Definition, Types, Risk Factors, Laparoscopic Repair, TAPP and TEP.

1. Different types of
Laparoscopic Hernia Repair
Advanced Laparoscopic in Robotic and Bariatric Surgery
King Saud University Medical City
3rd December, 2018
Ibrahim Abunohaiah
R1, Urology

2. Objectives
• To discuss the definition of a hernia.
• To discuss hernia types.
• To discuss laparoscopic repair options.

3. Definition of Hernia
• A hernia is an abnormal protrusion of an organ or
tissue through a defect in the fascia or muscles
that contain it.

4. Types of Hernias
• Inguinal (Indirect and Direct) & Femoral Hernias
• Ventral , Epigastric, and Incisional Hernias
• Umbilical and Para-Umbilical Hernias
• Hiatus and Paraesophageal Hernias
• Congenital Diaphragmatic Hernias
• Spigelian Hernia
• Others (Richter’s, Littre’s, Lumbar, Obturator
Hernias)

5. Risk Factors
• Smoking
• Obesity
• Steroid
• Diabetes mellitus

6. Inguinal and Femoral Hernias
Inguinal hernias:
• Indirect and Direct
Femoral hernias.

7. Incisional Hernias

8. Umbilical and Para-Umbilical
Hernias

9. Hiatal and Paraesophageal
Hernias

10. Congenital Diaphragmatic
Hernias

11. Spigelian Hernia
Surgical Anatomy
• It occurs through slit like defects in the anterior
abdominal wall adjacent to the semilunar line
Diagnosis
• Often Clinical
• Confirmed by CT or MRI imaging
Treatment
• As Ventral Hernias

12. Richter’s Hernia
Richter hernia (partial
enterocele) is the protrusion
and/or strangulation of only
part of the circumference of
the intestine's antimesenteric
border through a rigid small
defect of the abdominal wall

13. Hernia Surgical Repair

14. Hernia Surgical Repair
• Laparoscopic
• Open

15. Laparoscopic Inguinal
Hernia Repair

16. Background
• Laparoscopic inguinal hernia repair originated in the early 1990s.
• Inguinal hernias account for 75% of all abdominal wall hernias,
and with a lifetime risk of 27% in men and 3% in women.
• Repair of these hernias is one of the most commonly performed
surgical procedures in the world.1
• In the United States, approximately 800,000 inguinal
herniorrhaphies are performed annually. 2
1. Jenkins JT, O'Dwyer PJ. Inguinal hernias. BMJ. 2008 Feb 2. 336(7638):269-72
2. Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am. 2003 Oct. 83(5):1045-51, v-vi

17. Laparoscopic Options
• Totally extraperitoneal (TEP) repair
• Transabdominal preperitoneal (TAPP) repair
• Intraperitoneal onlay mesh (IPOM) repair

18. TAPP vs TEP

19. Laparoscopic repair
Preferred in:
• Bilateral Hernias
• Recurrent Hernias (Previous open)
• Female Hernias
• Combined with other procedure like Lap.
Cholecystectomy
Learning Curve:
Laparoscopy v/s Open = 250 v/s 25 cases

20. Anatomy
Adapted from Schwartzs Principles of Surgery, 10th Edition.

21. Anatomy, cont.
Adapted from Schwartzs Principles of Surgery, 10th Edition.
Posterior view of
intraperitoneal folds and associated fossa

22. Anatomy, cont.
Adapted from Schwartzs Principles of Surgery, 10th Edition.
Anatomy of the groin region from the posterior perspective.

23. Anatomy, cont.
Triangle of doom:
• Is an anatomical triangle defined by the vas deferens
medially, spermatic vessels laterally and peritoneal fold
inferiorly.
• This triangle contains external iliac artery and vein, the
deep circumflex iliac vein, the genital branch of
genitofemoral nerve and hidden by fascia, the femoral
nerve.

24. Anatomy, cont.
Triangle of doom
Adapted from Schwartzs Principles of Surgery, 10th Edition.

25. Anatomy, cont.
Triangle of Pain:
• The region bordered by the iliopubic tract and gonadal
vessels, and it encompasses the lateral femoral
cutaneous, femoral branch of the genitofemoral, and
femoral nerves.

26. Anatomy, cont.
Adapted from Schwartzs Principles of Surgery, 10th Edition.
Triangle of Pain

27. Anatomy, cont.
Corona Mortis:
• The circle of death is a vascular continuation formed by
the common iliac, internal iliac, obturator, inferior
epigastric, and external iliac vessels..

