Bilateral Laparoscopic Inguinal Hernia Repair with Mesh Using the Totally Extraperitoneal (TEP) Technique

CHAPTER 1

Hi, everyone. My name is Dr. Shirin Towfigh. I'm coming to you from the Beverly Hills Hernia Center. I'm a hernia and laparoscopic surgery specialist. Today's case is a seemingly straightforward operation. It's a middle-aged male who's had left groin pain for many years. Turns out that he has hernias on both sides and he has chosen to undergo a laparoscopic inguinal hernia repair with mesh. We chose this operation because it's very good to understand your anatomy and be able to learn how to do a straightforward laparoscopic inguinal hernia repair using the TEP technique. However, you must be prepared because not every patient's the same and it's not just a hernia. So we'll see. There's some tricks in there and you better know your anatomy and you better be prepared for things that you may not have predicted once you went inside. So this patient was known to have bilateral inguinal hernias, with the left side being symptomatic. His examination was consistent with that, but we had a long discussion to determine if he is good for a laparoscopic repair or open repair, a repair with mesh or repair without mesh. And that's a discussion I have with all my patients. This gentleman's middle-aged. He's active, he has bilateral inguinal hernias and they were not very large scrotal hernias. And so I felt that he would have the best outcome from a laparoscopic repair with mesh. It's proven to show in expert hands to have the best outcome, shortest recovery, longest outcomes with lowest recurrence rates and lowest risk of chronic pain. I don't restrict my patients after surgery for any hernia repairs, especially, not the laparoscopic repairs. So he should be very happy with three little scars on his belly fixing both his hernias. So before we operate, the anesthesiologist places the patient under general anesthesia and we prep and drape the abdominal wall and I always include a scrotal prep. For these hernia repairs, I also make sure that a Foley catheter is placed as a urinary catheter because we will be operating around the bladder and it's safer to do so. We prefer the laparoscopic TEP, T-E-P, totally extraperitoneal approach. And that starts with a belly button incision and we identify the rectus muscle and make a retrorectus plane. That's the TEP, totally extraperitoneal approach. We then follow the 9 commandments, as they're called, which are step-by-step ways of identifying the myopectineal orifice and all the hernias involved in it. In this patient, specifically, you'll see there's some pretty interesting findings for his hernias. We start on the left side and identify the pubic tubercle, the medial part of the inguinal area, looking for a direct and femoral hernia. Then we skip laterally for the lateral inguinal hernia. And once that is all cleared, the space is made ready for mesh placement. We do the same thing on the right side. Once all that is clear, we'll place the mesh and desufflate and we're done with the operation.

CHAPTER 2

So this is the positioning for the laparoscopic bilateral inguinal hernia repair. The patient's already been shaved where I plan to put my incisions. I used to shave in the groin in case we have to convert to open surgery, but I've stopped doing that because, not to jinx it, but we haven't had to ever convert to open surgery. The patient already has a Foley catheter in place. He's preshaven, but really you want the area of the dressing and the wound to be shaved. Then the arms should be tucked because you wanna get close to the abdominal wall as much as possible. And because for pelvic surgery, you're gonna be standing in the upper abdomen, so the arm will be in the way. So you wanna make sure that the arms are tucked tightly to the sides and, specifically, that the elbow is padded to prevent ulnar nerve injury. So we have padding here, and the fingers are with the thumb up and the fingers in neutral position. And no areas where there can be pressure points onto the hands. We have a normal-sized patient, so they should be able to have their arms tucked without a problem. I always double check that the fingers are in good position. I ask our anesthesiologist, do we have okay with the pulse oximeter is working okay? It's working great. Okay, great. All right, we'll do the same thing on the other side. So this green has a little blue sponge to allow for ulnar nerve protection. Make sure the elbow is padded with it. The hand again will be upright, with the thumb up and the fingers in neutral position. Usually, I do it underneath the mattress, but some people do it underneath the patient. Doesn't really matter. And so now you can remove the arm rests and as a surgeon, you can stand in the upper abdomen while you're operating in the lower abdomen. So that's how to prep. Patient's already had TAP blocks for good preoperative pain control. He has a warmer in the upper abdomen, Squeezing sequential compression devices for the legs and we're ready to prep. This time we're gonna prep the area. You can use ChloraPrep in your preparation, but since we do a scrotal preparation too for cleaning, so that's why it's safer to use Betadine for this one. Gonna drape the sides. Okay. We have the scrub solution to clean the area, sterilize the area. First, I like to clean the belly button. So that if there's anything that's in there, make sure the belly button is clear, is clean. And you wanna prep from the cleanest to the dirtiest. From inside out. And then make sure you rub it really good. We're gonna do that a few times. All the way down to the groin area here on both sides. So now your left hand is considered non-sterile. And then now, we're gonna pat dry this area here and paint it with the Betadine. The same thing. Circular motion, inside out. After we prep this, we're gonna put a rolled up towel under the scrotum. Just put a support under there. Make sure you've covered full area. Now we're gonna put a rolled towel under here. There we go. All right. So this is a patient with symptomatic left inguinal hernia and bilateral inguinal hernias on examination. He's agreed to a laparoscopic repair. He's had these hernias for many years, and it's become only recently symptomatic. He's been practicing what we call watchful waiting up until then. We know that's a safe alternative for asymptomatic or minimally symptomatic patients. And so this patient's been watching it until he started becoming symptomatic and that's really when we consider it the best time to repair inguinal hernias. It's kind of worth your while to undergo surgery once you have symptoms. The patient's been prepped. I always include a scrotal prep just in case. You just never know. The one time you don't do a scrotal prep is when you actually need to access the scrotum. So that's just my preference. I very narrowly drape. I don't like to have a lot of skin. We're putting in a mesh implant, so you wanna minimize as much skin exposure as possible. I use a 10-degree, a 10-millimeter - what's this? 30. 30-degree scope.

