Minimally Invasive Open Preperitoneal Inguinal Hernia Repair

CHAPTER 1

So - the landmarks are the anterior superior iliac spine and the pubic tubercle, if we can feel it. Your rectus should be inserting here, like this. Your obliques insert here. Your inguinal ligament will be here. So I - once we know the bony landmark - and it’s important because I'll use - so this is pubic tubercle here. So I'll choose the midpoint between the anterior superior iliac spine and pubic tubercle. I kind of eyeball that. I’ll go about a centimeter and a half above. I make my incision 2/3 medial and 1/3 lateral. So it's about a 3 1/2 to 4 cm incision, so we're in between 3 1/2 and 4, and that's a typical size of incision.

So let's have the local. So a little needle stick sir. I'll do an ilioinguinal nerve block. I always do it one fingerbreadth [medial] to the ASIS. I feel the bony resistance, come off, inject 5 cc's here, and then after 5 cc's, I withdraw the needle slowly and inject as I'm withdrawing.

CHAPTER 2

This approach is pretty standard like an open appendectomy in the first layers of the abdominal wall. So, we're going to go through the layers. We're going to go through internal oblique, we're going to go through external. Here's Scarpa’s fascia already, and typically we don't really see Camper’s very well. So we'll get some Army-Navy’s here. And we’ll expose so I can open up Scarpa’s a little bit better. Do you have DeBakey forceps after this?

So this is Scarpa’s, and what I do with Scarpa’s is I bluntly dissect with my finger and clear up the external oblique. I find that that's the most efficient way and the least bloody way. This is our external oblique. Now, our inguinal canal is going to start here and end here. All of this work is going to be above the inguinal canal. Lots of local before every step. 15 blade.

So getting back to why I do this - the surgeon that taught me - Metz - said that he used to do laparoscopic hernia surgery and converted to this, and I thought he was crazy. But, I think this method is so much nicer.

So we just opened up the external obliques along the length of their fibers, and here we're looking at the internal obliques. We have a beautiful view of the nerves. So here is one nerve coming through. Do you remember the nerves that we're going to see here? Here's one coming through the fibers of the internal oblique, and then so - ilioinguinal, iliohypogastric. And here's our other nerve right here. We're going to avoid those nerves and enter - medially, so away from the nerve. So we've got our nerves here. Actually - I want to move this nerve a little bit out of the way. We want to enter the preperitoneal space above the inguinal canal.

So I'm going to go in between the fibers of the internal oblique. At this point, the internal oblique is - you see the fibers look like my finger? When it gets down into the inguinal canal, they decussate. So people describe the conjoint tendon. The conjoint tendon is the spot where the internal oblique no longer exists, and in his case it just keeps going.

I'm trying to figure out - should we be a tiny bit lower because he's got a long pelvis and that - let me get a little bit more local. I'm just going to choose a point a little bit longer. As I look through, it looks like - he’s - I wouldn't say too tall, but he's tall enough.

So now I'm going to separate the internal oblique fibers just like we do with the regular appendectomy. So this part - up to this point, it's absolutely no different than old-fashioned appendix surgery. And as I separate the fibers of the internal oblique, I start seeing transversalis fascia. I'm going to put my finger into the hole that I made and stretch it out a tiny bit. I'll take a lady finger now, and I get the lady finger underneath my finger so that we expose - another one?

So now we're in the preperitoneal space. Now, we may be through transversalis fascia or we may be, so don't pull quite so hard. You just need to - so I’m going to grab and re-grab these retractors a lot Brandon, so all you have to do is just kind of hold them right where I let go. Now what I need to do is tell the difference. If you take a look here guys, I see some blood vessels at the beginning of my field, there’s a vein, an artery, and a vein. These are the inferior epigastric vessels, and here I see peritoneum medial - or lateral to them.

And so, I know that I'm in the preperitoneal space and that I'm actually superficial to the inferior epigastric vessels, and I want to get underneath them. So I'm going to put my finger in. Don't pull too hard because you're right on the inferior epigastric vessels. I’ll put some local anesthetic in without a needle.

