Post on 01-Apr-2015
Inguinal HerniaLaparoscopic repairSakib MotalibUniversity of Kentucky College of Medicine, M1
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
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
Direct Inguinal Hernia
Hernia protruding through a weak point in the fascia medial to epigastric vessels
Structures interacted with: hernia sac Hesselbach’s triangle
Indirect Inguinal Hernia
hernia protrudes thru the inguinal ring, lateral to epigastric vessels
Structures interacted with: spermatic cord vas deferens testicular arteries
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
Patient Symptoms Mass/bulge in the
groin A burning sensation
in the groin
Strangulated hernia: Sudden pain,
nausea, vomiting
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
Laparoscopic treatment Trocar: 10 mm trocar for
camera, 5 mm for operating devices
Camera: 30 degree laparoscope
Operating devices:1. Grasper2. Fine dissector3. Suction-irrigation device4. Curved dissector5. Finger dissector
TAPP vs. TEP TAPP
trans-abdominal pre-perotenial repair
Pneumoperitoneum is created by surgeon
Ports placed bilaterally, to either side of the camera
TAPP vs. TEP TEP
Total extraperitoneal repair
Extraperitoneal space is created by surgeon Using balloons
Ports placed below camera port, along midline
Laparoscopic Procedure TAPP
1. Make a small incision just above the umbilicus.
2. Lift up abdominal wall and gently insert Veress needle
3. Connect CO2 tube to needle4. Switch off gas when desired
pneumoperitoneum is created and remove the Veress needle
Laparoscopic Procedure TEPP:
1. 10 mm skin incision and retract to expose linea-alba (0:21)
2. small incision is made on the anterior rectus sheath on affected side (0:30)
3. Start blunt dissection to create a tunnel (1:00)
Laparoscopic Procedure4. Dissection balloon
advanced down into the pubic tubercle (1:20)
5. Balloon is hand pumped with guide of camera. (1:44)
6. Dissection balloon removed and replaced with structural balloon (3:36)
Anatomy Review
Laparoscopic Procedure
7. Insert ports, and inflate extraperitoneal space with CO2 (5:20)
8. Bluntly disect away pro-perotineal fat, identifying key organs:
• Cooper’s ligament• Epigastric vessels
(8:08)
• Spermatic cord (11:25)
Anatomy Review
Laparoscopic Procedure
7. Bluntly disect away pro-perotineal fat, identifying key organs:
• Cooper’s ligament• Epigastric vessels
(8:08)
• Spermatic cord (11:25)
Laparoscopic Procedure9. 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
Laparoscopic Procedure10. Second hernia on
opposite side identified – Direct hernia
• Identify the hernia sac and dissect (28:35)
11. 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)
Laparoscopic Procedure
11. 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
Laparoscopic Procedure
12. Start suctioning out the CO2 in the peritoneum (1:12:00)
Push down on the mesh with suction
13. Remove ports, close the patient (close fascial layers, then superficial layers)
Dangers/Areas to be Avoided Triangle of doom
vas deferens medially
gonadal vessels laterally
peritoneum inferiorly
Inside the triangle are the iliac artery and vein
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
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.
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
Acknowledgements James Hoskins, Director of MIS Training
Center Dr. John Roth, Director of Minimally
Invasive Surgery
Sources http://www.websurg.com/ref/ot-ot02en195_e
n.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]
Questions?