CHAPTER 3

So we start infraumbilically. Depending on the shape of the belly button, we'll either do an up and down or a curvilinear incision. This patient doesn't really have much of a fold, so we're gonna go up and down and hide as much of the incision into the belly button as possible. Local anesthetic, please. I mark it because once you put the local anesthetic in, it changes the anatomy a little bit. The patient's already had some local anesthetic as a preoperative TAP plane block, so we don't really need to use too much. I just use some local anesthetic in the midline. Incision. I like doing laparoscopic inguinal repairs as opposed to the more commonly preferred robotics nowadays. Mostly because, I like the more cosmetic scars of the lap and I don't see the need for extra technology in these operations.

CHAPTER 4

All right, so with a TEP, T-E-P, it's the totally extraperitoneal approach, I prefer that. So first we dissect down to the left or right anterior rectus sheath. It doesn't really matter which side you choose. If it's a unilateral hernia, then you would choose the ipsilateral portion. This patient's a little bit on the deeper side. You have an Army-Navy, please? See the anterior sheath? Do you see it? Yeah, I think so. We're getting there. There we go. Gonna make an incision. You can't see this very well. He's right on the anterior sheath, but I'll try and bring it up for you so you can see better. Might need another... Go this way. Yeah. Might need another Army-Navy. So it's a transverse incision. We're trying to use a smaller incision. Let me see if I can grab the fascia for you. So you want to incise only the... Keep making it larger. Yeah, just a little bit. If you look down deep, you see a shiny white. That's your retrorectus space. I'm retracting with my left hand on the rectus muscle. Now we're going to move this down towards the feet. That's the retrorectus space that you're looking for. See it. And then you wanna take an instrument, the tip up and help dissect the initial portion of this TEP plane by moving the posterior fascia off of the rectus muscle. You can take this either with a tonsil or a peon or with the back of a, basically, a blunt instrument. Back of a DeBakey will also work. And this can take you all the way down to the pubic bone. You ready with the finger? Yeah. So you can use a balloon spacemaker. they make these commercially or you can make one yourself. This is a gloved - fingers, two of them, over an irrigator and suction. You just moisten it and take it through this space that you already made. And then I put in 240 cc of water. It takes a little bit of muscle to do the initial portion, but basically a 60-cc syringe four times. And you'll start seeing, there'll be a bulging in this space. Ooh, little leak there. This will develop the preperitoneal space. It's not as good as a commercial product, but it's much cheaper. By hundreds and hundreds and hundreds of dollars. It's also latex-free for your patients who are latex allergic. Alright, you have the suction? So here we're bulging. Now we're going to suck it all out and slowly take out the balloon. There we go. It looks like there's a little bleeding, which is fine. Sometimes there's a branch of the epigastrics that can get hit. Then we'll put the 10 trocar in carefully. Once you're in, I take out the obturator because you don't want to have any potential tear of the posterior space. Pressure's gonna be 10 millimeters of mercury with CO2. Okay. Are we white balanced? It's very dark. So we have some bleeding, which means we probably got either muscle or a branch of the epigastrics, which is fine. It's not critically bleeding. Okay, two more trocars go in. Take a local. One's gonna be in the midline, one centimeter above the pubic bone. So here's his pubic bone. We're gonna go one centimeter above. He has a Foley catheter in place so that we do not risk injury to the bladder. We use a finder needle to identify the position. And then adds local anesthetic to it. Make sure you're at midline. A little bit more towards yourself. Knife, please. And these are gonna be five-millimeter trocars. Because it's a small space, I use the pediatric-size trocars. So there're shorter than your typical trocar. All right, once you're in, I need you to suck out this blood so they can see better. I see you're in. It's good. Just twist it in. All right, let me just suck out this blood. Make sure that we've got hemostasis before we move forward. Can you lower the bed all the way, please? Typically for a hernia surgery in the pelvis, you want the bed down. We'll spend some time sucking all this. It's a good amount of blood. It's hard to know where it's coming from, whether it's muscle or epigastrics. But it's stopped, whatever it is. It's clotted and it's not filling back up. Yeah. That's good. Keep finishing that up. Get this clot in front. Think it needs to be grasped? I think that one will need to be... Okay, the next trocar goes in between, usually at the level of the AS - anterior superior iliac spine, or the tip of your camera. So he's gonna use the needle finder again. Just on top here. There you go. That's good. All right, the tip of the camera's good. You don't want it to interfere with the camera. You also don't want it too low. You want it right the upper edge of the mesh and that's, usually, anterior superior iliac spine. Another five-millimeter trocar. Pediatric size. There you go. Aiming down towards the feet. Good. All right, I'm gonna focus on getting some of this clot out so we can see better.

CHAPTER 5

All right, so the first step is to identify the pubic tubercle. I've heard a surgeon call it the lighthouse. Remember that, Dos? Yeah, when we're reviewing videos and actually, it's almost... So we're almost dissected there, but that's the first place to go. A bit more medial. Okay. You don't want to just start because you may not understand the anatomy of the patient. And the pubic tubercle is the first identification of where you wanna be. Otherwise if you're too low, you end up being in the bladder or into the external iliac vessels. So no more medial and higher up. You got the pedal? Yep. All right, so show me the bone. There's the bone right here. Okay, and gonna use a lot of cautery throughout this process to make it as dry as possible. I use these very gentle instruments. They grasp okay, but they don't tear the peritoneum, so we like that. So first is to identify the pubic tubercle and really clear it off. So you have to use a lot of cautery in that area. All of that needs to go. Yeah. Yeah. All of this needs to go. Yeah. To the right of it. Yeah. You can increase the cautery by like up to 35. You wanna see a bright white of bone staring at you and that identifies your area of dissection. You don't wanna be below it because there's bladder there and the external iliac vessels. So this part you should not skimp on. You should always start here, no matter how much you wanna take down that hernia.

