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VID1-01360-EN | B | Laparoscopic Inguinal Hernia

Guy Voeller

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Laparoscopic Inguinal Hernia

So now to be able to fix this, we're going to put some instruments in that allow us to repair the hernia. You get stuck in that hole. Here's a example. The hole in this tissue mainly fat. Sometimes it's intestines. Sometimes it can be other organs can be bladder. In this area it's up in the hernia. This hole you're seeing start to develop is the actual hernia. And it's just a hole in the muscle, not from heavy lifting or straining or coughing. It's due to genetics and a weakness. I need the trocar or the cutter on the other one. So what we want to do is uncover the hernia, identify the hole and the boundaries of the hole or the hernia so we then can cover the whole up with a piece of mesh so intestine and other organs don't come down, because this thing that we just pulled out goes out on the groin and the patient feels the bulge. Right out there is the patient's pubic area. And he was feeling that bulge of tissue. There are a lot of vital structures in this area. These purple things are blood vessels. The blood vessels to the leg are in this area. I'll show you those in a minute. And the blood supply to the testicle is in this area. So I have to dissect all of those areas out so I can safely place the mesh and not injure any of those structures, which would cause some significant problems for the patient. So what we're going to be doing now is just delineating those structures so we can make sure we don't hurt them and place the mesh. As I mentioned, we have to develop a space To place a piece of mesh, which is just a material to cover up that hole and to develop that space, we have to avoid. Bring your hand toward yourself. We have to avoid damaging some very vital structures down here. And so that's what we're doing now, is trying to delineate those structures. This is the spermatic cord right here, which is the blood supply to the testicle. There's a little white tube over here to the side, which is the vast deferens which carries the sperm. That's right there. And these things are the blood vessels to the testicle. So we have to get all this dissected so we can place that piece of mesh and not damage those structures. So there's a layer of tissue. There's a line right here and that's called the peritoneum. And that is actually the sac that holds your intestines. And if I were to cut into that and look inside, we would see intestines. The color is on the wrong one. So what we have to do is push that back. So our mesh will lay nice and flat again. These are important structures to the testicle, and I don't want to hurt those. I don't want to damage them. But I have to get this layer, what we call peritoneum off of those structures without hurting those structures. So what we've done is we've dissected this entire area. This is the hernia. And again, if you drive down into there, you're right on top of his pubic bone. And there's a big bulge when the intestines and things go through that hole. This is the hernia. The pubic bone is right here. Going to dissect a little more off of the pubic bone here in a minute. The bladder is right there. You can see the bladder right there as we come over. The spermatic cord which goes to the testicle is here. And the testicle is going down through this hole, down into the scrotum. The testicle starts up here in the abdomen and migrates down into the scrotum through the hole here called the internal ring. These nerves are very important nerves. You can see these white structures are nerves that go to legs and other parts of the body. And we don't want to hurt those. So we have nerves. We have blood supply to the testicle. And below here you'll see some beading of blood vessels. There's a vein right there, a very large vein and an artery that supplies blood to the to the leg. There's the nerve that controls the leg. So if I injure any of those structures, the patient will not be able to move their leg. They can lose their leg. They can die. All sorts of things. There's many, many important structures here that you have to see well in order to not hurt the patient and repair the hernia. Well, okay. There's no hernia there. People say, oh, that's not a hernia. It's not. It will be a hernia if I take the piece of fat out. Okay. And there's the hole right there okay. So now I've got to cover that okay. And there's the obturator foramen right there which you can get an obturator hernia through. So now we've done all the dissection to place the mesh, the pubic bone, the hernia, the blood supply to the testicle that we don't want to hurt, the nerves that go down to the leg and body. This muscle back here is called the psoas muscle. You can see it right there. When you eat a piece of fillet, that's the muscle you're eating. And now we're going to place the mesh. So we've placed that material I mentioned the mesh to cover up the hole. We've placed it through one of the trocars, the cannulas that we've been working with, with our instruments. So now we've placed the mesh inside, and now I have to position it. So it covers all of these areas. There's 3 or 4 potential spaces for hernia. Here's one space called the direct space. The other space over here is called the indirect space, where the testicle goes through a femoral space right here. Those are the three most common areas. We want to cover all three areas with this piece of mesh. So now we get the mesh position properly. And we spent all that time with dissecting this area so that when we're ready to place our mesh, it lays over this entire area nicely, lays nice and flat and covers all the important areas that we just talked about. This mesh is made out of polyester. It's very soft and conforms to all the nice contours of this space, what we call the preperitoneal space. And what we really want to pay attention to is that hole that we had. There it is. There's our hernia hole. And we want to make sure our mesh goes way past that whole in all directions. So we now you can think of the mesh as a taco shell. And when we place it here, the intestines which are in this sac I was talking about earlier, will come up and actually hold the mesh in place. And they can't go through the hernia hole, which you can see right here, which is now covered by this mesh. Have the mesh in place. This is a type of hemostatic agent. It helps with bleeding in surgery. But another thing it does is it acts like an adhesive. So it goes away in about six days. It's broken down by your body, but it helps hold the mesh in place. It's called fibrin glue. It's not specifically developed for this. It was for blood bleeding issues during surgery. But we found that it works quite nicely in Fix the mesh in place. And that's what we're doing now, is we're gluing the mesh. Hold right here with the fiber and glue. So now we've placed the mesh which will remain. This will be part of the patient. And the patient's scar tissue will grow into these holes. And it will reinforce the area especially where the hole is now will be covered up. And we have the mesh around the area. So now here's the hernia hole. When we push you can see nothing will go through the mesh. So now what we're going to do is we're going to let the collection of air out, the gas out. And you can see the intestinal contents come up on the mesh. The taco is being filled by the intestines, which is the filling of the taco. And now they can't go through the hole anymore.

Laparoscopic Inguinal Hernia

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