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| Name | eTEP TAR | Dr Atul Mishra |
| Video Uploader | Video From Dr. Atul Mishra |
| Upload Date | This Video Uploaded At 04-04-2018 15:36:36 |
| Video Discription | The enhanced view totally extraperitoneal (eTEP) technique is a novel technique for the repair of ventral and incisional hernias. The eTEP technique has been initially used for inguinal hernia repair.The advantages were rapid and effortless creation of large extraperitoneal space with more flexible port placement.It is used for large inguinoscrotal, incarcerated or sliding inguinal hernia.It is also useful for obese patients and those with a short distance between umbilicus and pubis or multiple previous pelvic surgeries. Patients with loss of domain, ulcerated skin, active mesh infection and fistulae are absolute contraindication to eTEP technique.All other patients with ventral or incisional hernia can be suitable candidate for eTEP approach with or without TAR (Transverse Abdominal Release) . The eTEP approach is basically starting the dissection in one of the retrorectus spaces and then crossing over to the contralateral retrorectus space and then connecting the two spaces .Port placement and site of crossover depends on the defect location . Lower midline defects : 1st port is placed in left subcostal area just medial to linea semilunaris .2nd and 3rd ports are placed at and below umbilical level just medial to linea semilunaris on left side .4th port is placed through upper aspect of right rectus abdominis muscle . Balloon dissection is used at port 1 to develop left retrorectus space after dividing anterior rectus sheath .Left retrorectus space is created in caudal direction upto pubis .Medial aspect of left posterior rectus sheath is incised above the level of umbilicus and preperitoneal space is entered superficial to falciform ligament .Right posterior rectus sheath is identified and medical aspect of it is incised and released from cranial to caudal direction .The retrorectal dissection is done in caudal direction resulting in bilateral release of posterior rectus sheath (PRS) Upper midline defects 1st port is just below umbilical level on right side just medial to linea semilunaris .2nd and 3rd ports are placed on right and left suprapubic region medial to linear semilunaris . The space of retzius is developed bilaterally .PRS is identified and divided from caudal to cranial direction . The hernia sac is dissected and divided sharply.If the defect size is more than 10cm TAR is done. The transversus abdominis is released 0.5 to 1cm medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly to the space of retzius inferiorly and laterally to the retroperitoneum . A space between transversus abdominis and facia transversalis is created . This step is started in upper 3rd of abdomen where medial fibres of the transversus abdominis are easiest to identify and separate .This preserves the neurovascular bundle innervating the medial abdominal wall . The posterior rectus facia is advanced medially and closed .The mesh is placed on a sublay and the linea alba is restored ventral to the mesh creating a functional abdominal wall, while pneumoperitoneum is dropped to 8mm of mercury. The normal polypropylene mesh of size 30 cm x30 cm is deployed widely covering the defect.Mesh can be fixed with trans fascial sutures, tackers or 10 ml fibrin glue. It can be left without fixation also. |
| Category | People & Blogs |
| Tags | enhanced view totally extraperitoneal | eTEP | ventral and incisional hernia | port placement | inguinoscrotal | incarcerated | sliding inguinal hernia |
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