CHAPTER 6

Okay, so now you're gonna follow the bone laterally. This is his left side. The patient is known to have a larger, more symptomatic left inguinal hernia. So that we are gonna start on the more difficult side first. It's his symptomatic side. We're just gonna follow the pubic bone laterally and use a lot of cautery. All this can go. Yeah. Stay close to the abdominal wall. So we follow the dictums of the paper by Dr.'s Ed Felix and Jorge Daes, which talk about how to safely identify and clear off the myopectineal orifice. It's not a scientific paper, but we all agree to its findings. And the first step is what we did. We identified the pubic tubercle and then we're gonna follow that bone laterally. It's right here. There's the bone.

CHAPTER 7

And then the next step is to identify the direct space. So the direct space is at and just above the area of where we're operating. He has an abnormal scar here. This is way too much scar in this region. Yeah, so here's probably like sac potentially, something to work off. So he may have a direct hernia because he's got so much... This area should be pretty much virgin or clear. You can get that vessel there. This one right here. This is an unnamed vessel, you can just take it. This is very abnormal, which implies he may have a direct hernia. So we'll see. And specifically, a direct hernia that's incarcerated. One of the drawbacks with the self-made finger dissector is that it's done not under visualization. Oh, I keep going up. So we're gonna stay up a little bit because you wanna be above the pubic bone, but you see there's this, looks like a neck there. Right there. It looks like a sac with neck in it. Oh, look at that. Oh boy. This is why we do hernia surgery. This is it. Oh, boy, love it. Aww. That's a good one. So we are medial to the epigastric vessels. We're in the direct space. This is his wide direct inguinal hernia with a transversalis fascia that's somewhat redundant. Hold on. What is that? Just scar tissue? Yeah, I think it's just scar. I mean the only other possibility... There it is. Yeah. So you see the redundant white, that's the transversalis fascia. And then we're gonna take the fat off of it. Nicely done. And we prefer to use cautery so that when this goes back in, he doesn't bleed into that space. All right. Then we're gonna empty out the rest of that fat. And notice that the epigastrics are just lateral to us. So this is a medial space called the M1, M2, M3, based on the size. This is probably M2. And we're gonna take the rest of this fat out of that defect. That's an impressive direct hernia. Yeah, it is. A big one. Direct inguinal hernias tend to occur in older men. It's a sign of weakness in the transversalis fascia, as opposed to a more congenital problem seen with indirect inguinal hernias. Pull all of that out. Yeah. A little more. There you go. See the edge? Yeah. And buzz that. Beautiful. You notice we're working in a tight space. A lot of people don't like that. That's why they like the TAPP, the transabdominal preperitoneal. I like working in these tight spaces because once you're done, you're done. Okay, so we're taking down this fat and then once we're done with clearing it, right now it's too difficult to look at the femoral space. Or do you wanna do it? Can you do it? I think we can do that. All right.

CHAPTER 8

So femoral space, you identify the bone and Cooper's ligament, and just stay on the bone. And you dissect out laterally gently before you hit the external iliac vein. If there is a femoral hernia in that area, and you can use a lot of cautery in this area because there's a lot of blood vessels that can bleed. Okay, there may be a femoral hernia. I don't know. There's some fat right there. Let me clean the camera. Yeah. All right. Better view. So there seems to be a little bit of fat in this space, just above the bone. Go just above the bone. Yeah. Then you're gonna pull on that fat, but gently because the external iliac vein is just lateral to this area. Ugh. Let me get some more... There we go. So I'm pretty aggressive... Okay, buzz all of that off. Yeah. I'm pretty aggressive in the femoral space. Mostly, because I treat a lot of women. You don't have to take down the femoral lymph nodes, but if there's fat, that should be removed. Otherwise, you're just incarcerating it with your mesh and that can, potentially, cause pain. So just get above it there. Okay, so you can see here where lacunar ligament medial to this fat and above us is the iliopubic tract. There's a little bit of fat in this, but I'm not gonna call this a femoral hernia unless there's a full-thickness defect. A little plug of fat in the femoral space is considered within normal and that looks like just a plug of fat. Yeah. But we do have to take down the fat but leave the lymph nodes in place, so that when we place the mesh it's a well-placed mesh. So clear that just a little bit. Yeah. And be careful that the external iliac vein is right there. That feels like lymphatics. Yeah, I'd just say, I think. So, just get rid of the fat. That part's fine. I would leave all that in. That's lymphatics. And then this kind of softer fat... Right. You can just buzz it off to bring it down so that you can place the mesh without it interfering with that piece of fat.

CHAPTER 9

Okay. All right. So your epigastrics are up top. Now we're going to find our space lateral to the epigastrics and identify our direct space. So the plan is to keep the epigastrics up and dissect with one hand and dissect down with the other hand to get into the lateral space. This white tissue is the arcuate line. You wanna stay above that fat. Sorry, am I showing you okay? Yeah Just hold it up with your left hand and it can be more lateral. And just bring all that down. Um-hm. Many patients, the accurate line is very low and you need to take it down as part of your hernia repair to allow for the mesh to lay flat.

