloon dissection has been recommended for
creating the extraperitoneal space. Although
various balloon trocars are available, we prefer
to use our indigenous balloon for preperitoneal
dissection because it is cheap and as effective
as the commercial ones. We take two ngerstalls of a size 8 latex surgical glove (Fig.9.4a)
and tie one on top of the other on the tip of a
5mm laparoscopic suction cannula (Fig.9.4b).
This is then introduced into the preperitoneal
space and inated with 100–150mL of saline
(Fig.9.4c–f). It not only creates an initial working space but also brings about haemostasis by
balloon tamponade. The balloon is deated
after 3–5min and the cannula removed.
• Trocar placement
A 10mm Hasson cannula (blunt tip) is introduced into the preperitoneal tunnel through
the infraumbilical incision and is secured with
stay sutures. Insufation is begun with the
pressure setting at 12 mmHg. A pressure of
>12mmHg should be avoided as it may lead
to subcutaneous emphysema.
A 10 mm 30° telescope mounted on the
camera head is introduced through the subumbilical port. Next, two working ports are
placed in the preperitoneal space. First, a
5mm port is placed ~2cm above the pubis in
the midline, after which a 5mm port is placed
midway between the two placed ports (subumbilical and suprapubic) in the midline
(Fig. 9.5a, b). Along with the three midline
ports, additional ports, if required, can be
placed lateral to the rectus muscle below the
linea semicircularis. Use of ribbed trocars is
preferred as the ribbing prevents repeated slippage during change of instruments.
• Dissection of hernial sac
Dissection of the extraperitoneal space begins
in the midline with the surgeon standing on
the side opposite to the side of the hernia.
Beginners are advised to use a curved dissector in place of scissors during the learning
curve. Dissection of the loose areolar tissue is
performed using a combination of sharp and
blunt dissection supplemented by short bursts
of cautery (Fig.9.6a, b). The aim is to identify
the rst anatomical landmark, i.e. the pubic
bone (Fig. 9.6c), which appears as a white
glistening structure in the midline, marking
the distal limit of dissection.
9 Total Extraperitoneal Repair ofGroin Hernias
123
a, b
c
e
f
d
Fig. 9.4 (a) Suction cannula with ngerstalls; (b) pre-
pared ballon; (c) inated balloon; (d) inated balloon in
the extraperitoneal space; (e) Sketch of the path to the
The space below the pubic bone (retropubic space/space of Retzius) is exposed for
2–3cm to accommodate the lower margin of
the mesh (Fig. 9.7a, b). Extreme caution
should be exercised during this dissection as
the urinary bladder and venous plexus around
the prostate could be traumatized easily.
extraperitoneal space; and (f) creation of the preperitoneal
space using an inated balloon; the direction of the balloon cannula is towards the pubic bone
The pubic bone is traced laterally towards
the side of the hernia. The next anatomical
structure to be identied at this stage is the
Cooper ligament (Fig.9.7a, b).
In case of a direct hernia, it may become
difcult to identify the Cooper ligament as
124
a
b
Fig. 9.5 (a and b) Port sites
P. Chowbey
this area may be occluded by the hernial sac
(Fig.9.8a, b).
around the cord are lysed with extreme caution as
the external iliac vessels lie just below the cord
structures.
An attempt is made to reduce this direct sac
by traction on the peritoneal extrusion and
counter- traction on the fascia transversalis. Once
the complete sac is reduced, a denitive defect
would be seen in the anterior abdominal wall
(Fig. 9.9a, b). The anatomical landmarks that
would now become visible are the Cooper ligament, the iliopubic tract, femoral ring, and inferior epigastric vessels (Fig.9.10a, b).
It is suggested that the direct sac should be
inverted and anchored to the Cooper ligament to
decrease the risk of seroma formation.
The lateral extension of the pubic bone is seen
in the form of a Y-shaped fork. The superior limb
of the fork is formed by the ileopubic tract
whereas the Cooper ligament forms the inferior
limb. The femoral ring lies at the junction of the
two limbs. Superior to the iliopubic tract on the
anterior abdominal wall lies the direct hernial
defect, which is bounded laterally by the inferior
epigastric vessels and medially by the lateral border of the ipsilateral rectus muscle.
In case of a small direct hernia, ligation is not
needed once the sac has been reduced. Complete
reduction of the sac is ensured by identifying the
margins of the defect. The spermatic cord lies
immediately inferior and lateral to the inferior
epigastric vessels. The lateral plane of dissection
is created between the cord structures below and
anterior abdominal wall above, just lateral to the
inferior epigastric vessels. Flimsy adhesions
An indirect hernial sac is identied as a white,
glistening structure lying anterolateral to the cord
(Fig.9.11a, b). An incomplete sac is dissected off
the cord and completely reduced. No attempt
should be made to reduce a complete sac, as
extensive dissection may result in severe postoperative testicular oedema and pain. Such a sac
should be separated from the cord and ligated
using 2-0 vicryl (Fig.9.12a, b). The sac is then
divided distal to the ligature, leaving the distal
end of the sac open. Complete reduction is
ensured by identifying the reection of the peritoneum on the spermatic cord (Fig. 9.13). The
cord should be completely parietalized to the
extent where the vas deferens is seen turning
medially. This manoeuvre exposes the triangle of
doom.
The triangle of doom is bound medially by the
vas deferens and laterally by the testicular vessels. The peritoneum forms the base of the triangle and the deep inguinal ring forms the apex
(Fig.9.14a, b). Dissection should be best avoided
within this triangle as the external iliac vessels
are contained within it. A lipoma of the cord, if
present, should be completely reduced. A large
indirect sac may be ligated proximally and
divided distally. In case of indirect hernia, lateral
to the inferior epigastric vessels, the peritoneal
sac is dissected away from the cord structures,
both medially and laterally until it is completely
separated and then dealt with appropriately.
