Laparoscopic Totally Extraperitoneal (TEP) Left Indirect Inguinal Hernia Repair with Mesh

CHAPTER 1

Randy Haluck, surgeon at Penn State University, Hershey Medical Center. Today, we're gonna do an inguinal hernia repair, which will be via TEP technique, total extra peritoneal, laparoscopic mesh repair. It's a 60-some-year-old gentleman who came in, he had a previous inguinal hernia repair on the right as a child, but an uncomplicated, barely symptomatic left-sided inguinal hernia. So in doing a TEP, the key steps to this procedure are, first of all to get into the preperitoneal plane. Obviously, that's different than a TAPP, which goes through the abdomen and that preperitoneal plane is created. And that's one of the more challenging steps. Some patients have fused layers in their lower abdomen, some just the way they are, sometimes, with previous incisions. I use a dissecting balloon to do the creation of that space. Sometimes, it just doesn't go where you want it to go, or they're fused in the midline and only one side opens. So that can be one of the challenges. So the first key step to TEP is to create that preperitoneal space. The next key step is really to get your two ports in a good position. There's not much variation, at least that I'm familiar with, in where these ports go especially if you wanna do bilateral hernias. I do both in the low midline and that allows me to repair the left and the right simultaneously if in fact, they have those hernias. When I schedule a patient for a unilateral hernia, I always advise them that we're gonna look on the other side and if we find an incidental hernia, we would repair that. I don't think it makes much sense to repair one hernia and leave them with a hernia on the other side. So those are key steps. And beyond that, it's just identifying the proper anatomy, being careful with where you're working. Obviously, we're working around critical structures, major vessels, nerves, you know, things that'll bleed, little stuff that'll bleed, lymph nodes, that can make the operation, you know, a challenge and getting the mesh in and getting it in the right spot in a tight spot. A TEP is arguably a much tighter working space than a TAPP and manipulating mesh and such is a challenge there. But those are the key steps. And the biggest thing is getting the preperitoneal plane correct.

CHAPTER 2

So we're prepping out the umbilicus, the pubic tubercle, and the right and left anterior superior iliac spines. Hang on, if I could have some to cover him, that'd be grateful, thank you.

CHAPTER 3

So we're gonna make a midline incision just right below the umbilicus. We're gonna not gonna try to go into the umbilicus, we're gonna try to go through the anterior rectus fascia and into the preperitoneal plane. Some people will go off to the midline, off of the midline based on the side. I prefer to just go straight into the midline and... Incision. Take it from there. Great. Just bluntly bore down to the fascia. He's giving us some reaction. Yep. Great. So we're gonna find rectus fascia. We're gonna grab that and pull it up. May we have a - we got it here, good. We're gonna incise that and try to get into the preperitoneal plane, which would be at this location anterior to the posterior rectus sheath. And the reliable feature is seeing the rectus muscle, which we see here very nicely. Good. We'll take the dissecting balloon, please. Nice. So one of the keys here is there's a tendency to go too anterior, it's actually to go aim pretty far posteriorly. The tendency is to try to go anteriorly, and you should never fall off. We wanna bounce that off the pubic tubercle. Great. We're gonna put our camera in. Yeah, leave that on. Leave that one on? Yeah. Yeah, I pulled mine off. May we have room lights down, please. So this balloon is in the preperitoneal plane, ideally. Yep. Good. And - other side, the clear side. So we're gonna slowly inflate this balloon. We're looking for muscle on the ceiling, which is what in fact we're seeing. Nice. And we can already see kind of direct space on that side. Yep. Nice. Good. Just gonna put some pressure on this. So this rather than on like a TAPP where you do this dissection manually, this balloon does it for us. One of the difficulties of this case is if this balloon - that's good there. Let me raise that up. May we have some Trendelenburg position, please? You're fine there. I think trendelenburg position helps with just about any... That's great there. And if you'd raise the table just a bit. Trendelenberg position helps with - that's great, thank you. Just about any inguinal hernia repair. He may have had a repair on the... He did when he was younger. On the right. So yeah, I'm hearing he had one as a child, it looked like he had a scar over his right groin. So bladder down, space of Retzius. When I did these, when I started doing these, I always put Foleys in. Recently, we have not been putting Foleys in and it's pretty rare that we have trouble. Maybe like one out of 50 cases, we'll have to drain the bladder in the OR. But we're allowing this balloon to remain inflated for a minute or two to compress the veins here. Maybe reduce the risk of bleeding, but. So I'm just looking around. There's bladder. That might be midline there. Epigastrics on the left. I don't see his hernia just yet. I also don't recall the size of it. Sometimes, we just see these by ultrasound. But there's his evidence of a repair on the right. He was the one with the femoral... Possible - yep. Possible high ligation. This patient told me when he came to clinic that the ultrasound tech told him he had a femoral hernia, but the report in fact said he had an inguinal hernia. So there's some confusion going on. Two more Kellys, please. So we're gonna deflate this balloon. Nice, so we deflate that balloon, pull that out, and I'm gonna try to - yep, good. Pull that out with - put your finger on the thumb. Yeah, there you go. And hold this out. Yep, thank you. Nice. I'm gonna try to maintain the same spot. Sometimes you can't. Yep. Good, other balloon.

