HOW I DO IT DIFFERENTLY
|Year : | Volume
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Trocar insertion in enhanced-view totally extra-peritoneal (eTEP) repair of inguinal hernias
Rahul Mahadar1, Eham Arora2
1 Division of Minimal Access Surgery, Jeevanshree Hospital, Thane, Maharashtra, India
2 Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India
|Date of Submission||30-Nov-2020|
|Date of Decision||14-Feb-2021|
|Date of Acceptance||04-Mar-2021|
|Date of Web Publication||06-May-2021|
Department of General Surgery, 6th Floor, Main Hospital Building, Sir JJ Hospital Campus, Byculla, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: The enhanced view totally extra-peritoneal (eTEP) repair is a useful modification of the classic TEP operation which offers a more panoramic view of the operative field with greater flexibility in port positioning. It can offer greater ease of surgery in large, irreducible or bilateral inguinal hernias due to its improved ergonomics. Misunderstanding the myo-fascial anatomy, incorrect positioning or sequence of trocar insertion can lead to inadvertent peritoneal injury with pneumoperitoneum, impeding the operating surgeon.
Methods: We describe our method for the surface marking of the semilunar and arcuate lines which guides the site of initial optic access. After blunt/balloon dissection of the pelvic extra-peritoneal space, the lateral trocar is inserted first to clear the peritoneum off the posterior aspect of arcuate line, allowing us to divide it near its medial attachment. The second working trocar is inserted at the umbilicus after visually confirming the extent of dissection. Additional trocars are inserted depending on bilaterality or size of the hernia.
Results: We have operated 124 cases of bilateral inguinal hernia between April 2017 and February 2020, where we suffered peritoneal injury in only four cases, without leading to the conversion of the procedure. The widely dissected space with the division of the arcuate line further increased the ease of laying down a large prosthetic mesh.
Conclusion: The exact sequence of trocar insertion and their positioning described by us improves ergonomics and ensures a safe division of the arcuate line with minimal risk of damage to underlying peritoneum.
Keywords: Enhanced view totally extra-peritoneal, inguinal hernia, surface marking, surgical technique
| ¤ Introduction|| |
Endoscopic totally extra-peritoneal (TEP) repair of inguinal hernias has a few advantages over a trans-abdominal pre-peritoneal (TAPP) approach. The procedure is completed without violating the peritoneal cavity, and the surgery has a much lower risk of post-operative bowel obstruction due to the absence of a sutured peritoneal incision where the bowel may become adherent or traverse across. While the possibilities for port placement in TAPP are flexible, that for TEP are fairly restricted. With the optic trocar below the umbilicus, the operating surgeon may face a fairly cramped surgical field, especially in a short patient. The challenge is compounded in obese patients and those with irreducible or large hernias. This is one of the factors contributing to the steep learning curve in TEP.
Daes' description of the 'enhanced' view TEP (eTEP) modification in 2012 involved placing the optic trocar proximal to and on one side of the umbilicus, lying within the retro-rectus space. Division of the medial end of the arcuate line widens the transition from the retro-rectus to the pelvic extra-peritoneal space, permitting a more panoramic view for dissection. It also allows greater spacing between the operating trocars which improves ergonomics significantly. The operating trocars can either be placed along the midline or on either side of the optical trocar – one adjacent to the umbilicus and the other near the intersection of the arcuate and semilunar lines. In our experience with the approach, an incorrect identification of anatomical landmarks at the time of trocar insertion can lead to an inadvertent peritoneal injury with pneumoperitoneum which can impede the operating surgeon early in the procedure. We describe our technique for surface marking of trocar insertion in eTEP repair of inguinal hernias with a specific sequence of working trocar insertion to minimise the risk of pneumoperitoneum while facilitating dissection within the extra-peritoneal space.
The patient's midline, pubis and the site of hernia are marked on the skin using sterile marking pens after aseptic preparation of the surgical field. The semilunar lines are marked 7 cm away from the midline on both sides. The arcuate line is marked between the semilunar lines at a distance of 4 cm below the umbilicus [Figure 1]a. A line is drawn on the side of the hernia, or on the opposite side of the larger hernia in bilateral cases, connecting the umbilicus and the tip of the 9th costal cartilage. The 12 mm optic trocar is inserted at the midpoint of this line which comes to lie just medial to the semilunar line [Figure 1]b. Incision at the skin is deepened until the anterior rectus sheath is visualised, then divided using monopolar energy. The longitudinal rectus muscle fibres are spread apart with retractors until the posterior rectus sheath (PRS) is seen. The 12 mm trocar is inserted at an angle such that it is parallel to the PRS. Alternatively, an optical trocar with a 0° laparoscope can be used for initial access. The camera-surgeon usually stays on the opposite side of the hernia for the duration of the procedure. In bilateral cases, the operating surgeon moves from the ipsilateral shoulder of the patient to the other.
