Laparoscopic inguinal hernia repair - Tips and tricks by Dr D.U.Pathak

1. Lap groin hernia repair
Dr D.U.Pathak
MS FACRSI FIAGES FMASI
Shalby hospital Jabalpur (M.P)

2. The Logic ???
Results 1 - 10 of about 283,000 for is laparoscopic hernia
useful
IS LAPAROSCOPIC HERNIA REPAIR
USEFUL
IS LAPAROSCOPIC HERNIA REPAIR
USEFUL ? Dr Arun Prasad, MBBS (AFMC),
MS (New Delhi), FRCS (Edin) & FRCS
(Glas). Senior Consultant, Minimal Access
Surgery, ...
www.angelfire.com/ar/laparoscopy/hernia.h
tml -

3. This is now the history …

4. Enter the Dragon
• Remove reluctance.
• Get trained.
• Make a team.
• Fix the O.T.
• Wait for the appropriate patient.

5. SGRH Classification
• Prediction of operative difficulty.
• Based on Reducibility
Degree of descent
& Previous repair.
• Higher grades are for higher centers.

6. Grade 1
• Small, direct , reducible.
• Disappears on lying down.
• A finger breadth defect.
• Sac is easily separated from fascia
transversalis.
This one is for the beginners.

7. Grade 2
• Small, indirect, incomplete & reducible.
Sac will not require transection.
• Moderate size direct hernia, thumb sized
defect in direct floor.
Sac requires separation.
• Reducible femoral.

8. Grade 3
• Moderate sized indirect reducible.
• Sac up to the neck of scrotum.
Will require transaction & proximal ligation.
• Large reducible direct defect, big bulge.
Difficult medial dissection, distorted anatomy.
• Recurrent hernia.
Dissection difficult near the cord & laterally.

9. Grade 4
• Large, Reducible, Indirect hernia inguino scrotal.
• Sac up to scrotum. Testes cannot be palpated
separately in erect position.
• May contain omentum or small bowel.
The deep ring is enlarged. Difficult dissection.
Medial displacement and stretching of inf
epigastric. Higher incidence of
seroma/hematoma.
Not for the surgeon
with average set up and average exposure

10. Grade 5
• Large complete partially or irreducible.
• Sliding, with bladder or bowel.
• Irreducible femoral.
Bulky sac with adhesions. Injury to the contents likely.
This is Hegar Hernia the horrible !
This piece of cake is for advanced surgeons of
advanced centers.

11. Diagnostic
Adhesiolysis
Lap chole
Lap Append
Pelvic surgery
TAPP
TEP

12. Explore once by open method
Do few Stoppa’s operations.

13. Stoppa’s video

14. Lap repair – The different venture!
The Different –
• Anatomy,
• Anesthesia,
• Mesh,
• Placement,
No wonder it needs a different courage too!

15. TEP or TAPP
• Personal choice.
• The beginning is tedious in TEPP,
becomes easy as you progress
Where as
• The beginning is easier in TAP and
becomes more and more difficult as you
are near finishing.

16. Attempt, no choice, but don’t go
alone…

17. The new terrain
• Clear view.
• Fearsome magnification – Inferior
epigastric.
• The unseen - Ileopubic tract.

18. The pre flight preparations
• Plan it well.
• Sterilization can not be compromised.
• Most of the instruments can be
autoclaved.
• Camera head, cords can be ETO
sterilized.
• Forget formalin chamber.

19. Choose the method
• Master in both TEP & TAPP.
• Do not become member of a group
advocating only one.
• TEP is more physiological ; TAPP more
convenient.
• Simple herniae demand TEP, Complicated
ones TAPP.

20. TEP (Total Extra Peritoneal)
• Position of the patient.
• Port placement.
• Entry.
• Creation of space.
• Dissection / landmarks.
• Preparation of mesh.
• Laying / Fixation.

21. Anesthesia / Position / Ports
• Always G.A.
• Trendelenberg position.
• Surgeon on one side.
• Monitor at foot end.
• Ports all three in midline – Umblical
camera, Suprapubic and Midway. Few
prefer triangulation by ports in the flanks.

22. Entry Open by Hasson’s
• Infra umbilical incision away from the
midline, over one of the recti.
• Retract the muscle laterally & slide over
the post rectus sheath.
• Fix the Hasson’s securely to avoid
leakage.
• Only Dr Duluq enters blind, supra pubic.