CHAPTER 4

So that's the dissecting balloon. And this is a port that has a balloon tip and it has a - yep. Straight down. There we go. Good. So the next thing that I do is insufflate. So we'll take a pressure of 15 high flow. I wanna open that space up. We'll put our camera in. Hopefully, we're in the preperitoneal space there. We're gonna blow up this balloon. It's called a structural balloon. Gotta really wedge it on there. Yeah, maybe put your, yeah, yeah. There we go. Here you go. Good. Okay. So you can see this balloon. Nice. And then we're gonna get this to seal. You're good there. As long as the wrinkles are out, we're gonna get that to seal and then we're gonna lock this down. Good. Okay, so we're in the preperitoneal space. Epigastrics on the right. It's effectively the retroperitoneum. Camera to you. So a space that is not conducive to hemostasis. So I put my ports in the midline, which is not always easy to tell where exactly the midline is. If anything, I'm gonna err on my side, this side away. I'm gonna make these incisions super small. So one as low as I can go and one as high as I can go. And even at that, I can move these. If I'm not exactly on the midline, I can move them wherever I wanna go. And again, I'm gonna err toward, once it tends to wanna roll off the midline. So I'm gonna air toward this side. In a TEP, especially more so than most operations, the ports don't anchor very well. So if you're not gentle with your ports, they will start sliding and become difficult to manage. So my partner is first gonna take a quick look at the asymptomatic side. We'll take OR lights off, please. Just to make sure there's no evidence of a hernia on this side.

CHAPTER 5

And I mean, we're not gonna go crazy here looking for something. Great, thank you. So just, you know, yep. Direct space there. That all looks fine. Here's the femoral space. There's the medial wall of the external iliac vein. So that would be the femoral space there. There's a little bit of stuff going through there, but that's the nature of that space. And she's just gonna take a look here. Just find the edge of our... I don't think you even need to do that. Find the edge of our sack there, which is kinda right there. So you can see the, can you point to the where the highlight? Yeah, right there. So yeah, so maybe just look for a lipoma there, but yeah, we're not gonna do too much on this side. He does not have an obvious recurrence on this side. That's fine there, I think. That's good, yeah, that's good. Let's just look up toward the internal ring there. Oh look, that's nice and tight. I think we're good there. That's all we're gonna do. Thank you.

CHAPTER 6

So now we'll go look at the symptomatic side, what he came in for. So - and could you lower the bed just another inch or two? So - that's great. Thank you. So the challenging parts of TEPs are to, number one, get that balloon to give you an adequate space. If patients have low midline incisions where the layers of the abdominal wall are fused, then the balloon doesn't work. Sometimes, they have like a fused midline, like right here, that will not let the balloon cross the midline. So that can mess up the space here. But here, he's got some fusion. I don't know exactly why. I'm gonna try to - but it's something we see with some frequency. So that's challenge one. If doing a TEP by this, by the balloon dissection is getting the balloon to create the space that you want and you're expecting. Challenge number two is you don't have the references from the peritoneal cavity. So if I'm confused on where things are, I can just look from the intra-abdominal side and confirm things. The first thing I do is what I call a click maneuver. I try to find the pubic symphysis and do this little click, click, click, click, click. So I'm making this instrument click over top of the pubic symphysis. So this is right superior pubic ramus, left superior pubic ramus. Then we're gonna work just medial-to-lateral. Can you zoom in on that?

