Laparoscopic Repair of Complete Indirect Inguinoscrotal Hernia: A Comprehensive Overview

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  An inguinal hernia is a protrusion of abdominal cavity contents through the inguinal canal, which can be categorized into direct and indirect types. The indirect inguinal hernia follows the pathway that the testicles made during pre-birth development, moving through the inguinal canal. When this type extends into the scrotum, it is termed a complete indirect inguinoscrotal hernia. This article provides a detailed examination of the laparoscopic repair technique for this condition, highlighting its advantages, procedural steps, and postoperative care.  Understanding Complete Indirect Inguinoscrotal Hernia  A complete indirect inguinoscrotal hernia occurs when the herniated sac extends all the way into the scrotum. This condition is more common in males due to the descent of the testicles through the inguinal canal, creating a potential pathway for herniation.  Advantages of Laparoscopic Repair  Laparoscopic repair of inguinal hernias offers several benefits over traditional open surgery:  Minimally Invasive: Smaller incisions lead to reduced postoperative pain and quicker recovery. Better Visualization: The laparoscopic approach provides a magnified view of the internal structures, aiding precise dissection and repair. Reduced Recurrence Rate: Proper placement of the mesh during laparoscopic repair can lower the chances of hernia recurrence. Faster Recovery: Patients typically experience shorter hospital stays and faster return to normal activities. Preoperative Preparation  Before surgery, a thorough medical history and physical examination are conducted. Imaging studies, such as an ultrasound or CT scan, may be ordered to confirm the diagnosis and extent of the hernia. Patients are advised to avoid eating and drinking for a specified period before surgery and to follow any other preoperative instructions provided by their surgeon.  Surgical Procedure  The laparoscopic repair of a complete indirect inguinoscrotal hernia involves the following steps:  Anesthesia: The procedure is performed under general anesthesia. Trocar Placement: Three to four small incisions are made in the abdominal wall to insert trocars (hollow tubes) for the laparoscopic instruments and camera. Hernia Sac Identification and Dissection: The hernia sac is identified, dissected from the surrounding tissues, and carefully separated from the spermatic cord structures.

Transcript

00:00Hello Friends! This is a case of left-sided, indirect, complete inguinoestrotal hernia.

00:09Here we are standing on the right of the patient, left side is the head and right side you can see

00:15this is the leg end. So, whenever you have to perform the left hernia surgery, you have to

00:21stand right to the patient and after putting all the port, you have to go near the right shoulder

00:28and monitor should have position at the left hip. So, here we have started the pneumoperitorium by

00:36various needles and approximately 3.5 litre gas was used. This is a young male and probably he has the

00:44inguinal hernia on the left side since childhood. In those type of cases where the complete inguinoestrotal

00:52sac is there. Many a time it is not possible to remove the entire sac. So, probably you might have

01:00to cut the sac and leave little amount of sac in the scrotum. So, here we are introducing 10 mm port,

01:08optical port and we are performing this surgery by ipsilateral port. Most of the inguinal hernia,

01:16now we have started performing by ipsilateral port. That has advantage that your arm will not remain

01:22abducted and you will have, this is left sided you can see, this is a telescope entering into

01:28the sac and it is going long way inside the scrotum. So, we will start our dissection from the medial

01:36umbilical ligament. Medial to medial umbilical ligament, you cannot go ahead. We can see that

01:42inferior apigastic vessel is just started visible. This is inferior apigastic vessel.

01:49So, you have to be careful about that and we are using harmonic hair to incise the peritoneum.

01:57And we will start from medial umbilical ligament and we will go towards 10 o'clock position

02:03and approximately 6 cm lateral to the outer margin of the defect.

02:08We have to go. Generally, we use the mesh 12 plus defect or in the tape we use 8 plus defect.

02:18So, vibrating jaw of harmonic is taking a good plane because it vibrates and break hydrogen bond.

02:25So, you can easily dissect it. And once we have given the incision, after that we don't use any energy.

