LAPAROSCOPIC REPAIR OF INGUINAL HERNIA ( ADULT )
PRE-PERITONEAL APPROACH (TEP)

PATIENT SELECTION
THEATRE LAYOUT AND EQUIPMENT
PRE-OPERATIVE CHECKS
PATIENT PREPARATION
INSUFFLATION AND PORT INSERTION
DIRECT HERNIA
INDIRECT HERNIA
MESH INSERTION
CLOSURE

INTRODUCTION

The TEP repair for inguinal hernia is generally considered to be technically demanding, expensive and time consuming. As in other areas of laparoscopic surgery, much of the "specialised" equipment developed to aid the surgeon and adding to the cost is unnecessary and we have shown that, with experience, the operation now takes less time than open mesh repair. Mesh fixation is unnecessary and only adds to cost, time and complications. The only surgical consumables required are a 15x10 mesh, one vicryl suture, one packet of steristrips and one scalpel blade. TEP repair is technically demanding as the surgeon is working in a confined and anatomically strange space, has to learn both right and left sides, needs to deal with the normal variations of groin hernia and requires a high level of bimanual dexterity. However the conclusions of NICE, that laparoscopic repair is associated with less post operative pain and faster recovery, remain true. Post operative complications are reduced and chronic, sometimes severe groin pain is significantly less. For these reasons and others, surgeons who perform groin hernia surgery should seek out training in this important development in one of the most common conditions that we treat.

PATIENT SELECTION Top

SUITABLE PATIENTS

Patients aged 12 years plus
Male and female
Suitable for general anaesthetic with muscle relaxation

SUITABLE HERNIAS

Elective repair
Some emergency herniae (not strangulated)
Indirect, direct, scrotal, sliding inguinal hernia
Recurrent inguinal hernia(except after previous preperitoneal mesh repair)
Bilateral inguinal hernia (treated as below but using two meshes)
Femoral hernia (with no suspicion of strangulation)
Combined inguinal/incisional (eg after low transverse incision)
Exploration for suspected hernia
Sportman's groin

ABSOLUTE CONTRAINDICATION

Patient unfit for a general anaesthetic
Gross obesity
Massive scrotal hernia
Recurrence after previous preperitonal mesh repair
Suspected strangulation of hernia

RELATIVE CONTRAINDICATIONS (ALL SURMOUNTABLE)

Moderate obesity
Previous sutured preperitoneal hernia operation
Previous lower abdominal surgical incision
Renal transplant on same side
Hip arthoplasty on same side
Previous central dislocation of hip
Protrusio Acetabulae
Grid iron incision on same side
Stoma on same side

THEATRE LAYOUT AND EQUIPMENT Top

NON-SURGICAL EQUIPMENT LIST

Laparoscopic stack with camera, monitor, light source and insufflator

CABLES

High frequency connecting cable for diathermy

SPARES

Sterile filters for insufflator.
CO2 Cylinder
Spare light bulbs
Spare fuses

STANDARD STERILE SURGICAL EQUIPMENT

Basic surgical instrument tray
Two Langenbeck straight retractors
Three larger curved artery forceps

SPECIAL STERILE SURGICAL EQUIPMENT

TELESCOPE

Telescope zero degree 10mm diameter
Light Cable

TROCARS AND SLEEVES

10mm Blunt trocar with conical sleeve
Two 5mm trocars with external spiral grooving

LAPAROSCOPIC INSTRUMENTS

Two Wolfe atraumatic graspers
Metzembaum type laparoscopic scissors
Hook diathermy
Suction irrigation 5mm

THEATRE FURNITURE

1 x larger trolley
1 x small trolley
1 x drip stand
1 x pressure infusor
1 x diathermy machine

MATERIALS

15x10 cms polypropylene mesh
vicryl J suture
Steristrips
Three Mepore type dressings

PHARMACEUTICALS

Irrigation saline 0.9%
Bupivocaine 30 mls 0.5%
Dicolfenac suppository

PREOPERATIVE CHECKS Top

PATIENT CHECKS

Check you have correct patient
Check you have correct side or bilateral
Check the patient's bladder has emptied within last hour
Check patient has consented including conversion to open if necessary
Check there is no other procedure to do
Check patient is shaved from above umbilicus to groin

PATIENT PREPARATION Top

There is no evidence that prophylactic antibiotics reduce the minimal incidence of infection
There is no evidence that heparin DVT prophylaxis reduces the risk of venous thromboembolism but evidence that bleeding complications are increased.

ANAESTHESIA GENERAL

LOCAL anaesthesia is used during this technique as well as general anaesthesia.
A total of 30mls of 0.5% Bupivacaine is used,
A higher dose raises the risk of toxic effects if the drug reaches the circulation.
NB You MUST have facilities and staff to correct any complications of local anaesthesia eg Hypotension, cardiac arrhythmias, respiratory arrest, coma, convulsions, and anaphylactic reactions.