|Figure 1: (a) The midline and semilunar lines are marked on the patient as shown using a sterile marking pen. (b) The site of the hernia is depicted by the circle in the right groin (a). The optic trocar is inserted at the mid-point of a line connecting the umbilicus and the tip of the 9th costal cartilage on the side of the hernia|
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After optic trocar insertion, the retro-rectus space is dissected bluntly or with the aid of a dissector balloon. The first working trocar is a 5 mm port inserted just beyond the intersection of the semilunar line and the arcuate line ipsilaterally [Figure 2]. In patients with a short stature, with the distance between the pubis and umbilicus <12 cm, the first working trocar is inserted more proximally, above the level of the arcuate line, just medial to the semilunar line, to avoid crowding of instruments during dissection. Using this first trocar, the midline extra-peritoneal space is dissected, with care taken to free the peritoneum off the posterior aspect of the arcuate line. This step is visually confirmed by shifting the camera to the 5 mm port, using a 5 mm endoscope. The medial end of the arcuate line is divided under vision using monopolar energy with a laparoscopic hook or scissors [Figure 3]. This division of the PRS extends till the umbilicus. The median extra-peritoneal fat is then cleared bluntly. The second working trocar is inserted at the umbilicus [Figure 4]a. In bilateral hernias, the optic trocar is inserted on the contralateral side of the larger hernia and an additional ipsilateral working trocar is inserted mirroring the second working trocar, just beyond the semilunar and arcuate line intersection [Figure 4]b.
|Figure 2: The first working trocar is inserted just beyond the intersection of the arcuate and semilunar line markings|
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|Figure 3: (a) To permit a panoramic view of the pelvic extra-peritoneal space, posterior rectus sheath is divided at its medial attachment, starting at the arcuate line. (b) The midline extra-peritoneal fat (*) is revealed after division and the cut edge of the posterior rectus sheath is seen (green arrowheads)|
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|Figure 4: (a) The second working trocar is inserted just below the umbilicus after division of the arcuate line to permit further pelvic dissection. (b) In bilateral cases, we place the optic trocar on the opposite site of the larger hernia, with an additional working trocar on the contralateral side|
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Any hurriedness to insert both working trocars without safely clearing the PRS of peritoneum can produce problems. Insertion of umbilical port without dividing the PRS leads to a narrow surgical field where the port may erroneously be inserted into the peritoneal cavity with a risk of visceral injury. Inadequately clearing the peritoneum off the arcuate line and PRS may produce pneumoperitoneum early. The extra-peritoneal division of the PRS does not need to sutured back in place at the end of the procedure.
Patients of different heights or weights may exhibit some variability in the exact locations of the landmarks for which surface marking has been described. For example, a shorter, thinner, male patient is likely to have a narrower retro-rectus space than an obese, multi-parous female. However, the location of the first optical trocar in our technique remained medial to the semilunar line in all our cases as we use the tip of the 9th costal cartilage as one of the landmarks, which is dynamic in relation to the patient's overall dimensions.
| ¤ Results|| |
Between April 2017 and February 2020, we have performed 124 cases of eTEP bilateral inguinal hernia repairs at our centres with a mean operating time of 98 min. We have not witnessed any peritoneal injury during the initial dissection and trocar insertion in any cases. Four cases suffered inadvertent peritoneal injury during dissection of the hernia sac. However, the widely dissected extra-peritoneal space [Figure 5] in these cases afforded some immunity from pneumoperitoneum without the significant impediment of the procedure. The triangulated trocar positioning helped easily suture the peritoneal rent shut. We suffered no conversions to open procedure or TAPP in any of our cases. Division of the arcuate line with the proximal position of the trocars expands the available surgical space increased the ease in laying down a mesh.
|Figure 5: Final view of a widely dissected extra-peritoneal space during an enhanced view totally extra-peritoneal procedure for bilateral repair with the pubic symphysis marked (#) and right deep inguinal ring marked (*)|
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| ¤ Conclusion|| |
The eTEP modification significantly improves the ergonomics of endoscopic inguinal hernia repairs. The trocar arrangement offers a more panoramic view of the surgical field; however, this requires dissection around and division of the arcuate line. Our description of the surface marking for and sequence of trocar insertion ensures safe division of the arcuate line with minimal risk of damage to the underlying peritoneum while providing an ergonomic port arrangement.
No preregistration exists for the reported studies reported in this article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Bringman S, Blomqvist P. Intestinal obstruction after inguinal and femoral hernia repair: A study of 33,275 operations during 1992-2000 in Sweden. Hernia 2005;9:178-83.
Hasbahceci M, Basak F, Acar A, Alimoglu O. A new proposal for learning curve of TEP inguinal hernia repair: Ability to complete operation endoscopically as a first phase of learning curve. Minim Invasive Surg 2014;2014:528517.
Daes J. The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surg Endosc Other Interv Tech2012;26:1187-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]