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There are over 1 million hernia repairs performed annually in the US. Robotics is revolutionizing the adoption of minimally-invasive hernia repairs lately. For 20 years, in spite of the literature supporting the benefit of laparoscopic minimally-invasive repairs, only 25–30% of all hernias were performed laparoscopically. From 2015 to 2018, robotic laparoscopic hernia repairs have explosively grown from less than 2% to 20% of all hernia repairs performed in the US. Hernia repairs are among the most basic procedures for general surgeons, and there is substantial enthusiasm on the part of surgeons regarding the rapid changes in techniques as well as the best methods of teaching them. Surgical training programs may find it difficult to maintain training for their residents and fellows in the face of rapidly evolving technology. Therefore, we present the case of a 28-year-old male with bilateral inguinal hernias that were repaired using a robotic-assisted laparoscopic approach.
Inguinal hernias are among the most common surgical problems. Approximately 20 million hernia repairs are performed every year worldwide. Surgical repair of inguinal hernias is one of the oldest procedures in the history of medicine; it is not surprising, therefore, that herniorrhaphy has evolved substantially, particularly over the last 40 years.
The goals of hernia repair are prevention of incarceration with strangulation, reduction of acute and chronic pain, and rapid return to normal activity. The introduction of laparoscopic herniorrhaphy in the 1990s, as part of the general movement toward minimally-invasive surgery, provided several advantages for the treatment of inguinal hernias. These include smaller wounds, with subsequent lower incidence of wound infections and better cosmetic results. Patients in general complain less of postoperative discomfort and they enjoy more rapid recovery. An additional advantage of laparoscopy for this condition is the ability to treat several hernias during one approach.1
The introduction of robotic-assisted laparoscopic surgery added further advantages of three-dimensional vision and added degrees of freedom in terms of range of motion.2 Despite the many advantages of the robotic-assisted laparoscopic hernia repair, use of the technique is limited by lack of availability of equipment and a shortage of teaching materials for attending surgeons and surgeons-in-training. Therefore, we present the following case of a robotic-assisted laparoscopic bilateral hernia repair.
The patient is a 28-year-old male with bilateral inguinal hernias. The left-side hernia was somewhat larger than than that of the right, although both were relatively small. We elected to perform a robotic-assisted repair using the da Vinci device with 3 trocars placed straight across in a line. The first port was placed about 4 or 5 cm superior to the umbilicus in the midline.
Patients with inguinal hernias most commonly complain of a bulge in the groin, which may or may not be associated with pain. The focused physical exam consists of palpation of the inguinal canal with the patient standing. In a male patient, the examiner uses their gloved index finger to palpate the area of the external ring via the redundant skin from the scrotum. If an inguinal hernia is present the examiner will feel a bulge with the tip of their finger. The patient may be asked to perform a Valsalva maneuver. A second exam may be performed with the patient supine to determine reducibility.
Preoperative imaging is not required in the setting of a typical history and physical exam, and is reserved for complex and/or non-reducible cases.
Traditionally, it has been difficult to determine the true natural history of inguinal hernias because of the difficulty in identifying a sufficiently large cohort of patients who have elected not to have their hernias repaired. The general consensus is that inguinal hernias should be repaired to prevent intestinal strangulation.
Two randomized controlled trials in recent years have shed some light on the natural history of inguinal hernias.3,4 In both studies, men with asymptomatic hernias were randomized to either watchful waiting or surgical repair. Both trials found that the rate of incarceration in the watchful waiting group was low (2.4–2.5%). Nevertheless, both trials demonstrated that men who present to their physician with complaints of a lower abdominal bulge are highly likely to present for surgery within a few years of the initial visit.
In females, the current recommendation is that all groin hernias should be repaired, as the incidence of femoral hernias is higher, and the risk of groin incarceration/strangulation is much higher than in men.5
For patients with primary unilateral inguinal hernias, the surgical options are open, whether anterior and/or posterior approaches, or endoscopic. The anterior Lichtenstein procedure is considered the gold standard for open approaches in the US. For endoscopic approaches, the particular type of procedure chosen (transabdominal preperitoneal or total extraperitoneal) is left to the discretion of the surgeon. Currently available data do not indicate superiority of open vs. laparoscopic herniorrhaphies in terms of outcomes.6
The primary rationale for repair of inguinal hernias is to prevent or treat intestinal strangulation. The secondary rational is to relieve pain associated with the hernia.
Absolute contraindications to robotic inguinal hernia repair include contamination of the abdominal cavity, inability of the patient to tolerate pneumoperitoneum or general anesthesia, and uncontrolled coagulopathy.