Very often, some crossing vessels here. There are already one or two that are oozing just a bit. We're gonna get a good look at his femoral space since the tech told him he has a femoral hernia. I don't know that he does yet or not. This is gonna be his direct space here. We're just getting this fat out just so we can see fascia. Zoom in on that just a bit. Great. He has e femoral hernia. I think it's pretty subtle and pretty benign. Just teasing things out. This really isn't any different than a TAPP at this point. It's just kinda where our instruments are. And if we get a view of where the instruments are as I'm working laterally, you'll see that ergonomically, this operation is a challenge. That's sort of the third reason. So the first challenge of the TEP is getting the balloon or you know, whatever other dissection - some people will do it with like finger dissection or instrument dissection. But getting the preperitoneal space as you want it, that's challenge number one. Challenge number two is just figuring out where things are when you don't have that intraperitoneal reference. And then challenge number three is the ergonomics, also the tight space. This is a very small space. So here's this femoral space. We don't really see, you can see I'm sort of dipping into it here. Here's the medial wall of his vein. We saw it really well a second ago. I do not think he has a femoral hernia. I don't know, I'm gonna keep tugging on this little vessels that are gonna bleed here. Can you grab the Bovie, please? So I'm just gonna buzz a couple of these little vessels. Right hand, please. There we go, thank you. But just very carefully - yeah, I'm seeing - there's something big and blue there. Yeah. He's got a little bit of stuff here. Let's buzz this guy right hand, please. Oops, sorry. Yep. Nice. So I'm really... I would not be dealing with this space with this type of appearance unless he told me there was this question of a femoral hernia. I would argue that many patients are gonna have this appearance. Yep, right hand, please. I think these are kinda like lymph nodes that are gonna bleed and I'm gonna leave that alone at this point. So let's back up. We're gonna leave that femoral space alone.

So we have direct space, femoral space. Now we're gonna look at the - find the cord. And this is done by just going laterally here. Again, I think we're getting a view externally of what my instruments are doing. And I argue that there's nothing else we do in surgery that uses these moves that I'm doing here. These big sweeping moves. Not much else we do that uses those moves. So I've got - here's his hernia sac here, going up toward the internal ring. Get this stuff out of the way.