23. Making balloon
• Double layer of Latex over the suction
canula tip.
• Check for leak.
• Enter in midline to create the space.
• Infiltrate gradually with 150-200 ml saline.

24. Telescopic dissection
• Most popular.
• ‘0’ degree 10 mm mandatory.
• Go straight, aim for pubic tubercle.
• Then identify structures medial to lateral
and keep going.
• Scissors with energy is a good tool.
• Some like spatula or hook.

25. The Telescopic balloon
dissection

26. Problems …
• Gas leakage.
• Surgical emphysema.
• Bleeding.
• Smoke.

27. Convert to 30 degree

28. Keep going laterally
• Beware of the dangerous arcade of
vessels near pubic tubercle.
• Trace Cooper’s and run over ileopubic
tract.
• Identify and separate sac from cord.
• Preserve vas and go lateral over psoas,
up to the ant sup iliac spine.

29. Iliopubic tract
• Is the Laxman rekha in Lap hernia.
• All important structures are below it.
• Never Tuck or Staple below it.

30. Our familiar view

31. After removing Aponeurosis

32. After removing peritoneum

33. The angle of Doom…
• Separate the peritoneum and fascia
transversalis.
• Sac is also part of peritoneum.
• First you see the angle of doom, make it a
triangle by pulling the peritoneum above
and making post abd wall bare.

34. The nerves ??
• Do not try to see them.
• All are below the ileopubic tract.

35. Various mesh’s

36. The ideal mesh
• Is inert.
• Not carcinogenic.
• Resists mechanical strains.
• Can be fabricated in the form required.
• Easily sterilizable.
• Affordable & Available.

37. Unfortunately
No mesh
And
No wife is ideal !!!

38. Placing the mesh …
• Achieve complete haemostasis.
• It should be of adequate size – mostly
12x15 cms is good.
• Both should overlap at symphysis in
bilateral.
• It should go untouched from packet to
hernia bed ; change gloves, place it on
fresh sheet ; unpeel it at the last moment.

39. Please do not do this …

40. Introducing & spreading …
• From fancy roll of SGRH to crude ones.
• Meticulous insertion saves time of spread.
• At least 5 cms around Fruchaut’s.
• Midline overlap in bilateral.

41. Cover the Frauchet’s

42. Laying …

43. To fix or not ?

44. Fixation options
• Tuckers.
• Staples.
• Sutures.
• Glue.
• Two point – prevents rotation.
Leave it to God (The intra abdominal pressure)

45. Accidental Pneumo
• Put in Veress or a 5 mm port.
• Continue dissection

46. Deflation
• Keep mesh through out under vision and
straight.
• It is hear it rolls and leads to recurrences!

47. Compression & scrotal bandage
• In big hernias for seroma prevention.
• Normally not necessary.

48. Drain ?

49. Seroma
• Manage conservative.
• Be reluctant for even aspiration.
• Most of them disappear in few weeks.
• It is a sequel not complication.

50. Fear for infection …

51. Recurrence
• Missed sac.
• Wandering mesh over hematoma.
• Inadequate dissection.
• Small mesh – may displace, may enter the distal
sac.
• Too big – may roll.
• The fancy slit made for cord –
old habits die hard.

52. TEP video

53. TAPP
• Good for complicated ones.
• Entry into the peritoneum through
umbilicus.
• Involves all possible complications of
Pneumo peritoneum ; should be informed.

54. TAPP ..
• Reduce the contents.
• Semi lunar incision above the defect.
• The dissection is same.
• Familiar anatomy make your start good.
• The speed lessens as you go more and
more underneath.
• Structures , placement all same as TEP.

55. TAPP …
• The last part is most tedious – suturing
peritoneal flap over the mesh if you have
not mastered intra corporeal suturing.
• Shabby and costly alternative are tuckers
or staples.
• No need to place drain.

56. TAPP video

57. Conversion
• Be happy if you need to, because you
would be saved of a catastrophe.
• Conversion for my teacher is to pick up a
10 mm.
• For some it could be from TEP to TAPP.
• For me – no confusion – it is
Lichenstien’s.

58. The expectations …

59. When will I start ??

60. Thanks