Giovanni Dapri Left Inguinal Hernia (TEP)

Good morning everybody, I'm in Giovanni D'Apri, I'm in Bergamo, Italy, and I'm here with my team.

Today the surgeon helping me in the surgery is Dr. Giorgio Quartierini, he's on my left side.

On my right side there is Mrs. Pamela, she's a nurse, scrub nurse,

And the anesthesiologist is Dr. Constantino Solinas.

And today we are going to do laparoscopic left inguinal hernia repair by umbilical axis.

So Mrs. Greta is going to present the clinical case.

Please, go ahead.

Good morning to everyone. The patient that we are going to operate today is scheduled for a left inguinal hernia repair with a totally extraperitoneal approach. The patient is 52 years old and he has a BMI of 20.5. He has no comorbidities and the only previous surgery is an open right inguinal hernia repair.

pair. Around one year ago there was the appearance of a left mass in the inguinal region and at the

physical examination there was a left inguinal hernia that it was possible to reduce manually

with a hernia defect of around three centimeter. Goodbye, thank you. Perfect, so thank you very much

Dr. Greta. So now we are going to start the procedure. The patient is placed in

supine position. The head of the patient is here. The foot are here. The surgeon is

on the opposite side of the inguinal hernia. Since it is a monolateral and

left one, the surgeon is on the right side. The cameraman is on the side of

the hernia and the scrub nurse is on the right side of the surgeon. We already did

an opening of the fascia, the rectal muscle fascia on the right side of

the umbilicus. We insert now a 10 mm reusable troca into the muscles

fibers under view and once we are in this position we connect the trucker to

the pneumo-peritoneal tube and we before to start the insufflation we check with

the scope. The scope is a 0 degree 10 mm scope reusable standard and

And we introduce the scope.

Maybe, Andrea, you can say, perfect, thank you.

So here, you see, we are between the masses.

We push a little bit.

You see here that we are going now, perfect, Giorgio.

We are going now at the space between the,

at the space between the posterior fascia posteriorly

and the muscle fibers anteriorly, okay?

Now we are in good place, you see here.

So if I start a little bit going down before to insufflate,

I'm in the correct plane.

now I start the pneumoperitoneum with 14 pressure and high flow so here you

see the preperitoneal space okay we are going down and you see I go slowly in

order to show you this is the correct place you see the muscles anteriorly

you see the fascia here, posteriorly, we go down into the direction of the pubic bone, okay?

So here is a tunnel we just created with a zero-degree 10-millimeter scope.

You see here, this is a thin patient,

so we have to be we have to take a little bit care about the possible

bleeding here with the scope I do a slowly dissection of the preperitoneal

space okay look at this this is the pubic bone we are in a correct plane

there is a navascular plane and so we can continue now I asked to Dr. Salina

our anesthesiologist, please to place the patient a little bit in trend

position, and in this way I can get more access to the

regional region, okay? So here, okay, thank you. So now look at this, this

This is probably, this is the right side, okay?

This is the left side.

We have to go in the left side

because the patient presents an inguinal anion

at the left side.

There is no recurrence, as Dr. Greta said,

in the preoperative workup of the patient.

The patient was operated already by open surgery

on the right side.

So this is an example as we can do laparoscopic preperitoneal repair in a patient already operated by OPAN.

So you see that slowly and with gentle movement, I try to dissect, thanks to the pneumoperitoneum, the preperitoneal space.

Here, we identify already the peritoneal tear,

peritoneal sheath, sorry.

So this is the peritoneal sheath.

This is probably the hernia.

This is the epigastric on the left side.

So as I teach to my students,

whenever there is a defect immediately

to the inferior epigastric vessels,

we have a direct hernia okay so here what we do is to continue very gently

slowly because if you go fast in this process you can open the peritoneal

sheet and spontaneously you have difficulty to continue because you have

a pneumoperitoneal into the peritoneal cavity. So here I continue slowly. You see

here I identified where the peritoneal sheath is present and I try to

skeletalize the epigastric vessels. The anatomy of the patient is quite good

good, because the patient has a slow BMI.

I continue here, going slowly,

and suddenly you will see that we have the,

we have the inguinal hernia here, okay?

So this is the defect, okay?

And so we continue in order to reduce.

We start to see here very well

Well, the defect is here, the internal inguinal orifice is here, ring, sorry, the internal

inguinal ring is here, orifice is in French, and here we continue going laterally.

Now, the most important step is to dissect going into the lateral direction, finding, if it's possible, the fascia transversalis.