I'm looking for what I call the inside curve, which is the vas deferens coming around here. I'm gonna take that vas and hook it and push it way out here. There's bad stuff that lives there. There's really not too much out here to hurt. So I just move this all out here. There's his iliac artery. Pretty rare that you see it in all that glory, that's really something. So this is just hernia sac and vas and vessels. And now this is kinda like an open operation. You grab the sac, and vas, and vessels medially. The maneuver is to pull down on the sac and push up on the other stuff. So I'm looking for the actual edge of the sack, which I don't see just yet. It might be here. Again, just - vas and vessels come medially. Just like an open operation. Keep working on the sac. You see something white, grab it. Keep on keeping on. Grab what looks like sac. So a TEP is kinda my go-to approach. I don't like doing these on patients that have a bleeding diastasis. Again, this is the retroperitoneum. Hemostasis and the retroperitoneum don't go well together. If hernias are bigger, I would lean toward a TAPP. And again, if they've got a fused lower abdomen, I'd even think about moving toward open. So maybe that's edge of sac there, hard to know. This part is somewhat tedious. There's the edge of our sac right there, at the end of our sac. So this will be the processus vaginalis up there. And sometimes, you gotta just grab it and tear that. There's edge of sac, you can see it right there off the tip of my instrument. So I'm gonna grab this processus and I'm going to rip it. So now our sac should be down. There's obviously also a gonadal vein, which might look and feel similar. You don't wanna grab that and lyse it. Don't always see it. Vas. So I'm trying to create what I call a groove, and I want my mesh to stand in the groove. And I'll show what that means in, hopefully, not too long here. I want that hernia sac to be far, far away from the internal ring. And I'll even try to, if it's large enough, try to lay it on top of the mesh. Okay, good. I want this to be all beat up. I want it to be sticky and stay where I left it. Not sure what this is. Here's the shelving edge of the inguinal ligament going out there. Not easy to see, but that's where it is. Some nerves right there on the edge of my instrument. Again, gonna beat up this cord. Is there a lipoma here? Don't know. I don't think so. That looks like cord fat. The lipoma is always lateral. So I grab the cord, roll it around, reach up behind, grab the lipoma. That's exactly where you're gonna find it. If it's there, do that little rollover. And get that out of there. Like I said, and there's this wide open, blown out internal ring. So again, I want this lipoma to be way down. Yes, please. So I'm gonna use a Bard 3DMax inguinal hernia mesh, side-specific left, and lightweight. Anybody watching this would know: mesh, weight of mesh, kind of mesh, fixation of mesh is I would say controversial. I do it pretty much the way I've been doing it for a long, long time, which is tacking Cooper's. Tacking the conjoin and the shelving edge of the inguinal ligament laterally. When I first started doing these, I was using ProTack. Now we use - so yeah, we have that open, the secure strap and everything, Danielle? Yeah, yeah. We got the pro-OR team here. Everything's open and ready to go. Look at that iliac. Man, that's really something. So there's the cord. Okay? There's the cord all beat up, which is exactly what I want. Okay, let's look at this stuff here. And you can see just how kinda oozy and bloody things are here. And I would say this is pretty typical and you know, if you get a sucker in here, you're gonna suck out about three CCs of blood. Not gonna do that today. Sometimes, I'll do it. And I warn patients they're gonna have bruising and they do. So one of the challenges of these is, you know, this fat pad here. Could you buzz my left hand, please? You said left? Yeah. Nice. That's great, thank you. Patients have fat pads, they have lymph nodes, you know, and the question is what to do about them. And again, I think I'm gonna leave that alone. So again, I've created this groove from here. I want the bottom of my mesh to be in that groove. Yeah, we'll get to that. So I want everything that I've reduced to be on this side of the mesh. Which is what I'm doing. Let's look in here. Is there anything we can? So you can see I started manipulating this and we've got some oozing that I'm gonna try to buzz. Not sure that's it. Yeah, go ahead. Left? Yep. Go ahead. Nice, thank you. And when you're doing these things, you're applying cautery. Yep, I think we're fine here, let me just see this. So this is bone. You can't hear this on the audio, but that's hard. And then Cooper's is just right there. You can see it has some give - bone, and then just a couple millimeters away is actually Cooper's. Good. Can I have a cannula? Let's see if I can get some of that blood out of there. Thank you. I'm gonna just put a cannula in here and see if I can get a couple of cc out. I believe if you irrigate, you're gonna just push this all over the place. Okay.