CHAPTER 10

There we go. So we're beyond the preperitoneal fat laterally. We're pulling it off of the inguinal floor, lateral inferior abdominal wall. And the technique is a lateral-to-medial dissection. So left hand holds the epigastrics up, and the right hand goes lateral to medial as you're working your way towards the internal ring. That's very nicely done. So he looks like he's got some fat in the internal ring as well. The dominant hernia's probably the direct, but you can see that there's fat. So the fat is lateral to the spermatic cord. We're grabbing it right now. And he's kind of somewhat fatty on the inside. Makes this visualization a little bit more difficult. But you're allowed to grab the fat, but not the cord. So laterally you can grab the fat and then start dissecting it off the cord, the gonadal vessels, and then gently pull on the fat. This is preperitoneal fat, also known as spermatic cord lipoma, that we're pulling out of the internal ring. We know it's the internal ring 'cause we're lateral to the epigastric vessels. Just keep working on taking that fat down. Yeah. Many patients have hernias that only include this preperitoneal fat. Oh, that's good, right there. Some also have peritoneal involvement. Yeah, always double check that. It's a very two-handed operation. You need both hands working. So if you have an incarceration, sometimes the fact that we prep the scrotum in is helpful. Grab the fat, make sure you're not grabbing cord structures. There's no sac in this guy right now. All I see is fat. So peritoneal extension can occur, but usually it starts with the cord lipoma. And also it's important to know that it's normal to have fat with the spermatic cord. That's just preperitoneal fat, yeah. So you don't want to denude the spermatic cord of it's normal fat. You can grab that and pull it down, um-hmm, and then use your right hand to... This may be a fatty cord and not too much preperitoneal fat. Yeah. Although, laterally I think he's got that. So that fat definitely needs to be dissected down. Lift up. Yeah, so that's your lateral or your L1, L2, L3. This is probably L1.5. Yeah. I'm just gonna get some of this tissue up. Yeah, not that patulous. Just mildly patulous. The rest looks like it's, if you can look at the fat. The fat is, let me clean the camera. Yeah. Oh, it's very red. Why did it become so red? Oh, 'cause there was a little blood clot on it, that's why. If you look at most of the fat, it's got these squiggly blood vessels on it. Let's see if we can... Whereas this fat is mostly just a lobule of fat with not very much vessels on it. Okay. All right, let me take over. So we're not done yet on the left side. We just have you do a little bit better dissection for the mesh. But we're going to switch over to the right side right now and then before we put the mesh we'll finish the, we'll finish it, finish the dissection. I need the pedal on my left side, please. Walk that over, Bel?

