How to Treat Recurrence After TEP

  • 1,190 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
1,190
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
38
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • Reference #12-can’t get it online; 6-got it
  • Ref 27, 28-got ‘em
  • Ref 18-didn’t get it—try online at home with membership; 19, 20-got ‘em
  • Ref 29-can’t get it online

Transcript

  • 1. How to Treat Recurrence after TEP George S. Ferzli, M.D., F.A.C.S. Professor of Surgery SUNY Health Sciences Center Brooklyn New York George Al-Khoury,M.D.
  • 2. THREE OPTIONS
      • Open inguinal approach
      • TAPP
      • TEP
  • 3. Repair of recurrences after endoscopic repair TEP 1 Open 7 0 8 Richards 2004 TEP 12 12 Ferzli 2004 TEP 2 TAPP 3 Open 18 23 23 Tamme 2003 TAPP 4 6 6 Chowbey 2003 TAPP 0 46 Leibl 2000 TAPP 9 34 Knook 1999 TAPP 29 Open 4 11 34 Felix 1998 Repair Primary TEP Cases Study
  • 4. Repair of recurrences after endoscopic repair TEP 1 Open 7 0 8 Richards 2004 TEP 12 12 Ferzli 2004 TEP 2 TAPP 3 Open 18 23 23 Tamme 2003 TAPP 4 6 6 Chowbey 2003 TAPP 0 46 Leibl 2000 TAPP 9 34 Knook 1999 TAPP 29 Open 4 11 34 Felix 1998 Repair Primary TEP Cases Study
  • 5. Repair of recurrences after endoscopic repair TEP 1 Open 7 0 8 Richards 2004 TEP 12 12 Ferzli 2004 TEP 2 TAPP 3 Open 18 23 23 Tamme 2003 TAPP 4 6 6 Chowbey 2003 TAPP 0 46 Leibl 2000 TAPP 9 34 Knook 1999 TAPP 29 Open 4 11 34 Felix 1998 Repair Primary TEP Cases Study
  • 6. EERPE after TEP/TAPP
    • Stolzenburg et al. (2005)
    • 750 cases of endoscopic extraperitoneal radical prostatectomy (EERPE)
    • 14 had prior laparoscopic hernia repair
      • 8 TEP (2 bilateral)
      • 6 TAPP
    Stolzenburg J. et al: EERPE in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair. World J Urol 23:295-299, 2005.
  • 7. EERPE after TEP/TAPP
    • 1 conversion to transperitoneal approach
      • Prior bilateral TEP
    • 2 bladder injuries managed intraoperatively
      • 1 prior TAPP
      • 1 prior TEP
    • 1 inferior epigastric vessel injury
    Stolzenburg J. et al: EERPE in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair. World J Urol 23:295-299, 2005.
  • 8. EERPE after TEP/TAPP
    • More technically challenging
      • Access into extraperitoneal space
        • Port placement modification
      • Dissection of extraperitoneal space
        • Lymph node dissection is not recommended on side or previous mesh placement
        • Recognize and manage complications early
    • EERPE after TEP/TAPP is feasible for the experienced surgeon
    Stolzenburg J. et al: EERPE in patients with prostate cancer and previous laparoscopic inguinal mesh placement for hernia repair. World J Urol 23:295-299, 2005.
  • 9. TEP after TEP 14-year experience
    • September 1991 to September 2005
    • 1526 TEP procedures done
      • 1156 male patients
      • 786 unilateral / 370 bilateral
      • 141 for recurrence (12.2%)
      • 21 of 141 recurrence were after prior TEP
  • 10. TEP after TEP 14-year experience
    • 22 TEP after contralateral TEP
      • Primary hernia repair 13 months – 12 years prior
      • Mean operative time 36 min (20 – 100)
      • Mean age 56 years (35 – 84)
  • 11. TEP after TEP 14-year experience
    • 21 TEP after TEP
      • After 1995
      • 18 indirect hernias
      • 3 direct hernias
      • Mean operative time 47 min (31 – 120)
      • Mean age 52 years (29 – 79)
  • 12. Results
    • No bladder injuries
      • 1 suspected but none found
      • Jackson Pratt drain placed
    • No bowel injuries
    • No blood transfusions
    • No preperitoneal hematomas
    • No mortalities
    • All discharged on the day of surgery
  • 13. RESULTS
    • Peritoneal tears
      • 7 of our patients (33%)
      • 1 leading to conversion
    • 7 required ligation of epigastric vessels
      • 1 patient’s bleeding led to conversion due to obscured operative field
  • 14. Conversions to open
    • 5 of 21 cases (24%)
    • Reasons to convert:
      • Space of Retzius cannot be opened (3)
      • Peritoneal tear causes loss of working space (1)
      • Bleeding obscures operative field (1)
  • 15. PATIENT POSITION
  • 16. BLUNT FINGER DISSECTION
  • 17. LIMITED SPACE
  • 18. 7 STEPS
  • 19. CARDINAL RULES
  • 20. TOTAL ANATOMY
  • 21. MESH PLACEMENT
  • 22. EPIGASTRIC VESSELs
    • NEED a drawing with epigastric vessels and hernia medial and lateral and also that if there is a hernia then there is no adhesions
  • 23. INDIRECT
  • 24. INDIRECT 2
  • 25. DIRECT
  • 26. Lipoma
  • 27. Video tapes
  • 28. Conclusion
    • TEP after TEP is a feasible option
    • Steep learning curve for TEP because of unfamiliar anatomy
    • Key to successful TEP is knowledge of the anatomy
    • Mastery of the anatomy recommended before attempting TEP after TEP
