Welcome to Dr. Bhansali's Laparoscopic Surgeries
Key Hole surgeries for Groin Hernia
Laparoscopic Extraperitoneal Hernia Repair
The Logic & Technique
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Introduction:
"No disease of human body belonging to province of the surgeon, requires in its treatment a greater combination of accurate anatomical skill than hernia in all its varieties."
-Sir Astley Cooper
The success of Laparoscopic Cholecystecectomy resulted in establishment of a gold standard & replacement of techniques of certain conventional abdominal surgeries. In order to expand the indications and benefits of the minimal access surgery, surgeons started extending applications of this technique to repair of Inguinal Hernias. It was believed that the laparoscopic repair would combine the advantages of minimal access like reduced pain, better and magnified vision of anatomy, early return to work with proper and effective repair.
Bassini in 1884 demonstrated a combination of techniques to Italian Surgical Society.
This included 1) High ligation of peritoneal sac 2) Repair of floor of Inguinal Canal 3) displacement of cord to a position in front of reconstructed floor 4) Closure performed from internal ring to pubic tubercle 5) Closure of abdominal wall in individual layers 6) Use of non absorbable suture of silk
Various surgeons went on modifying marginally the basic technique of Bassini.
Bloodgood in 1899 and Halstead among others in 1903 appreciated the importance of 'Tension-free' repair. This gave the idea of the use of reinforcing material to strengthen weakened abdominal wall similar to concreting of a wall. Lichenstein popularized the concept of use of prosthesis. During the subsequent period, quite a bit of experimentation to find suitable prosthetic material was carried out.
Dr. Throckmorton in 1947 wrote that the choice of herniorrhaphy must have basic
1) Sound knowledge of anatomy 2) physiologic requirement of the region 3) recognition of factors concerned in wound healing and 4) certain ingenuity which allows an occasional divergence of " Routine Procedures".
The Preperitoneal approach to hernia with placement of prosthesis was popularized by Nyhus. Various surgeons and their students tried to improve the technique, size and material of prosthesis, use of suture material. The only driving force for various experimentation was recurrence rate, for it is frequently said that a surgeon's failures do not return but look for a better surgeon. Stoppa and associates adopted Rignault's theory of repair in which a large piece of prosthesis was placed posteriorly to repair or replace transversalis fascia. In Lichenstein repair, the approach was anteriorly.According to Stoppa, it is better to put the reinforcement in the shape of a mesh deep to the defect between the muscle and peritoneum which automatically implies between defect and the pushing intra-abdominal force. The posterior approach demands far more extensive dissection in 'open 'hernia causing more pain. In extraperitoneal hernia repair, precisely same results are achieved with minimum access and as a result less pain and morbidity. This technique thus achieves a perfect Tension-free repair
In 1962, Ger described the management of various abdominal hernias through a transabdominal approach in patients who had laparotomies for various other intra-abdominal conditions. One of his patients underwent hernia repair by stapler during a laparotomy and the approach to inguinal region was by a laparoscope inserted through the laparotomy incision. He further experimented in dogs for laparoscopic approach. Bogojavlowski in 1989 and Shultz in 1990 demonstrated repair of hernia by filling the defect with polypropelene mesh. This was a novel approach as against closure of defect with high ligation and tension-free repair by covering with a large mesh. However, they reported several early recurrences.
Since 1990, three main methods emerged for laparoscopic hernia repair.
1. Trans-abdominal Pre-peritoneal (TAPP)
John Corbitt of Florida after experiencing several recurrences, evolved a three puncture trans-abdominal technique wherein the peritoneum overlying the defect was incised to develop peritoneal flaps exposing the floor of inguinal region. A prosthetic mesh large enough to cover complete inguinal floor (indirect,direct and femoral spaces) was stapled The peritoneum was re-approximated.
2. The objection of the TAPP repair by few surgeons like Toy & Smo was that it requires a considerable dissection of inguinal area. So they tried to achieve the same result by stapling PTF patch as a 'Onlay ' patch. Theoretically, peri-operative morbidity is reduced as very little dissection is required.However,in 1990 Salerno, Fitzgibbons et al during experiments on animals at Creighton University did find adhesion between Urinary bladder and the mesh and in about 15% adhesion between intestine and prosthesis. For obvious reason ,there were more recurrences.
3. Total Extraperitoneal technique. In 1991,J Barry McKernan of Metropolitan Hospital, Atlanta and thereafter Phillips et al of US and Dulucq of France, advocated extraperitoneal hernia repair. Their surgery was almost similar to conventional surgery done laparoscopically. With this approach, the objections of surgeons about unnecessary intra-abdominal violation, use of only general anaesthesia for laparoscopic as against conventional which requires regional or local anesthesia were gently put aside.
In this article, we describe the logic and technique of extraperitoneal hernia repair with our modifications to suit Indian social and economic conditions and our experience in treating direct and indirect inguinal hernias extraperitoneally only. We have not included TAPP repairs which were done earlier in the series. We give the experience of 73 consecutive cases.
Surgical Anatomy: A view of Laparoscopic v/s open :
Anatomy of Inguinal region can be viewed in two perspectives.
1. Anatomy observed from outside the abdomen (Extraperitoneally)
2. Anatomy observed from inside the abdominal cavity (Intra-abdominally)
Inguinal region anatomy from outside the abdominal cavity can again be viewed in two ways.
? Where the study of the region is done in inguinal canal and above the deep inguinal ring as in 'Open' hernia repair (Study of anatomy done 'anteriorly' )and
? As in Extra-peritoneal repair, the anatomy is viewed deep to internal inguinal ring (study of anatomy done 'posteriorly' ).
