LAPAROSCOP I C I NGU I NAL HERN I A SURGERY TECHN I CAL ASPECTS, CASE SELECT I ON

1. LAPAROSCOPIC INGUINAL HERNIA SURGERY TECHNICAL ASPECTS,CASE SELECTION Asoc. Prof.Dr. Orhan Yalçın Ministry of Health Okmeydanı Education and Research Hospital İstanbul / Turkey

3. There are three techniques 1- Intra peritoneal only mesh ( IPOM ) 2- Trans abdominal pre peritoneal ( TAPP ) 3- Totally extra peritoneal ( TEP ) In all techniques, three trocars are used.

4. IPOM TECHNIQUE - One from umbilicus - Other two trocars , lateral to rectus muscles - Mesh is placed to overlap the defect - Fixed with tacks, sutures or combination - It is not used in routine practice

5. TAPP TECHNIQUE - Trocar sites are same for IPOM - Periton is incised 2 cm above to hernia defect at the medial umbilical ligament and peritoneal flaps are created - Dissection of hernia sac - Placement of mesh - Closure of peritoneum - In TAPP and TEP, dissection area and mesh placement area the same. Difference is “ to approach to the pre peritoneal area”

6. TEP TECHNIQUE Trocar position : There are two techniques 1. - Umbilicus ( 10 mm ) - Above the pubic arch ( 5 mm ) - Midway between two trocars ( 5 mm) 2. - Umbilicus ( 10 mm ) - Above the pubic arch ( 5 mm ) - Medial to anterior superior iliac spine or the side of hernia (5 mm )

7. TEP –CONT. A- First trocar is applied in a plane between posterior surface of rectus muscle and posterior rectus sheath and peritoneum with balloon – preperitoneal retzius area are dissected B- Second and third trocars are inserted C- 1- First landmark is pubic bone and Cooper ligament 2- Medially direct hernia reduction 3- Laterally indirect hernia sac: superio-laterally from spermatic vessels. Medially vas deferens is dissected.

8. TEP CONT. - Cord parietalization to a point that crosses iliac vessels Preperitoneal dissection should be so big that “ When preperitoneal area is closed, prosthesis should lie flat in the preperitoneal space and should not roll up.” D- Placement of mesh ( 12 x 15 cm polypropilen, polyester from umbilical port ) E- Fixation with tacks, staples, biologic glue. Fixation should be applied superior to iliopectineal ligament.

9. IN GENERAL IPOM Advantages -Minimal dissection -Minimal postoperative pain Disadvantages -Risk of bowel injury -Adhesive complications or herniations

10. TAPP Advantages - Easier to learn, anatomy is more familiar for the surgen. - The work space is larger than TEP - Allows to see the hernia sac contents Disadvantages - Potential intra abdominal injury risk - More time consuming than TEP - Potential adhesive complication at where peritoneum has been closed

11. TEP ADVANTAGES -reduced risk of potential intra abdominal injury -reduced risk of adhesive complications -operation time is less than TAPP DISADVANTAGES -learning curve is longer than TAPP -the working space is limited - inadvertently peritoneum can be torn.

12. CASE SELECTION TAPP preference -Recurrence after TEP • Patients in who had radical prostatectomy operation • Patients who has midline incision for major surgery • In the absence of this two conditions TEP is preferred technique.

13. LAPAROSCOPY CONTRINDICATIONS Absolute - Infection - Coagulopathy - In whom general anesthesia has increased risk Relative - Previous surgery in Retzius space - Incarcerated sliding scrotal hernia

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