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| Name | Laparoscopic Inguinal Hernia Repair (TEP approach ) | Dr Atul Mishra |
| Video Uploader | Video From Dr. Atul Mishra |
| Upload Date | This Video Uploaded At 04-04-2018 18:27:25 |
| Video Discription | Laparoscopic Inguinal hernia repair : TEP Inguinal hernia accounts for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women, repair of these hernias is one of the most commonly performed surgical procedures in the world. Laparoscopic repair started in early 1990’s. Advantages of laparoscopic repair are reduced postoperative pain, less requirement of painkiller, more cosmetic scar and early return to work. Poor familiarity with the complex anatomy of the posterior inguinal view is an important reason for steep learning curve for TEP (Totally extraperitoneal) repair. The preperitoneal space is contained between the transversalis fascia and the parietal peritoneum. The inferior epigastric vessels lie on the rectus muscle bilaterally. Medial to these vessels is Hasselbach triangle through which direct hernia arise. The internal ring is lateral to vessels. The femoral ring lies below the iliopubic tract medial to external iliac vessels. The cooper’s ligament is periosteum of the superior pubic ramus and an excellent starting point for dissection. The iliopubic tract (shelving edge of inguinal ligament) is aponeurotic stretch of tissue which is continuation of fascia transversalis extending from anterior superior iliac spine to the superior pubic ramus. The iliopubic tract forms superolateral border of the triangle of pain, an area bounded medially by spermatic vessels. Tacking of mesh is to be avoided in this area because of risk of injury to femoral branch of genitofemoral nerve. The triangle of Doom is bounded medially by vas deferens and laterally by the spermatic vessels with apex at deep inguinal ring. This area contains external iliac artery and vein, so tacking of mesh and extensive dissection should be avoided in this area. The vascular connection between obturator and external iliac system is called corona mortis. Gentle and judicious dissection should be done in this area. Port placement: A 10 mm longitudinal or a curvilinear infraumblical incision is made and anterior rectus sheath is divided longitudinally slightly off the midline. Underlying rectus muscle fibers are retracted laterally revealing the glistening white surface of posterior rectus sheath(PRS). The dissecting balloon is advanced superficial to PRS and beyond the arcuate line into the preperitoneal space down to the pubic symphysis and inflated. Once space is created Hasson”s trocar with cannula is inserted and laparoscope introduced. The rectus muscle should be visualized at the top of operative field. Two additional 5 mm ports are placed in the midline between umbilicus and pubis. Dissection: Dissection begins with gentle exposure of pubic tubercle and cooper’s ligament. Direct inguinal and femoral hernia is encountered during this initial dissection and reduced spontaneously with pneumoperitoneum. The inferior epigastric vessels are identified and dissection lateral to vessels keeping them on roof leads to the space of Bogros, the cord structures and indirect hernia. The proper plane of dissection is between transversalis fascia and the peritoneum. Inferolaterally the abdominal wall must be cleared below the iliopubic tract. Indirect hernia sac is located superolateral to the spermatic cord and carefully separated from it. The sac is either reduced or ligated proximally and divided. Lipoma of cord if present should be reduced cranially and laterally. The peritoneum should be dissected off the vas deferens to the point where vas courses medially. To prevent seroma formation the pseudosac of direct hernia can be tacked to cooper ligament. Mesh of adequate size is folded and inserted through 10mm port. Mesh is flattened and spread across the myopectineal orifice and fixed to the pubic tubercle and Cooper's ligament. |
| Category | People & Blogs |
| Tags | Laparoscopic Inguinal Hernia Repair | Inguinal Hernia | TEP | Laparoscopic | laparoscopy | hernia | repair | Dr Atul Mishra |
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