Transcript LAPAROSCOP*C *NGU*NAL HERN*A SURGERY TECHN*CAL

LAPAROSCOPIC INGUINAL
HERNIA SURGERY
TECHNICAL ASPECTS, CASE
SELECTION
Asoc. Prof.Dr. Orhan Yalçın
Ministry of Health Okmeydanı Education and Research Hospital
İstanbul / Turkey
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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.
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IPOM TECHNIQUE
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One from umbilicus
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Other two trocars , lateral to rectus muscles
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Mesh is placed to overlap the defect
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Fixed with tacks, sutures or combination
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It is not used in routine practice
TAPP TECHNIQUE
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Trocar sites are same for IPOM
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Periton is incised 2 cm above to hernia defect at the
medial umbilical ligament and peritoneal flaps are
created
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Dissection of hernia sac
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Placement of mesh
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Closure of peritoneum
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In TAPP and TEP, dissection area and mesh placement
area the same. Difference is “ to approach to the pre
peritoneal area”
TEP TECHNIQUE
Trocar position : There are two techniques
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Umbilicus ( 10 mm )
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Above the pubic arch ( 5 mm )
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Midway between two trocars ( 5 mm)
2.
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Umbilicus ( 10 mm )
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Above the pubic arch ( 5 mm )
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Medial to anterior superior iliac spine or the side of hernia (5 mm )
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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
C1- 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.
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TEP CONT.
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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.
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IN GENERAL
IPOM
Advantages
-Minimal dissection
-Minimal postoperative pain
Disadvantages
-Risk of bowel injury
-Adhesive complications or herniations
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TAPP
Advantages
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Easier to learn, anatomy is more familiar for the
surgen.
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The work space is larger than TEP
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Allows to see the hernia sac contents
Disadvantages
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Potential intra abdominal injury risk
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More time consuming than TEP
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Potential adhesive complication at where peritoneum
has been closed
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.
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CASE SELECTION
TAPP preference
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Recurrence after TEP
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Patients in who had radical prostatectomy operation
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Patients who has midline incision for major surgery
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In the absence of this two conditions TEP is preferred
technique.
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LAPAROSCOPY CONTRINDICATIONS
Absolute
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Infection
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Coagulopathy
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In whom general anesthesia has increased risk
Relative
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Previous surgery in Retzius space
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Incarcerated sliding scrotal hernia
THANK YOU
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