CHAPTER 11

All right, so we're gonna move on to the right side of the patient. Again, it's important to identify the pubic bone, which is here, and follow the pubic bone laterally. I get the easy side, I think. It's only fair for the last week. So down below the pubic bone is where the bladder is. You don't want to be diving down there. It gets bloody, and you can injure the bladder. I always put a Foley catheter in to help reduce that. So here's your rectus muscle from the left side dissection. Here's your pubic bone. You can see it wrapping around. We're gonna follow it to the right side and dissect out the right plane. Always kind of... The beauty of the commercial balloon system is that it does both sides at the same time. Dissects both sides at the same time. So with the homemade version, you have to do a little bit more dissection. Here's your bone on the right side and we're gonna follow the bone laterally. Mostly blunt dissection. But if you see little vessels, you can cauterize it so that the patient doesn't get a lot of ecchymosis postoperatively. He had a large direct on the left side. I suspect another one on the right side, but we never know. Most people are symmetric. I'm trying to get you a nice view here. So here's your pubic bone. There's your rectus muscle. We're gonna fall into Hesselbach's Triangle, which is the border of inguinal ligament or iliopubic tract. Lateral border of the rectus muscle and the inferior epigastric vessels. So as you can see up until here, we're pretty clear. This is Cooper's ligament. It's this white tissue. And it's important as part of the 9 commandments to completely clear off the direct space so you don't miss a direct hernia. The smaller ones can be missed. All right come in with the camera, please. So he has a slit here, again, which is not normal. See this slit? This is gonna be another direct hernia. Woo-hoo. Looks like a good one. Looks like a good one, huh? Not as good as he other side, maybe. All right, so we're gonna pull it down. That one got an A. This may be an A-minus. Ah, more of like a B-plus. Not as impressive. So here's your epigastric vessels. This is medial to the epigastric vessels. It's not as large of a direct hernia. It was still fun to remove. Little bit of fat coming out. There we go. Ooh. Now every little bit counts, huh? And very symptomatic. Yeah, you wanna remove all the fat. If you leave some fat behind, there we go, and then you put the mesh in place, the patient actually gets more pain because now you're trapping fat in there that was mobile before surgery. So, all right, I'm upgrading this from B-plus to A-minus. Man, it's a pretty good one. This is a pretty good one. It's a little trickier one, 'cause at first it looked like there wasn't that much fat in it. And so if you don't do an adequate dissection, you could think you're done. And then the patient will have pain after surgery and it's because you retained some fat. Oh, this is getting upgraded to a full A. Look at that. Yeah, a snake. Snake? It's like long and thin. Long and thin. Again, we're working in a small space, so a T-A-P-P or a TAPP you could maybe have better visualization. Nice vein. Yeah, this is your external iliac vein. But check this out. This is a good size, sorry. Actually, let me get this out of your face here. Yeah. That way you can show me better. Nice. There we go. Okay, come on in with the camera. So actually, here's your epigastric vessels. Why are we, we're pulling fat from the other side. Let's make sure the direct space is clear. And then this fat needs to go, looks like... Go around the fat. Well, I mean just take it out. Yeah. Oh! Sorry. Clean the camera. Okay. Ooh, nice navigation. Nice navigation. Okay, thank you. All right, so checking your anatomy here. Here's your epigastrics. We're having some fat from the other side coming through, but our first goal is to clear the direct space. So come on in with the camera. And this is our direct space. It's kind of like a slit type and it goes in there. So we're gonna leave it as is. And what is this? This is epigastrics. Yeah. Yeah. So we're gonna leave that alone. And there's your external iliac vein. Gonna follow the pubic tubercle laterally to the femoral space. Pretty clear femoral space. This is the bottom of the bone. This is your lacunar ligament. There's no hernia here. There's a little fat over the external iliac vein. But you can see external iliac vein. Lacunar ligament is this structure here. Pretty clear. No femoral hernia. All right, we're gonna move out lateral. All right, need me to clear it better for you? Yeah, a little. All right, we're moving from left to right. We're gonna clear this space a little bit better for the camera so I can see. Oh, you know what? Let's do it this way. There we go. All right. So it's all blunt dissection at this point. And sometimes what we call breast stroke, where you have your two hands moving against each other. And as you follow laterally, you wanna make sure the epigastrics are kept up. Here are the epigastrics. You see that? And you wanna be in this space just below the epigastrics until you find an empty space, which is right there. Dissect laterally, empty space. I'm pointing my instruments all the way to the anterior superior iliac spine right now. And then we start the lateral-to-medial dissection. Notice one hand holds counter traction. One hand goes down, the other hand goes up. Again, lateral to medial. And we're working our way toward the internal ring. Tell me when you want and I'll flip it around. This looks good. Okay, we got little bit of fat. So gentle dissection, lateral to medial. So now we have epigastrics and some fat lateral to it. I wonder if this fat communicates with the other fat. Did we just pull... Fats? I think we pulled abdominal wall fat through the epigastrics. This is a... Under. This is just his normal fat. It's unrelated to his hernia. So we're gonna leave it alone. He does have a little bit of tissue here that's in our way of no consequence. So we're gonna take that down. And get better visualization of our cord structures. So again, lateral to the epigastrics. This is going to be your cord structures. So down here you can see vessels and vas deferens is right there. Vas deferens which carries the sperm from the testicle to the prostate. That's that shiny white. And you have the vessels. I do not see a hernia coming through. This is a pretty clear, there may be a little bit of fat up here, but I don't see much. This is a pretty normal looking cord. So he had mostly a direct hernia. But I need to double check that we don't miss a small amount of fat. Nice. And here it is. We gotta double check. Always double check. Wanna peek around the corner? Give me a... No, not really. We're going to make sure that the spermatic cord is dissected down. You see these fat with a little squiggly vessels on it. That's spermatic cord fat. It's not herniated fat. So we're gonna leave that alone. I'm just gonna separate it out from this other fat. I'm just going to finish it off right here. It's okay. So this is preperitoneal fat down here. We're gonna dissect off of the cord so it doesn't get entrapped with the mesh, but we're gonna leave the cord alone. So if you identify the cord, the next step is to identify, make sure you have the vas and the cord cleared of any peritoneum. So I'm gonna hold it up, not really grabbing any critical cord structures. And to me, there seems to be a little bit of a white... You see that? Okay, here we go. Do you see this little line here? It's very thin, but that's his peritoneum. And you want this peritoneum to be, and it looks very thinned. You want this peritoneum to be gently dissected away from his cord and, therefore, away from the placement of the mesh. This is not adequate yet. We need better dissection of the peritoneum off the cord. So notice I have not grabbed the cord with my left hand. I'm just nudging it up. And I'm ensuring that this peritoneal fold, which you can see here, is gently taken down. We prefer not to make a hole in this. Although in these thin ones, it's very easy to make a hole. That's why I have this special instrument. It's less likely to cause injury. But sometimes you get little holes. It's not a big deal. Just prefer not to have it. If you do have a slight hole in the peritoneum, you've now shared the extraperitoneal space with the intraperitoneal space, at least with regard to the gas. That looks good. And, that's usually not a big deal unless it competes with your working space, in which case, you have to withdraw the gas. Okay, that looks really good. What you really want is this vas deferens to be very clearly dissected off of the peritoneum. It has the highest amount of stickiness and adhesion to the peritoneum. Okay, so we took down the fat and we took down the peritoneum. Can do a little bit better job laterally.