So the transversalis fascia is one on the landmark that can be found during the dissection going laterally in order to allow the correct placement of the mesh.

okay here you see I go slowly I use the zero degree scope as the finger okay and

like in open surgery and I continue with the section of the space trying to

to remove as much as possible the hernia sac,

which is in this case,

interested by the pre-hernia lipoma, okay?

So I continue here.

This is the step of usually during the dissection,

you can get a dirty camera,

but it is normal because you have a disector in the same time as the scope

with the same instrument, okay, here we go, voila. Now, look at this.

Hi Giovanni, can you hear me? Absolutely, who are you? I'm Novellino. Ah, Lorenzo, my friend, how are you?

stai stai lavorando da bergamo o da dal belgio no sono attualmente a bergamo da esattamente

mario si sono nella città di noi siamo nativi entrambi no io sono parte dei desi ma va bene

lo stesso ascoltami giovanni tu continua pure a parlare inglese io ormai da pensionato non

I don't want to make it difficult, but I've been following you up to now and I have to say that the fact that it is a direct left is practically reduced to hernia simply with insufflation.

Yes, almost, because you see that there is still ...

Yes, there is a little fat, lipoma that goes down.

Exactly, here, slowly.

Sure.

In theory, I should also look for it on the right, because the direct one is often bilateral.

It's bilateral.

Did you have a preoperative idea that it was a direct one?

Preoperative, I had, yes, absolutely.

So much so that I asked for an echography.

Contralateral, but the contralateral echography has a negative result.

and so if you kindly agree with me, I'll just do the left.

Sure, I agree.

How are you Lorenzo?

Good, from retirement very well.

Yes, can I invite you here with me some day when we do some live shows?

Yes, if you do something interesting I'll come to see you.

Now you, excuse me, I know that the congress yesterday moved, I was talking to Giorgio Palazzini, about 4,000 Italians, there was still no idea of how many there were worldwide.

You continue to present the case by speaking English.

I follow you and then I intervene on some passages, also because you are making me

relive, you think that I did this technique in 93-94 and then I left it for a

trasparent, but it is a splendid case and now I want to see, you go in

monoport and now I'm trying in mono you know it's true because we exchanged the book and

it's a simple inguinal hernia I would go in mono if you agree I agree but also because

there is a fact that while in the tonal transperitoneum the enlargement of the trocars can help

Here, as usual, I did the technique of McKernan, who put the trocars on the middle line,

2 and 3 on the middle line, and it was a mess.

So in this case, I believe that the trocar can be really helpful.

Lorenzo, you were the starting point of the celluloscopy development in Italy.

So, if you allow me, instead of using the trochers as you told me,

I would go with the technique that I developed in Brassers, peri-umbilical, parallel to the troca of 10 reusable,

introduced inside the tobacco bag that I made with a Vycril 1 on the front of the rectum on the right,

and I reduce internally the lipoma and in theory a bit of sac, then

I continue to prepare the hernia with the optical from zero because as I said before

I use it as the finger in open to put the part that protrudes inside

of the cavity and then we prepare the network. I agree with you. Fantastic.

Fantastic. Grazie, Lorenzo. È un onore conoscerti.

Continua pure a parlare in inglese.

Ah, ok. So, I continue the procedure.

Today, the work by the picture externally and internally is Mr. Ristelli Andrea.

white castors, and to use the grasper parallel to the trocker, I push the trocker, Dr. Quartierini

now remove the, take this, Giorgio, and he takes a little bit of the cocker, the tobacco

balls.

Now, we are internally, so Mr. Ristelli, please switch, perfect.

so you see here I reduce the hernia, okay, I reduce the hernia here, this is

the lipoma, so I try to reduce the lipoma, and here, one of the message is that when

When you have bleeding, it is not too much in this case, but when you have the bleeding,

you continue the procedure in case when the bleeding is too much, you can control.

But in this step, what it is important to do is to identify if it is present but it

it seems here, the cruralis mortis, okay?

The cruralis mortis is here, you see?

So this is something that must be identified

and overall the surgeon has to consider

during this step of the reduction, okay?

So now, yes, Dr. Greta maybe can show a picture

we have prepared and she can explain so Greta go ahead in so she can explain

this is the anatomy unfortunately we didn't phone yesterday the left side

online but with a picture but it is not important so here you see that

And now I try to have good Pneumo, okay perfect, thank you.

Dr. Quartanini is helping me very well.

So here you see that I remove the space here with a grasper, slowly, okay, perfect, yes.

Yes, so this is the...

Okay, you can see here the five different triangles.