POSITION SUPINE

With bare skin from costal margin to groin, free from all tubing, wires, electrodes, etc.
Do not place the patient's arms across chest as this impeded telescope

STANCE

Start by standing on the patient's left side for the cutdown procedure
Then move if necessary to the side opposite from the hernia with the assistant on the same side towards the head

PREPARING THE SKIN

Prepare the skin from costal margin to groin

SURGICAL DRAPES

Place an upper drape down 5cm above the umbilicus.
Place a lower drape up to the symphysis pubis.
Place a lateral drape to the anterior superior iliac spine.
Place a medial drape to the opposite anterior superior iliac spine.

FIX THE TOWELS

Use 4 towel clips

CHECK DIATHERMY IS WORKING

INSUFFLATION AND PORT INSERTION Top

INCISING THE UMBILICAL SKIN

Use a 15mm Swann-Morton scalpel.
Make a horizontal, midline, 2cm skin incision just below the umbilicus.
Deepen the incision to find the anterior rectus sheath.
Place the Langenbach retractors to aid vision
Coagulate any bleeding vessels.

OPENING THE RECTUS SHEATH

Use a 15mm Swann-Morton scalpel.
Pick up linea alba between two large artery forceps
Make a vertical 1cm incision in the linea alba taking care not to open the peritoneum.
If muscle is seen, identify the medial edge of the muscle and dissect downwards to enter the plain below the muscle fibres
If peritoneum is entered accidentally, close with vicryl sutures
Do not attempt to open the posterior peritoneum as you will almost certainly enter the peritoneum

OPENING THE PREPERITONEAL SPACE (PPS)

Place a large closed artery forcep into the preperitoneal space, just under the linea alba, in the mid line and push it downwards towards the pubic bone
Minimal significant resistance will be felt if in the correct space
Also, downwards pressure on the forceps towards the abdomen will pull the skin downward (if in the peritoneum downwards pressure simply pushes the forceps into the pelvic cavity)
Open the forceps gently and withdraw, developing the space
Repeat this 4 - 6 times gradually opening the space further.
It is possible to open these forceps into the rectus muscles causing bleeding. Minimal resistance should be felt at all times

PLACE THE PORT INTO THE PREPERITONEAL SPACE (PPS)

Place the port and trocar through the opening in the posterior rectus sheath.
Push the instrument downwards in the preperitoneal space
Waggle the instrument from side to side to free the preperitoneal fat from the posterior rectus sheath, and rectus muscle.
Suture (vicryl J suture) the port in place to fit the conical collar smugly partly closing the skin incision to reduce gas leakage
Ideally the port should be lying in a plain just deep to the bellies of the anterior rectus muscles which form the roof of the cavity entered. The floor is formed by the peritoneum and then the urinary bladder inferiorly.

ATTACH THE CO2 TUBE TO THE PORT AND SWITCH ON THE CO2

Take out the trochar
Inflate with CO2 at full rate 10mm. mercury pressure. (Too high a pressure leads to surgical emphysema)

INSERT THE TELESCOPE

Check that the camera in functioning, white balanced and the light source connected and on.
Insert the 10mm zero degree telescope.
Use the telescope to gently develop the preperitonal space further and identify the pubic bone by feel and vision
Use the left hand to palpate the pubic bone and act as a guide to its position
You should be under the muscle, not in the peritoneal cavity, surrounded by fatty connective tissue which separated easily

DEALING WITH ACCIDENTAL PERITONEAL ENTRY

Usually this problem can be overcome, a nuisance not a disaster
This may be recognised because the telescope is clearly within the peritoneum and bowel seen.
If this occurs, withdraw the telescope and port and try again to identify the preperitoneal space by keeping more superficial with blunt dissection beneath the linea alba
It may also be that the telescope is in the preperitoneal space but there is hole in the peritoneum allow gas to escape into it.
In this case, the view is limited and it is difficult to develop the preperitoneal space
In some thin cases with a weak abdominal wall the operation continues accepting the more limited space
If a real problem with vision occurs, place a Verres needle into the RIF, discontinue insufflation to extract as much gas as possible and then reinsufflate, leaving the Verres needle in situ as an escape valve.
For the inexperienced surgeon, peritoneal insufflation may lead to conversion to open surgery but can always be overcome by the experienced surgeon

DEALING WITH ACCIDENTAL PLACEMENT OF PORT INTO MUSCLE LAYERS

If it is clear that the telescope is surrounded by muscle, you have placed the port too superficially.
It is best to withdraw the port and re-insert it more deeply and the umbilical incision

DEALING WITH A CLOUDY VIEW

Withdraw the telescope and clean it with a saline swab and drip on Ultrastop.
Check the focus.
Check the irrigating saline is warm.
Check the is no condensation between the telescope and the camera.
Check there is no condensation inside the camera.
Remove any fat or Cidex contamination of the lens with 15 seconds rubbing with a swab plus drip on Ultrastop.
Check the seal on the Pre-Vu is not leaking.
Consider using a new telescope.

