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TEP repair that follows the anatomy of the inguinal fascia: A method for reaching the preperitoneal cavity through sharp incision of the posterior rectus sheath

Fujio Ito, PhD, Takao Tsuchiya, PhD, Satoshi Otani, PhD, Takahiro Saito, PhD, Hajime Matsuida, MD, Junichi Miura, PhD. Iwase General Hospital

Introduction: Totally extraperitoneal (TEP) repair that does not require peritoneal incisions is a good procedure that involves minimal visceral damage. However, balloon- or camera-assisted blunt dissections that are performed in a haphazard manner do not follow precise dissection of the fascia layer. Furthermore, they have a disadvantage in that they are difficult to understand anatomically. We therefore developed a novel preperitoneal approach to resolve this issue.

Methods: A 12-mm trocar is inserted into the rectus abdominis sheath cavity after a small incision is made below the umbilicus and the posterior rectus sheath is exposed. A 5-mm trocar is inserted 5 cm towards the pubic bone from the umbilicus. Using forceps from this position, narrow branches that enter the posterior rectus sheath from the inferior epigastric vessels are dissected, thereby broadly exposing the anterior surface of the posterior rectus sheath. The third 5mm-trocar is inserted near the lateral margin of the rectus abdominis.On the outside, local anesthetic is injected beneath the posterior rectus sheath and the preperitoneal cavity is separated in fluid so that the peritoneum is not injured during posterior rectus sheath incision. A small incision is made to the posterior rectus sheath or attenuated posterior rectus sheath at one finger width higher than the expected upper margin of the prosthetic mesh. Due to the effects of local injection, a sharp incision to the fascia can be made with an electric scalpel. Utilizing this mechanism, the posterior rectus sheath aponeurosis and the lining transverse fascia and superficial preperitoneal layer are individually identified. Once the preperitoneal cavity is reached, the peritoneal margin is determined in the lateral direction, and the peritoneum that is pulled due to pneumoperitoneum is separated from the preperitoneal fascia on the outside from the cranial side towards the deep inguinal ring. On the inside, the pneumoperitoneum pressure pushes the peritoneum inferiorly, leading to enlargement and increased visibility of the posterior rectus sheath deep fascia, which is dissected one layer at a time from the outside. The umbilical prevesical fascia is dropped inferiorly, and the dissection of the preperitoneal cavity necessary for mesh deployment is performed.

Results: By individually dissecting each fascia using emphysema through pneumoperitoneum and enlargement through local injection, the method for reaching the preperitoneal cavity could be successfully completed by following the dissection of the fascia layer without proceeding with the operation blindly, thereby resulting in the elimination of intraoperative bleeding and postoperative hematoma.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 87462

Program Number: P036

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

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