LAPAROSCOPIC EXTRAPERITONEAL HERNIA REPAIR This is a case of pre-peritoneal hernia repair using the pre-peritoneal distention balloon. This technique has a low recurrence rate and almost no incidence ofneuropathy. Patients undergoing this procedure return to their regular activities within 4 days after surgery. The following pictures also show the use of the ORIGIN MEDSYSTEMS 5mm tacker used to fix the mesh over the hernia defect. A midline 10 mm incision is made just below to the umbilicus. The dissection is carried out to the posterior rectus sheath which is divided along its fibers exposing the pre-peritoneal space. A pre- peritoneal balloon trocar is inserted along the posterior rectus sheath aiming toward the pubis. The trocar must be palpated above the pubis to avoid injury to the bladder. A 0 degree laparoscope is inserted into the trocar and the collapsed balloon is seen . As the balloon is inflated, soft tissue can be identified as seen in this picture. Note the pubic bone and the transversalis pseudo-sac. After the balloon is left in place for 2 minutes, it is replaced by the Origin blunt tip balloon trocar to prevent air leakage from the trocar site. Using a 45 degree laparoscope the dissection starts by mobilizing the epigastric vessels cephalad. The aim is to sweep the peritoneum both superiorly off the abdominal wall and inferiorly along the retroperitoneum to the level of the umbilicus. Identification of the peritoneum is critical, and loose tissues should be dissected in order that the peritoneal edge be revealed. The cord structures are grasped and pulled towards the feet revealing the peritoneal edge. In this case a direct sac lays on the cord structures, as opposed to an indirect sac which would be seen traversing the internal ring. In this picture the transversalis pseudo-sac is reduced and will be tacked to the rectus sheath. A 4 X 6 inch polypropylene mesh is introduced into the pre-peritoneal space through the camera trocar. The mesh is manipulated to cover both the indirect and direct spaces. The upper edge is attached to the anterior abdominal wall. The mesh lays over the cord structures. No cut is made to avoid injury to the cord. (Stopa’s posterioralization). The ORIGIN MEDSYSTEMS 5mm tacker is now used to fix the mesh. From two to three staples are inserted into the rectus muscle superior to the epigastric vessels. The mesh is then tacked to Cooper’s ligament. Two more staples are placed lateral to the epigastric vessels. Laparoscopy.com would like to thank Mark A. Seilo and Origin Medsystems, Inc. for their video contribution entitled Extraperitoneal Hernia Repair with PDB and Tacker by Guy R. Voeller, M.D., Version Two. The Tacker system is a registered product of Origin Medsystems. For further information regarding the Tacker, please contact Mark A. Seilo.