Laparoscopic Inguinal Hernia Repair

 

A sub-umbilical incision (midline-2cm) is made. Using "Army-Navy" retractors, the sub-cutaneous planes are retracted until the linea-alba and the anterior rectus sheaths are exposed. A 2 cm incision is made on the anterior rectus sheath, off the midline (on the affected side). The rectus muscle and its most medial aspect is visualized.

Using a finger and blunt dissection, a tunnel is created and the USSC dilating trocar is inserted.

The insert of the trocar is removed and replaced by the 0 Deg. Telescope. Under direct vision, the balloon is inflated with the hand pump.

The balloon is inflated, opened and unfolded.

When the balloon is totally unfolded [the balloon will look "unwrinkled'], the telescope is removed and the balloon deflated. The dilating trocar is then removed. The pro-peritoneal space has been created.

 

 

The structural 10 mm USSC trocar is inserted in the same position of the dilating trocar.

Using the hand pump, the structural balloon is inflated. It is then secured by sliding the adjustable outer ring of the trocar to seal the entry site.

The insufflation port is connected to the insufflation Pump. A pneumo-pro-peritoneum is created.

Two 5 mm Versaports are inserted under direct vision. Although some surgeons place these trocars in the midline [2cm and 4 cm below the umbilicus / midline], we favor the lateral placement of these trocars [identical placement as in a TAPP repair]. However, in most cases the dilating balloon does not extend and push the peritoneal layer superiorly enough to safely place these trocars without entering the abdominal cavity. Using the telescope, the dissection of the peritoneum is bluntly extended superiorly. Once the first 5 mm trocar is inserted a blunt grasper is used to perform the same maneuver on the other side.

If a peritoneal defect is created at this time it should be immediately closed [see "Closing Peritoneal Defects during a TEP Repair"].

 

The anatomical landmarks are identical when performing a TAPP repair. However, the view is not as "clean" as in a TAPP repair. Therefore, it is essential for the surgeon to get familiar with the actual pro-peritoneal view as seen in the picture below.

 

The entire area should be meticulous and bluntly dissected starting from the pubic ramus [easily identifiable landmark].  Cooper's Ligament, the Inferior Epigastric Vessels, the Spermatic Cord and  the  position of the iliac vessels are clearly identified.

 

The indirect inguinal hernia sac should be dissected  carefully  from the Spermatic Cord. Direct hernia sacs are easily dissected. This is done by gentle traction with atraumatic graspers.

 

The Mesh is rolled like a cigarette and inserted via the 10-5mm Structural Trocar , uncut into the pro-peritoneal space and deployed over the inguinal region.

Our current mode of placement of the mesh is the "onlay Mesh Placement" which cover the entire inguinal region. The graft is first attached or secured to Cooper's Ligament, and the superior aspect of the pubic ramus using the Protack™ Instrument. The Mesh is then tacked on the posterior aspect of the Linea Alba. The anchoring is continued around and lateral to the Inferior Epigastric Vessels.

Caution: Do not place staples or tacks over the inguinal vessels.

A few tacks are used to staple the Mesh lateral to the internal ring.

The Mesh should gently and generously cover the Iliac Vessels without major gaps.

 

The operator should check the Mesh is well anchored to the surrounding structures. Using a closed grasper, pressure is applied with the end or tip of the grasper directly at the center of the covered direct and indirect defect. The Mesh should not migrate and remain in place.

 

The pro-peritoneal space will be checked for any peritoneal defects. If any, they should be closed using a SURGICON Springlock. The 5 mm trocars are removed under direct vision. The pro-peritoneal space will collapsed.

If there are any question about a missed peritoneal defect, a completion laparoscopy should be performed.

The structural balloon is deflated. The trocar is removed and the fascial defect closed with the appropriate suture. The skin edges are approximated in the usual manner.