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How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
How to Treat Recurrence After TEP
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How to Treat Recurrence After TEP

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

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