This was a robotic-assisted laparoscopic repair of bilateral inguinal hernias in a previously healthy 28-year-old male. A notable feature of the case was the not uncommon finding of lipomas of the cord (actually preperitoneal fat) intimately associated with the cord structures. These lipomas can often balloon up into the defect and become significant. We were easily able to remove the lipoma without risk of injuring the vas or gonadal vessels. On the left, the moderately-sized indirect inguinal hernia sac was tightly adherent and tenacious. The robotic-assisted laparoscopic technique permitted relatively straightforward dissection. Technical steps of the procedure are reviewed in the video in detail with particular attention to achieving the standardized critical view of the myopectineal orifice dissection and mesh placement as codified by Daes and Felix.7
Inguinal hernia repairs have been reported since antiquity. Nevertheless, the procedure remained largely unchanged, even with the introduction of asepsis and anesthesia, until the late 20th century. For treatment of bilateral inguinal hernias, as in our patient, endoscopic approaches have proven to be as effective as traditional open approaches, with equivalent recurrence rates, better cost-effectiveness, and shorter operative times.8
Robotic-assisted laparoscopic surgery represents the latest technical advancement for the treatment of an ancient surgical problem. Widespread dissemination of robotic equipment combined with a better understanding of the anatomy afforded by enhanced three-dimensional visualization, along with the creation of innovative variations on the operation will likely improve outcomes in the near future.
- The da Vinci Xi system
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Elgeidie A, editor. Updated Topics in Minimally Invasive Abdominal Surgery. BoD–Books on Demand; 2011 Nov 14. doi: 10.5772/18278.
- Shraga S, Chang E, Radvinsky D, and Sugiyama G. Robotic Inguinal Hernia Repair. Hernia. Avid Science, 2019.
- Fitzgibbons RJ, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA. 2006;295(3):285-92. doi:10.1001/jama.295.3.285.
- Chung L, Norrie J, O'Dwyer PJ. Long‐term follow‐up of patients with a painless inguinal hernia from a randomized clinical trial. Br J Surg. 2011;98(4):596-9. doi:10.1002/bjs.7355.
- Ramanan B, Maloley BJ, Fitzgibbons RJ. Inguinal hernia: follow or repair? Adv Surg. 2014;48:1-11. doi:10.1016/j.yasu.2014.05.017.
- Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 2014;18:151. doi:10.1007/s10029-014-1236-6.
- Daes J, Felix E. Critical view of the myopectineal orifice. Ann Surg. 2017:;266(1):e1-2. doi:10.1097/SLA.0000000000002104.
- Escobar Dominguez JE, Gonzalez A, Donkor C. Robotic inguinal hernia repair. J Surg Oncol. 2015;112(3):310-4. doi:10.1002/jso.23905.
Table of Contents
- 1. Introduction
- 2. Surgical Approach and Port Placement
- 3. Mesh Preparation
- 4. Dock Robot
- 5. Dissection
- 6. Right Hernia Sac Dissection
- 7. Posterosuperior Peritoneal Dissection
- 8. Lipoma of the Cord Dissction
- 9. Left Preperitoneal Flap Dissection
- 10. Left Hernia Sac Dissection
- 11. Obtain and Verify Critical View of the Myopectineal Orifice
- 12. Mesh Placement
- 13. Closure
- 14. Post-op Remarks
- Insert 8-mm Optical Trocar
- Insufflate the Abdomen
- Inject Marcaine for Ilioinguinal Nerve Block
- Insert 8-mm Lateral Trocars
- Inspect Anatomy
- Dissect Peritoneal Flap Inferomedially
- Expose the Midline Pubic Symphysis
- Dissect Preperitoneal Flap Inferolaterally
- Develop a Groove Medial to the Iliac Vein
- Separate Peritoneal Sac from Cord Structures
- Parietalize Vas and Spermatic Vessels
- Nerve Identification
I'm Dr. David Lourié from Pasadena, California. Today we're going to showcase a young 28-year-old male with bilateral inguinal hernias. The issues that we'll highlight today are concentrating on the display of the myopectineal orifice and all of the critical structures, so we'll show you those during the procedure.
The steps of displaying the critical view of the myopectineal orifice are beginning by taking down the peritoneal flap. It's going to be important to identify the inferior epigastric vessels and the symphysis pubis. We want to dissect across the contralateral side of the symphysis pubis and display at least a few centimeters, even in an unilateral hernia. It's important to dissect inferior to Cooper's ligament by 2 to 3 cm. We need to display all the potential hernia defects, and we'll discuss those during the case. And look for any potential lipomas of the cord - make sure we have the peritoneum well dissected back enough to make room for wide mesh overlap well beyond the myopectineal area, and we use a large mesh that we will show you during the case. After this we'll reperitonealize and finish the surgery.
