All about Laparoscopy & Hernia - TAPP, TEP, Complications, Mesh Infection, Parastomal hernia, Hiatus hernia, Rare hernias, recuurence

1. LAPAROSCOPIC HERNIA SURGERY
Dr. K. Sendhilkumar, Chief Surgical Gastroenterologist
Dr. Piyush Patwa, Consultant Laparoscopic Surgeon
Dr. Latif Bagwan, Consultant Laparoscopic Surgeon
Gateway Clinics, Coimbatore, India

2. HERNIA SURGERY
• OPEN
• LAPAROSCOPIC
TEP : TOTALLY EXTRAPERITONEAL
TAPP : TRANSABDOMINAL PREPERITONEAL
IPOM : INTRAPERITONEAL ONLAY MESH REPAIR
Difficult Adhesiolysis, Epigastric ,Parastomal,
RIF, Recurrent Hernia, Sliding, Hiatus Hernia

3. LAPAROSCOPY FOR INGUINAL HERNIAS
Ideal for
• Bilateral Hernias
• Recurrent Hernias (Previous open)
• Female Hernias
• ? Unilateral Hernias
• Combined with other procedure like Lap. Cholecystectomy
• Learning Curve – Laparoscopy v/s Open = 250 v/s 25 cases

4. TAPP – Tips, Tricks &
Technique

5. Definition
• Transabdominal Preperitoneal technique:
A laparoscopic repair procedure wherein the surgeon enters the peritoneal
cavity, incises the peritoneum,
enters the preperitoneal space, and
places the mesh over the hernia;
the peritoneum is then sutured or tacked.

6. Lets do it step by step
• STEP 1: Entering the Intra-abdominal Cavity
• STEP 2: Creating the Peritoneal Flap
• STEP 3: Identifying the Anatomical Landmarks
• STEP 4: Dissecting the Hernia Sac
• STEP 5: Deploying and Anchoring the Mesh
• STEP 6: Closing the Peritoneum
• STEP 7: Taking out Sutures & Port Closure

7. Preoperative Care
• It is recommended that the patient empty his/her bladder before the
operation.
• Restrictive per- and postoperative intravenous fluid administration
reduces the risk of postoperative urinary retention.
• If you expect technical difficulties (e.g., after prostatic surgery, Scrotal
hernia) or an extended operating time, consider using a urinary
catheter during the intervention.

8. Preoperative Care
• The patient with unilateral groin hernia should be asked to give
his/her consent to allow simultaneous repair if a contralateral occult
hernia is found.

9. Table – Patient Position
• Patient in Supine position
• Head-down position during the operation and slightly (approximately
15°) turned toward the surgeon.
• The operating surgeon & the camera assistant stay on opposite sides
of the hernia.

10. TAPP STEP 1: Entering the Intra-abdominal Cavity
Trocar placement
• Establishing the carbon dioxide pneumoperitoneum
using the Veress needle.
• The 10 mm Camera trocar – supraumbilical
• Under laparoscopic view - Two 5 mm operating trocars on the
midclavicular line 2 cm below the level of the horizontal line from the
optical trocar.

11. Tips
• The intra-abdominal cavity is visualized with the Telescope and intra-
abdominal findings are reported [intra-abdominal pathology and
inguinal hernia defects and sacs].
• If an asymptomatic hernia sac is identified on the contralateral side,
our protocol mandates its repair, even though at this time we are unsure of
its exact clinical significance.

12. Preperitoneal dissection
The aim of this step is to ensure the best positioning of the mesh. In this way
several anatomic landmarks have to be identified, as well as a complete dissection
of the hernia’s sac.
 Epigastric vessels
 Urinary bladder
 Pubis
 Cooper’s ligament
 Gimbernat’s ligament
 Medial part of ilio-pubic tract
 External iliac vessels
 Corona mortis
 Vas deferens in males and Round ligament in females
 Spermatic vessels
 Internal inguinal ring

13. STEP 2: Creating the Peritoneal Flap

14. Incision of the peritoneum
The peritoneal incision starts 2 cm above the iliac spine/ 5cm above defect using the monopolar
scissors/hook.

