Extra Peritoneal Space The Last Frontier , Dr Jorge Daes

Introduction

The speaker introduces himself and the Sanadevan Education Foundation, which was launched in 2012. He explains that due to COVID-19, they have moved their platform online and have had a good global acceptance.

History of Sanadevan Education Foundation

• The foundation was launched in 2012 by Nannadardhan Prabhu Sashion Han Kim from Korea.

• They started with contact classes, lectures, and hands-on training programs in their hospital.

• Due to COVID-19, they moved their platform online from July onwards this year.

Global Acceptance

• They have been airing live surgeries and having live lectures with eminent faculties.

• Their last webinar had 790 participants across the globe.

• They have one Facebook group with more than 600 participants and two WhatsApp groups of 256 each.

Professor Orgy Days

The speaker introduces Professor Orgy Days as an eminent figure in the international arena of AWR and bariatric surgery.

About Professor Orgy Days

• He is known for his contribution to the he approaches in AWR.

• He is a researcher and inventor of new techniques.

• He has numerous publications starting from 1999 onwards.

Dr. Jignesh Gandhi

The speaker introduces Dr. Jignesh Gandhi as a young enthusiastic surgeon committed to teaching who is known as a champion in AWR.

About Dr. Jignesh Gandhi

• He is committed to teaching his students and was seen as a star in IHC Delhi last year.

• He is known as a champion in AWR.

Upcoming Webinar

The speaker announces an upcoming webinar on uterine transplant by Dr. Shyles Puntambakar, the first surgeon to do uterine transplant in India and probably second serving the world.

Details of Upcoming Webinar

• The webinar will be on uterine transplant.

• Participants are requested to mute their mic on entry and reveal their identity if logging in from outside India.

• Contact information is provided for those who want to get in touch with the Sanadevan Education Foundation.

Introduction to Extra-Peritoneal Space and TEP Technique

Dr. Juan Carlos Medina-Porqueres introduces the concept of extra-peritoneal space and discusses the advantages and disadvantages of working in this space. He also provides a brief history of the totally endoscopic extra-peritoneal (TEP) approach for hernia repair.

Advantages and Disadvantages of Working in Extra-Peritoneal Space

• The extra-peritoneal space extends from the peritoneum to the investing fascia of muscles in the anterior, lateral, posterior, and pelvic walls.

• General advantages of working in this space include decreased risk of bowel injury, less need for bowel retraction, less postoperative ileus, less potential for adhesion formation, and less adverse hemodynamic effects when compared with intraperitoneal approach.

• Disadvantages include steep learning curve requiring proper training orientation, difficulty accessing due to prior extraperitoneal surgery may contraindicate procedure, creation of large potential space gives opportunity for complications like hematomas and seromas to develop.

Three Ways to Access Extra-Peritoneal Space

• Open approach

• Hybrid approach - example is emulous technique described by Rainbow

• Totally endoscopic approach - main topic of presentation

History of TEP Approach

• First described by Ma Bartel in 1969

• Popularized around 1994 with introduction of balloon by Heroes

• Described as unaltered for over 25 years but has low implementation rate

• ETEP technique introduced in 2009 to enhance useful extra-peritoneal space for repair of inguinal, ventral, and lumbar hernias.

Introduction

The speaker introduces the topic of hernia repair and discusses their experience with publishing in Spanish and English. They also mention conducting clinical immersion courses in 2012.

Experience with Hernia Repair

• In complex cases, the speaker publishes their experience first in Spanish and then in English.

• In 2012, they conducted clinical immersion courses in their region to repair various types of hernias.

• They published their third L4 lumbar hernia repair.

Evolution of ETEP Technique

The speaker discusses how the ETEP technique evolved over time with the help of other surgeons.

Contributions from Other Surgeons

• Without a group of smart surgeons and friends, the ETEP technique would have remained provincial.

• Debbie Chap helped conceptualize ETEP as a concept rather than just a technique.

• Igor Belyansky revolutionized the field by describing crossover, which allowed for access to extra peritoneal space beyond known spaces.

• Yuri Novitsky witnessed one of their ETEP operations for inguinal hernia and invited them to publish his popular textbook on surgery.

• Brian Jacob's International Hernia Collaboration allowed for worldwide dissemination of this technique.

Traditional vs. ETEP Technique

The speaker compares traditional techniques to the ETEP technique and demonstrates port placement for an inguinal hernia repair using ETEP.

Port Placement for Inguinal Hernia Repair Using ETEP

• The traditional technique places the camera in the red spot, while ETEP has multiple possible camera placements.

• The most important instrument for ETEP is an S pediatric retractor that facilitates access to extra peritoneal space.

• Two common port setups for ETEP are shown, with the surgeon and camera operator on the same side opposite the hernia side.

• A balloon dissector is used to prepare the area for placement of working ports, which are inserted through small incisions.

• Dissecting peritoneum free from posterior fascia and dividing arc laterally but medial to semilunar line is a common approach.

Conclusion

The speaker concludes by showing an example of using a 5mm camera through the lowest trocar and how they didn't suspect nine years ago that they were performing at boron upta.

Final Thoughts

• Using a 5mm camera through the lowest trocar makes procedures much easier under perfect vision.

• They didn't suspect nine years ago that they were performing at boron upta.

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