Study of anatomy done 'Anteriorly' - open method
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Study of anatomy done 'Posteriorly' - As for Extraperitoneal Hernia
( Done after Balloon dissection to create a space of approximately 300 cc between Rectus sheath anteriorly and peritoneum posteriorly and inserting 0 degree video - laparoscope. )
Medially the view extends upto midline and laterally upto medial aspect of psoas. .Inferiorly, the view spans from medial to lateral exposing, the urinary bladder, pubic tubercle,Cooper's ligament,Internal ring with its contents and the Ileopectineal ligament.Anteriorly the space is bound by posterior aspect of Rectus sheath anteriorly and internal oblique with transversalis laterally.The inferior epigastric vessel forms an imprtant land-mark. It can be traced down to internal inguinal ring. Posteriorly is peritoneum with transversalis facia and extension of peritoneum as a hernial sac on the cord as in indirect and as a broad sac as in direct hernia.Inferiomedially, the structures recognisable from medial to lateral are Urinary bladder in the mid line,pubic tubercle is more felt thn seen . If the dissector is traced laterally from the pubic crest,leads to Cooper's ligament.The attachement of trnsversalis abdominis to Cooper's ligament and lateral margin of it forms medial margin of Femoral ring. Lateral to Cooper's ligament on a more anterior or cephalad aspect is deep inguinal ring, the inferior border of it isformed by a band of connective tissue, the 'Iliopubic Tract'. This structure is attached lateraly to ilio-psoas facia as it passes below the deep inguinal ring,forming upper margin of femoral sheath and then continues inferiorly to define medial margin of femoral canal and then getting inserted into superior pubic ramus.
In case of difficulty in defining internal ring, follow the inferior epigastric vessel to the ring.The spermatic cord enters the ring in a oblique fashion. The cord gets its coverings of cremesteric in canal only. Above the deep ring,it is covered in distal half by only internal spermatic fascia derived from transversalis abdominis. The Vas is on ainferiomedial aspect of the cord. Blood supply to the testicle via internal spermatic artery originating from aorta and external spermatic artery originating from inferior epigastric are the other contents of the cord. Artery to the vas arising from superior vesical is also present.The venous drainage of testicle at this level is seen as a two or three vessels forming the internal spermatic or testicular vein. The genital branch of genitofemoral nerve passes down down on psoas and then medially to enter the internal ring. The indirect hernial sac with or without content is on the anteriomedial aspect. Amongst other structures, few fatty tissue is also seen.
The inferio-anterior border is formed by ileo-pectineal band which is appreciated anteriorly as a Poupart's Ligament which is in fact a thickened portion of External Oblique.
The DANGER area is posterio-inferiorly to internal ring where dissection should strictly be avoided as it is occupied by Femoral vessel.The lymph node of Cloquet is often found in the femoral canal beneath the internal ring.
Superiorly, the space is bounded laterally by internal oblique,the lowermost fibres of it taking origin from iliopsoas coming downwards and obliquely to lower rectus sheath and pubis. Superio-medially is posterior rectus sheath.
The DANGER areas recognised are
K Medial to pubic tubercle where Urinary bladder is present
K Inferio-lateral to Cooper's ligament where Vas Deferens is present
K Inferior to deep inguinal ring where femoral vessels are present in femoral triangle.
K Inferior to Ileo-pectineal band because of the prescence of femoral vessels and nerve
Study of anatomy from inside the abdomen
This can be studied
a) With peritoneum intact
b) With peritoneum removed
This is done after insuffulation with CO2 gas at the intra-abdominal presuure of 14mm of Hg and inserting a video-laparoscope directed towards pelvis and with 200 head low position to allow a clear view of pelvis.
In the mid line is remnant of urachus ,
If medial umblical ligament is followed from the anterior abdominal wall towards the pelvis,a pearly white cord like structure traversing medially is seen.This is vas and along with its vessel.Followed laterally, the vas course to internal inguinal ring.The vessel joining the vas is spermatic vessel. It originates from aorta beloew the origin of renal arteries.Throughout the course, it is accompanied by coresponding vein.. in the male, the vessels cross the iliac fossa on the way to deepinguinal ring. In the females,they approach the pelvic brim and turn downwards & medially as they enter the pelvis and course towards the ovaries.
Once the vas and spermatic vessels are identified,we have the boundries of Triangle of Doom of Spaw. The triangle's base is an imaginary line joining these two structures with apex at internal ring.The contents of this triangle are a) external iliac vessels & b) just external to spermatic vessels, genital branch of genito-femoral nerve entering the deep ring. To perform safe laparoscopic hernia repair, it is a mandatory that the suturing or stapling be done only medial or lateral to this triangle.This area because of it's grave concern is also called Demilitarized Zone (DMZ) Here, No Dissection, No Cautery, No Staples, No Suturing.
The lateral umblical fold of Inferior Epigastric artery in obese patient is sometimes not distict.If not seen, follow the medial aspect of internal ring. Hesselbach's triangle is formed medially by lateral border of Rectus Abdominis muscle and sheath; laterally by inferior epigastric artery and inferiorly by inguinal ligament.It is divided in to lateral and medial compartment by obliterated umblical vessel.
To study anatomy of the second stage, now pick up the peritoneum about 1to 2 cm above the deep ring and just lateral to medial umblical ligament.It is incised vertically down upto iliopubic tract and then turned transversely upto 2 or 3 finger breadths from anterior superior iliac spine. The peritoneal flaps are developed using sharp and blunt dissection.
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