Laparoscopic Totally Extraperitoneal (TEP) Hernioplasty For A Giant Inguinoscrotal Hernia

A 69-year-old male patient with a history of hypertension, morbid obesity and ischemic heart disease.  He presented with a giant inguinoscrotal hernia. Surgical repair was proposed.

A CT-Scan  was performed in which the left inguinoscrotal hernia was found, containing the urinary bladder and the left ureteral meatus, causing an ipsilateral ureterohydronephrosis due to compression of the meatus at the level of the inguinal canal.

A total of 3 trocars were used. A 12mm trocar was placed in a supraumbilical position for a 30° scope, and the other two served as working channels for the leading surgeon, the 12 mm trocar in an infraumbilical position and the 5 mm one in the hypogastrium.

A 30º optical laparoscope was introduced through the umbilical incision for visualization and preperitoneal dissection, identifying the epigastric vessels. Insufflation pressure must stay below 12 mmHg. It is important not to grasp the peritoneal fold itself, to prevent tearing, and not to dissect with diathermy too closely onto the psoas muscle laterally, as this may cause nerve damage. Therefore, blunt dissection is performed mainly in the preperitoneal space until the hernial orifice is identified.

Once the hernial orifice is identified, its content is reduced. The reduction of the hernial content must be very carefully performed to avoid inadvertent injuries. We can see how with blunt dissection the bladder is gradually reduced, releasing the lax adhesions without difficulty.

Traction and contraction movements are important to maintain tension in the hernial content and to reduce it by means of careful maneuvers.  When dissecting out a hernia sac, adequate hemostasis while retracting must be ensured to avoid small bleeders. This might also prevent seromas and hematomas.

Finally the hernia dissection and reduction of spermatic cord structures are completed, in addition to the reduction of the hernia sac and its reflections. Attention must be paid to the “triangle of doom” delimited by the vas deferens (medially), the spermatic vessels (laterally), the internal inguinal ring (apex) and the peritoneum (base).

During peritoneal retraction, it is important to avoid grasping the ductus deferens as this may cause fertility problems, as well as overzealous dissection of the cord structures and genital branch of the genitofemoral nerve, as this probably contributes to postoperative neuralgia.

Finally, a ProGrip ™  Self-Fixating Mesh is introduced to cover the hernia sites: inguinal, femoral and obturator. The mesh is  Self-Fixating in order to avoid nerve injury. The mesh is screwed in and extended by means of two forceps covering the entire hernia defect. The hernia sac is placed behind the mesh. Then, an inspection for hemostasis in the extraperitoneal space, deflation and closure of skin incisions is performed. It is also important to remember that drainage is not necessary.

Outcomes

The surgery took 70 minutes. The patient started oral intake 5 hours after the surgery and left hospital on the 1st postoperative day. The patient remains asymptomatic 6 months after the revision.