INSERTION OF THE 5 MM PORTS

A 5 mm port is placed in the midline, 3 CMS above the pubic bone
A second 5mm port is place in the midline between the other two ports
Due to the low pressure, it is difficult to insert these ports under vision.
The telescope and 10 mm port can be used as a guide to depth and penetration, taking care not to damage the telescope
Two atraumatic Wolfe dissectors are now placed in the two 5mm ports, always inserting them in the midline under vision and then dissecting laterally

ENLARGING THE PREPERITONEAL SPACE

The overall aim is to develop the PPS from medial to lateral, demonstrating the pubic bone, direct hernia, inferior epigastric vessels, deep inguinal ring, indirect hernia, spermatic cord and peritoneal reflection in that order.
Always work in the roof of the space and not the floor
The bladder is lying in the floor of the PPS in the midline.
Do not deliberately dissect it out, because of the danger of bleeding from vessels on its surface.
The iliac vein and artery also lie in the floor of the dissection
They may be seen clearly in a thin patient but are better avoided and there is no need to formally identify them nor dissect them in any way.
Always hold the lower instrument with the lower hand ie when operating on a left hernia, stand on the patient's right side and hold the lower instrument with the right hand and upper with the left : when operating on a right hernia, stand on the patient's left side and hold the lower instrument with the left hand and upper with the right.
Use the lower instrument to elevate the abdominal wall and the upper instrument for dissection, pulling the peritoneum and hernia away from the muscle.
In most cases, sharp dissection, hook diathermy and suction irrigation is not required.

DIRECT HERNIA Top

FINDING A DIRECT SAC

Start at the pubic bone which should be cleared of attachments across the midline and down into the retropubic space for 2 CMS where the medial, lower corner of the mesh will eventually lie.
The gentle curve of the pubic bone, highest centrally, is an essential landmark allowing orientation of the camera and a useful horizon for the surgeon as herniae lie above this level and danger lurks below
A direct hernia lies immediately lateral to and above the pubic bone.
It looks like a lump of fat occupying the lateral part of the field.
The hernia pushes outwards through the transversalis fascia.
The initial appearance is of a white, sac like structure coming towards the surgeon with a fatty mass attached.
The surgeon pushes the white transversalis fascia away with the lower hand whilst pulling the fatty tissue towards himself.
Eventually the fatty direct hernia becomes detached and the white transversalis fascia is blown outwards by the gas pressure clearly demonstrating a weakness in the abdominal wall.
The inferior epigastric vessels may now be seen just lateral to the direct hernial defect.
Pull any residual adherent tissue out from the direct muscle defect
There is never a need to open a direct sac ; nothing needs to be done to it.
Even if a direct hernia is found, the surgeon needs to exclude an indirect hernia and also develop the space laterally for the mesh to be inserted.
Dissection proceeds laterally, elevating the inferior epigastric vessels with the lower dissector whilst pulling adherent preperitoneal tissues downwards to identify the deep inguinal ring and spermatic cord. The peritoneal reflection will be seen in the floor of the dissection, close to the deep inguinal ring, and is gently teased away from the ring by blunt dissection to allow placement of the lower edge of the mesh.
Further dissection laterally is performed to the level of the anterior superior iliac spine (which can be palpated externally but not seen internally) again to allow mesh placement

If there is no direct hernia, the fatty tissue lying against the muscle can easily be pulled away from the firm, posterior wall of the inguinal canal, working laterally and looking for the inferior epigastric vessels.
Care must be taken not to pull the vessels downwards away from the abdominal wall as this will increase the risk of bleeding, hamper further dissection and impede mesh positioning.

