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HOW TO DO ENDOSCOPIC HERNIA REPAIR

There are two endoscopic techniques for surgical procedure of inguinal hernias.

- TEP (totally extra-peritoneal) repair in which the approach is through the abdominal wall only (pre-peritoneal) behind the rectus muscle.

- TAPP (trans-abdominal pre-peritoneal) repair which is an approach performed through the abdominal cavity.

 

TEP (totally extra-peritoneal) repair

Description of the procedure: 

  • The patient is placed in supine position. Induction of General Anaesthesia.
  • Insertion of a foley catheter is done aseptically. Disinfection and covering of abdomen according to standards.
  • The first access is carried out through a infra-umbilical or para-umbilical incision of the skin until reaching the fascia.
  • pre-peritoneal space is entered after elevation of the rectus muscle.
  • Placement of Bilateral balloon trocar into the space behind the rectus muscles. Insufflation under direct visualisation and the removal of the bilateral balloon also under visualisation.
  • A 12 mm trocar is inserted into the pre-peritoneal space.
  • Insufflation of this space with CO2 gas to reach the maximum pressure of 10-12 mmHg using a flow rate of 3-4 L/min.
  • Placement of two 5mm trocars 5cm away from the umbilicus towards the pubis symphysis respectively.
  • Dissection of peritoneum is carried out on both sides (pre-peritoneal).
  • The hernia sac should be separated from the vas deferens and cord vessels in order to bring it in the pre-peritoneal sac. Then a 3D max MESH large size is brought and place in a way to cover completely the internal ring.
  • After deflation of the pre-peritoneal space the peritoneum and fatty tissue will get together with the mesh avoiding displacement.
  • All trocars are removed under direct visualisation. Closure of the infra- or para-umbilical incision is carried out with interrupted or non-interrupted sutures. Closure of the skin incisions. Removal of foley catheter. Wound dressing.

End of operation.

TAPP (trans-abdominal pre-peritoneal) repair.

Description of the procedure:

After general anaesthesia is induced.

  • Insertion of foley catheter aseptically.
  • The abdomen is prepped and draped sterilely. Small sub-umbilical incision is carried through skin and subcutaneous tissues until fascia is reached and dissected in a way to reach the peritoneum to get access to the abdominal cavity under visual control.
  • This is the open technique, otherwise gaining access to the abdominal cavity can be also done with the v needle. Insufflation of the abdomen cavity to establish pneumo-peritoneum at pressure about 12 mmHg.
  • The first port placed sub-umbilical, the second port para-rectal on the right side and the third port is placed para-rectal on the left side. Exploring the site of operation. In 10-15% of unilateral hernias cased, an intra-operative contralateral hernia can be found at the time of surgery.
  • The peritoneum is incised from anterior upper iliac spine to medial umbilical ligament above the inner ring. The hernia sac is brought into abdomen and completely reduced.
  • The inguinal canal is explored and lipomas, if present are extracted and resected. After then, non-absorbable light weight MESH is brought and adapted to underlying tissues and should be fixed by staples, absorbable or non-absorbable sutures or tags with fibrin or glue.
  • In order to prevent any bowel obstruction or direct contact with MESH, peritoneal closure is performed with running absorbable suture.
  • Removal of trocars under visual control while deflating the abdominal cavity. Bigger trocar wounds are closed in layers.
  • Removal of foley catheter. Wound dressing.

End of operation.

Surgical treatment of incisional, umbilical or abdominal wall hernia can be also treated endoscopically with low recurrence and complication rates.

Description of the procedure:

  • The patient is placed in supine position. After general anaesthesia is induced. The abdominal skin is sterilised and drapped.
  • A pneumo-peritoneum is achieved with the needle or in open technique. Ports are placed according to site of hernia.
  • Laparoscopic examination of the abdomen is performed and any abnormalities would be noted. If there is no contraindication to proceed, the incarcerated contents are reduced.
  • The under surface of the abdominal wall is cleared from any fatty deposits which may inhibit flat application of the MESH.
  • The fascial defect is closed with absorbable sutures. The MESH is then rolled and inserted through the port into the abdominal cavity.
  • The MESH is unrolled inside the abdomen and positioned against the abdominal wall. It is important to have 3-5 cm overlap over the entire fascial defect.
  • Fixation of the MESH on the under surface of the abdominal wall is achieved either with tuckers or extra sutures.
  • Control of placement is performed. Deflation of the abdominal cavity while removing the trocars.
  • Closure of trocar wounds.

End of operation.

This may be too much technical points, but many of my patients have asked very detailed questions about the procedure, hence I thought to put it in writing, if they wish to read it in full details. 

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