Totally Extraperitoneal Repair of Hernia
The inguinal hernia repair is a questionable area in the surgical practice by time it continues to be conceived. The history of inguinal hernia repair over several years implies how innovations are adopted into surgical practice through combination of scientific and subjective processes. The techniques of laparoscopic hernia repair have evolved in parallel with experience and technologies. Within the laparoscopic method, tension free repair is achieved by keeping a prosthetic mesh to cover the whole groin area such as the sites of immediate, indirect and femoral hernia. The laparoscopic strategy is based on the principle of tension free repair, which has also been well established by open operation by Nyhus and Stoppa. The greater accessibility to space in the extraperitoneal approach facilitates the insertion of a significantly bigger mesh.
Patient selection
TEP groin hernia repair is an sophisticated laparoscopic method. It takes higher skills of laparoscopic dissection and manipulation since the working space available is restricted. It features a long learning curve and should be done only following acquiring experience in basic laparoscopic procedures so when the learning curve is over. Today, we are well past the learning curve and also have performed well over thousand laparoscopic groin hernia repairs. Except for strangulated hernia, at present there aren't any absolute contraindications for this method. Relative contraindications consist of patients not fit for anesthesia, obese as well as pregnant patients and also patients with a good reputation for lower stomach surgery.
Preoperative preparation
A comprehensive good reputation for the presenting complaints along with other comorbid problems ought to be obtained. Specific measures should be used when the patient is on drugs such as Aspirin and warfarin, oral hypoglycemic brokers etc. Besides routine hematological investigations, other particular investigations like X-Ray chest, ECG, coagulation profile, pulmonary function test etc should be done for patients with history of cardiac or pulmonary pathology. A written consent should be taken explaining the probable complications and possibility of transformation to open surgery. Following preanesthetic check up and settlement for surgery, the individual is kept fasting overnight. The individual is ready adequately.
Surgical Technique
The procedure is completed below general anesthesia. The patient is catheterized or asked to empty the bladders before surgery and prophylactic antibiotic is offered at the time of induction of anesthesia. Following induction, complete reduction of the items in the hernial sac is actually made sure.
Extraperitoneal access
A 10mm infraumbilical transverse incision is created. The anterior rectus sheath is exposed and transverse incision will be made about the anterior rectus sheath to 1 side of the midline to avoid unavoidable opening from the peritoneum. The edges of incised sheath are locked in stay sutures using vicryl 1-0. The rectus muscle is retracted laterally in the midline and by finger dissection a space is created between your rectus muscle and also the posterior rectus sheath.
Balloon dissection of the extraperitoneal space
Any self produced balloon is then inserted on this preperitoneal space. The balloon trocar utilized by us is definitely an indigenously created trocar where we tie two finger stalls of the size 8 latex surgical glove on the tip from the 5 mm laparoscopic suction cannula. The balloon trocar is the inflated with 100-150ml of saline. It not only creates a preliminary working space brings about hemostasis by balloon tamponade. The balloon will be deflated and the cannula is removed.
A 10 mm Hassan’s cannula (blunt tip cannula) mounted with a conical sleeve is then introduced into the preperitoneal space through the infraumbilical incision. The conical sleeve snuggly suits the incision and it is secured with stay sutures. The insufflation tubing is attached to the Hasson’s Cannula and insufflation is begun with pressure setting at 12 mm Hg. A 10 mm 30° telescope is used. The camera is introduced through the sub umbilical port and preperitoneal space is visualized. Another two working ports are placed within the preperitoneal space. First, a 5 mm port is positioned about 2-3 cm above the pubic symphysis within the midline and 2nd, a 5/10 mm port is positioned in the midline midway between the two placed ports.
Dissection from the extraperitoneal space
The surgeon stands on the side opposite to the side where hernia is present. Dissection in extra peritoneal space commences by dividing the loose areolar tissue within the midline using sharp and blunt dissection. The very first landmark / reference point i.e. the pubic bone is identified which appears as white glistening structure in the midline. The pubic bone is visualized and bared of ligament creating a shelf extending about 2-3 cm in the retropubic space, which acts as a shelf to put the mesh.
The dissection will be traced laterally towards the side of the hernia. In the event of direct hernia, the hernial sac is visualized as a weakness within the Hasselbach’s triangle medial to the inferior epigastric vessels. However, within the indirect hernia, the inferior epigastric vessels are noticed prior to the hernial sac, that is encountered laterally. Once the adhesions are lysed or hernial sac is reduced as with direct hernia, the anatomical landmarks which now become visible are Cooper’s ligament, iliopubic tract, femoral canal and the inferior epigastric vessels.
The spermatic cord lies instantly inferior and lateral to the inferior epigastric vessels. The adhesions all around the cord are lysed with caution as the external iliac vessels lie just below the cord structures. The peritoneal extension is seen as an white glistening structure lying anterolateral towards the cord. The sac is totally dissected from the cord structures and reduced. In cases of complete hernia, attempt shouldn't be designed to completely reduce the sac as excessive traction and dissection causes severe postoperative pain and edema. The sac should be transected and ligated utilizing a catgut endoloop or by intracorporeal sutures, leaving the distal sac open in situ.
The peritoneal sac with reflection is totally reduced. The vas deferens sometimes appears lying separately on the medial side and gonadal vessels are seen on the lateral side forming a triangle. This triangle, known a “triangle of doom”, is bounded medially through the vas deferens laterally by gonadal vessels with its apex in the internal inguinal ring and also the base is formed by the peritoneum. No dissection ought to be carried in this triangle as it offers the external iliac vessels.
Dissection is extended lateral to the cord structures to create adequate space for the keeping mesh. The lateral space contains loose aerolar tissue, that is completely divided using sharp and blunt dissection. The psoas muscle is seen lying on the ground on which lateral cutaneous nerve of thigh and genito femoral nerve is visible transversing. The anterior superior iliac spine marks the lateral boundary of the dissection.
After creating the lateral space adequately the mesh is introduced through the 10mm subumbilical port. The mesh is placed over the space created in order that it covers the sites of direct, indirect, femoral and obturator hernias. The mesh may be the secured in position by using fixation devices like helical fasteners, staples anchors etc. based upon the preferred choice of the surgeon. After adequately spreading the mesh, which extends from the midline medially, to lying within the psoas muscle on the lateral side, preperitoneal space is deflated. In the event of bilateral hernias the same procedure can be achieved on both the sides using it . three ports designed for unilateral repair.