They are the most important thing to identify

when you are doing an inguinal hernia repair.

You can see medially to the hypogastric vessel

the triangle where you can find a direct hernia,

while laterally to the hypogastric vessel

vessel, you can see the triangle where you find the indirect hernia. While inferiorly

and medially to the inguinal ligament, you could find a femoral crural hernia. The important

triangles that you have to avoid when you are performing an inguinal hernia repair are

the pain triangle where there there are the nerves that so you have to avoid to

put stitches in that region of course this technique is stitch free so it's

not a big problem in this case but still you have to avoid to coagulate and

damage the nerves and then you have the doom triangle that is located between

between the spermatic vessels and the vas deferens.

And in between them, we have the iliac vessels

that of course we have to avoid to damage.

Perfect, thank you very much.

So we now, Andrea, please switch, perfect.

So you see here, look at this, this is the cruralis mortis.

you see here okay the epigastric are here so here you see the obturative vein

the femoral vein is here okay and so these are the elements that we just

spoke which are the spermatic on the left side here we identified the

the deferent duct, okay?

So what we try to do here is the dissection

of the peritoneal sheet from the deferent duct

and also from the spermatic vessels.

I have already done from laterally

the spermatic vessels which are here.

Now I try slowly to reduce here.

we can arrive at certain point where we see like a bridge

between the peritoneal sheath and the spermatic duct.

This bridge, to my knowledge, was reported by my friend

again, Dr. Jean-Louis Deluc from Bordeaux in France.

and here you see what we are doing to do here is the limit of the bridge you see

and what it happens and this is one of the reason I suppose that professor

Lorenzo Novellino is going to switch from tap to tap in female when you are

are at this place, when you reduce the peritoneal sheath here, there is a fusion between the

round ligament of the uterus and the peritoneal sheath.

So when you do the retraction like I'm doing now, what you are going to do is to open the

peritoneal sheath.

And so this is the reason why in a female, it's good to do a tap, but it's better to

to do a tap, like Professor Novellino said,

because when you open the peritoneal sheet,

you are already in a transabdominal,

so the opening of the peritoneum is already done.

And so you can close with two running suture,

converging and absorbable suture.

I used to close by suture the peritoneal sheet,

because I don't use a tux in order to avoid to tuck in the abdominal wall

and to avoid, if it's possible, potential pain due to a tux of the nerve

because, as Dr. Greta said, this is the triangle of the pain.

So when you place tux like here to close the peritoneal sheath in tap

and not in tap you are you you don't know exactly where the taps are going to

be placed and so you can occur pain in the post-operative time so here we

continue to reduce and now I'm quite good I think that it is enough because

Because the peritoneal sheath is here,

the triangle of doom, but in any case of dangerosity is here.

The spermatic duct is here, the vasa spermatica are here,

the epigastric are here, the hingual orifice internal ring is here,

the cruralis mortis is here.

This is the obturator vein, this is the epigastric, this is the connection of the coronal mortis,

this is the femoral vein, it's just here below.

You see here, this is the femoral vein, this is the ligament, the Cooper ligament is just

here, and so the defect we have to repair is here so we have to place our mesh more

more on the left side like here, and so it is quite done.

You see here on the right side that probably the ultrasonography

keep right because there is not a great defect and

I don't see exactly a defect to repair, so

we can go ahead with a monolateral repair.

Now, I leave the instruments like this, Andrea.

And so I ask to Dr. Quattarini to keep the camera and

to keep in this position and now I move myself close to my lovely scrub nurse

and I change the gloves and I prepare the mesh. In order to go to the

prosthesis repair what we go what we are going to do

is to take a polypropylene mesh. So the polypropylene mesh is a standard one

that everybody has in OR because we can use this one during the open surgery

and this mesh is very easy to be repaired and also very cheap. And so here

Here we have a mesh of 15, perfecto Andrea, this is 15 by 15, so I have to place from

lateral to lateral 15 centimeters and from up to down craniocaudal is 10 and is roughly

8.

we can measure maybe because dummy yes we can measure usually I don't measure

because I do by experience I take like this I arrive at one tier and I go in

this direction anyway now I keep the centimeter I do like here and so here

take it like this and here it's eight perfect so now what I used to do and

what I tried to teach here in Bergamo in Italy I arrived to one tier of 15

centimeters so roughly is a five centimeter you see is roughly not

No, not roughly, it's exactly 5.

I stop at 5, and I go, merci, yeah, merci beaucoup.

I go in the direction of the 8 centimeter, doing like an S.

And so this is where, on the left side, is the mesh.

