Totally Extraperitoneal Hernia Repair

Patient and operating room are prepared in a similar fashion to the transabdominal preperitoneal repair. After an infraumbilical vertical incision is made, the anterior rectus fascia is incised, and the rectus muscle lifted upward and laterally, exposing the posterior sheath. The surgeon's finger is then used to gently separate the rectus muscle from the posterior sheath. The dissecting balloon is placed into this plane and directed toward the pubic tubercle. A 10-mm laparoscope is then placed into the balloon and the balloon slowly inflated under direct visualization. The balloon is then left inflated for a short time to tamponade any small vessels. The inferior epigastric vessels should be directed anteriorly during this step. The balloon is then removed, and a Hasson type trocar placed and the cavity insufflated to 12 mmHg. Two 5-mm trocars are then placed in the midline between the pubic tubercle and the umbilical trocar under direct visualization.

The pelvic anatomy is then delineated with identification of the pubic tubercle, Cooper's ligament, and the epigastric vessels. The lateral space is then bluntly developed toward the anterior iliac spine. For an indirect hernia, the sac is dissected perpendicular to the cord structures. The sac is then completely invaginated if at all possible to allow for placement of the mesh. A10 X 15 cm mesh is placed into this space and tacked in a similar fashion as described in the transabdominal preperitoneal repair. Insufflation and trocars are removed and the skin closed. No fascial defect needs to be closed in the totally extraperitoneal repair.

Recent studies have shown the decreased necessity of fixation of the mesh in the totally extraperitoneal repair. This may lead to decreased postoperative neuralgia and decreased cost of surgery while not incur any an increase incidence of hernia recurrence (9).

Dynamic Six Pack Abs

Dynamic Six Pack Abs

Reasonable care has been taken to ensure that the information presented in this book is accurate. However, the reader should understand that the information provided does not constitute legal, medical or professional advice of any kind.

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