This is going to be a step-by-step, very detailed and in-depth teaching video. I'm going to go much, much more slowly than usual so that I can illustrate the finer points of the anatomy and dissection. So bear with me as we highlight the critical view of the myopectineal orifice from a robotic perspective.
Okay, so this is a young 28-year-old male with bilateral inguinal hernias. His left is a little bit greater than his right. They're both quite small. We're going to put our trocar placement for the XI Da Vinci inguinal hernia repair straight across in a line. We'll use 3 ports. First port will be about 4 or 5 cm superior to the umbilicus in the midline. We're using 0.25% marcaine with epinephrine, for local, long-acting anesthetic. He has had multi-modality preoperative medications, including oral Gabapentin, oral Tramadol, and Celecoxib before he even started the surgery, he's had the usual multi-modality intravenous adjuncts from anesthesia: Decadron, Zofran, Reglan, Pepcid. He's getting intravenous acetaminophen and likely will get ketorolac at the end of the procedure. The majority of these patients will not need any narcotics postoperatively.
So we're going to go in with an optical technique. We're going to be going through each layer. Here you can see through the sub-Q. That is the anterior rectus sheath. You can see that we are in the midline linea alba, and here we are already with the tips going through linea alba. That actually is probably just off midline in the posterior sheath. Here we go. That is intraperitoneal. You can see the white of the parietal peritoneum. And I have changed the angle of my insertion of the trocar to be very tangential, parallel to the anterior abdominal wall, to lessen the chance of any injury. Let's go ahead and change out the scope for the angled scope. And insufflation on with a pressure of 10, please - low-flow to start with.
One of the things you want to have your team do robotically is always swab out the cannula before you put any scope in every single time. That way you can avoid fogging issues because - even a little bit of condensation within the cannula is going to fog your scope. If you have them do that religiously, generally don't have issues with fogging.
So here we can see the bladder in white - can see the hernia defects. This looks like a direct defect. Medial umbilical ligaments - a little bit of the median umbilical ligament in the midline. Here's the other medial umbilical ligament. You can see the epigastric vessels, and you'll see his hernia on the contralateral side. We'll go ahead and put in an ilioinguinal nerve block now until we get our better insufflation. So we'll use the marcaine.
So on the inguinal patients - I'm going to need a full one - go ahead and look right here. I'm going to palpate at the anterior superior iliac spine. You can see the relationship to the hernia defect. I'm going to go about 2 cm medial to that, and I'm going to put this in in the plane between the internal oblique and the transversus abdominis in an ideal situation. So let's go ahead and fill that up and do the other side. Yeah. So we're going to have to watch out for the adhesed bowel right there. There's a little bit of small bowel adhesed close to that area. You can see where I'm pushing in is just medial to the anterior superior iliac spine. And there we go. That's what you want to see. You want to see just a wide diffusion of the local anesthetic. That's great. Okay, fill it up again, and we'll go ahead and put our trocars in.
So we’re going to go in a horizontal line. In this case, we’ve got plenty of room, so we're going to go what amounts to roughly 12 cm away. You want to be a minimum of 8 cm away, but you really don't need to be that close in an inguinal hernia repair. The patient is positioned in supine position with the arms tucked. Knife.
We are - in the Da Vinci XI system. We're using three trocars, all of which are non-bladed 8-mm metal robotic trocars. These trocars have a remote center around which they are fixed in three-dimensional space once they're hooked up to the robotic machine. You can see that thick black band there. That needs to be up in the abdominal wall, and in fact in hernia repairs, we tend to put this right at the second narrowband, so we don't have too much trocar sticking in the abdomen - so that we're too close to our target. I'll take marcaine.
Okay. Dr. Ybarra’s going to do the same thing. So you see I'm a little inferior to the midline. We'll keep this symmetrical. I would say about there. You can see the fibers transversely of the transversus abdominis muscle there. So we picked 12° Trendelenburg because we want to just a little Trendelenburg to get some of the bowel out of the way of the hernia areas. More than 12°, the legs of the patient tend to begin to get in the way of the robotic arms. We can actually see what degrees of tilt in any direction directly on the the remote control for the table.
