Hernia Surgery by Volker Schumpelick Georg Arlt Joachim Conze

Author:Volker Schumpelick,Georg Arlt,Joachim Conze
Language: eng
Format: epub
Publisher: Thieme Medical Publishing Inc.
Published: 2018-11-17T00:00:00+00:00

Fig. 2.129 Instruments.

Fig. 2.130 Skinpic.

Through the two trocars (each 2.8 mm) introduced laterally just medial to the anterior superior iliac spine, the peritoneum above the hernia is incised transversely over a distance of about 5 cm with a high-strength 2-mm dissector and a corresponding 2-mm scissors (Alphadur titanium ceramic 2-mm instruments, Gimmi, Tuttlingen, Germany).

The hernial sac is then dissected from the spermatic cord with 2-mm dissectors and the 2-mm scissors until it has been fully mobilized.

The hernial orifice in the transversalis aponeurosis is then apparent.

After extensive dissection of the spermatic cord and its structures from the peritoneum, a sufficiently large (10 × 15 cm) mesh with slightly rounded corners can now be placed safely over the spermatic cord, the vessels, and the hernial orifices (Fig. 2.131). The same rules apply as described in section 2.4.1. The delicate 2-mm micro-technique allows dissection close to the peritoneum to spare neural structures. When a large medial hernia is present, the rolled-out transversalis fascia is dissected gradually and is then “flattened” and sutured with polyglactin.

The peritoneum must be mobilized extensively off the vas deferens, the vessels, and the spermatic fascia over the psoas to prevent the lower edge of the mesh from rolling up.

The peritoneum is finally closed with a conventional 3/0 polyglactin continuous suture using the 2-mm needle holder and a corresponding dissector (Fig. 2.132).

The individually trimmed mesh and the suture material are introduced through the 10-mm umbilical trocar.

The residual suture material is buried through the 10-mm trocar by pushing the needle holder backward and pushing it through after removal of the valve head of the 10-mm trocar (Fig. 2.133).

Incision or fixation of the mesh is not necessary as it is pressed onto the transversalis fascia in the tailor-made preperitoneal space by the closed peritoneum and the viscera that “lean” on it, once the pneumoperitoneum is released, just like in the TEP procedure. The pressure on the mesh following release of the pneumoperitoneum leads through the expressed fibrin to rapid adhesion of the mesh to its surroundings so mesh displacement is largely excluded. Very large medial hernias are an exception, where leveling suture of the rolled out transversalis fascia is indicated to ensure that the mesh remains in place and to avoid mesh bulking in the hernial orifice. Moreover, in this case, the mesh should be secured temporarily medially with a 3/0 polyglactin suture.

If the mesh were to be fixed, a tacker or fibrin glue would have to be introduced through the 10-mm trocar (Use of a 5-mm trocar in the umbilicus is theoretically possible but does not appear rational, as the mesh and suture must be introduced through it). To carry out this maneuver under optical control, insertion of a 2-mm (needlescope) optic into one of the two 2.8-mm trocars is necessary and possible.

Fascial closure at the umbilical trocar incision may be required in individual cases. The operation concludes with a continuous, buried intracutaneous absorbable suture of the umbilical incision. The 2.8-mm stab wounds do not require treatment (Fig. 2.134).

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