CHAPTER 12

And now we can focus on mesh placement. So you want, medially, you want about two centimeters of dissection below the Cooper's ligament for the mesh. You don't wanna go down too low 'cause you can get into obturator space problems. You want the medial space to be freed of all fat. Epigastrics should stay up. Laterally, can you see me laterally? Yeah. Laterally, you want good lateral dissection for the mesh edge, mesh tail to lay flat. This seems to be in the way. This is just preperitoneal tissue. There's no consequence to it. We are above where the nerves are. Notice that there are two triangles we talk about, triangle of pain and triangle of doom. Triangle of pain is below this. Do you see this white line? That's the iliopubic tract. It's actually a very well defined iliopubic tract. Deep to it and below it back here are where the ilio, sorry, the lateral femoral cutaneous and the general femoral nerves lay. You don't wanna be in that space. You also do wanna take down this specific fascia here, which everyone has. This is a very dominant fascia in him, but it doesn't really have any consequence. But you need to remove this to have the mesh lay flat. And we're well above the nerves here. Okay, just wanna flatten that out a little bit. Here are some little stragglers. We're gonna clear that off to allow for the mesh to lay flat again. And this is your triangle of doom. You notice that I kind of ignored this, that was in our face most of the time. Deep to that fat is the external iliac vein, which you can stay here. And the external iliac artery, which is in here somewhere. I don't wanna see those arteries. I can just take some fat off of it. But I plan not to cause any injury. So as long as the fat is off of it, I'm okay with that. This is good. So this side is good. I'm gonna prepare the other side and then we're gonna put the mesh in and we'll be done. So I like this, having a wet and a dry always for our laparoscopic cases. Helps you clean the camera. Thank you. Okay, this side was more difficult. It was the larger side and he seemed to be more fatty. So let's just make sure we're clear enough for the mesh. So here we go. Pubic tubercle. Pubic tubercle, there's a little old blood, but not too bad. Femoral space. Femoral space. There's a vein. You see there's your iliac vein, external iliac vein. I would say no to femoral hernia on him on this side. Bilateral direct hernia's larger on the left side. This is your direct hernia here. Nicely dissected out. Doesn't need any cleaning. And this fat that was in it needs to be moved away, so that the mesh goes on one side of it. So I'm just gonna do some cleaning here. That's just kind of stuck to a lot of things. Okay. Not as bad. I'm just examining this area with the mesh, view of the mesh. The epigastrics are up. This is very low arcuate line for some reason. That's better. This is just some fat in the area. We're gonna move it back. This is just fat. Sometimes there's little blood vessels communicating with the epigastrics back here. And then laterally, all this needs to come down. So you want the mesh to lay flat. So we're gonna work on taking down all this tissue. It's just mush. There's nothing of interest in here. The inguinal, the indirect inguinal space... Oh, come on. I'm sorry. So just like the right side, we're going to clear the left side of any adhesions. It needs more... Yeah. Fred, can we get more of the liquid, Fred? Just put it right over the camera. Yeah. Thank you. Yes, let's do it. All right, let's take some of this fat off of the cord. I don't see much peritoneum on it like I did on the other side, but... Yeah, it looks pretty clear. Here's your vas deferens. I don't see any peritoneal involvement. And then let's go laterally and just double check that. Ah, looks like peritoneum's way down here. You see that? Yeah. There's a little lip of it right there. You see that edge there? I can see the edge. Right there. There we go. Right there, there's your edge of your peritoneum. Not a big deal on the left side of this guy, this lovely gentleman. Okay, and... Clean again for you? Clean again, please. So his direct hernia's interesting, in that it is not a punched out hole and it's a slit. So in some ways he's gonna have a better repair than people who have direct inguinal hernias that are just a wide-mouthed hernia. His is not wide-mouthed at all. It's a slit, but it goes deep. So if it's wide-mouthed, I usually take the transversalis arch. I'm sorry, the transversalis redundancy and I tack it down. We'll see if we have to do that in him. Okay, so now I'm preparing the lateral edge for his, this is a vessel by the way, not a ligament, and it's not a nerve. Prefer not to see the nerves laparoscopically. I'm just making a space for the lateral edge, lateral tail of the mesh. Oh, you got dirty again. And then just double checking. Yeah, the mesh is gonna go way down here. Beautiful. Let's just take some of that blood out. This blood is just gonna seep down and cause him to be ecchymoses. Prefer that he doesn't have too much bruising after this surgery. Okay, I'm gonna analyze the direct space really quickly to see if we need to take down the redundant transversalis fascia or not. So I'm gonna go inside. 'Cause see if you want, you can just put the mesh on and it'll just, boop, go right over it. Let's see if we need to do any tacking of the transversalis fascia. What do you think? I'd say it's probably, it's just harder to grab with the... There we go. Oh, you know what? It's kind of, it's not very, this one's very thinned. Yeah, attenuated. I'm not sure it's gonna help us. Yeah, it's so small and slit-like. But I'll just demonstrate. What you can do is, actually it's getting thicker. Ah, it's getting thicker. There we go. All right. So I'll show you. You're gonna take this transversalis fascia and you just wanna make it so that you don't get a big hematoma. Double check that we have that and not cord structures, right? Yeah. No, that's cord structures. See how it got thick all of a sudden? You really want this stuff. Sometimes it's not worth the effort to do it because you can injure nerves in doing this activity. But see, that's cord up there. Yes. And this is transversalis down here. All right, we won't do it in this patient. But if you had a very punched out hole, and you don't wanna bridge it, you can bring in the redundant. All right, ready for the mesh?

CHAPTER 13

Let's change our gloves, please. Thank you. Thank you both. I like to change gloves before touching an implant. The risk of infection is low. We prepped and draped very narrowly, so there's very little skin visible. But just in case, I always use fresh gloves when handling an implant. There's some studies that show that that's a benefit, especially in the orthopedic literature. Thank you. Um-hmm. We're almost done. We'll do left side. You wanna do right side first? I'm gonna have you do it. All right.

