The anterior rectus sheath is incised to one side of midline below the
umbilicus, and the rectus muscle is retracted laterally. A space is bluntly
created within the medial part of rectus sheath down toward the pubis. The
posterior rectus sheath down to the arcuate line helps keep the dissection
in the proper plane outside of peritoneum. The preperitoneal fat
aids in the dissection. The bladder is decompressed with a Foley catheter.
A balloon trochar is introduced into the rectus sheath and the dissection
continued with the trochar down to pubis. The balloon is then slowly
inflated under direct vision with the camera in the port (within the balloon).
The balloon is left inflated a few minutes for hemostasis, then deflated
and withdrawn. The balloon dissection opens the space of Retzius, pushing
the bladder posteriorly.
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Depending on the system used, a working trochar is then placed (with
or without a retracting balloon) and two smaller trochars are placed, usually
in the midline between the 10mm camera port and pubis. A supplementary port
can be placed laterally if necessary. The dissection exposes both inguinal
areas including pubis, Cooper's ligaments, falx, inferior
epigastric vessels, vas, iliac and spermatic vessels
the deep inguinal ring, the direct space and the femoral canal. Initial
instrument dissection sweeps the remaining peritoneal attachments posteriorly
to complete the exposure.
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