eTEP
Groin Hernias
Operative Steps
- 12mm optiview entry, go parallel as soon as you see a tinge of the posterior sheath
- Dissect with trocar in
- 15mmHg insufflation
- Can vent peritoneum if required with a port - 5mm LUQ optiview
- Head down, ipsilateral side up
- 5mm ports in midline but can direct them a little obliquely towards ipsilateral side as camera - first one near umbilicus, second a few centimetres below - but not as low as top of mesh
- Find pubic ramus go lateral
- Fully dissect cord - remove lipoma
- Fully parietalise the peritoneum/sacs
- Mesh - laparoscopic ProGrip, green medial - cut mesh more obliquely laterally and more curved inferiorly
- Triple/double breasted roll-up and push in lateral side as far as possible thru trocar.
- 0 PDS endoloop for peritoneal breaches.
Tip
Can divide posterior rectus sheath at arcuate line for more space. Make sure to be right up on rectus muscle do not to get into peritoneum.
Tip
Can place mesh on one side before dissecting the other. Generally do the bigger hernia first.
Tip
Can perform TAR if more space needed laterally
Steps for success
- 4cm above DIR for TAP
- Peritoneum is plane of dissection - leave fat on muscle
- Zone 2 dissection 3cm below pubic symphysis and 4cm above DIR
- EIV must be seen to not miss femoral hernia
- Parietalisation is complete when vas crosses EIV zone 3 and psoas seen zone 1
- Round ligament divided 1cm above DIR so not to damage genital branch of GFN
- Can transect sac in scrotum
- Lipoma of cord must be reduced above mesh and iliopubic tract visualised
- 10 x 15cm mesh without wrinkles or folds
- Good overlap
- Avoid fixation esp below iliopubic tract
- Deflate under vision
Triangles of Dissection
Ventral Hernias
Ports as lateral as possible, dissect ipsilateral side, then inferiorly below arcuate for cross-over
Then work back to hernias, crossover, dissect other side.
Close defects and plicate divarication with 0 Vlok suture, going back at end so it doesn't slip
ProGrip mesh.