CHAPTER 14

So the mesh we use is preshaped to follow the curve. These are large? Large? It's a large? So I used to roll these. I don't roll these anymore because it tends to give a memory. So you just grab the tail and pull it through. You wanna make sure that the camera is showing you a nice unobstructed path. Push it on. Good. And it's a nice weight for direct hernias. You don't wanna use the lightweight mesh for direct hernias because of the redundancy and weakness in the muscle tissue. This is a right-sided mesh. We're gonna move it. We already made a nice space for it. So this should kind of just flop into the space. So for direct hernias, you should use heavyweight meshes. This is what this mesh is. It's easier to handle than lightweight meshes. It's also older technology and it has the weight to be able to counteract the effects of the weaknesses of the abdominal wall. So it has a tail which goes laterally and it has a broader medial position, which is marked by an M for medial. It's a little sticky, but not like some of the Velcro meshes. So in this small space, it's a little easier to handle. So you want the medial edge to be just at midline. For a direct hernia, you the medial edge to be just two centimeters off midline to the contralateral space. There you go. Very good. All right, so let's get that tail out there. Yep. He's not that large inside. Move up the mesh. Yeah. Pull it up. Yeah. Okay, that tail needs to go lateral. Yes. Okay, bring that medial edge in. Should be lateral. There's your tail, way over there. That's good. It needs to go a little bit higher. Yep. Ah, it's nice. Okay, good. Walk your way back. So you want wide medial coverage for a direct hernia. For femoral hernias, you want to make sure you have good dissection and coverage. And then for indirects, it's usually the easiest one to get coverage for. So bring down that M. Yeah. Change the angle, basically. Yeah. I don't use fixation for small hernias, especially for indirects. But for femorals and directs and large indirects, I do use fixation to prevent the mesh from either falling into the hole or shifting so it exposes the hole. The M needs to come down some more. I'm a stickler on placing the mesh. So the right hand needs to pull up right. Left hand pull down. There you go. That's good. And then walk that around. Great. Grab this edge and pull it up a little bit. Good. Yeah, there you go. You don't want the mesh too low, because it can interfere with the bladder and the psoas muscles. Oh, that's nice. That opened really nicely. Okay, show them the midline. So our ports... Our ports are in the middle, so it's just two centimeters beyond midline, which is good. You wanna make sure the inferior edge is flat and down. Right now it's folded forward. You're gonna push that fat away and make sure that medial edge lays flat down. So there. Yeah, there you go. Because we made it a little bit of space just inferior to the Cooper's to accommodate. See that? See the difference? Right there. Nice. Push it in, right there. Good. Much better than the fat flops over it. Nice. Fix that. Um-hmm. Okay. And then laterally, wanna make sure that the tail is flat. So, this is very key, otherwise, once you desufflate, you're going to have the mesh fold in. So push the mesh up a little bit more. Yes, a little bit more. I need more dissection out here. You see that? Yeah. Yeah. Yep. Better. Yep. Get that tail in there. Get those things. Just needs to moved up a little bit. Yeah, move that up. And then take that fat away with your other hand. Yeah, there you go. Take that off and then tuck it in. So mesh works best against muscle, not against fat. Oh, it was... Okay. Then double check all the fat we removed is actually reduced. That's nice. Yeah, I like... Okay. All right, I'm gonna put the other side. I'll take the left side. Oh, just leave it there? Yeah. Okay, I got it. All right, same thing with the other side. I'll try and put it in without disrupting what beautiful job you did. So M is medial. Just kind of gotta tell the mesh who's boss. Nope. Yep, wanna make sure that it's not upside down. There we go. All right, so mesh goes up, tail goes laterally. The mesh is often much higher than you think it needs to be. So I'm gonna make all this fat come down and make sure that this tail is way out there. Pull this up. So the fat needs to come down and the peritoneal dissection needs to be on the other side of the mesh. There we go. See that? Look medially for me. So medially, again, direct hernia you want a little bit of overlap medially. With the TEP if you put your instruments in the midline, sometimes that makes it difficult in this portion because you have mesh covering your port sites. But that's okay. Makes the insertion more... A little challenging. But I like the... Okay, so see I'm moving this fat away so that the mesh can lie right down flat over the bone. And here over the femoral space. We did a nice job of dissecting it. So you want it to lie flat there. Great. And again, just keeping the fat down. It's nice dissection. Laterally, you want the mesh tail, see how the tail is flat right there? Beautiful. Okay tacker, please. Okay, so for a direct you want three tackers. You want one... Too fast with the camera. You want one on the pubic bone, just below the pubic, just below the femoral space, which will be right here and you can kind of feel like a sponge area. You wanna triangulate. So you want one... Want one onto the rectus muscle, just medial to the epigastrics. If this were a large indirect, I would put it lateral to the epigastrics. But the goal is to prevent the mesh from falling into the defect. And this one needs to be very light. You don't need it to be taut. Make sure it's not on the epigastrics. Before I do that, I'm gonna put this other one just above the M, which'll be above, here's the bone. This'll be above the bone into the rectus insertion on the pubic tubercle. Oops. Right there. And the third one will go up high, triangulating over the medial space right there onto the rectus muscle. Notice that the mesh is not taut. It's a little bit loose. This will shrink up to 25%. Let's switch. Gonna double check the right side. Make sure it's symmetric. Let me take this extra little tacker out. Inferiorly, looks really good. Yeah, maybe a little too lateral even? I'm gonna clean real quick just so they have good... Yep. Inferior looks really good, nice and flat. Two centimeters below the inferior border of the Cooper's ligament. I'm gonna walk this out, laterally confirm that all the fat is removed. It is. It's a little bit low laterally. So I'm gonna pull it up a little bit, otherwise they can feel, they can feel the mesh as their hip is flexing. Yes, push on the tail, kinda... Yeah, I just wanna pull this up a little bit. Tail looks beautiful. Looks good. All right. Similar tacking because it's similar meshes, similar hernias. So start with the femoral space. Identify the Cooper's ligament right there, till you feel a little sponginess. Medially as the right, not on the bone, but on the rectus insertion onto the bone. And then up here medially on rectus muscle, again medial to the epigastric vessels. I need to see where the epigastrics are so that I don't accidentally injure it. That looks like it's clear up high. And we're done. Before we desufflate... Flip that up. I'm going to use, that'll flip up with the gas. We hold the tail down with this instrument. So let's double check that I have that done before I do. So just gonna hold it there and then use the other instrument, oh, to hold up that portion, then go the tail and hold that tail down. Got it. Oop. Right there. And then as we desufflate, you'll see that this is all going to go up. Ready? Yep. Beautiful. That fat will just move that mesh up to where it belongs. Okay. All done.