Just take a quick peek around here - you see a normal liver, as well on that side, the patient's stomach. You can see the heart beating through the diaphragm through the pericardium. Okay, so at this point, we're going to leave that adhesion. We are going to be putting in our mesh, and - first we're going to go over folding of the mesh.
So I'm going to bring this right here. Just tuck this - yeah, hold that. The mesh we're using today is ProGrip mesh. It is a polyester mesh backbone that is permanent. It has 2 coatings on each side. One of them is like little adhesive nubbins much like velcro. The other side is this shiny coating that is there for stiffness and handling. It is not an intestinal barrier, and you cannot put this into the peritoneal cavity.
So to fold the mesh, we're going to turn it lengthwise. We're going to keep all of the velcro nubbins exterior. We're going to make a crease in the center. This is merely a marking crease that shows us the center, and then we're going to take each limb and fold that to the center. And then we're going to take the whole piece of mesh and fold it once again in the center. That gives us a ridge on one side and two limbs on the other side. We're going to mark the ridge side right in the center. So to find the center we can just temporarily fold this horizontally. Here's our center, and I'm going to mark this on each side of the ridge - the single ridge, with an indelible marker. You'll notice that when I unfold the mesh, that mark is in the very center of the mesh. So let's take some scissors now. I'm just going to round off the corners of the mesh.
And after this, you'll notice that we have kept this mesh dry. That's very important. If you wet the mesh, it becomes very difficult to handle and to mark on. Once we have finished preparing our mesh, then we actually are purposely going to soak it, and I find that the more you soak it, the wetter it is, the better it is - the easier it is to handle on the inside. So we're going to soak this piece of mesh and prepare the other one, and then we'll put them both inside.
So I like to place my mesh and my sutures inside the peritoneal cavity at the very beginning of the case before I even dock the robot. Many surgeons will put their mesh in as they find they need it during the middle of the case. This works very well, but the problem for me is that it interrupts the flow of my case. With an efficient team, it doesn't take very long, but if you think about it, you have to take out one of the robotic arms, you have to bring in the mesh with a laparoscopic grasper, release it, reinsert the robotic arm, and all of that just takes a little time and breaks the flow of the case. So in these inguinal hernias, where I know what size mesh I'm going to use, we can put everything in in the beginning of the case. This ProGrip mesh, which is 16 by 12 cm, will fit down an 8-mm trocar if you narrow it by giving it one more temporary vertical crease so that it can get down the trocar.
Okay, let's look up toward the spleen, way up high, and look down here. You can see the edge of the liver there. And we're going to put that up against the abdominal wall slightly, and that'll stay there until we're ready for it later in the case. We'll place our second piece of mesh. This case is a bilateral inguinal hernias as we've seen. Okay, now let's have our suture. No, no problem. Okay, look over here. So what we're going to do is take the needle and put it in the gutter, so we have an adhesion there. We're going to jump ahead of that piece of bowel and put it right down in the gutter there, so it doesn't go anywhere. If you put the sutures in the middle of the peritoneal cavity on the bowel, the bowel can peristalse, and you can lose sutures. Same thing. We're going to take these needles - there's the sigmoid colon - and we're just going to set them adjacent to the sigmoid right there. Okay. All right. Okay, let me just have a grasper, and we'll see - this patient has bit of a redundant sigmoid. Shouldn't be a problem, but you can see how much is laying down there. This is sigmoid colon, down toward the rectum. We're just going to let that stay in there. It's going to go right back. Okay.
All right, we are ready to dock the robot. So the first step will be to - light source off on the camera. Second step will be to turn the robotic source on the side cabinet to all the monitors. We're using a smoke evacuation system here. Great. You can drive straight in. We're taking advantage of the Da Vinci XI system, and its laser targeting system. You'll see the crosshairs in a moment. You can go ahead and drive straight in. So we're going to be using just 3 of the 4 arms. In hernia repairs - and that goes for inguinal or ventral repairs - we use just 3 arms.
Going to wrap the cable around here for a little cord management. We're going to stabilize the trocar and target with the scope. You can see that the machine is aligning itself into the optimum configuration. This system is very nice because we just click right into the ports, and it's fairly quick and straightforward.
Long bipolar grasper on the left for me - and scissors in the right at number 3. Okay, we're going to watch the scissors come in to the center. Okay, that's great. Let's bump this up a little bit, so there's not pressure on the skin. That looks very good. No pressure on the skin - we're ready to move to the console. Excellent.
