Single port laparoscopic total hand-sewn treatment of a right indirect inguinal hernia: TAPP approach

This video demonstrates the single port laparoscopic treatment of a right indirect inguinal hernia in a 21-year-old male patient using the E.K. Glove port. This video will show the polypropylene mesh fixation and the repair of the peritoneal flaps performed exclusively by hand suturing.

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Single port laparoscopic total hand-sewn treatment of a right indirect inguinal hernia: TAPP approach

Authors

E Khiangte, I Newme, P Phukan

Abstract

This video demonstrates the single port laparoscopic treatment of a right indirect inguinal hernia in a 21-year-old male patient using the E.K. Glove port. This video will show the polypropylene mesh fixation and the repair of the peritoneal flaps performed exclusively by hand suturing.

Classification

single port

Keywords

Single port, laparoscopic total hand-sewn treatment, right indirect inguinal hernia, TAPP approach

Media type

Surgical video

Duration

09'07''

Publication

2012-01

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E-publication

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3464.htm

Single port laparoscopic total hand-sewn treatment of a right indirect inguinal hernia: TAPP approach

1. Case presentation 00'05''

We present the single-port laparoscopic treatment of a right indirect inguinal hernia in a 21-year-old male patient using the E.K. Glove port. This video will show the polypropylene mesh fixation and the repair of the peritoneal flaps performed exclusively by hand suturing.

2. Peritoneal cavity exploration 00'26''

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

3. Lateral peritoneal dissection 00'39''

The right anterior superior iliac spine is identified and the peritoneal dissection is started just below the anterior superior iliac spine. Monopolar scissors are 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.

4. Medial peritoneal dissection 01'30''

The peritoneal dissection is extended to the medial side up to the medial umbilical ligament but not crossing it. Care is taken not to injure the inferior epigastric vessels. A pair of scissors is used with minimal use of diathermy current.

5. Dissection in Retzius’ space 02'08''

Dissection in Retzius’ space is achieved mainly using traction and counter-traction. Dissection is continued until Cooper’s ligament and the pubic symphyses are identified and a large space is created. Retzius’ space is the prevesical space between the symphysis, the bladder, and the anterior abdominal wall. It contains loose connective tissue and fat.

6. Dissection and division of hernia sac 02'45''

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. 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.

7. Parietalization 04'05''

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. This is a delicate procedure, and care should be taken not to injure the vessels or tear the peritoneum.

8. Cooper’s ligament 04'42''

This is the area of Cooper’s ligament and the wide Retzius’ space.

9. Creation of space under the superior peritoneal leaf 04'50''

The superior leaf of the peritoneum is now held by the two grasping forceps and pulled gently to create an extra space for easy placement of the mesh.

10. Mesh introduction 05'03''

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 entering the abdomen. The mesh is unrolled to cover all the myopectineal orifices of Fruchaud. In conventional laparoscopic hernia repair, we usually fix the mesh in three sites; Cooper’s ligament, rectus muscle on the superomedial aspect of the mesh, medial to the inferior epigastric vessels and on the superolateral aspect of the mesh. The same has been duplicated here. Posterior sutures should be avoided because of the proximity of cord structures and iliac vessels. Before fixing to the Cooper’s ligament, the dangerous area of corona mortis should always be carefully inspected. As the area of triangle of Doom and triangle of pain are totally avoided, the incidence of vascular injuries and neuralgias are negligible following this approach.

11. Re-approximation of the peritoneum 07'24''

After fixing the mesh, the peritoneum is sutured over the mesh to prevent bowel or omental adhesions. 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, thus eliminating the need to knot. The peritoneal suture completely closes the flap without any gap. Due to ergonomics and space constraints, single port suturing and knotting are technically more challenging. Patience and practice will help to master this art. This technique will help the surgeon to master the art of endo-suturing. More effective peritoneal closure is made possible by a reduction of the pneumoperitoneum to 8mmHg at this stage. This is a cost-effective technique of single port inguinal hernia repair.