Now, the tips, the tricks that I developed in process,

doing courses that we are going to do here in Bergamo next here please take

this is to do some suture at the corner the inferior one medially and

laterally okay so this is this is the inferior medial corner so Pamela is

going to cut here a longer one and now I place another one in the inferior

lateral corner and the suture I use is a Vicryl 2.0 so this step is just to

have if you want a good orientation of the mesh internally because especially

Especially with a single incision like we are doing, merci, it's very difficult to do

very good orientation.

So this is the medial inferior corner.

This is the lateral inferior corner.

This is a longer stitches and this is a short one.

it's very good difficult to orientate. Now lastly since we are going to do a

left one when we do a right one what we are what we used to do is to do the same

mesh shape but on this way so in the case of bilateral or right

inguinal hernia is simply the same shape 8 centimeter laterally 10 centimeter

medially and 15 centimeter lateral lateral okay now I again I take the

grasper the right one I keep the mesh with the longer suture so the medial one

into the grasper. I do like a cigarette, like in this way, very gently. Importantly,

you have seen that before to prepare the mesh, I change the gloves. Now, I introduce

this mesh into the trocker, okay? So I go back, I arrive here, I ask to Dr. Quaterini

to remove the scope and now look at this I introduce the mesh into the trocker

and I push the mesh very gently into the preparatorial space and I introduce like

this reaching the pubic bone I open the mesh and I remove the trocker okay and I

remove sorry the grasper and Dr. Quartianini stop look at this Dr.

Quartellini is pushing the mesh with the scope okay so don't worry there is no

problem you have mesh into the correct place and now what we have to do is

to place the mesh correctly and so simply we take the grasper we have

already inside okay and we try to position the mesh correctly okay so here

I push the mesh

Like this

Perfect

So here

This is not the opening

It's just a space we have created

With the intersection of the mesh

Into the

You see this is not the opening

Of the peripenetronium because we are not

Into the peritoneal cavity

Okay

So here look at this

Now since we are here

We take the lateral one

laterally okay we place we take the grasper here we push the mesh medially

and now you see already that thanks to the suture look at this this is my

suture this is the lateral one so it means that I'm in good way because the

lateral is like he said on the lateral side now this part where there are no

suture so are up in the upper part so we are good and here we place the mesh

inferiorly look at this this is not correct but we place this one anteriorly

more in the upper side we take this one on the lateral side and we push this on

the in the corner of the opening space now what we used to do is to place

first, this is the best, is to place the medial corner correctly because when you

place the lateral and the medial inferior corner then the mesh is going

to be in the correct place, correct position, sorry, immediately and

spontaneously okay look at this here we are here okay and now we are at the we

reach the step where the mesh is in a good way here maybe we have to open a

little bit more and so like this okay like this like this and like this now

the mesh is not covering enough of the orifice you see here so what we used to

do is to take the mesh a little bit more upper okay like this and now we are in a

good way okay now another important point is you're going to fix or you're

not to fix. So as by school, we can fix usually the direct hernia. But like in this case,

since the lateral one corner is in a good position, we don't have to, maybe we can avoid

to fix because it remains in place in a correct one. Look at this. There are some tricks.

here the mesh is going here so there is no too much possibility to move, here is

here so there is not too much again okay now the ring, the inguinal defect is

here so it is covered and so I'm in a good one and I think we can finish

because look at this finally this is the peritoneal sheet you see the

The peritoneal sheet is here, is just close to the opening of the space.

And here, it is quite impossible to have a shaving on the mesh, okay?

So since it is here, look at this.

I keep the mesh correctly.

then I find the image beautiful but beautiful the image that you have shown and the simplicity

that you have shown in positioning a network with a single trocar passing laterally with a

single access passing laterally to the trocar where there is the optics and the trick of putting the two

lower ribs, one longer and one shorter, which allows you, having hooked the medial,

if the net is rolled on the medial point taken by the instrument, in such a way that you have put

the net practically in the right position with the input. This case, however,

that shows your ability and also the concept of having identified a system that of the two nodes

that allow you to never find yourself in difficulty on the position of the corners of the network

but it must be said that it is a hernia this one that has been pleasant if you have shown a

a perfect anatomy. What is my problem that made me abandon the preperitoneal technique

is the fact that my research was to do those hernias that were difficult to do in the open,

I'm talking about the plurirecidive, often oblique external, which made in preperitoneal

the idea of large surgical maneuvers to free the internal inguinal ring,

often with rupture of the peritoneum, and therefore difficulty in proceeding.

