TEP

Tips & Tricks

Yasser Hamza
MD, FRCS, FRCSEd
Assistant Professor of Surgery
Faculty of Medicine, University of Alexandria
How to start your experience
 Laparoscopic Anatomy
 Videos
 Attending operations
 Tutor
 TAPP
 Open pro-peritoneal
 Choice of patients
Laparoscopic anatomy
Patient setup
 Slight Trendlenberg position, raise the head.
 Screen at the feet of the patient.
 Arms flexed along the sides of the patient.
 Camera operator to the other side.
 Groin and scrotum sterilized and kept exposed in
the field.
Patient setup

M
Patient setup Alternate

S
Opening for the first port
 Incision is made just lateral or inferior to the
umbilicus
 Same side of the hernia
 Anterior rectus sheath should be opened under
vision
 The muscle is retracted laterally.
 A finger, artery forceps or blunt trocar is then used
to open the tunnel
 Video link
Developing the space
 The gas does the main job
 The telescope is used only to:
 Open a tunnel straight down
to the pubic bone
 Break down the flimsy areolar
tissue that remain after
insufflation
 For lateral dissection of the
peritoneum, the use of the
instruments is also possible
 Video.
 Scissors
Developing the space
Developing the space
 The gas does the main job
 The telescope is used only to:
 Open a tunnel straight down
to the pubic bone
 Break down the flimsy areolar
tissue that remain after
insufflation
 For lateral dissection of the
peritoneum, the use of the
instruments is also possible
 Video.
 Video
 Scissors
Developing the space.
 While sweeping with the lens, look for crossing
vessels and avoid tearing them.
 Identify the inferior epigastric vessels and keep them
towards the anterior abdominal wall.
 Avoid using the port as a fulcrum for the lens
 Use external palpation for orientation if needed
 Insert the 2nd port early and use it to open the space
careful, mind the urinary bladder
Developing the space..

video
Developing the space..

video
Inferior epigastric vessels

video
Arcuate line

video
Arcuate line

video
Port sites
The sac and cord
 After developing the space, the part connecting the
retracted peritoneum to the area of the internal ring
will be the sac/cord complex.
 Reduce the hernia manually from outside and keep
applying pressure to keep it reduced if needed.
 Start peeling the sac off the transversalis fascia
slowly laterally.
The spermatic cord
 The vas is in intimate relation to the poster-lateral
aspect of the sac.
 It might be so adherent so that it can tear the
peritoneum while dissecting it off.
 The most critical part is the postero-medial corner of
the internal ring -away from the vas- where the sac
is most firmly attached to the internal ring and where
the inferior epigastric vessels are in the depth of the
space
The spermatic cord

video

 Inferior epigastrics Thick adhesions

The spermatic cord

video

 Inferior epigastrics Thick adhesions

The sac
 For small and direct sacs, continue peeling till
complete reduction is achieved.
 For longer sacs or adherent ones, reduce enough
length to apply suture. Ligate and cut the sac
leaving the distal part open
 Try to be very accurate to identify the fundus of the
sac.
 Use scissors or diathermy to separate it from the
internal ring very important
The sac

video
 The sac

 Video for reduction Fundus Dissection Video for ligation

What to do if the peritoneum is
breached?
 Continue with the operation so long
as you have a space to work.
 Insert a 5mm trocar intraperitoneal
and use it as a vent.
 Inset Verrus needle intraperitoneal as
a vent
 Convert to TAPP
 Video 2
Pneumoperitonium
Parietalisation of the cord
 It is a mandatory step
 Down to the crossing of the iliac vessels
 The mesh should sit in the depth of the
angle between the vas and peritoneal
reflection
 Slitting of the mesh in not recommended
 Video
The spermatic cord

video
Mesh type
 PTFE (Gortex)
 Molded mesh
 Coated mesh
 Partially absorbable mesh
The mesh Type polypropylene
Mesh size & shape
 Average 10 X 15 cm

 Should fit the pocket

 Should occupy the whole

pocket if it will not be fixed

 Square, oval, kidney

shaped, others
Fixation of mesh
 Not necessary as a routine.
 It is desirable in large hernia
 Limit the umber of fixation points to 3 or 4
 Avoid triangles of pain and doom.
Fixation of mesh
 Devices:
 Staples
 Tacks
 Absorbable tacks
 Tissue glue
 Sutures
Fixation of the mesh
Fixation of the mesh
Mesh Orientation
 Rolled mesh:
 Medial to lateral
 Top to bottom
 Umbrella insertion
 Mark the corner and
center with sutures
 Adjust the top medial
corner and fix it
 Adjust axis before
unrolling
 Spread corners carefully
 Hold with instrument,
deflate under vision
Mesh Orientation
Light weight mesh
Light weight mesh
Bilateral Hernia
 Routine exploration of epsilateral concomitant direct,
femoral and obturator hernias. Up to 30% of patients will
have a second undiagnosed hernia. The mesh should cover them all!
 Exploration of contralateral side:
 Take urinary bladder down
 Sweep the cameral and instruments to other side
 Swap places to face the contralateral side
 Make sure that the 2 meshes overlap in the midline by at
least 1cm.
 Video
Bilateral Hernia
 Video
Fatty patient
 The open technique is more demanding. Needs
special long narrow retractors and good light.
 The planes are more difficult to identify. They tend
to bleed.
 Lipoma of the cord
 Positioning of the mesh
 Missed hernia, incomplete dissection of the
peritoneum
Residual swelling in the groin
 Perceived by the patient as a hernia
 Possibilities are:
 Persistent hernia
 Missed hernia
 Lipoma of the cord
 Hematoma
 pneumatocele
Cord lipoma

video
Persistent hernia
 Missed sac
 Incomplete separation of the sac from the internal
ring
 Folded mesh
 Small mesh
 Slit mesh
Trauma
 Inferior epigastrics
 Vas difference
 Spermatic vessels
 Iliac vessels
 Urinary bladder
 Nerves:
 Testicular pain
 Groin pain
Other complications
 Pnumothorax
 Hyoercapnia
 Brain edema

Recurrence