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Lap groin hernia repair
1) The document discusses different techniques for performing laparoscopic hernia repair surgery, including Total Extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP) approaches. 2) It provides details on pre-operative preparation, port placement, dissection techniques, types of mesh that can be used, and methods for fixing the mesh. 3) Potential complications of the procedures are noted, as well as tips for dealing with issues that may arise like accidental pneumoperitoneum or difficulty dissecting in complicated cases that could require conversion to an open surgery.
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Lap groin hernia repair
- 1. Lap groin herniarepair Dr D.U.Pathak MS FACRSI FIAGES FMASI Shalby hospital Jabalpur (M.P)
- 2. The Logic ??? Results1 - 10 of about 283,000 for is laparoscopic hernia useful IS LAPAROSCOPIC HERNIA REPAIR USEFUL IS LAPAROSCOPIC HERNIA REPAIR USEFUL ? Dr Arun Prasad, MBBS (AFMC), MS (New Delhi), FRCS (Edin) & FRCS (Glas). Senior Consultant, Minimal Access Surgery, ... www.angelfire.com/ar/laparoscopy/hernia.h tml -
- 3. This is nowthe history …
- 4. Enter the Dragon •Remove reluctance. • Get trained. • Make a team. • Fix the O.T. • Wait for the appropriate patient.
- 5. SGRH Classification • Predictionof operative difficulty. • Based on Reducibility Degree of descent & Previous repair. • Higher grades are for higher centers.
- 6. Grade 1 • Small,direct , reducible. • Disappears on lying down. • A finger breadth defect. • Sac is easily separated from fascia transversalis. This one is for the beginners.
- 7. Grade 2 • Small,indirect, incomplete & reducible. Sac will not require transection. • Moderate size direct hernia, thumb sized defect in direct floor. Sac requires separation. • Reducible femoral.
- 8. Grade 3 • Moderatesized indirect reducible. • Sac up to the neck of scrotum. Will require transaction & proximal ligation. • Large reducible direct defect, big bulge. Difficult medial dissection, distorted anatomy. • Recurrent hernia. Dissection difficult near the cord & laterally.
- 9. Grade 4 • Large,Reducible, Indirect hernia inguino scrotal. • Sac up to scrotum. Testes cannot be palpated separately in erect position. • May contain omentum or small bowel. The deep ring is enlarged. Difficult dissection. Medial displacement and stretching of inf epigastric. Higher incidence of seroma/hematoma. Not for the surgeon with average set up and average exposure
- 10. Grade 5 • Largecomplete partially or irreducible. • Sliding, with bladder or bowel. • Irreducible femoral. Bulky sac with adhesions. Injury to the contents likely. This is Hegar Hernia the horrible ! This piece of cake is for advanced surgeons of advanced centers.
- 11. Diagnostic Adhesiolysis Lap chole Lap Append Pelvicsurgery TAPP TEP
- 12. Explore once byopen method Do few Stoppa’s operations.
- 13.
- 14. Lap repair –The different venture! The Different – • Anatomy, • Anesthesia, • Mesh, • Placement, No wonder it needs a different courage too!
- 15. TEP or TAPP •Personal choice. • The beginning is tedious in TEPP, becomes easy as you progress Where as • The beginning is easier in TAP and becomes more and more difficult as you are near finishing.
- 16. Attempt, no choice,but don’t go alone…
- 17. The new terrain •Clear view. • Fearsome magnification – Inferior epigastric. • The unseen - Ileopubic tract.
- 18. The pre flightpreparations • Plan it well. • Sterilization can not be compromised. • Most of the instruments can be autoclaved. • Camera head, cords can be ETO sterilized. • Forget formalin chamber.
- 19. Choose the method •Master in both TEP & TAPP. • Do not become member of a group advocating only one. • TEP is more physiological ; TAPP more convenient. • Simple herniae demand TEP, Complicated ones TAPP.
- 20. TEP (Total ExtraPeritoneal) • Position of the patient. • Port placement. • Entry. • Creation of space. • Dissection / landmarks. • Preparation of mesh. • Laying / Fixation.
- 21. Anesthesia / Position/ Ports • Always G.A. • Trendelenberg position. • Surgeon on one side. • Monitor at foot end. • Ports all three in midline – Umblical camera, Suprapubic and Midway. Few prefer triangulation by ports in the flanks.
