Mahadar Rahul, Arora Eham
Division of Minimal Access Surgery, Jeevanshree Hospital, Thane, Maharashtra, India.
Department of General Surgery, Grant Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India.
J Minim Access Surg. 2021 Oct-Dec;17(4):580-583. doi: 10.4103/jmas.JMAS_312_20.
The enhanced view totally extra-peritoneal (eTEP) repair is a useful modification of the classic TEP operation which offers a more panoramic view of the operative field with greater flexibility in port positioning. It can offer greater ease of surgery in large, irreducible or bilateral inguinal hernias due to its improved ergonomics. Misunderstanding the myo-fascial anatomy, incorrect positioning or sequence of trocar insertion can lead to inadvertent peritoneal injury with pneumoperitoneum, impeding the operating surgeon.
We describe our method for the surface marking of the semilunar and arcuate lines which guides the site of initial optic access. After blunt/balloon dissection of the pelvic extra-peritoneal space, the lateral trocar is inserted first to clear the peritoneum off the posterior aspect of arcuate line, allowing us to divide it near its medial attachment. The second working trocar is inserted at the umbilicus after visually confirming the extent of dissection. Additional trocars are inserted depending on bilaterality or size of the hernia.
We have operated 124 cases of bilateral inguinal hernia between April 2017 and February 2020, where we suffered peritoneal injury in only four cases, without leading to the conversion of the procedure. The widely dissected space with the division of the arcuate line further increased the ease of laying down a large prosthetic mesh.
The exact sequence of trocar insertion and their positioning described by us improves ergonomics and ensures a safe division of the arcuate line with minimal risk of damage to underlying peritoneum.
完全腹膜外强化修补术（eTEP）是经典TEP手术的一种有益改良，它能提供更广阔的手术视野，且在穿刺孔定位上具有更大的灵活性。由于其人体工程学设计得到改进，对于大型、难复性或双侧腹股沟疝，该手术能使操作更简便。对肌筋膜解剖结构的误解、穿刺套管插入位置不当或顺序错误，可能导致气腹时意外损伤腹膜，给手术医生带来阻碍。
我们描述了一种用于半月线和弓状线表面标记的方法，该方法可指导初始光学入路的位置。在钝性/球囊分离盆腔腹膜外间隙后，先插入外侧穿刺套管，将腹膜从弓状线后方推开，这样我们就能在其内侧附着处附近将其分开。在目视确认分离范围后，于脐部插入第二个操作穿刺套管。根据疝的双侧性或大小插入额外的穿刺套管。
2017年4月至2020年2月期间，我们共为124例双侧腹股沟疝患者实施了手术，其中仅4例出现腹膜损伤，且均未导致手术方式改变。广泛分离的间隙以及弓状线的切开进一步提高了铺设大型补片的便利性。
我们所描述的穿刺套管插入的准确顺序及其定位改善了人体工程学，并确保在对弓状线进行安全切开的同时，将对下方腹膜的损伤风险降至最低。
