Laparoscopic TEPP Inguinal Herniorraphy
- 5mm disposable trocar
- Oval balloon
- 5mm fenestrated grasping forceps
- Extra View Oval Balloon (OMSXB2)
- Structural Balloon Trocar (OMST10SB)
- 30 degree laparoscope
Remember the anatomy!
Make a circum-umbilical incision on the same side as the hernia (easier if non dominant thumb placed in umbilicus). Make a longitudinal incision in anterior rectus sheath.
Insert index finger through this incision and sweep under/down behind the rectus. Insert the Extra View oval balloon dissecting system anterior to the posterior rectus sheath. In unilateral cases direct towards the superficial ring. In bilateral hernias direct it towards the symphysis pubis. Alternatively use the laparoscope to dissect (15mmHg pressure) the space (this does not work so well with bilateral hernias as it can be difficult to cross the midline).
Introduce the laparoscope down the port and into the balloon system. Pump up the balloon - 20 to 30 times (see bellow - fascia transversalis & posterior sheath lie inferiorly). If you distend it too much, it will burst.
Look out for the edge of the hernia. Indirect sacs lie lateral to the inferior epigastric vessels (see below). Direct hernias are usually completely reduced by the balloon.
Introduce a short stubby 5mm disposable screw operating port (Ethicon model is ideal) in the midline 2/3 of the way between the pubis and umbilicus. Watch out for the structural balloon. They are very easily punctured. If you place the port mid way between the pubis/umbilicus it can be difficult to site and tack the mesh. Dissection is usually possible with a single 5mm fenestrated dissector. Dissection is facilitated by the surgeon holding the camera at the same time.
Indirect sacs always run lateral and anterior/superior to the spermatic cord which always run lateral to the inferior epigastric vessels. The Storz dissector below points to the deep inguinal ring. The first thing is to always reduce the lipoma of the cord.
If you make a small tear in the peritoneum (see below -created by Maryland; a blunt fenestrated grasper should have been used), balance intra and extraperitoneal pressures with either a Veress or 16G hypodermic needle. If a balance can not be obtained, close with a suture (it needs closing at some time!). It is in situations like this that the Structural Balloon Trocar comes into its own by its ability to maintain the operative space. Sometimes a degree of Trendelenburgh tilt helps.
Sperate the sac from the cord structures and pull it back/out from the inguinal canal. A little hand pressure to fix the cord structures within the inguinal canal can be of help.
Strip the indirect sac from the cord for approximately 3 cms (see below).
Identify the lateral cutaneous nerve of the thigh so as not to catch when fixing the mesh (lies between the points of the Maryland disector see below). It is important to fully expose the deep inguinal ring laterally. In some cases it may be necessary to divide the lower most fibres of the arcurate line.
Peritoneal defects that can not be included within a twisted sac (see below) must be repaired (prevent delayed small bowel obstruction) using either a suture, an ENDOLOOP or 5 mm clips. The edges of the defects are approximated with a clip applier. If you are uncertain that all defects have been closed, undertake a completion laparoscopy at the end of the TEP repair.
Lateral or anterior parietal perforating vessels are controllable with diathermy.
Transect the sac of large inguino-scrotal hernias (this is much easier than you think!). Allways use sharp scissors.
Fold/plicate the upper 2/3 mesh & anchor with a running suture (2/0 prolene) leaving a 1/3 under-hang (mesh is now very easy to move about and position). This underhang allows mesh placement 3cm below the deep inguinal ring. We have use Polypropylene Mesh (Ethicon) 15x12cm with great success. It is softer than the USSC SurgiPro Mesh. Fix the mesh laterally to the ilioinguinal tract (below), watching out for the lateral cutaneous nerve with a protack staple (see below).
A newer and increasingly popular mesh is the Bard 3DMax. This is a "three dimensional mesh" and is constructed to deploy and mold the inguinal region (left or right side). It is a very good "fit" for TEP and many authors have used it without fixation. The postulated advantage of placing a mesh without fixation is a decrease in postoperative neuropathies (see below). The Mesh is unilateral and comes in different sizes.
We however strongly believe in mesh fixation. Anchor to Cooper’s ligament medially with two ProTack staples.
Remove the prolene suture and unfold the mesh by pulling upwards. Always anchor mesh above/around direct defects or a large deep ring (see below). Remember, meshes tend to migrate and/or contract superiorly. There is some suggestion that lightweight polypropylene mesh may be associated with less contraction.
In large direct hernias, evert the fascia transversalis and fix to Cooper’s ligament witha ProTack (prevents seromas). Twist the indirect sac and fix laterally with a ProTack (see below). The latter manoeuver also closes any peritoneal split (see above).
Examine the other side for a hernia - small recurrence at deep ring (see below).
Inject local anaesthetic directly into dissected space.
Do not attempt a TEP repair of large sliding hernias - they always recur.
Injuries to the lateral cutaneous nerve and to the genital branch of the genitofemoral nerve can be minimized by using simple maneuvers.
Do not use abdominal wall counter pressure when placing a tack,
Dissect the abdominal wall meticulously and try to identify obvious neural branches,
Do not place and tack the Mesh under tension,
Make all patients exercise starting the day after the procedure [minimal exercise: a 1 to 3 miles, daily walk].
Meta-analyses, Systemic reviews and randomised controlled trials
Laparoscopic vs. open repair
TAPP vs. TEPP