CHAPTER 15

Lights on, please. We'll take the gas off. Take our instruments out. Spots back. Then we are gonna close the anterior fascia. Thank you very much. S-retractors, please. Thank you. You have a rat tooth there? Yeah. Yeah, I'll take that. We did this one through a little guy, huh? Yeah, small incision, but it worked out just fine. Yeah, no, it worked. It's just deep. So we're gonna close the anterior rectus fascia with absorbable suture. This part just helps restore the normal anatomy, but it's otherwise not part of the hernia repair. More than one? No just run it. Hmm, deeper. Let me show you. I see it. See it? Yep. One more and then that's it. Yep. Um-hm. Gonna grab some of the... Yeah, I got it. Okay. We need 4-0 Monocryl next. Scissors for this. Oh. Sharp back on your table. Let's dry it off. Not too tight. Yes. All righty. Got a little fat on it. So where's your Bovie? Adson, please. See that fat being stuck there? Closer up. One more, right there. Yeah. Okay, good. 4-0's, please. Thank you. Thank you. Can I get another 4-0 Monocryl PS2, please? Which one you wanna do? Your angle's better, I think, for that one maybe. Won't be in the light. The five-millimeter trocars don't need to be close at the fascia level, just the skin. And this is all extraperitoneal. There's no intraperitoneal risk for herniation, like an incisional hernia. And that's why I like these TEPs, T-E-Ps, once you're done, you're done. It's a beautiful little operation. It started a little bloody because of the imperfection in the dissecting balloon and it turned out at the end just absolutely beautiful. Had some really great fat to dissect out and that was a fun case. He'll do very well. My patients are not restricted after surgery. He's encouraged to walk around warm Beverly hills. We encourage shopping. Here, I'll just take it from this angle there. Thank you. It's easier if you start from the deep ones. Ah. Yeah, if you don't completely close the skin they start getting wet dressings and then Bel needs to keep changing their dressings. Beautiful. We have more local anesthetic? Yes. How much did I use? So we used a total of eight. Eight cc. Okay, let's use a little bit more. Sure. We usually use a lot, but the patient's had a TAP block so you don't want to overuse. So I'm just gonna add local anesthetic to the fascial closure in case that's causing him any pain. This is dry, right? Yeah, full dry. Stick that inside, or do this one. Yeah, this one. I don't like belly buttons to get all moist, so I pack the belly button usually. It also gives them a nice innie, which I insist all my patients have an innie belly button. Uh, up and down for this one. We're not done with the operation. The patient's Foley catheter needs to be removed and most importantly, both testicles need to be pulled down into... So that both testicles need to be pulled down into the scrotum because we tugged on the spermatic cord. And if we don't do that they may retract up and scar up and that's very uncomfortable for the patient. Alrighty, thank you very much.

CHAPTER 16

All right, so you just finished seeing a full laparoscopic bilateral inguinal hernia repair, T-E-P, TEP with mesh. And I hope you got some little pointers and tips and tricks out of it. This patient had unexpected bilateral incarcerated direct inguinal hernias and there was a lot of fat involved with this and it was such a pleasure to be able to reduce it. We made sure that the whole myopectineal orifice was well dissected out. Despite the obvious findings of a direct hernia, we still ruled out a femoral hernia and indirect inguinal hernias and he had a little bit of that on the left side with a small spermatic cord lipoma. And we made sure we had very wide dissection and I hope you learned why we chose the mesh we did. Heavyweight mesh for direct hernias and why we use fixation, which we do for most direct hernias. A couple things about laparoscopic inguinal hernia repairs. Number one, they have to be eligible for general anesthesia and they must not have a bleeding problem. Critical bleeding is an issue with this operation. It's very uncommon, but when it happens it's risky. So if you have a tendency to bleed or need to be on blood thinners, I prefer not to do the laparoscopic repair. If you have obvious inguinal hernias, there's really no need to get any more imaging or workup for it. This patient happened to have a CAT scan which confirmed he had bilateral inguinal hernias. There's some controversy as to what's the best hernia repair. There is no best hernia repair. Every repair is different. We know, in general, laparoscopic repair with mesh is considered to be superior, all patients considered, because it has the lowest chronic pain rate, the lowest recurrence rate, the shortest recovery time. However, it involves mesh. It involves general anesthesia. You often need a catheter in you. There are other options for hernia repairs where you don't need any of those and some patients do not need these operations. If you're elderly and not a good candidate for laparoscopic surgery, I would not offer it. If you're super thin or a female and you have a really small hernia, you don't need a mesh-based repair. You can have an open repair. So you need to tailor the operation to the needs of the patient. A typical male who's active with bilateral inguinal hernias does best with this type of operation. You may wanna ask what's going on with mesh? Aren't there risks with mesh? Yes, there are risks with all operations and the use of mesh. It is an implant. It is a permanent implant and we believe it's safe. But in some patients they react to mesh. In some patients they feel more of the implant or it's more inflammatory than is expected. We're kind of in the discovery stages to see what the best mesh is. Similar to surgery, there is no best mesh. There's no ideal mesh and, hopefully, in the future there will be.