15. Incision of the peritoneum

16. Light House Sign

17. Crossing the Midline in RIH

18. Entering the Lateral Inguinal Space

19. STEP 3: Identifying the Anatomical Landmarks
• Exploration and anatomical landmarks
• The aim of the laparoscopic exploration is to identify the anatomical
landmarks, site and type of hernia
• In this way, the Trendelenburg tilt should be increased to 30-45°.
The two dangerous “triangles”,
• 1) vascular triangle- Triangle of Doom and
• 2) Triangle of Pain has to be well identified
And Corona Mortis

21. Death, Destruction,or some other terrible fate

22. “Triangle of doom" landmark does protect the surgeon from damaging
the external iliac vessels, a portion of these vessels lie outside of this
area.

24. Triangle of Pain
• The so-called "triangle of pain" & "triangle of doom“ are misnomers
• Not a triangle - has only two boundaries
• The "triangle of pain" is an inverted "V" shaped area with its apex at the internal
(deep) inguinal ring. It is bound anteriorly by the iliopubic tract / inguinal ligament and
by the Gonadal vessels posteromedially

25. Triangle of Pain
• Don’t place staples or sutures to anchor the mesh – as several nerves
which usually cannot be seen as they run just deep to the
Endoabdominopelvic fascia
• TIP – Don’t open this fascia to see nerves !
• These nerves can suffer damage with electrocautery or entrapment -
cause pain (hence the name of the area)

27. CORONA MORTIS
• Latin - [corona] meaning "crown' &
[mortis] meaning "death‘
the "crown or circle of death".
The corona mortis refers to an anatomical variation, a
vascular anastomosis between the obturator & the external iliac
vascular systems that passes over Pectineal (Cooper's) ligament and
posterior to the lacunar (Gimbernat's) ligament.

28. Corona Mortis on left side

29. • In some cases, the corona mortis is the actual obturator artery- arises
from the inferior epigastric artery instead of the internal iliac artery
• It can also arise from the external iliac artery. In both cases, it has
been called an "aberrant obturator artery"

30. • The Preperitoneal dissection ends when the anatomic landmarks
previous described are well exposed and the two dangerous triangles
(vascular and pain triangle) can be identified

31. STEP 4: Dissecting the Hernia Sac
• The indirect inguinal hernia sac should be dissected carefully from the Spermatic
Cord
• It is essential to expose and know at all times where the spermatic cord is
located. Direct hernia sacs are easily dissected
• Particular care should be taken not to dissect lateral and inferior to Cooper's
ligament, as the Iliac Artery and Vein will enter the femoral canal at this site

32. The hernia sac dissection is performed using traction contra-traction maneuvers and fine
coagulation. To avoid the injuries of the ductus deferens and spermatic vessels the
sac dissection always starts anteriorly

33. Pseudosac dissection in a Direct Hernia

34. • A large indirect sac may be ligated proximally and divided distally
without the risk of a higher postoperative pain & recurrence rate, but
with an increased postoperative seroma rate *
* Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International
Endohernia Society) Surg Endosc (2015) 29:289–321

35. • When performing inguinal hernia repair in women, extra effort should
be undertaken to reveal and treat occult synchronous femoral hernia

36. STEP 5: Deploying and Anchoring the Mesh
• A large (15x12 cm) polypropylene mesh.
• The mesh is inserted from the Camera trocar. Then, the mesh is
placed in the appropriate position and fixed by 1 Polypropylene
sutures (or tacking staples, glue in some centres). The first suture is at
the level of pubis
• The mesh is fixed on the upper and internal edge
• The mesh shouldn’t be sutured/stapled at the level of dangerous
triangles and epigastric vessels

37. Mesh is inserted from
the Camera Trocar

38. The 15X12 cm Mesh is folded & inserted

39. The Mesh should cover Myopectineal orifice
When the mesh is smoothed out, it overlaps the pubic bone & crosses midline
TIP – wrinkles or folds should not be seen

41. •The mesh is fixed on the upper and internal edge

42. 3 Point Fixation

43. STEP 6 - The peritoneal closure
• A thorough closure of peritoneal incision or bigger peritoneal tears
should be achieved
• The peritoneum is closed by a running suture using a 2-0 vicryl
• Look - Mesh is not exposed now to abdominal organs

