Laparoscopic groin hernia repair anatomy & technique


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Laparoscopic groin hernia repair anatomy & technique

  1. 1. Anatomy & Technique of the Laparoscopic Totally Extra-Peritoneal Approach for Groin Hernia Repair Abeezar I. Sarela Consultant Surgeon St James’s University Hospital, Leeds
  2. 2. Agenda <ul><li>Preparation & Positioning </li></ul><ul><li>Access to Pre-Peritoneal Space </li></ul><ul><li>Surgical Anatomy </li></ul><ul><li>Dissection </li></ul>
  3. 3. Preparation & Position <ul><li>Ask patient to empty bladder just prior to transport to theatre </li></ul><ul><ul><li>Catheterization is not routinely necessary </li></ul></ul><ul><li>Position on operating table: Supine with arms tucked in the sides. </li></ul><ul><ul><li>Do not fold arms across the chest </li></ul></ul><ul><ul><li>Do not have contralateral arm extended on a arm-board </li></ul></ul>
  4. 4. Theatre Set-Up <ul><li>Stand on left to introduce primary port </li></ul><ul><li>Surgeon and assistant stand on side of the patient opposite to the hernia </li></ul><ul><li>Scrub nurse on same side as the surgeon </li></ul><ul><li>Slight head-down position </li></ul>
  5. 5. Steps for TEP Repair <ul><li>Access to the pre-peritoneal space </li></ul><ul><li>Blunt dissection with laparoscope </li></ul><ul><li>Insertion of additional 5 mm ports (x 2) </li></ul><ul><li>Complete dissection of pre-peritoneal space </li></ul><ul><li>Dissection of retro-pubic space </li></ul><ul><li>Dissection of the hernia </li></ul><ul><li>Placement of mesh </li></ul>
  6. 6. Access to Pre-Peritoneal Space <ul><li>Infra-umbilical transverse incision, sited over medial end of ipsilateral rectus abdominus </li></ul><ul><li>Exposure of anterior rectus sheath. Transverse incision of anterior sheath. </li></ul><ul><li>Identification of medial border of rectus abdominus muscle, followed by lateral retraction </li></ul><ul><li>Introduction of a short-port with a blunt trocar, posterior to the rectus muscle. Fix port and achieve seal around port with a suture. </li></ul><ul><li>Insufflation of CO2 – 12 mmHg </li></ul>
  7. 15. Creation of Pre-Peritoneal Space <ul><li>Mid-line tunnel directed to pelvis </li></ul><ul><li>Remember: No posterior rectus sheath below the umbilicus </li></ul><ul><li>Aim to stay just superior to posterior lamina of fascia transversalis, so that all fat is reflected anteriorly with rectus muscle. </li></ul>
  8. 16. Placement of Accessory Ports <ul><li>Two additional 5 mm ports </li></ul><ul><li>Higher port </li></ul><ul><ul><li>Midline or offset towards side of hernia </li></ul></ul><ul><ul><li>As close as possible to primary port </li></ul></ul><ul><ul><li>Direct vertically and then obliquely toward pelvis </li></ul></ul><ul><ul><li>Introduce grasper and dissect supra-pubic area </li></ul></ul><ul><li>Lower port: </li></ul><ul><ul><li>Just above the symphysis pubis </li></ul></ul><ul><ul><li>Offset to contra-lateral side </li></ul></ul>
  9. 17. Steps of Dissection <ul><li>Identify pubis in midline and develop the space of Retzius </li></ul><ul><li>Trace Cooper’s ligament </li></ul><ul><li>Work superiorly to identify inferior epigastric vessels </li></ul><ul><li>Dissect posterior to inferior epigastric vessels. </li></ul><ul><li>Dissect lateral to inferior epigastric vessels (space of Bogros) </li></ul><ul><li>Continue dissection up to ASIS </li></ul>
  10. 18. Direct Hernias <ul><li>Majority contain pre-peritoneal fact only – no peritoneal sac </li></ul><ul><li>“ Pseudo-sac” </li></ul>
  11. 19. Indirect Hernias <ul><li>Sac is antero-lateral to vas deferens and testicular vessels </li></ul>
  12. 21. Caution <ul><li>Triangle of pain : area lateral to the internal spermatic vessels. Contains femoral branch of genitofemoral nerve and lateral cutaneous nerve of thigh. </li></ul><ul><li>Triangle of Doom : Area between vas deferens medially and internal spermatic vessels laterally </li></ul>
  13. 22. Placement of Mesh <ul><li>Create a wide pre-peritoneal space </li></ul><ul><li>Use a large piece of mesh </li></ul><ul><li>Avoid fixation </li></ul>