Inguinal Hernia Laparoscopic repair

1. Inguinal HerniaLaparoscopic repair SakibMotalib University of Kentucky College of Medicine, M1

2. Inguinal Hernia Repair • About the pathology • Patient Symptoms • Laparoscopic Treatment • Procedure • Types of the Procedure: TEP vs. TAPP • Steps for the repair • Post-Operative Care • Benefits of Laparoscopy vs. Open Surgery • Acknowledgements • Questions

3. About Inguinal Hernia’s • The inguinal region has anatomical and clinical significance • Inguinal canal components: • Males = spermatic cord • Females = Round ligament • Formation of the hernia involves protrusion of peritoneum through a defect, forming a sac. • Two types of hernia’s for inguinal region: direct and indirect

4. Direct Inguinal Hernia • Hernia protruding through a weak point in the fascia medial to epigastricvessels • Structures interacted with: • hernia sac • Hesselbach’s triangle

5. Indirect Inguinal Hernia • hernia protrudes thru the inguinal ring, lateral to epigastricvessels • Structures interacted with: • spermatic cord • vas deferens • testicular arteries

6. Causes of Inguinal Hernia • Increased pressure within abdomen: • Severe coughing • Straining during heavy lifting • Straining during constipation • Obesity • Pregnancy • Aging • Genetic predisposition • Pre-existing weak spot

7. Patient Symptoms • Mass/bulge in the groin • A burning sensation in the groin • Strangulated hernia: • Sudden pain, nausea, vomiting

8. Laparoscopic treatment • Position of patient: • Trendelenburg • Surgeon positions: • Surgeon on opposite side of hernia • Camera operator opposite side of surgeon • Monitors at feet of patient

9. Laparoscopic treatment • Trocar: 10 mm trocar for camera, 5 mm for operating devices • Camera: 30 degree laparoscope • Operating devices: • Grasper • Fine dissector • Suction-irrigation device • Curved dissector • Finger dissector

10. TAPP vs. TEP • TAPP • trans-abdominal pre-perotenialrepair • Pneumoperitoneum is created by surgeon • Ports placed bilaterally, to either side of the camera

11. TAPP vs. TEP • TEP • Total extraperitonealrepair • Extraperitoneal space is created by surgeon • Using balloons • Ports placed below camera port, along midline

12. Laparoscopic Procedure • TAPP • Make a small incision just above the umbilicus. • Lift up abdominal wall and gently insert Veressneedle • Connect CO2 tube to needle • Switch off gas when desired pneumoperitoneum is created and remove the Veress needle

13. Laparoscopic Procedure • TEPP: • 10 mm skin incision and retract to expose linea-alba (0:21) • small incision is made on the anterior rectus sheath on affected side (0:30) • Start blunt dissection to create a tunnel (1:00)

14. Laparoscopic Procedure • Dissection balloon advanced down into the pubic tubercle (1:20) • Balloon is hand pumped with guide of camera. (1:44) • Dissection balloon removed and replaced with structural balloon (3:36)

15. Anatomy Review

16. Laparoscopic Procedure • Insert ports, and inflate extraperitoneal space with CO2 (5:20) • Bluntly disect away pro-perotineal fat, identifying key organs: • Cooper’s ligament • Epigastricvessels (8:08) • Spermatic cord (11:25)

17. Anatomy Review

18. Laparoscopic Procedure • Bluntly disect away pro-perotineal fat, identifying key organs: • Cooper’s ligament • Epigastric vessels (8:08) • Spermatic cord (11:25)

19. Laparoscopic Procedure • Continued dissection • After further dissection, hernia clearly identified – Indirect hernia (17:55) • Spermatic cord teased away from hernia sac (16:00) • Grab edge of peritoneal sac and drag away from defect and key structures

20. Laparoscopic Procedure • Second hernia on opposite side identified – Direct hernia • Identify the hernia sac and dissect (28:35) • Pull down on plane of attachment, cleaning off fat on the abdominal wall so it does not get in the way of the mesh (32:00)

21. Laparoscopic Procedure • Put in the mesh that will cover the defect (54:00) • polypropylene mesh • Mesh is curved, with label M • Positioning of mesh is significant • Tack mesh in place or no fixation

22. Laparoscopic Procedure • Start suctioning out the CO2 in the peritoneum (1:12:00) • Push down on the mesh with suction • Remove ports, close the patient (close fascial layers, then superficial layers)

23. Dangers/Areas to be Avoided • Triangle of doom • vas deferens medially • gonadal vessels laterally • peritoneuminferiorly • Inside the triangle are the iliac artery and vein

24. Dangers/Areas to be Avoided • Triangle of pain • Contains cutaneous nerves  neuralgia • Major arteries and spermatic vessels • Epigastric vessels • Specific example: tension on vas deferens

25. Post-Operative Care • A prescription for pain medication is given to you upon discharge • Light diet the first 24 hours after surgery • resume regular (light) daily activities beginning the next day • Refrain from any heavy lifting or straining until approved by your doctor. • Follow up appointment with doctor 2-3 weeks after procedure.

26. Advantages/Disadvantages • Advantages • less tissue dissection and disruption of tissue planes • smaller incisions just for the trocars • Less pain postoperatively • earlier return to normal activities for the patient • Disadvantages • Learning curve for the procedure

27. Acknowledgements • James Hoskins, Director of MIS Training Center • Dr. John Roth, Director of Minimally Invasive Surgery

28. Sources • http://www.websurg.com/ref/ot-ot02en195_en.html • http://cme.medscape.com/viewarticle/420354_5 • http://www.webmd.com/digestive-disorders/tc/inguinal-hernia-symptoms • http://www.centralcarolinasurgery.com/forms/JAN/postop%20inguinal%20hernia%2001092009.pdf • Times listed for the procedure : based on Laproscopic inguinal hernia repair DVD; instructors: Dr. Scott Roth [S2]

29. Questions?