| |
Inguinal Hernia
Surgical Technique
Dissection of Retzius’ space
- Dulucq technique
A Verres needle can be inserted suprapubically and directed dorsally until it perforates the rectus muscle fascia. It is then pushed deeper until a second, less resistant membrane (the deep layer of transversalis fascia) is perforated. One liter of CO2 is then insufflated in Retzius' space. This insufflation facilitates subsequent dissection which is carried out from an infra-umbilical position. To do so, a small incision is made and a reusable 10 mm trocar is introduced subcutaneously over 2 cm. It is then oriented caudally and posteriorly at a 45° angle, the rectus fascia is perforated and the already insufflated Retzius' space is reached. A 0°, 10 mm laparoscope is placed through the trocar. The preperitoneal fatty tissue is then dissected, under direct vision, by the laparoscope itself, using careful sweeping motions, until the pubis bone is reached which can readily be felt and seen. The Retzius space is further dilated by CO2 insufflation while all fibrous tracts are being severed by the laparoscope. Finally, a working space will be created.
- Insertion of second trocar and lateral dissection
Lateral motions increase the retropubic space and a second, 5 mm trocar is then introduced under direct vision. In unilateral hernias, we prefer to insert the trocar a little off the midline on the opposite side of the hernia. In bilateral hernias, the midline is used. This second trocar is inserted halfway between umbilicus and pubis and preferably even a little more cephaled. A forceps is passed in this latter trocar and blunt dissection is initiated laterally. To do so, the surgeon preferably stands on the opposite side of the hernia. In case of a remaining direct hernia, the dissector is placed on top of the hernia and dissection is carried out from lateral to medial, away from the iliacs. Reduction of a direct hernia is usually straightforward. This step ends the dissection of Retzius’ space. Dissection of the epigastric vessels gives access to the superior edge of the protruding peritoneum which may extend in to an indirect hernia.
The peritoneum is now pushed posteriorly and the space lateral (Bogros’) to Retzius’ space is entered (fig 3). The peritoneum can now be reclined away from the abdominal wall, on the lateral side of the spermatic cord.
- Dissection of Bogros’ space
The key in opening Bogros’ space is the dissection of the epigastric vessels. As already mentioned, the epigastrics are superficial to the deep layer of transversalis fascia in close relation to the umbilico-visical fascia and the peritoneum. The plane to be entered is between transversalis fascia and umbilico-vesical fascia. If one penetrates the plane superficial to the deep layer of transversalis fascia, which can happen very easily, the bare epigastrics will be exposed and the fascia will be separated from the deep aspect of the transversalis muscle. This is the wrong plane. To find the right plane, the easiest way is to gently brush the tissue away from the epigastric arcade, which is usually seen easily. The plane of motion of the dissection is sagittal ( the same direction as the fascia and the epigastrics).
- Dissection of the psoas
Dissection lateral to the cord structure reveals the psoas which is cleared over 10 cm. The nerve fibers running over the muscle belly are clearly identified.
- Dissection of the lateral abdominal wall
After clearance of the psoas, the dissector gently separates the peritoneum from the deep layer of transversalis fascia. This plane is avascular and characteristically has the aspect of “ angel hair ”, caused by the insufflation of CO2 in the loose areolar tissue of Bogros’ space. This dissection has to be carried out high so that all of the abdominal wall up to the level of the umbilicus is cleared of peritoneum.
A third trocar (5 mm) is now placed 5 cm cranial to the anterior and superior iliac spine. Bimanual dissection can now be initiated.
- Bimanual dissection
A grasping forceps is inserted in the midline trocar and a second one in the 5 mm flank trocar.
The hernia sac is carefully grasped and dissected away from the neighboring structures. The peritoneum ending blindly needs to be dissected from the elements of the cord until no protrusion of peritoneum can be seen. Once the sac is completely free, it is left alone and not resected nor ligated. Thorough dissection of the sac result in a satisfactory parietalization of the elements of the cord. In case of inguino-scrotal hernia the sac is transected at the level of the internal inguinal ring. The proximal sac does not need to be ligated since it will entirely collapes at the end of the dissection.
- Insertion of the mesh
We use a 15 cm by 12 cm knitted polypropylene prosthesis, preferably a three dimensional preformed one (Dulucq). The prosthesis rolled like a cigarette is introduced through the 10 mm optical trocar,. A Vicryl stitch, which has been placed on the short side of the mesh gives a good orientation for placement. Once unrolled, the prosthesis can be stapled to Cooper's ligament using a 5 mm tacking device (Protac, VSSC, Norwalk Ct). The mesh has to perfectly parallel the peritoneal sac. Therefore, laterally the mesh has to cover the abdominal wall, reflect on the iliopubic tract and cover several cm of the psoas. This will provide to the mesh the aspect of an open book, the back parallel with the iliopubic tract, the front cover deep to the abdominal wall and the back cover overlying the psoas. In case of a bilateral hernia, after full dissection of both sides, a fourth trocar (5 mm) can be inserted 5 cm cranial to the anterior and superior iliac spine of the side dissected last. A roll of mesh is then inserted on the left and another on the right side, through the 10 mm optical trocar. The midline 5 mm trocar is then withdrawn and the opening in the abdominal wall is covered by an assistant’s finger. Both mesh rolls are then unrolled and manipulated with 2 grasping forceps introduced in the two lateral 5 mm trocars. Both meshes have to be similarly positioned. It is important that they overlap over the midline so that the functional result will be that of one large piece of mesh, especially if the bilateral hernia is of the direct type, with only a small bridge of rectus muscle between the 2. The two pieces of mesh need to be fixed with a few tackers as well. A suction drain is introduced through the midline trocar opening. The pneumoperitoneum is released and one can watch the patch being squeezed between the abdominal wall and the peritoneum. The trocar openings are closed.
The patients are allowed to walk and to eat the same day. They leave the hospital the same day or the next morning. The drain can be removed after 6 hours.
|
|
