Single-Port Hernia Repair
The patient is placed in supine, slight Trendeleburg position with the monitor at the caudal side of the patient. The bladder is drained by a urethral catheter to maximize the working space. An ipsilateral to the hernia incision, approximately 3cm infero-lateral to the umbilicus, provides access. Following balloon dilation of the extraperitoneal space, a disposable multi-instrument access port (TriPortTM – Olympus) is inserted. The TriPortTM consists of a retractor and a valve. The retractor includes one internal ring and two external rings and a doubled-over cylindrical plastic sleeve. The inner ring is inserted with a trocar-introducer system and tightened against the rectus muscle using the sleeve. The port allows for the introduction of two 5mm instruments and one 10mm instrument while an additional port for gas insufflations is available on the port. Curved HiQ LS 5mm hand instruments (Olympus) are inserted via the lubricated TriPortTM (Figure 1). A combination of scissors and graspers is used. The curved shaft of the laparoscopic instruments is responsible for the decreased instrument crowding during the procedure. The distal end of the instruments can be rotated via the knob on the hand piece. Thus, the handle is not necessary to be rotated for the rotation of the instrument. In order to allow the surgeon unhindered freedom of movement outside the patient we prefer a 5mm EndoEYE (Olympus) Laparoscope with flexible handle 300 (Figure 2).
A combination of sharp and blunt dissection defines and reduces the hernial sac. A straight 5mm bipolar Johann grasping forceps is used for dissection and haemostasis. In cases of indirect hernias the spermatic cord is carefully isolated and freed from the hernial sac. It is important to ensure adequate lateral dissection to the level of the anterior superior iliac spine to allow placement of the mesh. A 10 cm by 15 cm Premilene ® (B:Braun, Germany) mesh is prepared by making a 6cm cut vertically 7.5cm from the lateral end. A small cut is fashioned to accommodate the cord structures. The incised mesh is covered by a flap of mesh approximately 6cm by 4cm and sutured medially into place using a continuous 2.0 prolene suture (Figure 2). The flap is temporarily sutured back with a single prolene suture allowing the mesh to be placed around the cord and structures. The mesh is rolled up and tied with two stay sutures to allow easy insertion through the 12mm trocar. Once inside, the stay sutures are cut and the mesh unfurled. It is positioned in place around the spermatic cord from the pubic symphysis in the midline to the anterior iliac spine laterally (Figure 3). The gas is then released from the extraperitoneal space and intraperitoneal pressure holds the mesh in place. No sutures or clips are used to fix the mesh in place. We have previously described this method in patients undergoing endoscopic extraperitoneal radical prostatectomy with concomitant inguinal hernia repair.
Figure 1: Instruments used for LESS extraperitoneal hernia repair.
- A) HiQ LS Curved 5mm Hand Instruments (Olypmus, Germany).
- B) A TriPortTM Disposable Multi-Instrument Access Port (Olypmus, Germany) with the appropriate trocar for placement.
- C) A TriPortTM placed at a 3cm infero-lateral to the umbilicus site.
Figure 2: Instrument configuration and mesh for LESS hernia repair.
- A) Laparoscopic camera with flexible handle and 5mm diameter (EndoEYE 300, Olympus, Germany). Prebent laparoscopic instruments are also used.
- B) The Premilene ® (B:Braun, Germany) mesh used for the hernia repair with the flap sutured on it.
- C) The Premilene ® (B:Braun, Germany) mesh rolled and ready for insertion through a 10mm channel of the Triport.
Figure 3: The technique of LESS extraperitoneal hernia repair:
- A) The hernia sac is carefully prepared and reduced inside the abdomen.
- B) The mesh is placed under the spermatic cord.
- C) The mesh is unfurled and positioned in place.
- D) The appearance of an incision performed for LESS hernia repair. Notice the limited length of incision.