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INGUINAL HERNIA REPAIR: OPEN vs TEP APPROACHES

INGUINAL HERNIA REPAIR: OPEN vs TEP APPROACHES. Prof Dr Orhan Alimoğlu Department of General Surgery Istanbul Medeniyet University. Inguinal hernia. One of the most common surgical problem in daily practice Different operations and approaches Gold standard : repair with mesh

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INGUINAL HERNIA REPAIR: OPEN vs TEP APPROACHES

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  1. INGUINAL HERNIA REPAIR:OPEN vs TEP APPROACHES Prof Dr Orhan Alimoğlu Department of General Surgery Istanbul Medeniyet University

  2. Inguinal hernia • One of themostcommonsurgical problem in dailypractice • Differentoperationsandapproaches • Goldstandard: repairwith mesh • Currently • Lichtensteinherniarepair • Endoscopictotallyextra-peritoneal (TEP) repair • Laparoscopic trans-abdominalpreperitoneal (TAPP) repair

  3. General Precautions • No place for routine antibiotic and thromboembolic prophylaxis, only in selected patients • Risk factors for wound and mesh infection • Advanced age • Corticosteroid use • Immunosuppression • Obesity • Diabetes • Malignancy

  4. Characteristics of mesh • Large vs small • Low-weight vs heavy weight • Micropore vs macropore • Conclusion: Efficiency of lighter mesh with larger pores only during the first few postoperative weeks

  5. Lichtenstein Inguinal Hernia Repair • Large mesh (7*15 cm) • 2 cm medial to the pubic tubercle, 3–4 cmabove the Hesselbach’s triangle, and 5–6 cm lateral tothe internal ring, trimming3–4 cm from its lateral side • Crossingandsuturing tails of mesh behind spermatic cord • Securing mesh with two interrupted sutures on upper edge and one continuous suture with no morethan three to four passes on lower edge of mesh • Keeping mesh with a slightly relaxed, tented up, ordome-shapedconfiguration • Identification and protection of the ilioinguinal, iliohypogastric,and genital nerves

  6. Advantages • Every type of inguinal hernia • Local anesthesia • Easy to learn and perform • Low rate of recurrence • Gold standard?

  7. Disadvantages • Postoperative chronic pain • Higher than TEP or TAPP ? • Return to daily activity • Later than TEP or TAPP ?

  8. TEP Inguinal Hernia Repair • Technique • Trocars • Direct access of one subumblical 10 mm and two 5 mm at the midline • Preperitoneal dissection • Dissection of hernial sac • Parietalization of spermatic cord and its content • Placement of mesh

  9. Technical difficulties • Preperitoneal space creation • Baloon dissection in early learning curve besides its cost • Peritoneal injury • Loss of exposure • Closure of defect via pretied suture, loop ligation, endoscopic stapling or endoscopic suturing • Port-site closure • Closure of fascial defects larger than 10 mm

  10. Dissection and Landmarks • Superior • Subumblical area • Inferior • Space of Retzius • Inferolateral • Psoas muscle and Bogros space • Medial • Beyond midline • Pubic bone • Cooper’s ligament • Inferior epigastric vessels • Cord structures • Myopectineal orifice boundaries • Fascia over psoas muscle

  11. Controversies • Preoperative urinary catheterization • Preoperative emptying of urinary bladder by him/herself • Catheterization in difficult and long-standing surgery • Access for pneumopreperitoneum • Subumblical direct trocar vs suprapubic Veress

  12. Technical Key Points • Inversion and anchoring of direct sac to Cooper’s ligament to decrease risk of seroma and hematoma formation • Proximal ligation and distal division of large indirect hernia sac • Drains only in selected patients • Fixation of mesh in hernias greater than 4 cm

  13. Recommendations • Larger mesh (12*17 cm) in larger hernia (>3-4 cm) • Stapled fixation of mesh to the symphysis, Cooper’s ligament and rectus muscle in larger direct hernia (>3-4 cm) • Overlapping of mesh approximately 1-3 cm lateral to the spina iliaca anterior superior in large indirect hernias (>4-5)

  14. Advantages of TEP repair • Early return to daily activities • Low rate of postoperative chronic pain • Exploration of contralateral side for hidden hernias ?

  15. Disadvantages of TEP repair • General anesthesia; regional anesthesia in selected patients • Longer learning curve • At least 50 to 60 cases • Applicability on incarcerated and scrotal hernias • Applicability on patients with previous lower abdominal surgery

  16. Learning Curve for TEP repair • Can J Surg, 2012, 55: 33-6 • 700 patients • Learning curve after the first 60 cases • A plateau of less than 30 min for duration of surgery • A plateau of 1 day for length of stay • Conclusion: learning curve for TEP hernia repair as 60 cases for a beginner surgeon

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