Laparoscopic Herniorrhaphy: TEP


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Laparoscopic Herniorrhaphy: TEP

  1. 1. Laparoscopic Herniorrhaphy: TEP G. Ferzli, MD, FACS Professor of Surgery, SUNY DownstateChairman of Surgery Lutheran Medical Center
  2. 2. I- Anatomy of thepreperitoneal space
  3. 3. q Bogros (1823) : Preperitoneal approach through the inguinal floor for aneurysm (Bogros space) Bogros space
  4. 4. q Retzius (1858) : Defined the prevesical space (Retzius space) Retzius space
  5. 5. II- Evolution of preperitoneal herniorrhaphy
  6. 6. q Bassini (1884) : Preperitoneal approach through Transversalis fascia the inguinal floor
  7. 7. q Nyhus (1959 ) : Preperitoneal approach through a transverse abdominal incision for posterior repair
  8. 8. q Nyhus, Read (1975): Preperitoneal approach and posterior prosthetic buttress repair for recurrent hernia
  9. 9. q Stoppa (1984): Giant prosthetic reinforcement of the visceral sac (GPRVS)
  10. 10. Principle of the “Stoppa repair”1) All hernias of the groin begin in themyopectineal orifice of Fruchaud (1956)2) GPRVS replaces the transversalis fascia inthe preperitoneal space by a large prosthesisthat extends far beyond the borders of theorifice of Fruchaud in all directions3) The prosthesis is held in place byintraabdominal pressure and ingrowth ofconnective tissue
  11. 11. III- Technique of the TEP* It has to reproduce the Stoppa repair Laparoscopically*Ferzli G., Sayad al Surg Endosc 1998;12:1311-1313
  12. 12. 1-Anesthetic choices q General anesthesia – Analgesic – Neuroleptic – Neuromuscular blocking agent q Regional anesthesia – Sensory block q Local anesthesia*(with or without LMA)*Ferzli G, Sayad P.(1999) The feasibility of laparoscopic extraperitoneal hernia repair under localanesthesia. Surg. Endosc. 13, 588
  13. 13. 2- Patient preparationq No NGTq No Foley ( patient has to empty the bladder before entering the operation room)q Slight Trendelenburgq Flexed table
  14. 14. 3- Initial trocar placementTransverse incision of the anterior rectus sheath, lateral retraction of the muscle
  15. 15. 4- Finger dissection of the preperitoneal space
  16. 16. Disadvantages of balloon dissectionq Higher costq Longer operative timeq Asymetric dissectionq More traumatic with risk of vascular injury (epigastic)
  17. 17. 5- Insufflation of the preperitoneal space to 10mmHg
  18. 18. Type of insufflation gas Price Solubility Pain Flammable Metab. Lap hernia activity under local/reg. CO2 NO2Helium
  19. 19. 6- Trocars placement
  20. 20. 7-Dissection of the hernia spaces Direct Indirect Femoral Obturator
  21. 21. What to do if a peritoneal tear occurs during the dissection?q No need for decompression of the peritoneal cavity (using needle or Veress)q If the tear is away from where the mesh is going to be placed it can be left aloneq An initial generous dissection of the Retzius and Bogros spaces can easily preserve an excellent working space
  22. 22. 8- Reduction of the hernia sac Direct Hernia•Easily identified medial to the epigastric vessels•Easily reduced away from the thinned transversalisfascia Direct hernia sac
  23. 23. Reduction of Hernia Sac Indirect Herniaq In the presence of hernia: – The vas deferent is not visible – The sac is seen over the spermatic cordq The sac has to be always separated from the cord structures prior to any attempt of reduction
  24. 24. Scrotal HerniaScrotal Herniaq May need to divide epigastric vessels in scrotal herniaq Use additional 5mm trocar in the anterior axillary line at the level of ASISq If necessary, open the sac in the upper outer quadrant in order to avoid visceral injury if a sliding hernia existsq May need to amputate hernia sac
  25. 25. Reduction of Hernia Sac Femoral Herniaq The femoral space has to be explored systematicallyq Careful dissection to avoid femoral vessels and nerve injuries
  26. 26. Reduction of Hernia Sac Obturator Herniaq Obturator hernia can be repaired laparoscopicallyq Bilateral inspection is mandatoryq Bowel viability must be assessedq Mesh repair can be performed
  27. 27. 9- Placement of the meshPlacement of a large prosthesis ( 5x6 in polypropylene) that extends far beyond the borders of the orifice of Fruchaud in all directions
  28. 28. Is mesh slitting necessary? Parietalization of the cordq The Stoppa repair uses a large prosthesis that is not slitq The spermatic Peritoneum cord is part of the retroperitoneal Spermatic cord structures
  29. 29. Disadvantage of mesh slittingq It increases testicular pain and discomfort*q Increases testicular swelling*q Increases the risk of recurrence through the key hole***Felix EL. et al Surg Endosc 1995;9:984-989** Bittner et al Ann Surg 2000
  30. 30. 10- Fixation of the mesh q Stapler q Tacker q Adhesive butyl-2- cyanoacrylate* q Fibrin sealant** (fibrinogen plus thrombin) q No fixation*Farouk et al Br J Surg 1996;83:1100** Katkhouda Ann Surg. 2001;233:18-25.
  31. 31. Disadvantage of mesh fixationq 1) Nerve irritation after laparoscopic hernia repair (E. Stark et al Surg Endosc 1999) Nerve TAPP Shouldice Total (n=448) (n=445) (n=893) Genitofemoral 9 6 15 Ilioinguinal 5 1 6 Lat.fem.cut. 5 1 6 Total 19 8 27 % 4.2 1.8 3
  32. 32. Disadvantage of mesh fixationq 2) “meshalgia” “Stapalgia” “tackalgia” secondary to fixation?q 3) Stapling increases the cost of the procedure
  33. 33. 11- Systematic contra-lateral exploration *q No need for complete contra-lateral dissection*q Incidence of incipient contra-lateral hernias : 11.2%* (724 patients)q Safe and does not considerably increase the operative time (2-5min)*q Obviate the need for re-operation, reduces the overall costs to the health care system and eliminates any further work loss for the patient* *Sayad P, Ferzli G. Surg Endosc 1999;13:1168-1169
  34. 34. In conclusion Important!q Generous dissection of the Bogros spaceq Complete parietalization of the cord structuresq Placement of a large meshq Minimal or no placement of staples