So this is a very sensitive part of the case here. The peritoneum has lots of nerve endings. And I found over the years that if I give local at this point, patients can tolerate this much better under local. If you hold this one, I'm going to grab the one from your right hand. So what I'm doing now is bluntly with my finger creating the preperitoneal plane. And - I'm encountering a hernia as soon as we're in here. So he's got what kind of hernia if it’s lateral to the inferior epigastric vessels? Indirect. Indirect, you buy that?

So here's my finger inside the inguinal canal. It’s occupying the canal and it's right next to the hernia sac so we actually entered the preperitoneal space pretty quickly right through transversalis fascia. So I'm going to treat this like my hernia sac here and start doing a little dissection.

CHAPTER 3

This is my peritoneum. So this is hernia sac. And this is just like a pediatric hernia repair or a laparoscopic repair. I'm slowly teasing fibers around the sac just to reduce the hernia sac. And the goal here is to try to avoid getting into the hernia sac. If I do, we can just repair it pretty easily. It’s a nice advantage over a laparoscopic repair. In laparoscopy, if you cause a hole in the sac, it's challenging to repair, and there's a - a higher likelihood of intestinal issues like bowel obstructions after surgery.

So you can see the hernia is resistant, he's had this since birth probably. So we'll slowly and tediously dissect it out of the canal. Any questions right now? Because this is kind of a long tedious part of the case here. When you say resistant do you mean when you’re pulling out? So I'm pulling - if I pull and I let go, it bounces right back, so there's some adhesions here that he was likely developed over time having this hernia for 18 years. And, we just need to deal with all those adhesions and get the hernia sac down.

Now I'm going to take a feel and see is my cord here, or are we near the end of the sac, or do we have a long way to go. And I think we have a long way to go. So I can pull pretty hard with my hand - get my finger to provide some exposure here, and then really tease stuff off the hernia sac until we can define it. I'm feeling some scarring in here still. But it's starting to come into view nicely. This is all hernia sac.

So in terms of the age, I’ll typically around 18, I'll start putting plastic in the patients and do a repair. Below that, oftentimes I'll still do a pediatric repair. It really depends on how - how old and how big the patients are. So if they’ve stopped growing a long time ago, there's really no need to.

Now, if I look here I'm starting to see what? Sarah what do you see there? This white spaghetti noodle thing - if you take a feel of it - what's a spaghetti noodle? Vas deferens. Right, so we got the vas deferens, so we’re on the cord now. So we see the cord well exposed, so that means we're getting close to the edge of our sac. I think this is all sac, and I think the edge is here.

So, I have to pull pretty hard just to get the exposure that we need here. Do you have another Kelly maybe? So depending on how long and hard the sac is, we might do a high ligation like we do in a pediatric repair. I think the ligation sometimes causes pain. Let’s take a look. Here's our peritoneum. l haven't seen the edge of the sac just yet, and so I was hoping maybe we can see it a little bit better. We’re starting to look like it here. I think I see a little edge starting to come into view I think. We got to peel it so it's completely clean.

So this is our sac. You can see it's kind of thick. So I’m being cautious here because I don't want to injure anything on - on anyone. Let’s do another Kelly, I think that might help us. Sorry guys, I tend to move my head around. So Sarah, you're going to hold this retractor, and then you’re going to hold this for me. You can let go of this one. I'm going to use two hands here and see if we can really separate the cord here a little bit better. And really identify our hernia sac. Hernia sac is made out of peritoneum.

When I do a direct inguinal hernia - this is indirect - there is a real easy way to identify the direct defect, and at some point if we can film a direct hernia - not that I know which one is going to be direct or indirect - it's an incredible demonstration of what the tissues are for the abdominal wall. I'll try to demonstrate it a little bit here.

So here’s hernia sac. You're going to pull a little harder. I’m going to put my finger behind so I can see the edge of my sac and I know where to go. But you can see the fibers of his cord are kind of really closely wrapped to the sac, and so that's how we know this is congenital and it's been there for a while because it's scarred in. That and he’s only 18, right?

So this is the tedious part of the surgery, but it’s the most important part. Sometimes I use a sponge to help me identify the anatomy a little bit better. I see the vas. This is the cord vessels here and the vas is here, so I'm thinking this is starting to be just scar tissue here. So pretty soon we'll be able to just bovie.