44. The peritoneum is closed by a running 2-0 vicryl suture
TIP – Far to Near

45. • To improve postoperative pain control, trocar wounds can be
infiltrated by local anaesthetic drug

46. TEP REPAIR

47. Contraindications for TEP
• Multiple prior lower abdominal surgeries
• Large Irreducible Hernias
• Previous Pre-peritoneal Surgeries (prostate / inguinal hernia)
• Patient not fit for GA

48. INSTRUMENTS
• Trocar tip
• Retractor

49. Retractor

50. INCISION

51. INCISION
• Umbilicus
• Starting point – from the depth of the umbilicus
• Length

53. ANTERIOR RECTUS SHEATH

54. WHICH RECTUS SHEATH?
Right Hernia
Left Hernia
Bilateral Hernia
Level of exposure

55. POSTERIOR RECTUS SHEATH

56. PROBLEMS
• Air leak
• Trocar slippage

57. PREVENTION OF AIR LEAK

58. CREATING SPACE
• Telescopic dissection
• Balloon tipped trocars

59. Various Balloons

60. WHERE TO GO?

61. Loose Areolar Tissues - CORRECT PLANE

62. PREPARATION FOR
1st WORKING PORT

63. FIRST WORKING TROCAR
Midline vs lateral ports
Risk of injury to the inferior epigastric artery
Risk of injury to the peritoneum