28. Anatomy, cont.
Circle of Death

29. TAPP - Transabdominal
Preperitoneal technique

30. TAPP: Definition
• 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.

31. TAPP: Steps
• 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

32. TAPP: 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 operation.
• Patient with unilateral groin hernia should be asked to give
his/her consent to allow simultaneous repair if a contralateral
occult hernia is found.

33. TAPP: 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.

34. TAPP: STEP 1: Entering the Intra-
abdominal Cavity
Trocar placement
• Establishing pneumoperitoneum using the Veress needle.
• 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.

35. TAPP: STEP 1: Trocar Placement

36. TAPP: STEP 1: Tips
• The intra-abdominal cavity is visualized with the Telescope
and intraabdominal findings are reported [intra-abdominal
pathology and inguinal hernia defects and sacs].
• If an asymptomatic hernia sac is identified on the
contralateral side, consider repair.
• The bladder, median and medial umbilical ligaments, external
iliac, and inferior epigastric vessels are visualized.

37. TAPP: STEP 1: Preperitoneal
dissection
• The aim of this step is to ensure the best positioning of the
mesh.
• An incision is made in the peritoneum at the medial umbilical
ligament 3 to 4 cm superior to the hernia defect, and it is
carried laterally to the anterior superior iliac spine.
• In this way several anatomic landmarks must be identified, as
well as a complete dissection of the hernia’s sac.

38. TAPP: STEP 1: Preperitoneal
dissection
• The inferior edge of incised peritoneum is retracted, and the
preperitoneum is dissected to expose the spermatic cord.
• If a direct hernia is encountered, the sac is inverted and fixed
to Cooper’s ligament to prevent development of hematoma or
seroma.

39. TAPP: STEP 1: Anatomical Landmarks
• 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

40. TAPP: STEP 1: Anatomical Landmarks

41. TAPP: STEP 2: Creating the
Peritoneal Flap

42. TAPP: STEP 2: Creating the
Peritoneal Flap

43. Entering the Lateral Inguinal Space

44. TAPP: STEP 3: Identifying the
Anatomical Landmarks
• The aim of the laparoscopic exploration is to identify the
anatomical landmarks, site and type of hernia.
• The two dangerous “triangles”:
1. Vascular triangle- Triangle of Doom and
2. Triangle of Pain must be well identified
And Corona Mortis

45. TAPP: STEP 3: Identifying the
Anatomical Landmarks

46. TAPP: STEP 3: Identifying the
Anatomical Landmarks

47. TAPP: STEP 4: Dissecting the
Hernia Sac
• The indirect inguinal hernia sac should be dissected carefully
from the Spermatic Cord.
• It is always essential to expose and know where the
spermatic cord is located.
• Direct hernia sacs are easily dissected.
• 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

48. TAPP: STEP 4: Dissecting the
Hernia Sac
The hernia sac dissection is performed using traction contra-traction maneuvers and
fine coagulation. To avoid the injuries of the Vas deferens and spermatic vessels the
sac dissection always starts anteriorly

49. TAPP: STEP 5: Deploying and
Anchoring the Mesh
• The mesh is inserted from the Camera trocar. Then, placed in
the appropriate position.
• It is unrolled in the preperitoneal space and secured medially
to Cooper’s ligament using a spiral tacker.
• The mesh shouldn’t be sutured/stapled at the level of
dangerous triangles and epigastric vessels.

50. TAPP: STEP 5: Deploying and
Anchoring the Mesh
• During this fixation, the surgeon palpates the end of the
tacker from the abdominal surface to ensure its proper angle
and to stabilize the pelvis.
• The mesh is then pulled taut and fixed lateral to the anterior
superior iliac spine.
• Tacks are placed above the iliopubic tract to avoid injury to
the lateral cutaneous nerve of the thigh and the femoral
branch of the genitofemoral nerve.

51. TAPP: STEP 5: Deploying and
Anchoring the Mesh

52. TAPP: STEP 5: Deploying and
Anchoring the Mesh

53. TAPP: STEP 6: The peritoneal
closure
• The peritoneum should be closed completely to avoid contact
between the mesh and the intestine.

54. TAPP: STEP 7: Taking out Sutures
& Port Closure
• Local Anesthetics infiltrated to improve postoperative pain
control.
• The abdomen is desufflated and the trocars are removed.
• The fascial defect of the 12-mm port and the skin incisions
are appropriately closed.

55. References
• Laparoscopic Hernia Surgery, Gateway Clinics,
Coimbatore.
• Medscape.
• Schwartzs Principles of Surgery, 10th Edition.