So, so far I haven't shown you anything unique in terms of compared to regular hernia surgery because all we've done is get in higher than normal and get - and do regular hernia surgery. The unique part - the part that same as laparoscopic will come next once we’ve cleared out the sac. And that's where the headlamp really makes a huge difference.

So here, it's coming down nicely now that we've gotten some of the scar. You can see the edge of the sac real nice, and you can see how the tissues almost fall apart here. Once you get into the retroperitoneum, the hernia has no longer been sliding up and down through the inguinal canal, and there's very little adhesions. So you can see here, we're getting to an area where tissues are just kind of falling apart almost. And here's where I want to go as high as I possibly can.

I was talking with one of my partners who still does laparoscopic hernia surgery, and his thoughts are - is that an advantage of this repair is that in this part of the dissection here, because you're able to pull up on things in a way that you can't laparoscopically, you're able to do the dissection a lot farther. So here I'm going to grab his cord - I'm going to grab the vessels, I’m going to grab the vas. I'm able to pull up on them and I'm able to tease the peritoneum way off of them well into retroperitoneum, and I think this is one of the parts where you just can't do this laparoscopically very well because there’s no way for you to pull the cord one way, have a retractor, and still do the dissection because you're only limited with two instruments. So you really have much better exposure here and can do much more than you do lap. And I think that the biggest pitfall in terms of recurrences with this is with - indirect recurrences - because - of this part of the dissection. You can see how the peritoneum is densely adherent to the cord here, and here's the peritoneal edge - this white edge over here. And if I don't get this really far down - so far down that I can see the vas deferens here go medially and the spermatic vessels go laterally - you haven't done enough dissection.

So with this, I'm pretty happy with the amount of dissection we have here, and we've got this hernia sac way out - out of the way. There’s some adhesions here. Let's have a DeBake. I’m going to have you pull up a little harder. The enemy of good is perfect, but I try to do as much as I can get without getting into the peritoneum here. So at this point I feel like I'm on as far as I can get. I might try to get a hint more. And we're sitting on top of the iliac vessels, so I’ll show you guys those in a minute once we get the hernia sac out of the way. Just looking to see the edge of the sac here. So we've got hernia sac clearly here. We've got some adhesions here that are not part of the sac. And - I want to see if these are adhesions or if this is part of sac - looks like adhesion still.

So here's our hernia sac dissected free. Laterally it looks like we're stuck a little bit so you’re going to take this with your left and this with your right here, and I just want to get these little adhesions even further away. Here's edge of the sac. We can take this down. Good. And even a little bit more. So there's probably some omentum here you can see through the hernia sac.

So what I'm going to do next is we’ll do a little bit of work all around and get this out of the way, and we'll do the preperitoneal dissection now. So I'm looking deep into the preperitoneal space. I see bowel through my peritoneum. We're going to put a little bit more local as we do this part of the dissection. And now I have to create a big pocket in here for our mesh to fit in.

CHAPTER 4

So part of this is blind dissection as long as I'm in the right space. And I'm just taking a feel of the anterior abdominal wall and looking through with my headlamp to make sure that I'm off the inferior epigastric vessels. Let's find those again. They're right here. We're underneath them, but I have peritoneum. Let’s see. Not too hard. So here's inferior epigastric vessels. Here's peritoneum. So we need to be between peritoneum and inferior epigastric vessels. So here's the space that we need to be in. You can see, Sarah, here’s inferior epigastric vessels. Oh yeah? Okay. Artery. Two veins. Mm hmm. And so now I'm going to get my finger into that space, then a retractor into that space, and then I know I'm in the preperitoneal space. And this now - it comes down like butter almost. If you're in the right space, my finger can just separate the perineum from the anterior abdominal wall, and I see this cotton candy plane, and I'll do that all around.

So if I take a moist sponge, I'm going to use that to push the peritoneum out of the way. So that goes into the hole, and now we're in the preperitoneal space completely. And all I see is cotton candy. Basically it's loose adhesions that go from the peritoneum here to the anterior abdominal wall. Now we're just inside of transversalis fascia, so I'm teasing that bluntly. In a laparoscopic case, this is the part that the balloon would dissect out for us, so it’s a pretty avascular plane. Having said that, I've seen some laparoscopic cases where you’ve had bleeding in this space. And so if there's anything of significance I'll cauterize it. And - as I tease through, I'm starting to see clear peritoneum, and I’m seeing some shiny white tissue on the bottom.