But I admire and appreciate, this intervention was beautiful,

because you showed how in four strokes of the hand, one hand alone,

you managed to put the right net in the right place,

you covered a couple of centimeters on the right side from the median point, the median position, the median line of the cube,

so the network perfectly covers the entire region, direct, oblique, internal oblique, external oblique and crural,

and consequently this is an intervention, now you will fix it with clips in the upper part, right?

No, I usually... Lorenzo, as you can see...

What do you do with the glue?

No, I leave it like this, because you see that here...

You leave only the support of the peritoneum that goes to close it and put it on and leave it there?

Look, I'll explain to you. As you know, I come from the Perlenian school of Jacques Impense,

who was with me, my teacher, together with Guy Bernard Cadier.

and Jacques taught you during the courses, when you have a decision like in this

case, now I, wait I'll show you, give me some more H, when you have a

decision of the space that is however limited because you have, perfect Giorgio,

Laterally, I congratulate you for all the compliments that are not necessary.

Here I have not opened more than necessary laterally, the peritoneum is here,

I have still left the adhesions precisely because I leave this

of the hernia in such a way that here it can't move, it can't escape.

On the other hand, what I tried to say, since I had opened here that there was

like a beginning of defect, this will be on this vase and

above all, as you said, I'm more than two centimeters lower

because immediately you see the metal grasper are two and a half and I am

almost look here they are almost you see the five are almost so that the

prosthesis slides upwards and especially the peritoneum because the

recidivum you have it when this part here slides if you say slides in Italian

but I don't know sliding inside the mesh so when this goes behind here you have the

recidiva in questo caso credo che sia quasi impossibile perché hai la

fissazione naturale attraverso un'apertura che ho fatto non su misura

ma sono stato attento di non aprire più del dovuto

certo giovanni nella mia tecnica quello che poi io ho sposato

indipendentemente dal farla pre o transperitoneale è che generalmente io

I make a longitudinal lateral cut to the net leaving two centimeters below to pass that tongue that is created to the bottom of the spermatic funicle

so that by connecting it from the other side I used the spermatic funicle by rebuilding the internal inguinal ring

so that the network did not roll upwards and therefore it was a point of natural anchorage.

But rightly, and this is also said by open techniques, the pre-peritoneum of Stoppà, etc.,

that theoretically when the space is well built, but not exaggeratedly enlarged as you did,

you have put the net between structures that remained in their place and you go to cover

widely to the right of the middle line of the pub and at the bottom you cover the region

by almost three centimeters, it is clear that when the peritoneum is close to it, theoretically

Theoretically, that network does not go anywhere and the first few days are enough for such a network to do its work of important adherence,

flat, without disturbing anything inside the abdominal cavity, such as the plug and all the extraperitoneal maneuvers.

How many times have you found the plug put from the outside that falls into the peritoneum and creates dents?

Those who marry the previous open technique with the plagues, the small cuts, etc.

do not often realize how much mess those plagues create inside the abdomen.

Anyway, congratulations because the intervention ...

And then people have to learn this, that of this passage that you showed,

what I think is the key part of the intervention is those two lines that you have

put in order to remain always oriented on how the network is put in the operating room. This is important.

Lorenzo, first of all I thank you for all the compliments and for your very professional comment.

and it will be a pleasure, since you have been the king of the area where I have moved,

to have you here with us in Humanitas Gavazzini in Bergamo,

and I will often invite you to moderate me.

If you agree, I will now finish, and to finish I simply ask Dr. Quartierini

di lasciare leggermente

il post ring

Andre, please

you can take a picture

we remove now the trucker

ok

we remove the trucker

no no

sgonfia

un saluto a quartierini

un saluto a quartierini

che è un po' che non lo vedo

tutto bene

Giorgio ti saluto

buongiorno professor Novadino

ciao

ciao ciao okay now we remove look at this now give me the grasper so look i i slowly you see

okay like this you see hopla perfect and so we finish this is i close now the pustule suture here

here okay at the umbilical side maybe we can show uh this the opening is a

so this is the opening and you see here that is 1.5 centimeter opening for a mesh of 15 by 10

centimeters. So these patients benefit by a single incision from 1.5 centimeter

and the placement of 15 by 10 centimeter meshes. Now I finish, I thank you very

much. First my help and very good surgeon Dr. Giorgio Quartirini who is here with

me. Please you can take a picture. So this is Giorgio and this is my lovely

Scrubner's, Parmela, and the anesthesiologist is Dr. Solinas, he's just behind me, so thank

you very much, and we keep in touch later for total gastrectomy, thank you, bye-bye.