64. 1st WORKING TROCAR

65. 1st WORKING TROCAR ENTRY

66. CROSSING THE MIDLINE

67. Entering into the opposite side

68. 2nd WORKING PORT

69. IMPORTANT LANDMARK

70. PUBIC ARCH

71. PREPARATION TO GO TO
LATERAL INGUINAL SPACE

72. PREPARATION TO GO TO
LATERAL INGUINAL SPACE

73. PREPARATION TO GO TO
LATERAL INGUINAL SPACE

74. PREPARATION TO GO TO
LATERAL INGUINAL SPACE

75. PERITONEUM

76. EXPOSURE OF THE SAC

77. FASCIA TRANSVERSALIS SLING

78. SAC DISSECTION

79. SAC ISOLATION

80. SAC DIVISION

81. LIGATION OF THE SAC

82. MEDIAL DISSECTION
OBTURATOR NERVE

83. OBTURATOR NERVE

84. PERITONEAL INJURY

85. POSTERIOR MOBILISATION
OF THE PERITONEUM

86. VAS DEFERENS

87. TRIANGLE OF DOOM AND PAIN

88. THE HERNIA ANATOMY

89. MESH PLACEMENT

90. MESH FIXATION

91. MESH FIXATION

92. PROPERLY PLACED MESH

93. Other Ways Of Fixation
TACKERS

94. DEFLATION

95. PORT PLACEMENT

97. HIATUS HERNIA

98. TYPES OF HIATUS HERNIAS

99. FIRST LOOK
STOMACH
LEFT LOBE LIVER

100. EXPOSURE
LEFT LOBE LIVER
UNDER SURFACE OF DIAPHRAGM
STOMACH
HEPATIC BRANCH OF
VAGUS

101. ANATOMY OF THE HIATAL REGION
CAUDATE
LOBE
LEFT GASTRIC
PEDICLE
STOMACH
LEFT LOBE LIVER
HEPATIC BRANCH
OF VAGUS

102. ENTERING THE LESSER SAC
GASTRO HEPATIC
LIGAMENT
KUTZNER WINDOW
LEFT LOBE LIVER
UNDER SURFACE OF DIAPHRAGM

103. ANATOMY AFTER GHL DIVISION
LEFT LOBE
LIVER
CAUDATE
LOBE
LEFT GASTRIC
ARTERY
LEFT GASTRIC
VEIN
RT
CRUS

104. RIGHT CRUS
RT CRUS.
WHITE
LINE
CAUDATE
LOBE
ESOPHAGUS

105. ANTERIOR
VAGUS
STOMACH
ESOPHAGUS
RT
CRUS
LEFT LOBE
LIVER

106. GOING BEHIND THE ESOPHAGUS
PHRENO
ESOPHAGEAL
MEMBRANE
ESOPHAGUS
RT CRUS

107. DEFINING THE LEFT CRUS FROM ABOVE
BARE AREA OF
STOMACH
STOMACH
ESOPHAGUS

108. EXPOSURE OF THE LEFT CRUS FROM ABOVE
INFERIOR PHRENIC VESSEL
STOMACH
ESOPHAGUS
BARE AREA OF STOMACH

109. DIVISION OF SHORT GASTRIC VESSELS
SPLENIC ARTERY
GASTRO SPLENIC
LIGAMENTSTOMACH

110. RETRO ESOPHAGEAL WINDOW
RETRO
ESOPHAGEAL
WINDOW
RT
CRUS

111. POSTERIOR VAGUS
ESOPHAGUS
RT
CRUS
LEFT
CRUS

112. CRURAL REPAIR
AORTA
RT CRUS
LT
CRUS
ESOPHAGUS

113. CRURAL CLOSURE

114. FUNDAL
WRAP
CAUDATE
LOBE
ESOPHAGUS
FUNDUS

115. Large Hiatus Hernia.(Laparoscopic Nissen’s Fundoplication)

116. DISSECTING AND EXCISINS THE SAC

117. LARGE HIATAL OPENING

118. DIAPHRAGMATIC HERNIA

119. •Laparoscopic Repair of Incarcerated
Bochdalek Hernia in Elderly:
A rare emergency easily overlooked

120. CXR(PA)

121. Upper GI Endoscopy

122. Barium Swallow

123. HRCT

124. Diagnosis
Left sided Bochdalek hernia with stomach herniating into left chest.
PLAN
Laparoscopic repair of Bochdalek hernia with reinforcement by dual mesh.

125. LEFT POSTERIOR LATERAL
DEFECT

126. CONTENTS ADHERANT TO THE SAC

127. EXPOSURE OF THE HIATUS

128. DEFECT CLOSURE

129. MESH PLACEMENT

130. MESH PLACEMENT

131. Left Posterolateral Defect In Adult

132. DEFECT CLOSURE AND MESH PLACEMENT

134. MANAGEMENT
• Misdiagnosis of BH is common, as reported in this case, and may be
fatal
• Clinician should take great care during the management of patients
with persistent pulmonary symptoms and abnormal chest findings
• CT Scan are the only way to direct visualize the focal defect of
diaphragm, and also helps in establishes a definitive diagnosis

135. MANAGEMENT
• Very few cases of Laparoscopic management of incarcerated BHs in
elderly have been reported
• The ideal technique is not yet determined because of lack of
randomized trials comparing the procedures
• Procedure of choice depends on the surgeons

136. Conclusion
• BHs are uncommon clinical findings in adult population and cases
presenting with incarceration are even less common
• CT is preferred diagnostic tool for BHs
• Laparoscopic repair of an incarcerated BH is an excellent option
because of the advantages of its unique, minimally invasive nature

137. VENTRAL HERNIA

146. Recurrent Incisional Hernia

148. Multiple Defect With Bowel Adhesion (Ventral Hernia)

149. Ventral Hernia With Bowel Adhesions

150. Parastomal Hernia Repair(Post APR)

151. Parastomal HerniaTechnique-Keyhole (direct)
1
5
1

152. Parastomal Hernia
Technique- Sugar-baker (indirect)
1
5
2

153. DEFECT CLOSURE AND MESH PLACEMENT

155. Hernia in Paediatric age Group

163. • Laparoscopic hernia repair also allows contralateral patent process
vaginalis (PPV) hernias to be defined and repaired in the same
operation
*F. Schier, P. Montupet, and C. Esposito, “Laparoscopic inguinal
herniorrhaphy in children: a three-center experience with 933
repairs,” Journal of Pediatric Surgery, vol. 37, no. 3, pp. 395–397,
2002.