Robert, can you see the shiny white tissue at the bottom? So that is Cooper's ligament. So what I'm able to do here is really free up the entire peritoneum. And typically I'll use my finger to do all of this dissection. Using the instrument allows me to show you what I'm doing here. And it's nice to be able to see when I see the cotton candy plane that I do at the edge of the picture, I'll just take my finger and sweep, and we'll see if we have a little bit better visualization now. So now there's more of a space down here, and then as I tease tissues out laterally we’ll get to the iliac vessels soon.

See the white tissue at the end of my light? So that's Cooper's ligament. So I’ve separated all of the peritoneum away - from it. So we know we don't have a medial component - if I put my finger in here, I'm in the direct space, and it's nice and tight here. So we've done that component. Now the indirect component, I’m going to move this again. We're going to tuck the peritoneum out of the way. I'm going to hold it this way for a second just for - let's have the sponge. We got to make sure we have enough space here. So I'm taking my finger and just creating a plane between the peritoneum and the abdominal wall to allow my patch to sit in here. And I'm going to tuck the hernia sac as far back as I can. Hopefully I've done enough work so that there's room for our patch next.

And then let’s review the anatomy because if we can review the anatomy, and I can show all the anatomy - cuz it's the same every single time - then I know I've done enough work. So, let’s take a look here. So let's see. Here's our spermatic cord. Here's the vessels of the cord. Here's the vas deferens. So I'm holding onto vas deferens, and I can see the vas deferens diving down medially. This is a little sleeve of peritoneum, so I'm going to take this down, being very careful because I'm on top of iliac. In fact, what I'm going to do is feel my iliac pulse first, and as I feel it, I'm right on top of the iliac vessels here so I've got to be really careful. And the reason I'm doing this is that this will hold up our patch because this is peritoneum. And if I can see through it, I can cut it. So this is loose adhesions to the peritoneum that I'll take down. And as I pull, I pull toward iliac vessels. I don't want to pull away from them. We have a vascular surgeon next door, but I prefer not to call him in. I've never had to - hopefully never will.

So - that’s that part of the dissection. There’s still a little bit more preperitoneal fat, and I wanted to show the iliac vessels here just to demonstrate how close we are. My finger is on it. And there is a little bit of preperitoneal fat sneaking in here, but I think we may not need to go that far.

All right so in terms of the dissection, we've cleared off Cooper's ligament. Here, can we see the iliacs? There's a little bit of loose areolar adhesions here - you got this Sarah? Pull a little harder - pull - both of you pull a little harder, yep. Perfect. I'm going to get this sponge out of the way and clear out where the femoral canal is, which is here. A couple of loose - you can see the pulsation on the bottom part of the field. That’s the iliac vessels. And - so if there's a femoral hernia, it would be right here. Here's our iliac vein is right in here. There’s a little fat overlying it. I don't think it's worth messing with this anymore. And then I just want to see the edge of my hernia sac, and see do I need to do anything else, and if we don't, we'll try to put the patch in and see if it lays in there flat.

So I'm just teasing the last little bit of tissue here off the - the iliacs just to skeletonize everything, and I see a little peritoneal edge here. And - there is iliac vein in the blue here. If you hold this, I'll show you guys. Here's iliac artery. Sarah, you can put your finger in and take a feel. It's very superficial. You're deep to it. Oh, yeah - wow. That's iliac artery right here, and the blue is iliac vein. And we can see we've got peritoneum away.

CHAPTER 5

So I’ll take a 14 by 11 patch. In a hernia state, the internal ring is completely opened up, so here's the internal ring where we can show you the inguinal canal. Sarah, if you hold this while we’re waiting for our patch - that’s okay - we can see spermatic cord going through a structure that's not quite a ring, but here's - we’re inside the inguinal canal and here’s our inferior epigastric vessels. It shows you the three-dimensionality of the inguinal canal. Not only does it come up and then it comes over. And then your finger is - your retractor is occupying the inguinal canal. Oh yeah, okay. Okay? So this is our inguinal canal. External ring is here. Internal ring is here. The internal ring is almost non-existent in a hernia state. And there’s a few more little adhesions here. When we get below the pubic bone, we’ll get down to the obturator canal, and I don't want to do a lot more because we risk bleeding.

