Management of Abdominal Hernias by Karl A. LeBlanc Andrew Kingsnorth & David L. Sanders

Author:Karl A. LeBlanc, Andrew Kingsnorth & David L. Sanders
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

The steps of the dissection for a TEP repair are otherwise standardized: firstly, dissecting the extraperitoneal space toward and identifying the pubic symphysis to minimize the risks of accidental injury to the urinary bladder; secondly, identifying and dissecting high and lateral to the inferior epigastric vessels to create the lateral space sufficient for placement of the mesh; thirdly, identifying and reducing an indirect sac, often with its accompanying lipoma of the cord; fourthly, dissecting the peritoneum proximally so that the mesh can be comfortably placed without the inferior edge curling up; and finally, medially dissecting the peritoneum away from the vas deferens and external iliac vein. One point of difference with the multiport dissection is that the dissection of single-port totally extraperitoneal dissection with telescopic dissection starts superiorly into the inferomedial and lateral direction, whereas the multiport dissection begins inferiorly and continues laterally and superiorly. Telescopic dissection allows for cautery of all small blood vessels crossing the extraperitoneal space, thus potentially minimizing post-op bruising and pain [15] while specifically allowing for preservation of a thin layer of areolar tissue overlying the retroperitoneal nerves (Fig. 17.7), as achieved during a transabdominal preperitoneal (TAPP) repair, which may be protective against post-herniorrhaphy chronic groin pain.

For a unilateral inguinal hernia repair, the extraperitoneal space is dissected across to the contralateral side by approximately 2 cm especially for a direct hernia. Any significant direct hernia sac is reduced and plicated to the posterior pubic ramus with a couple of nonabsorbable tacks to minimize the risks of post-op seroma formation [13]. Reducing the sac by ligation is not necessary as this increases operative time, costs, and complexity.

For bilateral inguinal hernias, the surgeon and assistant must move to the contralateral side of the patient to resume dissection. In these cases, the dissection starts at the level of the symphysis pubis and continues laterally and superiorly. Depending on whether the median raphe is well developed or not, one may encounter some difficulties dissecting the lateral aspect of the second side in which case the inferior portion of the raphe can be divided to ease dissection. It is usually possible to complete the repair of the contralateral side within 20 min of starting the dissection [13]. The anesthetist is warned (unless they are very familiar with SIL TEP repair) so that reversal of muscle relaxant can be instituted in good time to allow the patient to wake up without significant delay. This ensures that the procedure can be completed with the patient completely paralyzed to the end of the procedure, since the fascial and skin closure only takes a few minutes, the so-called fast finish.

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