Transcript Attachment

Indications:
• For many patients, either a laparoscopic or open
approach to inguinal hernia repair is appropriate
to consider.
•
In experienced hands, outcomes are similar in
terms of hernia recurrence.
The advantages of the laparoscopic
approach are more apparent in the
following situations:
1. Bilateral inguinal hernias.
2. Recurrent inguinal hernia after a prior
open anterior approach.
3. Patients who are undergoing another
laparoscopic procedure who also have
an inguinal hernia.
Laparoscopic approach:
• Totally Extra Peritoneal (TEP)
• Trans Abdominal Pre Peritoneal (TAPP)
Types of Hernia
Direct inguinal hernia
Types of Hernia
Femoral hernia
Types of Hernia
Indirect inguinal hernia
Anatomy
Types of Hernia:
•Direct
•Indirect
•Femoral
•Obturator
Anatomy
LIGAMENTS:
1. Median Umbilical
Ligament-Obliterated
Urachus
2. Medial Umbilical
Ligament- Obliterated
umbilical arteries
3. Lateral Umbilical
Ligament- Inferior
epigastric vessels
Anatomy
•TRIANGLE OF DOOM
•TRIANGLE OF PAIN
Anatomy
. Preperitoneal anatomy for right inguinal hernia displaying vital structures and their
structures and their relationships to indirect, direct, and femoral hernia spaces.
I indirect space, D direct space, F femoral space, EV epigastric vessels, R rectus
muscle, P pubic bone, IT iliopubic tract, CL Cooper’s ligament, V vas deferens,
CVcord vessels, IV iliac vessels, LFN lateral femoral cutaneous nerve.
Patient Position and Room Setup:
1. The patient is supine with both arms tucked.
2. Surgeon stands on the side opposite of the
hernia.
3. The monitor should be positioned at the foot
of the bed.
Patient Position and Room Setup
Port Position:
LIH
Port Position:
BIH
Port Position:
RIH
TAPP Procedure:
Incision of Peritoneum
• incise the peritoneum laterally by the anterior superior iliac
spine at a distance of approximately 3 cm over the internal ring
all the way to the median umbilical ligament.
TAPP Procedure:
Lateral Dissection
Sweep the peritoneum down to view the preperitoneal space.
TAPP Procedure:
Medial Dissection
Sweep the peritoneum down to view the preperitoneal space
TAPP Procedure:
Medial Dissection
TAPP Procedure:
Hernia sac Dissection
TAPP Procedure:
Fixation of Mesh:
• Select a large (10 cm by 15 cm) piece of mesh (usually
polypropylene or polyester based) and place it into the
abdomen via the10-mm port.
TAPP Procedure:
Fixation of Mesh:
• Position the mesh so that the entire myopectineal orifice
is covered with good superior, medial, and lateral overlap.
• The mesh necessarily overlaps the cord structures in
order to cover the indirect space completely.
• It is important that the peritoneum and sac be reduced
proximal to where the inferior border of the mesh will lie
so that it cannot slip back under the mesh and lead to a
recurrence.
TAPP Procedure:
Fixation of Mesh:
Bilateral Hernia
For bilateral hernias, perform a similar dissection and mesh
placement on the contralateral side.
TAPP Procedure:
Closure of Peritoneum:
• The peritoneal flap is closed back over the mesh either
using a staple fixation device or an absorbable suture.
• It is important that there be no gaps in the peritoneal
closure through which bowel could herniate.
Thank You