Okay so, the first step when we're doing a transabdominal preperitoneal approach is to survey the anatomy. We've already noticed that there is adhesion of the terminal ileum up to the pelvic sidewall. We're actually going to leave that alone and carefully take that down with the peritoneal flap. You can notice through the translucent peritoneum the gonadal vessels, the spermatic vessels. The vas deferens is rounding the corner right here. There's the vas deferens. Notice that it arches over and comes over the medial umbilical ligament. Dr. Ybarra, do you see that?
I see that.
So we'll point that out on the inside and look at that relationship on the inside. And then we’ve got a bit of a wide-based defect here. The medial umbilical ligaments will form the medial border of our peritoneal incision to get in the preperitoneal space. We have one on each side. Again, we have the epigastric vessels, a larger hernia defect as we knew, but both small. This is the left-sided defect. Again, we see the same structures. Here we see the iliac artery pulsating right here. The vein is going to be under it here, and the vas deferens - there's a bit of a fold adjacent to the bladder - is going to be arching right over here. You can see the vas deferens moving under my instrument tips. There is the bladder. You can see that this bladder in this patient arches all the way up here. It looks more white in color, and you can see the differentiation. We will now being the peritoneal flap dissection. Here is the medial umbilical ligament. We will start the peritoneal incision approximately 8 cm superior to the middle of the inguinal hernia defect.
We'll tent the peritoneum down away from the abdominal wall so we don't injure this and begin the incision with light cautery. If you start high enough, you'll see the posterior sheath where it ends right here at the semicircular line of Douglas, or the so-called arcuate line, here.
So let’s pause a while as we talk about the layers of the abdominal wall as we take down the peritoneal flap. So, in this example clip, I have just divided the medial umbilical ligament in taking down the peritoneum. Right away we're going to come up against a second fascial layer, so I'm making an opening or a hole in this layer on purpose. Here's the peritoneum, here is the intermediate fascia, and anterior to this, you see the epigastric vessels right up against the anterior abdominal wall. So there’s actually a third fascia, which we’re all very familiar with - the transversalis fascia, which would be just anterior to the epigastric vessels, right up against the abdominal wall itself. Many people feel that the transversalis fascia is actually bilaminate, and so they call this intermediate layer the posterior layer of the transversalis fascia. Others feel this is a completely separate layer called the extraperitoneal fascia. Either way the really important thing is to understand which side of that fascia you're on during your dissection.
Anterior to this fascia is the so-called parietal compartment, where the epigastric vessels are. Posterior to the intermediate fascia between that and the peritoneum, is the so-called true preperitoneal space, or sometimes it's called the visceral compartment. You'll see later in today's case, that we will put our mesh, medially, directly against the muscle in the parietal compartment, but laterally, it's the opposite - as we get far lateral, we're going to put the mesh directly against the peritoneum in the visceral compartment.
So the first step, as I get to this landmark, is to actually physically divide - with cautery - divide that medial umbilical ligament. You can see the round cut edge right here. In the space medial to both umbilical ligaments at the midline, we have to get into what is called the the prevesical space anterior to the bladder.
To do this, we have to actually cut through the intermediate fascial layer to get into the proper parietal plane just under the rectus muscles. You can start to see the rectus muscle fibers right here, so we know we're in the proper plane. Now, we'll look for the epigastric vessels, and because we're still in the parietal plane against the muscle, we actually have the exposed vessels. If we were actually in the true preperitoneal plane, this intermediate fascial layer would still be covering the vessels, and we would not be able to see them quite as well.
So there are the epigastric vessels. I'm going to turn up the intensity of the light here. And you can see those vessels quite nicely there. That's our first landmark in the preperitoneal space.
The second landmark in the preperitoneal space is going to be the midline pubic symphysis, and that is going to be much deeper. We've got quite a ways to go before we get to that. You can see the excellent visualization that's afforded by this robotic visualization on the video recording. This is generally a two-dimensional picture. On the robot of console, we have three-dimensional vision, and we can see quite a bit better. You can see that this visualization is far superior to anything that we would be able to get to see either laparoscopically or with our own human eyes, if we were doing an open repair.
You'll also notice that I'm going to the contralateral side with my dissection, and that is not only because this is bilateral and I'm going to have to be there anyway, but it's also easier because of the direction of my scissors, given that I'm right-handed, is pointing in this direction - and it makes it nice and straightforward. If I had to dissect with my right hand to the left, I would be arched over and angulated like this and dissecting this plane. That's quite doable, but this is more straightforward. So bottom line is we do a lot of contralateral dissection in a bilateral. Even in a unilateral, I will dissect several centimeters across to the contralateral side because I want to overlap Cooper's ligament. That is one of the principles of adequate mesh placement in the critical view of the myopectineal orifice.