02:32After giving the incision to the peritoneum in all the hernia surgery, we perform it by 2 atraumatic

02:39rasper. We don't use any hook or scissors and we do the blunt dissection. Even semi-traumatic

02:47rasper we don't use because that will create the window formation in the peritoneum. So, here we can see

02:54this is a lateral dissection and slowly slowly it is separating and this lateral pocket has been made

03:03at the triangle of pain. And you have to pull the peritoneum inferomedially. Below you can see

03:11sigma-air colon but we don't mobilize sigma-air colon. Once you will mobilize the peritoneum,

03:18sigmoid will automatically drop together with the peritoneum. So, this lateral dissection is over.

03:26After that we will go medial. Here you can see nerve is also visible. That is LFCN. GFN will be more

03:34medial. LFCN lateral. Now this is medial dissection and we will medialize the medial umbilical ligament

03:43in feromedially to find out Cooper ligament. So, that is just two stick techniques. We use the shaft of

03:51the grasper to bluntly push in feromedially and we will enter a little bit in the space of radius

03:59from the left side. And here we can see lighthouse that is called Cooper ligament started visible.

04:06So, this is Cooper. And medial dissection is over. After that you should go for the shack dissection.

04:16And this is the shack which you will pull it. And you have to pull inferomedially and you must separate

04:23it from VAS and spermatic. We can see that when you will pull the shack you have to separate it from

04:30pseudo-sack. And here below is the spermatic vessel and VAS difference that has to be separated.

04:39And you have to make a window posterior to the shack so that VAS and spermatic

04:44accident. This is the VAS and spermatic and a window is created in between the shack and VAS and

04:50spermatic so that you will not accidentally injure it. This type of hernia we can see there is a very

04:58large shack and it is reaching up to the escrotum. So, you will ask your assistant to hold the testis

05:05because sometimes the testis can come into the ring and you may pull it. Here this is pseudo-sack

05:12but it is very difficult to separate in this situation. And in this situation if we feel it

05:19that it is not possible to separate completely then it is better to struggle you may cut it.

05:28So, here we are trying to pull it but it is not separable it is inseparable. In those situations

05:36you can use harmonic scalpel and directly you can cut the shack.

05:45Taking care that towards the which is going towards the escrotum that should remain open it should not

05:52seal by the harmonic. And now it is over. We are inspecting for any bleeding. It's beautiful. There

05:58is no bleeding and it is over. Now this is triangle of dome, VAS and spermatic vessel,

06:05Cooper ligament, inferior epigastic vessel, triangle of dome, triangle of pain and trapezoid of disaster.

06:11All is nicely visible. These are nerves also visible. After that we will put the mesh and mesh

06:19has to be spreaded over all the myopectinial orifice. An inferomedial end of the mesh should go to the

06:27Cooper ligament. So, this is on the lighthouse on the Cooper ligament and now we will do the fixation

06:34of the mesh. This is mesh fixation we are using protac that is titanium tacker and only one tacker we apply

06:42over the Cooper ligament and another we apply complete superolateral over the arc of transversal

06:51abdominis muscle. So, only two tackers we use our hernia surgery. We don't use much because pain will be

07:00more and after that you will decrease the pressure of pneumopectinium. This is infiapigastic. Always

07:07take care that accidentally you should not fire your tacker over the infiapigastic vessel. So, after

07:14that we will decrease the pressure of the pneumopectinium to 8 mm of mercury and then you will do double

07:22brass technique. You can lift the lower edge of the plutonium and you can fix it with above the

07:28ingoinal ligament. So, this is a very interesting case simple case rather for the and take care that

07:36accidentally you should not fire it over the infiapigastic vessel. Now, extreme laterally we can

07:43see sigmoid and sigmoid also help once you remove the pneumopectinium then sigmoid also help to support

07:51the peritonium. Right now you can see sigmoid is stretching because there is pneumopectinium but once

07:58the abdomen will be deflated after that sigmoid will become loose and it will go to the natural

08:03position. So, it's over now we will remove the carbon dioxide and slowly slowly telescope will be

08:11withdrawn into the cannula. So, thank you very much for watching this video. This was a simple case of

08:18hernia surgery.

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