164. Epigastric Hernia

165. Port Placement – Epigastric Hernia

167. Reducing the contents

168. Defect

169. Defect Closure
 Stomach

171. 20x15 cms Elliptical Dual Mesh

172. Sliding Hernia

184. RIF region hernia after Bone graft Surgery

186. Position

198. Eventration of Diaphragm

199. MRI

210. Goal of Hernia Repair
• Minimal operative and post operative discomfort
• Effective repair
• Lowest possible recurrence rate
• Rapid return to normal activities
• Cost effective
• Reproducible among Hernia Specialists and General Surgeons
210

211. Ideal Prosthesis
• Chemically inert
• Minimal inflammatory or foreign body reaction
• Non-carcinogenic
• Does not induce a state of allergy or hypersensitivity
• Resists infection
• Minimal shrinkage
• Capable of resisting mechanical strains
• Strong enough to prevent recurrence
• Easy to handle and use
• Provides for appropriate tissue in-growth
211

212. Prosthetic Materials
• Meshes
• Anchor
• Tacker
212

213. Meshes
• Single Layered
• Double Layered
• Biological
213

214. What is the ideal mesh?
Covidien? Ethicon? Bard?
Gore? Atrium? Dynamesh?
GFE?...
Lightweight? Ultra-
light? Heavyweight?...
Polyester?
Polypropylene?
ePTFE?...
Weaved? Braided?
Knitted?...
Permanent?
Absorbable? Semi-
absorbable?
Monofilament?
Multifilament?
214

215. H+ or H- , Surface, absorbable,
Non absorbable, mixed
mesh, foil, knitted, braided, woven expanded
monofilament, Xfilament,
elasticity, weight
Macroporosity
Microporosity
Effective porosity
Construction
Material
Porosity
215

216. 1mm 1.5mm
The porosity of a mesh influences capsule formation
and shrinkage of the mesh
Optimal porosity provide sufficient
space for tissue ingrowth
Poor porosity leads to capsule
formation and shrinkage
3
216

217. Currently used Prosthetic Meshes
• Polyester (Dacron)Mesh
• Polypropylene Mesh
• e PTFE mesh (Expanded Polytetra fluoroethylene)
• Composite Mesh
217

218. Polypropylene Mesh
• Thermoplast based on propane with MW of 100000
• Resists physical decay after years
• As strong as steel but 1/8 the density
• High bending stiffness is a disadvantage
• Causes sub-acute inflammatory reaction causes fibrosis
and stability
• Direct contact with bowel can lead to intestinal
adhesions and fistulas
218

219. Polypropylene Mesh
• Considerable shrinkage (20% in length to 40% in
area)
• Leads to early edema (2-7 days), so needs drains
• Intense fibrosis embedding the mesh into scar leads
to restriction of wall mobility
• In case of infections leave the mesh and give
antibiotics
• If not settled the mesh should be removed
219

220. Traditional Weight Mesh
• Used for over 30 years
• Secure repair
• BUT….
• Does it optimize wound healing?
• Patient complaints
• Loss of abdominal wall mobility
• Post-operative discomfort
• Ability to feel the edge of the mesh
220

221. Lightweight Mesh
The lightweight mesh hypothesis:
• Alter construction of the mesh in such a way as to
allow handling characteristics of a traditional mesh
while delivering:
• More natural abdominal wall compliance
• Improved patient comfort
• Less foreign body implanted over the lifetime of the patient
• A secure repair
221

222. • Traditional weight meshes allow for scar tissue to form a bridge from
filament to filament. This results in what is called bridging fibrosis and
consequently, a rigid scar plate.
• The lighter weight polypropylene encourages an orderly ingrowth of
tissue and allows for healthy, flexible collagen to form between the
filaments…resulting in a flexible, more compliant scar plate.
222

223. Abdominal Wall Compliance
0.8 mm Pore Size
4.0 mm Pore Size
Heavyweight, or traditional weight mesh
Lightweight, or “physiologic” weight mesh
Granuloma
Granuloma
223