  • 29. Conclusion 2
  • 30. TEP technique – indirect hernia
    • Management of sac
      • Invaginate and reduce
      • Transect and close proximal end
    • Management of cord
      • Total parietalization with posterior wall is necessary
  • 31. TEP technique – indirect hernia
    • Cord structures dissected in direction perpendicular to the structures
    • Medial approach:
      • Sweep cord structures posteromedially while holding sac superolaterally
    • Lateral approach:
      • Pivot hernia sac medially and posteriorly, while sweeping cord posterolaterally
    • Alternate between medial and lateral approaches
  • 32. TEP technique – direct hernia
    • Redundant thickened transversalis and peritoneal sac are demarcated by rolled edge or fold
    • Gentle traction and counter traction
    • Rarely requires sharp dissection
    • Clean adherent tissue off edge of hernia defect
  • 33. To reduce hernia recurrence
    • Mesh must fully cover all potential hernia defects
      • Internal inguinal ring
      • Femoral canal
      • Hesselbach’s triangle
      • Obturator canal
  • 34. TEP after TEP
    • Blunt finger dissection and camera dissection
      • Keep camera in midline as anterior as possible
      • Dissection plane is anterior to old mesh
    • Limited visualization
      • Small working space: Retzius and contralateral space does not open up
      • Pubic tubercle obscured from view by adhesions
      • Branches of epigastric vessels ligated
      • External palpation and pulling on testicle to help orientation
  • 35. TEP after TEP
    • Sharp dissection without cautery
    • Loss of anatomical landmarks
    • Epigastric vessels lead to the hernia
      • Direct hernia medial to epigastric vessels
      • Indirect hernia lateral to epigastric vessels
      • If there is a hernia there will be no adhesions around it.
    • Dissection of sac as described for primary repair
    • Oversize Mesh placement
  • 36.  
  • 37. Repair of recurrences after endoscopic repair
    • Small case series
    • Technical choices
      • Open tension-free Lichtenstein repair
      • TAPP
    • Some have concluded that TAPP is the only possible endoscopic repair choice for these hernias
      • Liebl et al. (2000)
      • Felix et al. (1998)
  • 38. TEP after TEP
    • Technical concerns
      • Prior preperitoneal mesh placement
        • Open and laparoscopic
      • Re-entry of preperitoneal space limited
      • Experience of urologists and vascular surgeons
      • Some cases impossible
      • Steep learning curve
  • 39. TEP after TEP
    • Tamme et al. (2003)
    • 5203 TEP repairs over 7.5 years
    • 29 of these recurred (0.6%)
      • Recurrence rate of first 2 years 1.8% (n = 15/825)
      • Subsequent recurrence rate 0.3%
    • 2 of 29 recurrences treated with TEP after TEP
    • TEP recommended for recurrent hernias
      • but no specific comment on TEP after TEP
    Tamme C. et al: TEP: Results of 5203 hernia repairs. Surg Endosc 17:190-195, 2003.
  • 40. TEP after lower abdominal surgery
    • Paterson et al. (2005)
    • Retrospective review
    • 47 patients with inguinal hernia
    • Prior lower abdominal surgery
      • 20 appendectomy
      • 10 lower midline
      • 18 suprapubic
      • 5 paramedian
  • 41. TEP after lower abdominal surgery
    • TEP repairs for all 47 hernias
      • 35 unilateral
      • 12 bilateral
    • 2 conversions to open
    • No complications
    • No early or late recurrences
    • TEP can be carried out safely in the presence of scars from previous lower abdominal surgery
    Paterson H. et al: Totally extraperitoneal laparoscopic repair in patients with previous lower abdominal surgery. Hernia June 24, 2005.
  • 42. TEP after TEP 14-year experience
    • Cause of recurrence
      • Missed hernia
      • Migration of mesh
  • 43. TEP technique
    • Positioning
      • Supine, slightly flexed, slight Trendelenburg
      • Arms tucked
      • Monitor at feet
    • General endotracheal anesthesia
    • Rectus fascia incision over left or right rectus muscle
    • Blunt extraperitoneal finger dissection in midline toward pubic symphysis
  • 44. TEP technique
    • 3 ports
      • 10-mm infraumbilical camera port
      • 2 lower midline 5-mm ports
    • CO 2 insufflation to 10 mm Hg
    • 10-mm 30-degree operative scope
    • 5-mm trocars inserted under vision
    • Sharp lysis of adhesions without cautery
  • 45. TEP technique
    • Anatomical landmarks
      • Midline pubic symphysis
      • Cooper’s ligament
      • Hesselbach’s triangle
      • Transverse abdominis muscle
  • 46.
    • For better visualization
      • Divide small branches of epigastric vessels
      • Maintain excellent hemostasis