Laparoscopic single-port treatment of a left indirect inguinal hernia: TAPP approach

This video demonstrates the single-port laparoscopic treatment of a left indirect inguinal hernia in a male patient aged 50 using the E.K. glove port. The peritoneal dissection, the separation of the hernia sac and placement of the polypropylene mesh are demonstrated. Single-port intracorporeal suturing of the peritoneal flap is also shown in the video.

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Laparoscopic single-port treatment of a left indirect inguinal hernia: TAPP approach

Authors

E Khiangte, I Newme, P Phukan

Abstract

This video demonstrates the single-port laparoscopic treatment of a left indirect inguinal hernia in a male patient aged 50 using the E.K. glove port. The peritoneal dissection, the separation of the hernia sac and placement of the polypropylene mesh are demonstrated. Single-port intracorporeal suturing of the peritoneal flap is also shown in the video.

Classification

single port, contribution

Keywords

Laparoscopic single port, treatment, left indirect inguinal hernia, TAPP approach

Media type

Surgical video

Duration

07'24''

Publication

2011-12

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E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3437.htm

Laparoscopic single-port treatment of a left indirect inguinal hernia: TAPP approach

1. Case presentation 00'07''

We present the single-port laparoscopic treatment of a left indirect inguinal hernia in a 50-year-old male patient using the E.K. Glove port.

2. Introduction of the EK port 00'19''

The umbilicus is everted using a Kocher’s forceps and a curvilinear incision of about 2.5cm is made in the umbilicus. It is deepened till the peritoneum is reached. The inner ring with the glove port is then inserted through the wound of the umbilicus with the assistance of a retractor and a finger. The outer rigid ring is then placed and the open end of the glove is wrapped around the outer rigid ring.

3. Peritoneal cavity exploration 00'56''

The abdominal cavity is explored. A left indirect inguinal hernia can be observed. There is no contralateral hernia.

4. Adhesiolysis 01'09''

Adhesions of the omentum and the sigmoid colon to the hernia sac are evident. An adhesiolysis is done carefully using the monopolar hook.

5. Lateral peritoneal dissection 01'28''

The left anterior superior iliac spine is identified and marked using the diathermy hook. The peritoneal dissection is started above the internal ring and lateral to the inferior epigastric artery until the previously marked anterior superior iliac spine is reached. Monopolar hook or scissors may be used to complete the dissection. Care is taken to minimize the use of monopolar current in this area. To be positioned in the correct embryological plane, traction and counter-traction can be used. There is a completely bloodless extrafascial plane between the peritoneum and the preperitoneal fascia. It is usually done by blunt dissection and by pushing the tissues away from the underlying peritoneum.

6. Medial peritoneal dissection 02'29''

The peritoneal dissection begins on the medial side. Care is taken not to injure the inferior epigastric vessels. The monopolar hook or a pair of scissors may be used. Dissection in Retzius’ space is achieved mainly using traction and counter-traction. Dissection is continued until Cooper’s ligament and the pubic symphysis are identified and a large space is created.

7. Dissection and division of hernia sac 03'00''

Once the medial and lateral aspects have been dissected, the sac structures and the peritoneum attached to the spermatic sheath remain in the medial aspect. These can now be dissected safely off the structures of the cord without endangering either the vessels or the vas deferens. This plane is bloodless and very little sharp dissection is needed to clear this structure. The hernia sac is then separated from the cord structures. The sac is then ligated with a 2/0 Vicryl suture and divided using monopolar scissors. Utmost care is taken not to injure the vas deferens or the gonadal vessels. Once the sac is divided, the peritoneum is separated from the vas and gonadal vessels towards the cranial aspect. This wide parietalization is carried out so that a large size mesh can be positioned without folding. The inferior epigastric artery and the structures around the “triangle of Doom” are demonstrated here.

8. Mesh introduction 04'31''

A 15 by 12 polypropylene mesh is introduced through the E.K. port. The advantage of this port is that you can place the mesh as desired, as you can see it as it enters the abdomen. The mesh is unrolled to cover all the myopectineal orifices of Fruchaud. We usually deploy 3 tacks to keep the mesh in place. Posterior tacks should be avoided because of the proximity of cord structures and iliac vessels.

9. Re-approximation of peritoneum 05'12''

The peritoneum will now be sutured to demonstrate that single port intracorporeal suturing is not impossible even though it is difficult. A 2/0 Vicryl suture is introduced under vision and the peritoneal flaps are sutured. A loop is made in the tail of the Vicryl suture and the needle is passed through it which eliminates the need to knot. Due to the ergonomics and space constraint single port suturing and knotting are technically more challenging. Patience and practice will help to master this art. More effective peritoneal closure is made possible by a reduction of the pneumoperitoneum to 8mmHg at this stage. The peritoneum is sutured over the mesh to prevent adhesions of the bowel or omentum. Metallic clips are applied to hold the suture in place which will be removed after the knot is applied. The peritoneal rent which occurred during the adhesiolysis is repaired using a 2/0 Vicryl suture. Proper closure of the peritoneum is necessary to prevent Richter-type hernias.

10. Needle extraction 07'12''

The needle is extracted from the abdomen and placed into the finger of the glove. It can be delivered safely as can be seen in the video.

11. Suction of retroperitoneal gas 07'22''

We routinely place the suction cannula through the suture gap in order to aspirate retroperitoneal gas.