Dulucq's technique for laparoscopic totally extraperitoneal hernioplasty.

BACKGROUND: Inguinal hernia repair has been a controversial area in surgical practice. Its complexity is reflected by the fact that numerous different procedures including both open and laparoscopic techniques are in use today. Laparoscopic totally extraperitoneal (TEP) repair is preferred over transabdominal pre-peritoneal repair as the peritoneum is not breached and also due to fewer intra-abdominal complications. This is the most elegant technique but rather difficult to perform. AIM: The purpose of this study was to describe Dulucq's technique for inguinal hernia repair and the use of three-dimensional mesh without fixation in laparoscopic TEP inguinal hernioplasty.
METHODS: Surgical technique of laparoscopic TEP inguinal hernia repair is detailed in the text.
RESULTS: A total of 945 hernia repairs were included in the study. The hernias were repaired by Dulucq's technique. Mean operative time was 45 min in unilateral hernia and 65 min in bilateral hernia. There were no serious complications.
CONCLUSION: The laparoscopic TEP hernioplasty by Dulucq's technique is feasible with fewer intra-abdominal complications. The dissection must always be done with the same stages with minimal monopolar diathermy and patient in a slight Trendelenburg position.

INTRODUCTION

The inguinal hernia repair has been a controversial area in surgical practice ever since it was conceived.[1] The fact that numerous different procedures are in use reflects the complexity of inguinal hernia and its repair. The totally extraperitoneal (TEP) method allows access to the pre-peritoneal space and avoids the need for a peritoneal incision.[2] The establishment of this technique by Dulucq in Europe may be considered a logical further development of transabdominal pre-peritoneal hernia repair.[3] We describe and discuss our techniques and modifications when accessing the pre-peritoneal space and using three-dimensional (3D) mesh without fixation in laparoscopic TEP inguinal hernioplasty.

STANDARD TECHNIQUE

Traditional TEP repair is performed using three ports placed in the pre-peritoneal space.

The first 10-mm port is placed using an open technique.[4] A subumbilical transverse skin incision is made and then advanced slightly off the midline, in front of the anterior rectus sheath. If the fascial incision is placed in the midline, it will enter the peritoneal cavity. The anterior sheath is opened transversely, and the rectus muscle is swept laterally and retracted anteriorly. The posterior rectus sheath is seen and left intact. The 10-mm port is then inserted bluntly into the pre-peritoneal space and CO2 inflated

A 10-mm, 0° laparoscope is inserted and used to bluntly dissect the areolar tissue in the pre-peritoneal space, using a gentle sweeping motion. Alternatively, a balloon dissector can be used to bluntly dissect out the pre-peritoneal space

The pre-peritoneal space is dissected laterally to the anterior superior iliac spine in order to place the 5-mm ports [Figure 1]

Figure 1

Port positions for the standard technique of totally extraperitoneal

The passage to do the lateral dissection is in the angle between the arcuate line and the inferior epigastric vessels. The lateral dissection is done all the way up to the psoas muscle inferolaterally, thereby exposing the nerves. The lateral space contains loose areolar tissue, which is completely divided using blunt dissection

After the two 5-mm ports are placed, the inferior epigastric vessels, the pubic bone and Cooper's ligament are identified. A hernia is completely dissected from the cord structures and reduced [Figure 2]

Figure 2

Medial and lateral dissections. Reduction of sac

In general, a large 15 cm × 10 cm flat mesh is used to cover the defects with an adequate overlap. Few tacks may be used to secure the mesh in position, depending upon surgeon preference. The deflation process happens under direct visualisation, and the skin incisions are then closed.

MODIFICATION OF STANDARD TECHNIQUE

A Veress needle is first inserted in the midline three fingers above the pubis in the suprapubic space of Retzius [Figure 3]. The needle is pushed in till it gives a single click, ensuring that it is in the extraperitoneal space. A cautionary rider may be used for the blind Veress needle access. CO2 is then insufflated at a pressure of 15 mmHg. With the correct placement of the Veress needle, the recti become prominent after gas insufflation

Figure 3

Veress insertion technique

An infraumbilical incision is made, and a 10-mm trocar is inserted in the subcutaneous plane in a horizontal direction for about 2 cm (subcutaneous tunnelling), then slowly lifted up, and introduced at an angle of 60° toward the sacrum. The trocar is inserted such that there is a smooth, gentle give way feel. This ensures that the trocar is placed in the correct plane, which can be confirmed by the pre-peritoneal gas already present in the space [Figures 4 and 5]

Figure 4

Dulucq's technique for entering the pre-peritoneal space (note the subcutaneous tunnelling and angle of the port)

Figure 5

As seen after trocar entry, lighthouse

The insufflation continues with a pressure set at no higher than 12 mmHg. One hand holds the optic and the other leans on the abdominal wall. It is a question of balance between left and right

The first 5-mm port is placed at the point of entry of the Veress needle. Most of the dissection is achieved using the scope and one working instrument. The second 5-mm port if required is taken, as shown in Figure 6

Figure 6

Port positions for the modified technique (right-sided hernia)

The rest of the steps are similar to the standard technique

We use a 3D anatomically contoured mesh for each case without tacks or any fixation. When the mesh is correctly positioned, carbon dioxide is slowly released from the pre-peritoneal space (under direct visualisation), allowing the peritoneum to “sandwich” the mesh in place against the abdominal wall [Figure 7].

Figure 7

Mesh placement

RESULTS

Dulucq's technique was used in a total of 945 hernias repaired by laparoscopic TEP hernioplasty. Mean operative time was 45 min in unilateral hernia and 65 min in bilateral hernia. There were 19 cases of seroma formation and 1 hematoma which resolved on its own. Most of these were encountered in cases of direct hernia. There was a single case of hematoma which required surgery. About 15 patients had urinary retention which were managed conservatively. There were two recurrences during the initial cases which were unrelated to the technique.

CONCLUSION

We routinely follow the Dulucq's technique during laparoscopic inguinal hernia repair by TEP approach. This technique seems to be simpler, elegant and quick. It reduces the operative time and has no serious complications associated with it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.