So here you can see the two rectus bundles - one from each side.
Smoke evacuation is turned on at the field appropriately, guys? Tubings are all on and everything looks good? Great.
So here you can see Cooper's ligament from the contralateral side, the white shiny stuff. Right in the midline there is the pubic symphysis. We're going to ultimately dissect a few centimeters inferior to Cooper’s. You can also see that by having cautery on our scissors, we have a nice dry field, and we don't have to have red blood absorbing the light. You can see some of the branches of these vessels going either superiorly or inferiorly over the pubic ramus. These are ultimately branches from the epigastric vessels. This is the second landmark exposing the pubic symphysis.
Now we're going to go back and do a little bit more lateral dissection. So when we go laterally, it's important to now stay directly against the peritoneum in the visceral compartment, keeping both the transversalis as well as the intermediate fascia up against the abdominal wall. We are re-establishing ourselves in the true preperitoneal plane, right here up against this thin peritoneum whereas medially, we actually want to be, as you've seen, in the parietal compartment anterior to the bladder, right up next to the muscle.
Okay at this point, we are going to be following the lateral aspect of this funnel of the peritoneal sac that goes into the hernia defect. You can see how thin that peritoneal sac is, and you see that all passing just to lateral side of the epigastric vessels. I'm going to actually now flip the lens and look 30° down, and there you see Cooper's ligament. Here you see the cord bundle.
We're going to establish a groove just medial to the iliac vein. So you begin to see the blue iliac vein there. So you see this crossing vein here that crosses the pubis between the external or epigastric system and the obturator system. This is a portion of what's known as the corona mortis and everyone has a vein in this location - sometimes it can be quite large - and a much smaller percentage of people have a dominant artery that takes over as the main blood supply that then goes through the obturator canal. This is the bladder. Here you see nicely the iliac vein. Here is the iliac artery, and do you see this structure running alongside the iliac artery. Dr. Ybarra, do you see that?
That is the - do you know what that is? Can you tell me what that is? It's the genital branch of the genitofemoral nerve, and that's going to run along with the vessels and then come up - up into and through the internal ring to pass with the cord structures in the inguinal canal.
At this point, we're gently dissecting some of the cord structures. So that will be the vas deferens medially, and the spermatic vessels laterally, and here you can see, this is where this fine, thin hernia sac ends in him - not very big. There is the vas right here near my scissor tips. Here is a band of fascia that runs behind the vas that we need to cut. Peritoneum is back here. Here you can see the gonadal vessels or spermatic vessels. So if I retract this quite high in the air and medially, that provides the proper traction and counter-traction angles, and we will gently make little cautery and sweeps to bring the peritoneum down off the vas so that we have plenty of room for mesh placement. So I like to dissect the tissue back in this area, medial to the vas, until I can usually see the vas crossing the iliac vein.
As we get in this area, we often will encounter the inside of the medial umbilical ligament, and this is a structure that, after thousands and thousands of laparoscopic inguinal hernia repairs, I was never aware of from the inside. And you see right here - remember where we saw from the peritoneal surface that there was a ligament that crossed around the ureter - the - sorry, the vas - crossed - this is not the ureter. This is the inside of the medial umbilical ligament. If I tug on that in some patients, you'll get the sensation of where that comes up right up here, and that again was our now cut medial umbilical ligament. That's an example of something you may not used to - be used to seeing laparoscopically, but it's there in almost every patient. So we have plenty of room for mesh.
So the way we're going to determine how far down to dissect so that we have room for the inferior border of our mesh is we're going to look at Cooper's ligament, we're going to drop down 2–3 cm inferior to Cooper's ligament and posterior to it, and then we're going to draw an imaginary line more or less parallel to Cooper's ligament, running 2 cm inferior to it and coming along here, and that's going to be the inferior border of our mesh. What that means is we have to dissect the peritoneal flap back far enough so that it does not interfere with that mesh. So it is much more cephalad, towards the patient's head, compared to that line that we've just drawn. So we're going to dissect this back a little farther. You can see again how thin his peritoneum is. And little by little, we're getting a nice dissection, rolling back the perineum away from those cord structures. What we really want to see is the vas lying laterally against the iliac vessels rather than being tented up with the peritoneum. That means that the mesh will not be tented up by the vas.
So we're getting right down to that white medial umbilical ligament. Here we see it again right here. It's just under this, and there we see it. You have to be a little careful because this is the obliterated umbilical artery, and as you get much more medial than this, it recanalizes, and it can bleed. This will connect to the hypogastric or internal iliac artery, and this will lead toward the superior and inferior vesicular arteries.