- 22. Entry Open byHasson’s • Infra umbilical incision away from the midline, over one of the recti. • Retract the muscle laterally & slide over the post rectus sheath. • Fix the Hasson’s securely to avoid leakage. • Only Dr Duluq enters blind, supra pubic.
- 23. Making balloon • Doublelayer of Latex over the suction canula tip. • Check for leak. • Enter in midline to create the space. • Infiltrate gradually with 150-200 ml saline.
- 24. Telescopic dissection • Mostpopular. • ‘0’ degree 10 mm mandatory. • Go straight, aim for pubic tubercle. • Then identify structures medial to lateral and keep going. • Scissors with energy is a good tool. • Some like spatula or hook.
- 25.
- 26. Problems … • Gasleakage. • Surgical emphysema. • Bleeding. • Smoke.
- 27. Convert to 30degree
- 28. Keep going laterally •Beware of the dangerous arcade of vessels near pubic tubercle. • Trace Cooper’s and run over ileopubic tract. • Identify and separate sac from cord. • Preserve vas and go lateral over psoas, up to the ant sup iliac spine.
- 29. Iliopubic tract • Isthe Laxman rekha in Lap hernia. • All important structures are below it. • Never Tuck or Staple below it.
- 30.
- 31.
- 32.
- 33. The angle ofDoom… • Separate the peritoneum and fascia transversalis. • Sac is also part of peritoneum. • First you see the angle of doom, make it a triangle by pulling the peritoneum above and making post abd wall bare.
- 34. The nerves ?? •Do not try to see them. • All are below the ileopubic tract.
- 35.
- 36. The ideal mesh •Is inert. • Not carcinogenic. • Resists mechanical strains. • Can be fabricated in the form required. • Easily sterilizable. • Affordable & Available.
- 37. Unfortunately No mesh And No wifeis ideal !!!
- 38. Placing the mesh… • Achieve complete haemostasis. • It should be of adequate size – mostly 12x15 cms is good. • Both should overlap at symphysis in bilateral. • It should go untouched from packet to hernia bed ; change gloves, place it on fresh sheet ; unpeel it at the last moment.
- 39. Please do notdo this …
- 40. Introducing & spreading… • From fancy roll of SGRH to crude ones. • Meticulous insertion saves time of spread. • At least 5 cms around Fruchaut’s. • Midline overlap in bilateral.
- 41.
- 42.
- 43. To fix ornot ?
- 44. Fixation options • Tuckers. •Staples. • Sutures. • Glue. • Two point – prevents rotation. Leave it to God (The intra abdominal pressure)
- 45. Accidental Pneumo • Putin Veress or a 5 mm port. • Continue dissection
- 46. Deflation • Keep meshthrough out under vision and straight. • It is hear it rolls and leads to recurrences!
- 47. Compression & scrotalbandage • In big hernias for seroma prevention. • Normally not necessary.
- 48.
- 49. Seroma • Manage conservative. •Be reluctant for even aspiration. • Most of them disappear in few weeks. • It is a sequel not complication.
- 50.
- 51. Recurrence • Missed sac. •Wandering mesh over hematoma. • Inadequate dissection. • Small mesh – may displace, may enter the distal sac. • Too big – may roll. • The fancy slit made for cord – old habits die hard.
- 52.
- 53. TAPP • Good forcomplicated ones. • Entry into the peritoneum through umbilicus. • Involves all possible complications of Pneumo peritoneum ; should be informed.
- 54. TAPP .. • Reducethe contents. • Semi lunar incision above the defect. • The dissection is same. • Familiar anatomy make your start good. • The speed lessens as you go more and more underneath. • Structures , placement all same as TEP.
- 55. TAPP … • Thelast part is most tedious – suturing peritoneal flap over the mesh if you have not mastered intra corporeal suturing. • Shabby and costly alternative are tuckers or staples. • No need to place drain.
- 56.
- 57. Conversion • Be happyif you need to, because you would be saved of a catastrophe. • Conversion for my teacher is to pick up a 10 mm. • For some it could be from TEP to TAPP. • For me – no confusion – it is Lichenstien’s.
- 58.
- 59. When will Istart ??
- 60.