So what I'm going to do is I'm going to test the - test my dissection. The way I test my dissections, I'll put my patch. It's got a ring made out of Vicryl so this is dissolvable material. This is a light wave polypropylene mix, and the underside is coated with Seprafilm so that if you were to have adhesions with the peritoneum on this side, it would slide, and basically I'm going to lay it down and then let the peritoneum kind of push it in a place, and then we’ll sandwich it in place. So I'll have a three-dimensional configuration somewhat like this. Oh, okay. So, I'm going to take my finger and slide it in until I feel my pubic bone, and then when I withdraw my finger, I'll leave an instrument in there and I'll push it in so it's nice and medial to the symphysis. I hold my finger here and then I sweep with my finger so that I’m feeling the mesh lay flat on the preperitoneal space. And then so that we can see what we've done, we're going to take this retractor and hold the mesh in place. And then we’ll take a look. So if I take a look, I've got smooth mesh and peritoneum. So I've got my peritoneum on this side. I've got mesh and anterior abdominal wall on this side. I'm going to confirm that it's smooth all the way out laterally - by feeling it. And then we’ll take a look here as well, and we can see our peritoneal edge, and our peritoneal sac is up in the air. Hold this for me, Sarah. We’ll take our sponge out gently so we don't dislodge the mesh. Sometimes it takes me three or four tries to get the mesh in perfect spot, and sometimes we get it right the first time. And I have to hold the mesh down as I pull this one out because this is what is holding my hernia sac. So I don't want the hernia sac to slide underneath the mesh.

So here's our hernia sac that we've dissected out. The mesh is sitting underneath it as I pull the cord vessels. So that's laying in smoothly. So now the part is we need to wrap it around a mesh. And if I've done enough work this should sit in there nice and smoothly and should have a nice three-dimensional curvature that's perfectly smooth without any kinks. So I take my finger and sweep. And I'm feeling some kinks initially, so I’m smoothing them out, and medially I really need my headlamp to see where the mesh is so I can sweep it and take a look. And then we’ll check to see if it's laying in there smooth and nicely.

So I take my finger and really feel, and then if I look medially, I can see my pubic bone and my Cooper's ligament. I see that there is mesh deep to it and medial to it. I see some smoothness in my mesh going all the way down below the femoral canal, which is right here, which is intact. And then the mesh lays in there smoothly, and we saw our hernia sac laying in there in between the mesh and the abdominal wall, and then we look up here, and the mesh is perfectly smooth. Up here there's a little bit of kinking to it. That's because of the retractor. If we lay it down flat, you can see the inferior epigastric vessels sitting on top of my mesh. So we've successfully covered the direct space, and there's perfect curvature to the mesh here, and the indirect space as well as the femoral.

So that was an open preperitoneal repair. So the mesh looks fine to me here. We've essentially created a Spigelian defect here. I don't close the hole. What I'll do is if you take these for me, is I'll take a couple of very loose stitches here - so 3-0 Vicryl. This is what's left of transversalis fascia, and I'll put a couple just so that the mesh doesn’t rotate in the first couple of days. And - we’ll get this - sutured into place for us. So really not for strength, more for prevention of rotation. We’re away from any nerves here, so the risk of nerve injury is a lot less than any other type of repair. There is one report that said that chronic nerve pain was higher in this than in a traditional repair, and the surgeon that taught me how to do this told me that don't - if you don't close the internal obliques, you're not going to get nerve injuries, and since we know we - we saw the nerves and we saw that they're sitting on the internal obliques. I have learned that my mesh is strong enough to prevent anything from popping through here, and I don't close the internal oblique. And I had one patient that I can remember about 8 years ago that I ended up sending to a pain clinic because of chronic pain, and I haven't had one since that's come back to me.

So here's our internal obliques, and we'll just let those be. We're not going to touch them. And we've got external obliques - see how the muscles actually come back on their own here? So there’s really no reason to suture them. So let’s have some Army-Navy’s and then another full-length 3-0 Vicryl.