224. In Favor of
Polypropylene Mesh:
• Extensive fibroblast in growth , incorporation by the
host and can be used in contaminated fields
Franklin ME et al. Lap ventral and incisional hernial repair. Surg Lap End
8(4):294-299 1998
285 lap ventral hernia and 520 lap inguinal hernia using IPOM with
polypropylene mesh. 1 fistula formation (0.14%), 4 mesh infections
(0.50%), and 6 reoperations for bowel obstruction secondary to mesh
adhesions (0.75%). Relaparoscopy 27 patients (19 incisional, 8 inguinal):
1/3 no adhesions, 1/3 mild adhesions, 1/3 severe.
Chowbey PK et al. Lap ventral hernia repair J La Adv Surg
Tech 2000; 10:79-84
Bingener J et al. Adhesion formation after laparoscopic ventral
incisional hernia repair with polypropylene mesh: a study using
abdominal ultrasound, JSLS (2004)8:127-131 224

225. Against polypropylene mesh:
• It is extremely difficult to lyse adhesions to
polypropylene without causing enterotomies*
• Major complications with polypropylene not evident
until years later
• 9 cases of mesh erosion fistula stainless steel (1)
tantalum (1) mersilene (1) dexon (1) ppm (5).
The time to the development of these fistulas
ranged from 3 months to 14 years
*Losanoff JE et al. Entero-colocutaneous fistula: a late consequence of polypropylene mesh
abdominal wall repair: case report and review of the literature, Hernia 2002; 6: 144-147
225

226. In Favor of ePTFE
• Microporous, smooth texture minimizes tissue
in-growth and limits adhesion formation and
bowel injury
• Combined with a large pore second layer it
can adhere well to the abdominal wall
226

227. Against ePTFE
• Microporous construction limits ability of
macrophages to destroy bacteria
• Mesh infection is not well treated by antibiotics
and requires mesh removal
• Does not integrate well into host tissue when
not combined with a large pore mesh
227

228. Polyester Dual Mesh
• Parietex (polyester and atelocollagen type 1, polyethylene glycol, glycerol) Covidien, Hamilton,
Bermuda
• Polyester mesh incorporates well into the abdominal wall
• Collagen covering on the visceral surface protects bowel and dissolves as the polyester is
incorporated
228

229. Composite Meshes
• Combination of 2 materials
• Surface facing the peritoneal aspect
• Promotes tissue ingrowth
• Increases adhesion between mesh & parietal wall
• Eg. Polyproplene/Polyester
• Surface facing the abdominal contents
• Inert
• Prevents adhesion between mesh & bowel
• Absorbable or nonabsorbable
229

230. Composite Meshes
• Composix
• Peritoneal surface : Polyester
• Abdominal surface : ePTFE (nonabsorbable)
• Parietex
• Peritoneal surface : Polyester
• Abdominal surface : Hydrophilic collagen
coating
• Gore Tex
• Both surface : ePTFE
230

231. Composite Meshes
• Proceed
• Polypropylene
• Oxidised Reinforced Collegen
• Atrium
• Polypropylene
• Omega 3 Fatty Acid
231

232. Proceed mesh
232

233. Parietex mesh
233

234. Composix mesh
234

235. Goretex Dual Mesh
235

236. Atrium mesh
236

237. DR. LATIF BAGWAN. GATEWAY CLINICS 237

238. Biosynthetic mesh
• Surgisis gold 8ply mesh - Processed porcine small
intestinal submucosa
• Alloderm – Processed cadaveric human acellular
dermis
238

239. Surgisis mesh
239

240. Advantages
• Resists infection well
• Conforms well to the abdominal wall
• Physiological collagen deposition
• Can be used in infected fields
240

241. Disadvantages
Occasional severe host reaction
Seroma common with surgisis mesh
High incidence of post op diastasis and recurrence with
alloderm
Cost
241

242. Take Home message
Material nature is important for cells attachment
Porosity is more important than the weight of the mesh
For ventral hernia, the elasticity of the mesh is key
Not all materials behave the same way on long term
242

243. COMPLICATIONS

244. Mesh Infection And Removal

245. REMOVAL OF MESH AND TACKS
TACK

246. EXTRACTION OF THE MESH
MESH REMOVAL IN
ENDOBAG

247. Entero-Cutaneous fistula
Previous Open Ventral Hernia and Lap IPOM Repair for Umbilical Hernia

248. CECT- abdomen