Okay. So that is enough. That's how we want to stop our dissection - when we've crossed the vessel and when we see this medial umbilical ligament. And now we need to do a little more lateral dissection, and then we'll take a look and see what we have accomplished.
Again it's this motion of gentle buzzing in short bursts and then pushing down with the back of the scissor bluntly, and you can see the spermatic vessels nicely there. And there's the peritoneum rolling back, and you see a little bit of this fine fascia. That is more fine, protective fascia. You can see this white line rolling back on itself. Like a fine - fine sheet or fine curtain - and this, in fact, what I'm grabbing now, is the backside of that adhesed terminal ileum that we saw. But we're leaving that with the peritoneal flap, and that's going to give us just about enough room for our mesh placement. So we'll get a little bit more here. Okay, very good.
Now let's take a look for some nerves. We've left this thin endopelvic fascia intact, but you can see as I move this layer, there's another set of striations here. That's the extension of the iliopsoas fascia, and the nerve - this happens to be the lateral femoral cutaneous nerve - runs underneath that. More medially, we would expect branches of the femoral branches of the genitofemoral, and I don't want to go digging around trying to find those. Here's the genital branch of the genitofemoral nerve. If I were to open this fatty layer, we'd see the femoral branches of the genitofemoral nerve.
The next point in dissection of the myopectineal orifice is this structure right here. So it's very important to go after these so-called lipomas of the cord, which are of course not lipomas, but they are merely preperitoneal fat - and they can actually balloon up into the defect and be significant. Notice that we have transversalis fascia that's forming a sling around all of the cord structures. You see that? All the way around there. That's called the deepest or secondary internal ring.
So let's go ahead and gently dissect out this lipoma. That's typically occurring on the lateral side of the cord structures there. You can see the cremasteric fibers. So the cremasteric fibers originate from generally mostly the internal oblique layer, and then they form a sheath as the cord passes through and becomes external to the abdominal wall. So here you can actually see where they arise from, and they're going to start wrapping around the cord as it gets more distal. There's the vas deferens. We're going to have a specimen at the end - at least one. It's going to be lipoma of the right cord. Yeah, we'll need an Endo Bag like we use to take the gallbladder out. So there we are with the lipoma removed. We'll flip the lens. You can see in through the - the internal ring there.
Now we'll begin the left flap, I'm just leaving a small bridge of peritoneum here to make closure easier at the end. You can cut this and make one big continuous flap if this center bridge gets in the way. Once again, we see the peritoneum funneling into the hernia defect, the indirect inguinal hernia defect on this side. You can see transversus abdominis fibers, and this stuff is the separate intermediate fascia so extraperitoneal or posterior transversalis fascia. You can see the epigastric artery with a couple of veins running on either side and occasional anastomoses between the two.
Here is the larger hernia sac, going well into the inguinal canal. You can see the cremasteric fibers again, arising from the internal oblique coming onto this. We're actually going to have to peel them off. You see these - how these muscle fibers are coming like this? Lots of cremasterics - it's a longer sac. Here's the vas. Vas deferens. And there are the spermatic vessels.
So I think this sac is turning right about here. There it is. The white is the hernia sac.
He's quite adherent, this guy.
There is the anastomotic branch between the external and obturator systems.
Here's where the vas begins to turn.
Cut the thin band.
Here is the medial umbilical ligament in white that we're getting very used to now today.
That was lipoma there.
There are the gonadal vessels there. You can see them quite nicely. Psoas muscle. Medial umbilical ligament. Femoral branch of the genitofemoral - lateral femoral cutaneous.
What is this little dude doing? I don't think that's anything. That is not a named nerve.
Let's go over some of the tenets of the full dissection of the myopectineal orifice. So I'm going to flip the scope and look 30° up, and let's just start naming them. So these were - have been promulgated by many people. The two pioneers I would say are Jorge Daes and Ed Felix, and they published an article - but there's been a lot of talk on the - before that on the International Hernia Collaborative of standardizing how we do these preperitoneal repairs, and this has led to the terminology of - again, the critical view of the myopectineal orifice just as we have a critical view of safety for gallbladder dissection.
All right, so, the tenets of the myopectineal orifice are: number one - you want to see the symphysis pubis, and even on a unilateral, at least 2 or 3 cm to the contralateral side of the midline exposed. In this case we have it fully exposed as it's bilateral. Secondly, you want to have 2–3 cm inferior to your Cooper's ligament. That's point number 2.
