The Pre-Peritoneal Laparoscopic Inguinal Hernia Repair

Laparoscopic Inguino-Femoral Hernia Repair

PART I PART II PART III PART IV PART V

THE PREPERITONEAL OR TEP REPAIR

This technique is identical to the TAPP technique. However, it entirely takes place in the preperitoneal space. Thus, it is a totally extraperitoneal repair. The indications, the operating room setup and the placement of the trocars are also identical to the setup described in the new TAPP Repair.

Instruments

2 USSC VERSAPORT* trocar-5 mm

1 USSC ENDO SHEARS* Instrument with cautery connection

1 USSC ENDO DISSECT* Instrument

1 reusable Storz 5 mm dolphin nose grasper

1 6" x 6" USSC SURGIPRO* Mesh (Open weave) or a Mesh

1 disposable USSC PROTACK* (30 tacks) or 5mm USSC™ Tacker.

1 TEP USSC Disposable Set ( 1 distension balloon trocar, 1 structural trocar, 1 pump)

Entry and creation of the pre-peritoneal space

No pneumoperitoneum is created. Instead, a small incision is made below the umbilicus (midline). The midline is exposed. An incision is made slightly lateral to the midline aponevrosis ( on the ipsilateral side of the inguinal hernia). The anterior and posterior Rectus Muscle Sheaths are exposed. A small space is developed bluntly with a finger. The balloon expander is then inserted. The remainder of the technique varies with the instrument used.

Creation of the pre-peritoneal space

The USSC™ Preperitoneal distension balloon system is inserted in the pre-peritoneal space. The balloon is inflated under direct vision with the telescope in place.

Once the balloon has been inflated to full capacity, it is deflated and the entire system removed.

The USSC™ Structural Balloon Trocar is inserted into the pre-peritoneal space. The structural balloon is inflated through the balloon inflation port with 4 pumps of the bulb. (CAUTION: do not overinflate.)

By depressing the latch of the exterior sponge-seal, the Structural Balloon Trocar will be locked in position. This device will seal off the pre-peritoneal space and maintain the trocar in place.

The repair

The extra-peritoneal or pro-peritoneal space is now well-expanded and ready for the inguinal hernia repair. The two lateral 5 mm trocars are inserted under direct vision. They can be placed laterally or in midline position. The operator should be certain to enter the pre-peritoneal space and not the intra-abdominal cavity to avoid a CO2 leak. This will generate a pneumo-peritoneum and will greatly impair visualization.

As for the TAPP repair, the anatomy has to be clearly identified. Cooper's ligament should be first visualized as well as the Inferior Epigastric Vessels. The direct peritoneal sac is easy to identify and reduce. An indirect hernia sac should be bluntly pulled away from the Spermatic Cord and the inguinal canal using the atraumatic grasper. The hernia sac should be dissected as medially as possible to allow the Mesh to cover the entire inguinal region.

The Mesh is inserted via the medial, sub-umbilical trocar and deployed over the entire inguinal region. A 6" x 6" SURGIPRO MESH is used. The Protack* Instrument is used to anchor the mesh (Cooper's Ligament, around the epigastric vessels, lateral to the inguinal ring, midline rectus Musle Aponevrosis).

Once the repair is completed, the pre-peritoenal space is deflated and the trocars removed. The facial defect is closed.

Technical Notes

The Graft: A 6x6 inch SurgiPro* Mesh (Open weave) is usually used.
Trocar Placement: An identical placement as seen in the TAPP repair can be used. However, there are some problems inherent to this placement. It is essential to bluntly dissect the peritoneum proximally and cephalad prior to inserting the trocar. If not done, a peritoneal leak will be created thus impairing future visualization. We now also place our two 5 mm VERSAPORTS* trocars in midline position under the umbilical trocar. One is placed two centimeters below and the other, one centimeter above the pubic bone.
The Peritoneal Hernia Sac: In most cases, the peritoneal sac can be dissected bluntly from the spermatic cord using atraumatic grapers. The peritoneal sac should be generously retracted toward the midline away from the placement of the future SurgiPro* Mesh (Open Weave).

References:

Vellasco JM et al: Preperitoneal bilateral inguinal herniorraphy: evolution of a technique from conventional to laparoscopic. 1996-SURG ENDOSC10:122-127
Phillips E et al: Laparoscopic preperitoneal inguinal hernia repair without peritoneal incision: technique and early result. 1993-SURG ENDOSC 7:159-162
Korman JE et al: Mesh Configuration in laparoscopic extraperitoneal herniorrhaphy 1997: SURG ENDOSC 11:1102-1105