INDIRECT HERNIA Top

FINDING AN INDIRECT SAC

An indirect sac lies lateral to the inferior epigastric vessels

DISSECTING AN INDIRECT SAC

The inferior epigastric vessels must now be identified.
Usually the vein comes into view and the artery is just behind it
No dissection of these vessels is necessary
They are simply held upwards onto the muscle whilst adherent preperitoneal fat is pulled away from them.
The lower dissector is placed just below the vessels and used to elevate and protect them.
The upper dissector now pulls adherent tissue downward until the vessels are fully exposed.
The deep inguinal ring lies just lateral to the vessels
The spermatic cord structures are seen emerging from the deep inguinal ring
If an indirect hernial sac is present is lies in front of the cord, hiding the cord from view.
The indirect sac is separated from the cord and then reduced back into the abdominal cavity
If extremely long, it may be necessary to divide the sac
Holding the sac, 2-3 CMS from the deep inguinal ring, with the lower dissector, it is pulled downwards and medially whilst the upper dissector is used to push away adherent tissue on its lateral side
Dissection is kept very close to the wall of the sac.
As the sac mobilises further, cord structures may be seen deeply placed posteriorly.
The sac is now held with the upper dissector and pulled upwards, outwards and laterally whilst the lower dissector pulls adherent tissue downward and medially.
Again, the cord structures should be seen lying beneath the sac.
A plain is now opened between the medial and lateral dissections so that the sac is separated from the cord and held upwards and laterally whilst the cord falls downwards and medially
Take care that none of the cord structures are still adherent to the sac, particularly vessels which might cause bleeding
Once the surgeon has separated the sac and cord, the sac can be held by the upper dissector, pulling it out from the deep inguinal ring, whilst the lower dissector pushes the abdominal wall away until the whole sac has been pulled back into the abdominal cavity.
The sac progressively thins out and finally its tip is reached and detaches from cord.
If the sac is extremely long, it can be cut using diathermy scissors. Neither end needs to be closed.
As in open surgery, in some cases the sac is very adherent to the cord and this dissection can be difficult.
During this dissection a fatty lipoma may be seen and is simply grasped and pulled back into the abdomen
Take care not to mistake lymph nodes around the iliac vessels for a lipoma
When the sac is fully reduced or divided, it is pulled well back into the abdominal cavity.
Dissection continues laterally to the level of the anterior superior iliac spine which is felt externally, to allow placement of the mesh
Also, tease the peritoneal reflection in the floor of the dissection back into the abdomen. This is aided by grasping the cord structures with the lower graspers and hold them towards the deep inguinal ring while brushing back the peritoneal reflection with atraumatic graspers in the upper port

SLIDING HERNIA

To the TEP surgeon, a sliding hernia is a direct type inguinal hernia passing outwards through the deep inguinal ring. Indeed that is exactly what it is. It is very easy to separate from the cord as, unlike the indirect hernia, it is not enveloped in the same fascial plains. It also attaches to the transversalis fascia just like the direct hernia and on reduction, the white sheet of transversalis fascia is seen to be adherent until it is dissected free. It presents the TEP surgeon with no technical difficulties

FINAL CHECK BEFORE MESH INSERTION

MESH INSERTION Top

A 15cms x 10cms polypropylene mesh is used without any modification
The telescope is carefully withdrawn, holding the port so as to align it directly into the PPS.
The lower medial corner of the mesh is held with atraumatic graspers and placed fully down the port into the PPS with as little folding as possible
On reinsertion of the telescope, there is usually some mesh still in the port, easily pushed downwards by the telescope
Using the upper dissector the mesh is further pushed downward and also laterally as the nearest part of the mesh to the surgeon should be the upper, outer corner.
The mesh is gently teased open and flattened
First identify the lower medial corner and place it into the retropubic space just across midline
Now find the upper medial corner and hold it with the upper dissector, keeping it up against the abdominal wall and not downwards into the PPS which easy to do but unhelpful
Use the lower dissector to place the medial short edge in position.
Now work from medial to lateral, holding the top edge with the upper dissector whilst using the lower dissector to iron out any folds
Keep repositioning the upper dissector more laterally until the whole mesh is flat and in good position
When complete, the lower medial corner should lie behind the pubic bone just over the midline to the opposite side from the hernia
The upper edge should be very close to the lower port
The lateral upper corner should be well lateral of the deep inguinal ring.
The lateral and lower edges should be as flat as possible
The reduced direct hernia and/or indirect sac should be on the abdominal side of the mesh
The direct defect, deep inguinal ring and femoral canal should all be well covered by the mesh

CLOSURE Top

CLOSING STAGES

Switch of Insufflator and camera and monitor
This will prevent the CO2 bottle emptying.
Place 20 mls 0.5% Bupivocaine through the lower port into the PPS
Deflate the PPS, holding the mesh in place especially inferiorly and laterally while you deflate
Remove all the ports
Close the rectus sheath at the umbilicus with the remainder of the vicryl J suture
Inject a total of 10 mls of 0.5% Bupivocaine into the three skin incisions
Close each small incision with Steristrips, best applied as an X so they do not interfere with one another
Check swab, needle and instrument counts
Check there is no other procedure to do

FINAL TOUCHES

Write legible operation notes
Fill in audit forms
Dictate operation note and letter to GP and referring physician
Explain to the patient prior to discharge that a lump may appear at the site of the initial hernia and this is most likely to be a seroma or haematoma and not a recurrent hernia. If necessary it is easily dealt with by aspiration