You want to have the direct space, which is in Hesselbach's triangle right here, medial to the epigastric vessels, fully exposed, to make sure you don't have a direct inguinal hernia. It's best to expose the medial border of the iliac vein and make sure there's not a lot of fat going into the femoral canal to rule out an occult femoral hernia. It's not uncommon to find occult hernias. This is the lacunar ligament between Cooper's ligament and what will be deep to this - or actually, superficial, anterior to this - the inguinal ligament. We see that the vas deferens has come medially.
We already discussed how we decided the inferior border of our dissection to allow enough space for the inferior border of the mesh. Notice these two structures are now splaying away from each other in a wide V-configuration. That's just what we want to see when we finish parietalizing the cord structures so they lie against the posterior abdominal wall and vessels in a flat configuration with no tenting. Also, ensure that there's no indirect sac that's sneaking up between the vas and vessels right here. You want to see the direct space - the indirect space right here. We've already looked at the femoral space. The obturator would be where this - this anastomotic branch is ending here, and it's going to dive down through the obturator canal right there.
Okay, once again, we'll review the critical points of the myopectineal orifice dissection. They'll be a little out of order, but we'll emphasize them one by one. Expose 2 cm across and contralateral to the pubic symphysis. Expose 2–3 cm deep to Cooper's, and create that groove medial to the iliac vein and vas for the inferior border of the mesh to tuck into. There's no tenting of the peritoneum over the lax cord structures splayed well apart from each other. Great views of the myopectineal orifice on each side - direct space, femoral space, obturator, indirect. We got the lipoma out proximally.
Take out the scissors from arm 3 and let's have the Mega Suture cut instead, please.
So we're going to put that spot that we previously marked right at the medial border of the internal ring where the inferior epigastric vessels overlap. That again will be the center of the mesh, and that will allow for good wide overlap over all the critical structures of the myopectineal orifice. We want to orient the mesh diagonally from medial being up and lateral being slightly downward toward the floor, parallel to Cooper's ligament. I'm going to unfold the mesh from the center. We want a couple of centimeters inferior to Cooper's ligament. You want to be able to tuck this corner deep down against the abdominal wall with no peritoneum in the way. Again, the test is that if you pull on the peritoneum, the mesh and the cord structures should not move. If they do, you need to dissect the peritoneum back farther. And we want a little bit of overlap over the midline.
So the consensus for minimum mesh size for proper myopectineal orifice coverage is felt to be 10–15 cm. This mesh is larger: 12 by 16 cm. Cross the midline by 2 cm and overlap Cooper's ligament by at least 2 cm. It doesn't matter which way the mesh is turned. Since the spot is in the center, we can place it in the same location that we described right over the internal ring, where the epigastrics meet. Unfold the mesh in the center. You can see the little velcro knobs. Make sure to tuck the mesh in the nice groove we previously dissected. You can see the little velcro knobs. Again, pulling on the peritoneum, we don't want to see any mesh attached to the peritoneum.
There's the ureter, by the way. See it peristalse?
I really want to make sure I get the mesh back enough off the peritoneum. There we go - like that.
Again, this is self-fixating mesh, so no need to tack or suture it in place. We have a nice, wide mesh overlap over the entire myopectineal orifice there. Nice, wide coverage well beyond the myopectineal orifices bilaterally.
Okay, can you reduce the intra-abdominal pressure down to 8, please?
Once that collapses, this'll settle down. Once we deflate a little bit.
Throw. Throw, catch, reset, throw. Needle’s dull. Throw.
And we have our specimen.
Okay, no holes. We'll take a peek at our small bowel. You can see that just came down with the peritoneal flap.
Okay. Let's go ahead and undock the robot.
So we have only 3 sutures total. Here they are.
Okay, and let's have a regular grasper. We'll just use the Endo Bag.
This is lipoma of the right cord. And we'll take the obturator for this - the see-through obturator for the robotic cannula back. Thank you. Nice move.
Jim you can take him out of Trendelenburg, look over at my instrument.
Look at the catheter.
So this guy - again, most patients will be able to go home and not take post-op narcotics. We'll see him back in the office in a week.
So you saw during this procedure some of the advantages of the robotic platform. Getting out the lipoma of the cord that was intimately fused with the cord structures. We really had excellent visualization and could do that without injury to the vas or the gonadal vessels. Likewise, on the left side, the indirect inguinal hernia sac, which was of moderate size, was really stuck and tenacious, and again we had a lot of advantage in that, and you saw a nice dissection there.