9 Total Extraperitoneal Repair ofGroin Hernias
125
a
b
a
b
c
Fig. 9.6 (a) Extraperitoneal space with loose areolar tis-
sue; (b) trocars in the extraperitoneal space; and (c) pubic
bone
Adequate space has to be created lateral to the
cord structures as the lateral part of the mesh
would lie in this space. This space contains only
loose areolar tissue, which is completely divided
using sharp and blunt dissection. The inferior
Fig. 9.7 (a) Space of Retzius; and (b) intraoperative view
of the space of Retzius (CL Cooper ligament)
extent of dissection in this space is the psoas muscle (Fig.9.15a, b), whereas the lateral limit is the
anterior superior iliac spine, as seen from outside.
Cranially, the peritoneum would be seen to be
densely adherent to the abdominal wall at the level
of the arcuate line. This needs sharp dissection to
further expand the extraperitoneal space in a cranial direction. The extraperitoneal space is now
fully prepared for mesh insertion and xation
(Fig.9.16a, b).
In the case of bilateral hernias, the surgeon
and camera assistant change sides and a similar
dissection is performed on the opposite side.
• Mesh preparation and placement
The minimum size of the polypropylene mesh
to be used on each side should not be less than
15cm×13cm (Fig.9.17a). The mesh should
be taken out of its packaging under absolutely
126
P. Chowbey
a
b
a
b
Fig. 9.10 (a) Anatomical landmarks seen after reduction
Fig. 9.8 (a) Direct sac; and (b) intraoperative view of a
direct hernia
a
Fig. 9.9 (a) Appearance after reduction of a direct sac; and (b) operative view after reduction of a direct sac (CLCooper
ligament; DD direct defect; IEV inferior epigastric vessels; SC spermatic cord)
of a direct sac; and (b) Intraoperative view of the structures
seen after reduction of a direct sac (CL Cooper ligament;
DD direct defect; FR femoral ring; IPT iliopubic tract; IEV
inferior epigastric vessels; SC spermatic cord)
b
ab
9 Total Extraperitoneal Repair ofGroin Hernias
Fig. 9.11 (a) Indirect sac dissected; and (b) Laparoscopic view of the dissected indirect sac (CL Cooper ligament; IPT
iliopubic tract; IEV inferior epigastric vessels; SC spermatic cord; IS Indirect sac)
127
a b
Fig. 9.12 (a) Transected and ligated indirect sac; and (b) Endoscopic view of the transected and ligated indirect sac
sterile conditions just before introduction into
the site. To handle a mesh of this size in the
restricted preperitoneal space is not easy. We
have developed a technique of introducing a
rolled mesh in this space for easy handling
and accurate xation.
The mesh is rolled like a carpet to twothirds of its length, leaving 5 cm free. Two
stay sutures are tied on the roll using an
absorbable suture (Vicryl 2-0) 3 cm away
from the margins to keep the rolled mesh in
position (Fig.9.17b, c).
The rolled mesh is then held with a 5mm
Fig. 9.13 Peritoneal reection on the spermatic cord (SC
spermatic cord; PR peritoneal reection)
grasper and introduced into the preperitoneal
space through the 10mm subumbilical port.
128
P. Chowbey
a b
Fig. 9.14 (a) Triangle of doom; and (b) Laparoscopic view of the triangle of doom (PB pubic bone; IEV inferior epi-
gastric vessels; TV testicular vessels; VD vas deferens; IV iliac vessels)
a b
Fig. 9.15 (a) Psoas muscle with femoral branch of genitofemoral nerve; and (b) endoscopic view of the psoas muscle
with femoral branch of genitofemoral nerve (SC spermatic cord; GN genitofemoral nerve; PM psoas muscle)
a b
Fig. 9.16 (a) Completely dissected right extraperitoneal space; and (b) intraoperative view of the completely dissected
right extraperitoneal space (SC spermatic cord; CL Cooper ligament; IEV inferior epigastric vessels)
9 Total Extraperitoneal Repair ofGroin Hernias
a
b
129
Fig. 9.18 Two-point xation of the mesh
c
Knot on flat side
of rolled mesh
Unrolled mesh
5 cm
Fig. 9.17 (a) 15 × 15 cm polypropylene mesh; (b) rolled
mesh; and (c) sheath of roll
• Mesh xation
The mesh is placed such that the medial margin extends for 2–3 cm beyond the midline
and 2–3cm below the pubic bone inferomedially. Laterally, the inferior margin of the mesh
should lie over the psoas muscle. It should be
ensured that no extraperitoneal fat lies beneath
the lower margin of the mesh. The fold of the
Fig. 9.19 Unrolled mesh after cutting the stay sutures
peritoneum should lie below the inferior margin of the mesh.
The mesh is xed at two places on the
Cooper ligament using a 5 mm xation
device—ProTack™ (Autosuture, Tyco
Healthcare, US Surgicals, Norwalk, CT, USA;
Fig.9.18). No xation should be done laterally for fear of cutaneous nerve entrapment. In
the case of bilateral hernias, a similar xation
of the mesh is done on the opposite side with
a 2–3cm overlap in the midline.
After removing the stay sutures, the mesh is
unrolled to lie within the extraperitoneal space
(Fig.9.19). After keeping the unrolled mesh in
position, CO2 is exsufated and the trocars are
removed. As the extraperitoneal space is an