CHAPTER 7

Alrighty. So the mesh that we're gonna put in, again, you know, here's the mesh. Goes in through this 10 port. Yep. We're gonna try to aim it toward that side. Yep, go ahead and plunge it in. Plunge it in with the camera. Nice. And I call this a Rubik's cube. If I want this tail to go that way, which I don't, then I gotta make something else go this way. Let's see, what did I do here? There's a little M on this mesh that I believe stands for medial and it's got a little arrow. I'm not sure which is the bottom and which is the top of my mesh at the moment. Is that M right side up? I have to ask the home audience. I think it is. Looks like it. Everybody says yes here in the OR. So yeah, so usually, it goes in a little more cleanly a little, but that just means we get to play with it more. Sometimes, you can grab the mesh and move it around. Sometimes you just have to bump it into place. This little tail has to go laterally down in this little pocket that we made. Let's see if I can get the top of this straightened out. And this was an indirect hernia, so if anything, I'm gonna err on keeping it more lateral. If it was primarily a direct hernia, then I might scoot it more medial. Let's see if I can get this up on the ceiling. Let's see if I can get this instrument on this side of the mesh. Alrighty. And again, one of the challenges to a TEP and I think to some degree a TAPP as well. You put this mesh in there, you lose your landmarks. All of a sudden, you can't figure out where anything is. Let's look, yeah, look here. Okay, so you need to go out there. Yep. This is gonna go down into my groove that I keep talking about. And now I'll see if I can get this where I want it. Nice. So not bad. I've seen worse. One thing that you can do if you're struggling with the mesh like I am a little bit is - yep, tacker, please. We know that it's in a good spot over Cooper's so we'll... Yep, zoom on in. Where's my M? Yep. So it's in a good spot over Cooper's. So we'll tack it in. And again, I'm gonna do that thing - bone. And then move up just - you can see it, soft. So now I can use that point. I can move it around around that point of fixation. So I'm gonna bring it down here just a little bit. Nice, nice. Oh good. I would like you to come down here just a little. This is rarely a problem that it's too high. So my partner here is going to find the anterior superior iliac spine on the left and then bounce - come in a centimeter medial and bounce just a little bit. Yep, go ahead. So that's actually pretty high up here. Just - yeah, ASIS and just one centimeter. Hang on. Let's see. So yeah, so I think we said we could see the shelving edge there. I'm just gonna put a tack in. And again, I don't push on this, I just gently... I'm gonna try to get most of the wrinkles out. If it has a wrinkle in it, I'm not too worried about it. When this space collapses, it's gonna be a little bit wrinkled, anyway. So I'm gonna slide this up onto the conjoint. And that's it. What I do want is this mesh absolutely held down in this space here. Nice. Okay. Right like that is what I think is absolutely critical. Nice. So we're gonna now release our pneumoperitoneum. May we have steep reverse Trendelenburg, please? Put our patient in steep reverse t-burg. And now everything's gonna be held in that spot. And there's the hernia - what was the hernia sac coming up over top. That's great, camera out. Good. That's perfect. Thank you. And that's it.

CHAPTER 8

Ports out, balloon please. And you blew up that other? I did. Nice. We'll take room lights on, please. Here we go. And this is what this balloon looks like when it's inflated. So it pushes down and helps to open up that space. And that was the dissecting balloon that we put in. So you can see it's not a big space, right? All of it's pretty tiny. And that's about it. I'm gonna try to get any CO2 out through this little incision here. We do put a stitch in this anterior rectus sheath. Would you lower the bed some? Great. Yeah. Perfect. Yeah. Nice. And we'll just close these incisions. We don't do anything with these fives, you know, down here, and that's about it. Laparoscopic left inguinal hernia. Yep, clean. No specimens, no complications. Thank you. Thank you.

CHAPTER 9

So I felt that that case went very well. I think that was pretty much a textbook TEP. When we made our umbilical cutdown, we were immediately right in the preperitoneal plane, we could see the rectus muscle, which helps us identify exactly where we are. So we found that right away. The balloon went in, blew up both sides symmetrically. So we saw both sides - that worked well. And we had plenty of space, not much bleeding, the bladder wasn't in the way, so everything went very well. On the right side, we didn't find any recurrent hernia on the right. The left side, again, somebody told this patient he had a femoral hernia by an ultrasound, which doesn't make any sense at all. But he brought that to my attention so I said we would look at that space. And again, there's always gonna be fat and lymph nodes, and things going through all of these spaces. And so we spent a little extra time there, but I did not think that represented a true hernia there. There's just normal stuff going through there. Found a nice, large, indirect hernia. Got the sac off the cord. Again, everything, you know, pretty much by the book. I think in the end I said yeah, there was maybe this little wrinkle in the middle of the mesh. You know, I think we all like to have it laying in there absolutely perfectly. I don't think that's absolutely essential. I just think you need coverage in key areas, which I think we absolutely achieved. So I thought that was very straightforward and pretty much how a TEP goes.