TEP hernia repair
Whilst it is possible to dissect the pro-peritoneal space using a 30 degree laparoscope (used by BLA in over 350 cases), our prefernce is to utilise balloon dissectors. They are particularly useful in bilateral and large indirect inguinal hernias. The biggest advantage is speed (remind your managers that theatre costs £33/minute. They allow for up to six hernias on a day case list. They are also essential when it comes to dissecting the retroperitoneum. They may also slightly reduce the amount of bleeding by a pressure effect.
Again, there are two manufacturers, Tyco and Applied Medical. The latter has a re-usable component with cost playing a major role in their marketing stratergy. Their major drawback is that they need to be taken apart, cleaned and steralised between each case.
BLAs preference is the Autosuture™ Extra View™ Balloon system (Order code - OMSXB2) which uses a distention balloon (oval) to separate tissue planes and in doing so, produce a discrete cavity. They come in 5/box. The "circle" balloon is used in carrying out retroperitoneal dissections.
Following tissue separation insert a second cannula with a balloon anchor (Autosuture™ Structural Balloon Trocar - order code OMST10SB) into the cavity and then insufflate the extraperitoneal space. Again they come as 5/box. It comprises a blunt obturator connected to a handle and a valve body assembly. The body contains an internal flapper valve and seal to prevent gas leakage when instruments are inserted or withdrawn. There is a one-way valve for gas insufflation. To minimize leakage and secure the trocar, the distal end of the sleeve has a tripod balloon which is complemented by a proximal foam sponge/collar assembly.
The tripod is very useful if you puncture the peritoneum and create a pneumoperitoneum. The tripod keeps the operating space distended.
It is not infrequent to displace the rubber flap valve when inserting a large piece of mesh. The maximum mesh size (rolled up) that it can take is 12cm. It is easily relocated using an artery forceps.
Instructions For Use
Insert the end of the baloon dissector behind the rectus muscle/in front of the posterior rectus sheath on the sided of the hernia. Dont let the scrub nurse remove its outer plastic covering (it wont work otherwise).
Advance the balloon cannula carefuly and without force behind the symphysis pubis.
Connect the bulb extension to the reflux valve. The bulb extension should remain connected to maintain bulb inflation. The obturator is removed and replaced with the laperoscope. With the reflux valve pointing directly upwards, the balloon is inflated using the inflation bulb. Do not inflate more than 30 pumps. Monitor the progress of the dissection via the laperoscope.
Inflate slowly if the patient has an apendicectomy scar etc.
Once the extraperitoneal space has been adequately dissected, deflate the distention balloon by removing the laperoscope and remove it. Replaced with a Structural Balloon Trocar.
Insuflate the preperitoneal space under low pressure.
Whilst we accept that some surgeons do not fix the mesh in a TEP hernia repair, BLA consider it essential. It is particularly important in direct and large indirect hernias. We have had no recurrence recurrence since adopting routine mesh fixation, or any problem with permanent nerve irritation in over 1000 repairs. Our preference is Tyco's
(Ref 174006 or PTACK-5mm) which come in 6/box @ £ 351.17
Each ProTack™ contains 30 titanium helical fasteners. The diameter of the fastener measures approximately 4mm and the length is approximately 3.8 mm. The instrument is introduced through a 5mm trocar. The length of the shaft is 36 cm.
We use the same product to fix the mesh to the sacral prominentry in ventral rectopexy and attach the sigmoid mesentry.
Place the nose of the instrument on the tissue or mesh, directly over the target site. To ?re it, squeeze the handle completely; this sets the instrument for the next ?ring. Do not use it on tissue which cannot be inspected visually for hemostasis. Avoid applying external counter-tension to the area being stapled as this increases the chances of nerve ingury.NOTE:
- If necessary, use the ProTacker to remove a fastener from tissue by placing the instrument’s shaft directly upon the fastener, applying light pressure and rotating counter clockwise for 3 turns.