CHAPTER 6

So I grab external oblique. You just want to grab a little bit of it and a little bit here, so you're bringing them together. And then we’ll just run this.

So postoperatively, I - I tell them not to work out at the gym or do heavy exercise - sorry, hold this for us. You know how to follow? Yep. Grab that. Perfect. So if you pull up a little bit - that way you're helping me out - you’re giving me a little exposure here, and then you guys are going to keep me in the middle of the field. So a little bit of fascia. I don't want a lot, there's no strength to this.

But postoperatively I just tell them to avoid the gym for a couple of weeks and strenuous exercise. In reality, since I placed a mesh underneath the abdominal wall, all of his abdominal pressure are going to work to keep the mesh in place. So theoretically, he can do what he wants. I've had people do a 50 km cross country ski race a week after surgery. I had a guy recently that I told him, you know, just go for long walks, so he went for a 10-mile hike in the White Mountains the week after surgery. And recently I had a guy come to me two weeks after surgery and say, you know, it's starting to hurt a little bit more. I said well what did you do? Well, I went to the gym on Monday - this is after a Thursday operation - and then I lifted a granite countertop at a kitchen on Thursday, so a week after surgery, and he said it hurt him a little bit. Well - his hernia didn't come back, but you know, he kind of re-injured - tissue, so it caused a little bit more inflammation, so it slowed down his recovery a little bit. But in terms of the repair, since it's in place and the abdominal pressures are holding it in place, I'm not too worried about them causing a recurrence.

Toradol no, right? Toradol is fine. Oh,okay. Yeah there's no bleeding. I like Toradol after surgery. So most people get Toradol unless there's bleeding. And then…

So that's external oblique. I'll take Adsens and a couple stitches for the internal oblique.

Postoperatively, because it's preperitoneal, any bleeding or any blood will track down into the - inguinal canal, the scrotum, and the penis, so I warn them all that it may turn black and blue. It's just like a laparoscopic repair. When there is a direct inguinal hernia, they get the postoperative induration fluid collections that all patients with a big laparoscopic hernia have because it's essentially the same repair. But we've given a lot of local after, so hopefully he'll be pretty comfortable when we're done. 50% of patients doing this roughly don't take anything stronger than Tylenol or Motrin. And 50% do. And they’ll usually take it for a couple of days. For my own - from my experience with my patients, I know that about 90% who have this done on a Thursday or Friday go back to work on a Monday. People who work for themselves go back to work - go back to work the next day.

So this is just a running intradermal suture. I do my sutures the way a couple of plastic surgeons in residency taught me, and it worked for me. So - I always go - instead of lining across, I just go back to my last stitch here, grab my needle, and then go. And that way brings the edges together nicely. You can take bigger bites once you get out of the corner.

And - so I have a lot of patients who come to me initially who were referred for laparoscopic repair, and what I tell them is I used to be a laparoscopic hernia surgeon, but I now do a technique that's ultimately less invasive, causes less pain, allows them to get back to work faster, and because I did a few hundred laparoscopic hernias before learning this technique, people believe me, and I've done over a thousand this way. So - there's a rare patient that insists on a laparoscopic case, and then I send them to one of my partners who does laparoscopic hernia surgery, and we keep it in the same group. Last stitch, Mary. Good. You did a right inguinal hernia repair with mesh? Yep. And no specimen… It’s called an Aberdeen hitch. No specimen, correct. I think there's more pain when you cut the peritoneum, so when you do a high ligation, I think patients have more pain. It's just anecdotal, I don't know that there's any literature to support that statement. And cut the near - suture at the skin edge - good. And wetness.

So most patients can get away with an incision this size. You can do a little bit smaller, maybe 3 cm. A bigger, heavier person, I might need a 4.5 cm incision. Bullet of Mastisol. And I'll take the Steri-Strips. So I usually cut them the length of the incision. That way we are kind of minimalists with the dressing. And, this is the only part of the work the patient ever sees of what I do. And a 2 by 2. Do you have a Tegaderm there? Can you just open that for me? Thanks.

So I talked with him, and I gave him a prescription for Vicodin, but I told him just to take Tylenol every 8 hours, and alternate it with Motrin every 8 hours, and hopefully he'll be fine with just that. We're done.