Technical Pearls Bleeding

Significant bleeding may occur from various sources, including the epigastric vessels, the crossing veins over Cooper's ligament, and the iliac vessels. Proper trocar placement and dissection in the correct plane prevents injury to such vessels.

The use of a small gauge needle and syringe filled with anesthetic at the time of initial trocar placement during the transabdominal preperitoneal repair will allow for direct placement of trocars lateral to the epigastric vessels. During initial dissecting balloon placement in the totally extraperitoneal repair, it is important to visualize balloon expansion of the cavity and the correct anterior displacement of the epigastric vessels. If it becomes apparent that the epigastric vessels are being displaced incorrectly, insufflation should be stopped and the remainder of the dissection done under direct visualization. If the vessels become torn in either operation, they can be directly ligated using a suture passer and absorbable suture or clipped. Confidence with anatomy and location of the external iliac vessels and the constant

Avoidance of tack placement below the iliopubic tract and constant palpation of the tacker against the abdominal wall will ensure correct placement of tacks. However, if nerve entrapment occurs in the immediate postoperative period, the patient should be brought back to the operating room for tack removal.

TABLE2 ■ Postoperative Complications crossing vein over Cooper's ligament will help the surgeon in avoiding these structures during the dissection.

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