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A D V E R T I S E M E N T
A D V E R T I S E M E N T
Both the patient's hands are tucked so that the surgeon can stand at the level of the patient's shoulder on either side. A 10/12 mm subumbilical port is placed first. The Hasson technique is safest, especially for herniorrhaphy where any visceral injury is unacceptable since such a risk is not inherent in open repairs. The abdomen is insufflated to 13mm Hg, the patient is placed in 30 degrees of Trendellenburg position and the camera on a 30 degree scope is introduced to explore both groins. If only one hernia ispresent, a second large port is placed on the side of the hernia at the edge of the rectus level with the umbilicus and a 5mm port is placed on the opposite side slightly below the level of the umbilicus. If bilateral hernias are present, a third large port is placed at the level of the umbilicus. The camera is moved to the side of the hernia and the surgeon stands on the opposite side and operates through the two remaining ports.
A D V E R T I S E M E N T
The most prominent anatomic landmark is the medial umbilical ligament, often having an apron of fat. The ligament leads down to the prominence of the external iliac vessels. Just above the disappearance of the iliac vessels through the anterior wall is the trifurcation of inferior epigastric vessels, vas deferens and internal spermatic vessels at the deep inguinal ring. An indirect inguinal hernia as in this case is immediately evident. A direct hernia may be more subtle because of the invagination of properitoneal fat. The only clue may be the separation of the inferior epigastric vessels and medial umbilical ligament near the iliacs so that they are parallel to each other rather than in the shape of a V. The scrotum is left exposed by the drapes so that a finger can be placed in the inguinal canal to help delineate a direct hernia. A femoral hernia also may not be evident until the peritoneum is opened.
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A D V E R T I S E M E N T
The medial umbilical ligaments, the remnant of the umbilical arteries, lie on either side of the bladder and mark its lateral margins. The peritoneal incision is begun lateral to the ligament to avoid injuring the bladder. It is carried lateral across the top of the deep inguinal ring or indirect hernia defect. The camera is directed into the indirect defect to determine its depth. A small sac may be left with the inferior flap and peeled out of the inguinal canal. A larger sac that descends to or beyond the pubic tubercle is left in place to avoid compromising the blood supply to the testis.
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This page was last modified on 3/1/1998.
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