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Inguinal Hernia Repair by TEP - general and visceral surgery
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Access to the preperitoneal space
1 cm subumbilical skin incision Split the fatty tissue with Langenbeck retractors and expose the fascia/anterior rectus sheath. About 1 cm paramedian scalpel incision on the side of the hernia. Pull the medial flap of the fascia anteriad with a sharp clamp. Slip the Langenbeck retractor below the rectus muscle and lift it anteriad.
Tip: If the fascia is incised precisely in the midline, this will open the abdominal cavity and not the rectus sheath. In this case, close the fascia and incise more laterally.
With a long peanut sponge on the posterior lamina of the rectus sheath, bluntly dissect the preperitoneal space down retrosymphysially. Follow this with blunt insertion of the 10 mm trocar and then gas inflation at a pressure of 10 – 15 mmHg. Insert the laparoscope with the camera Under visual control insert a 5 mm trocar in the median plane exactly halfway between the umbilicus and pubic symphysis
Tip: Note the epigastric vessels regularly seen here, before inserting the 5 mm trocar. Use trocars with a locking mechanism since otherwise they will slip and massively hinder any preparation!
Dissecting the preperitoneal space
Dissect the preperitoneal space, primarily with the scissors, through the 5 mm trocar. Starting retrosymphysially, clear the tissue in one anteroposterior sweep from the posterior aspect of the pubic symphysis down to the bladder. Small vessels traversing the field can be coagulated.
Follow this by bluntly dissecting the lateral space in the same way until the lateral margin of the rectus sheath is seen. Transect it in small steps with the scissors up to the plane of the superior anterior iliac spine. Under visual control, insert the second 5 mm trocar about 2 cm medial to the iliac spine.
Tip: Sharply transect the lateral margin of the rectus sheath as far anterior as possible since otherwise this would open up the abdominal cavity!
Hernia sac dissection in direct hernia
From now on work with the dissector and scissors through 5 mm trocars. Traction and counter-traction will provide thorough blunt dissection of the preperitoneal space.
This example demonstrates dissection of a right-sided direct hernia. With both instruments bluntly pull the hernia sac and its contents back from the defect.
Tip: Since the dissection is carried extremely close to the femoral vessels, care must be taken to spare venous branches which, when injured, tend to hemorrhage and require lots of patience and extensive experience in hemostasis!
Hernia sac dissection in indirect hernia
In this example the left-sided indirect hernia sac is located lateral to the epigastric vessels and spermatic duct and within the spermatic cord.
With traction and counter-traction bluntly dissect the hernia sac off the spermatic cord and as far posteriad as possible. Preperitoneal lipomas can be managed in the same way.
Then pull the tensing peritoneum off the spermatic cord as far posteriad as possible.
Tip: There are always numerous lymph nodes lateral to the spermatic cord. Dissection by the inexperienced surgeon in this area may result in hard to control persistent bleeding!
After having completed the dissection prepare the mesh whose corners are rounded off with the scissors. Tightly roll up the mesh, grab one end with the dissector and then insert it blindly through the 10 mm trocar of the laparoscope. Unfurl the mesh and place it such that it completely covers the medial and lateral hernial orifices. During posterior placement ensure that the hernia sac and peritoneum, as well as any preperitoneal lipoma, will end up anterior to the mesh and not posterior to it. If so desired place a Redon drain. Deflate the gas under visual control and note that the peritoneum will mold to the posterior aspect the mesh.
Closing the incisions