We found this to be very annoying probelm during TEP hernioplasty. Even no tear is seen in the peritoneum at the end of the procedure pneumoperitoneum is present. We've tried changing troacar positions, lowering the pressure of insuflator- no significant effect. Finally we found solition for this situation by placing a Veress needle lateral to the 10mm port for the camera. What is your experience with this problem?
We try to make digital dissection as far as it is possible in order not to open peritoneum.
You are right, it is an annoying problem. Even in case you perform a cautious preparation it might happen that you get a leackage. In such a case we use a Verres needle via the subumbilical incision (next to the camera) as you describe, with overall good results.
I do not use verres needle. After incision on the anterior rectus sheat,I use digital dissection and after than I inserted camera trocar. After than I make dissection with camera. Camera dissection results are very good. When dissection is completed I insert another trocars. I have no pneumoperitoneum in my operations.
I agree with Dr Fahrner ; in my experience ( 22 yrs of TEP., > 1500 cases ). , pneumoperitoneum is very frequent, even without noticeable perforation of the peritoneum. The verres needle in the umbilicus indeed solves the problem lost if the time. If there is a noticeable hole I try to close it, if impossible I convert to TAP nat the end of the procedure to tack the hole against the abdominal wall, if there is a really big hole I convert to TAP immediately.
As compared with a balloon dissector, doesn't the camera dissection result in more bleeding..... And do you prefer a 30 degree scope or?
I prefer 0 degree scope for dissection latter convert to 30 degree scope for the remaining part of the surgery.
verres needle insertion in upper quadrants to "defflate" pneumoperitoneum. Careful dissection of hernia sac is advised to avoid peritoneal rupture an CO2 leakage into peritoneal cavity. Lateral dissection i usually acomplished wuth a "fanning" potion of the scope (10 mm 0 degree).
Performing initial dissection using the balloon is far better than dissection using the telescope 0 or 30 degrees, but definitely more expensive due to the price of the disposable balloon trocar. Perforation of the peritoneum with consecutive pneumoperitoneum usually appears during lateral dissection and the dissection of hernia. If such a situation occurs, a Verres needle inserted in upper quadrant of the abdomen usually allow evacuation of pneumoperitoneum and the possibility to complete the laparoscopic procedure without conversion.
Balloon dissection is useless and expensive in my opinion. It merely helps for the easiest part of the dissection : the central part. It does not help for the more difficult lateral dissection. On top of that , using the balloon can help you to dissect in a plane
Yes Charles Gheldere.... balloon dissection is an useless but an expensive gadgets.
Peritoneal tears are a recognised complication of extraperitoneal inguinal hernia repair (TEP) and can necessitate conversion to transabdominal pre-peritoneal (TAPP) repair due to loss of the extraperitoneal space. To avoid this conversion, which carries with it risks of further complications, it is possible to decompress the pneumoperitoneum and complete the TEP repair. This decompression can be performed with a Verres needle at Palmer’s point; however, this decompression is slow, rarely provides a complete decompression and carries the risk of further complications .
Good technique is the only answer,by way of creating an extra peritonial space and careful dissection of the sac.Ba loon dissection is good but not fool proof.
Good surgical technique is the most important, specially in the lateral dissection and hernia dissection.
Pneumoperitoneum occurrence significantly prolongs the length of operation.
In identified peritoneal tear endoscopic stapling and pre-tied suture loop ligation are safe and quick techniques for the closure of peritoneal tear during TEP.
When no peritoneal tears identified, Verres needle inserted in upper quadrant of the abdomen may helps in evacuation of pneumoperitoneum.
IF difficult, convert to TAPP
Pneumoperitoneal decompression by Verress needle is counterproductive. It leads to ongoing pressure changes between compartments and continous movement of the peritoneum. We made the same mistake in our upstart many years ago.
My advice, as I teach in my immersion clinics, is to tilt the patient to a moderate Trendelenburg position to move bowel away from the inguinal area by gravitation and wait for equalized pressure between compartments. The space is of course a little less than without pneumoperitoneum, but still much better than the everchanging space with Verress' decompression. TAPP is a rescue option, but has never been needed in our clinics experience.
As for the size of mesh we never use a size less than 15x13 cm. If that doesn't fit the trocar placement (lower trocar 3 fingers from os pubis) or the dissection is inadequate.
Often the peritoneal tears are small and even undetectable, but when the size/topography leads to risk of mesh exposure, i.e. not complete peritoneal cover we use clips/suture/loop to approximate the peritoneum - and in rare cases choose a coated mesh.
The balloon dissector is not useless, but very helpful in a teaching environment where new surgeons are introduced to the method all the time.