TEPP procedure > 의학

Procedure

1. 10 mm port infra-umbilically, pre-peritoneally
- through curved infraumbilical incision; open anterior sheath to one side of midline, retract rectus laterally, insert finger
-->

- this sweeps peritoneum away so that the trochars can be safely placed.

- S retractors on either side of the mideline, elevating the anterior rectus sheaths.
- divide linear alba using Metzenbaums under direct vision
- Hasson inserted in this space and secured using stitches through skin.
- Inflate pre-peritoneal space to 10mm Hg (12 if young) / balloon dissector inserted and preperitoneal space dissected with insufflated air
- Use a 10mm 30o scope; moving it side to side can divide remaining adhesions.

2. Two low midline 5mm ports; good mobility here and will not bleed through rectus.
- first one high, but not so high as to puncture the balloon
- both as close to umbilical trochar as possible



3. Dissected out preperitoneal space, displaying hernia anatomy
i) identify pubic symphasis in midline; safe landmark for orientation.
--> do no dissection posterior to this or may injur the bladder.
ii) bluntly dissect coopers ligament bilaterally to open Space of Retzius
- stay close to the ligament / pubic bone, using slow sweeping.
--> allows visualization of the femoral and obturator spaces and keeps you in the parietal space.
iii) identify Hasselbach's triangle and the three potential sites of herniation related to it (direct, femoral, obturator)
- femoral and direct spaces are separated by the medial aspect of the iliopubic tract.
- direct hernia will obscure the pectineal ligament, readily identifiable during initial dissection of preperitoneal space
- while convexity of the Hesselbach triangle indicates a large indirect hernia.
iv) identify and elevate inferior epigastrics
v) bluntly develop space of Bogros to level of ASIS

4. Dissect off cord structures
- bluntly reduce hernias.
- direct sac by blunt peeling from attenuated transversalis fascia; avoid sharp dissection
- use constant gentle traction and countertraction.
- if large, some suture redundant transversalis to iliopubic tract to reduce seroma.

Elevate the inferior epigastrics with the rectus to limit bleeding.
- can control with direct pressure against the anterior abdominal wall if necessary.
- occasionally, clips or cautery.
- elevate with one grasper, and develop space of Bogros laterally, essential to place a decent mesh
Indirect space now indentifiable by finding cord structures passing through the internal ring
- can see the indirect hernia overlying cord structures in me and round ligament in women.
--> remember that round ligament / vas is always adjacent to the epigastrics
--> if you can't see them, then they have in indirect hernia.
Reduce all lipomas before reducing the indirect hernia.
- lipomas are always on the upper outer quadrant of the indirect ring.
--> this makes reduction easier and reduces chances of recurrence.
Reduce the indirect sac by sweeping cord structures posteromedially while holding the sac superolaterally.


Sac then pivoted medially and posteriorly, while cord structures are swept posterolaterally.

Alternating these two maneuvers allows separation of cord from sac.
Then reduce sac by passing hand over hand until delivered into preperitoneal space.
Must remain within the visceral component o the extraperitoneal space, this will protect those structures.
- i.e., keeps you away from the lateral cutaneous, femoral and femoral branches of genitofemoral nerve.
- and iliac vessels must remain within the visceral component of the extraperitoneal space.
- and do not denude the psoas lateral to the cord; keep these membranes intact as much as possibe.

5. Place mesh
- 15cm2 lightweight polypropylene mesh trimmed to size and rolled tightly, introduced through Hasson.
- over the hernia defect and the direct, indirect, and femoral spaces
- fix superiorly and laterally but not in triangle of doom and triangle of pain

Mesh placed in space of Retzius; should extend from midline to ASIS minus 1cm (2cm if very fat)
Should be diamond shaped, with tail extending out into space of Bogros, lateral to medial umbilical ligaments.
Mesh should li ein the visceral plane of extraperitoneal fascia.
- allows parietal nerves (genital and femoral branches of gfem nerves and parietal vessels to be safe
Medial to umbilical ligaments, mesh should lie more anteriorly in the parietal plane of extraperitoneal fascia.
- avoids it sitting on the prevesical space, directly over bladder.
Do not slit the mesh; associated with recurrence.
Mesh should be slightly redundant because: it shrinks; reduces pain, reduces recurrence.
Note that the mesh reinforces the visceral peritoneum or sac and not the abdominal wall itself.
- no need to tack it in place, this increases the risk of pain.
- though some may find it helpful in their early experience to tack onto the pectineal ligament medially
If bilateral repair, use two pieces and overlap them in the middle.

6. Remove trocar sheaths and desufflation under direct vision to keeps mesh in place.
- local in wounds.