LAPAROSCOPIC INGUINAL HERNIA REPAIR- OPERATIVE SURGERY #surgicaleducator #operativesurgery #laparascopicinguinalherniarepair #usmle #babysurgeon #surgicaltutor Dear viewers, • Greetings from “Surgical Educator” • Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. • I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and Laparoscopic Cholecystectomy and Open inguinal hernia repair • In this video today, I have discussed Laparoscopic Inguinal Hernia Repair- both TAPP and TEP approaches. • However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. • Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. • This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links: • surgicaleducator.blogspot.com • youtube.com/c/surgicaleducator • Thank you for watching the videos.

1. LAP INGUINAL
HERNIA REPAIR
DR.B.Selvaraj MS; Mch; FICS;
“ Surgical Educator”
Malaysia
OPERATIVE SURGERY

2. LAP INGUINAL HERNIA REPAIR
APPROACHES
1. Trans-Abdominal Pre-Peritonal Approach- TAPP
2. Totally Extra Peritonal Approach- TEP
 The obvious advantage of the TEP over the TAPP approach is
the peritoneum does not have to be closed over the mesh.
 The potential complications associated with the TAPP
approach are avoided, as the peritoneum is not entered.

3. LAP INGUINAL HERNIA REPAIR
ANATOMY
Recognition of anatomy of the preperitoneal space is essential for a safe and effective
laparoscopic hernia repair.

4. LAP INGUINAL HERNIA REPAIR
ANATOMY
CORONA MORTIS
(CROWN OF DEATH)
TRIANGLE OF DOOM
TRIANGLE OF PAIN

5. LAP INGUINAL HERNIA REPAIR
ANATOMY
Knowledge of anatomy of abdominal wall
muscles, specifically recognition of transition
zone that occurs at the arcuate line of Douglas, is
key to the success of the TEP repair
SPACE OF RETZIUS
SPACE OF BOGROS

6. LAP INGUINAL HERNIA REPAIR
• INDICATIONS:
 Recurrent hernia
 Bilateral hernia
 The role of laparoscopic repair of primary
unilateral hernia is debated and is not
recommended.
• CONTRAINDICATIONS:
 Patients unfit for general anaesthesia
 Active infectious or inflammatory process (mesh
at risk)
 Strangulated/incarcerated hernia
 Previous retropubic open prostate surgery.
• ANESTHESIA:
 GA (ETT)
• Informed consent- risks of surgery:
 Recurrence: the common cause is technical fault and use of
a small mesh.
 Bleeding: avoid dissection in triangle of doom and beware
of accessory obturator artery- Corona Mortis
 Neuralgia: due to injury to genitofemoral or lateral femoral
cutaneous nerves.
 Damage to vas
 Bladder injury
 Seroma/Hematoma/Hydrocele
 Bowel obstruction: due to adherence to mesh (disturbing
complication occasionally reported with TAPP procedure).
 Mesh infection.

7. LAP INGUINAL HERNIA REPAIR
• Pre-Op Preparation:
Obtain informed consent including conversion to open repair if necessary
Consent for contralateral repair if unsuspected hernia identified at
laparoscopy
Mark the hernia side
Empty the urinary bladder immediately before induction of anaesthesia
Place the patient supine with the head end slightly lower (Trendelenburg
position)—keep bowel away from operating site
Place the monitor at the foot end of the table
The surgeon stands on the side opposite the hernia.

8. LAP INGUINAL HERNIA REPAIR
• POSITION & THEATRE
SET UP:
Slight head down position-
Trendelenburg position to keep
bowels away.
Both arms are tucked by the
side, to make enough room for
surgeon and assistants

9. LAP INGUINAL HERNIA REPAIR
• Creating Pneumoperitoneum:
Closed or Veress needle method
 Open or Hasson’s cannula method

10. LAP INGUINAL HERNIA REPAIR
• Port Placement for TAPP:
Port placement: one at the umbilicus
(10mm) and one on each side at the
lateral border of the rectus muscle
(both 5mm).
• Port Placement for TEP:
 Primary port- 10mm infra-umbilical
 Secondary ports: One 5mm at suprapubic
Another 5 or 10mm in between the two

11. LAP INGUINAL HERNIA REPAIR
TAPP
• Incision of peritoneum:
Reduce the herinal content- omentum or
intestine
 From medial umbilical ligament to ASIS
2 cms above internal inguinal ring
• Elevation of flaps:
 Peritoneal flap is dissected towards the iliac
vessels inferiorly and then superiorly towards
the anterior abdominal wall muscles.
 Peritoneal flap includes the hernia sac. This is
the technique for direct hernias, but with very
large indirect inguino-scrotal hernias, the
distal part of the sac is divided and left within
the scrotum.

12. LAP INGUINAL HERNIA REPAIR
TAPP
• Dissection of preperitoneal space:
Dissection of the areolar tissue
Identify important anatomical landmarks
like Cooper’s ligament, iliopubic tract,
internal ring, vas deferens, gonadal
vessels, iliac vessels and nerves
• Dissection of cord structures and vas
deferens:
 Parietalization of the cord (STOPPA): (a)
indirect sac before parietalization; (b) after
parietalization
 Blunt dissection of hernia sac from cord and
vas also

13. LAP INGUINAL HERNIA REPAIR
TAPP
• Placement & fixation of Mesh:
Rolled-up mesh is loaded through umbilical port
Unroll the mesh and place it over 3 hernial orifices- myopectineal orifice of Fruchad-
medially mesh should cover upto median umbilical ligament
Fix the mesh with tackers, fibrin glue spray or sutures
Laterally, it is essential to stay above the iliopubic tract, but medially tackers are
inserted into the rectus muscle and on Cooper’s ligament.

14. LAP INGUINAL HERNIA REPAIR
TAPP
• Closing the Peritoneal flap:
 With the mesh now secured in place, the pressure of the pneumoperitoneum is reduced to 9
mmHg.
 The peritoneal flap is replaced over the mesh and is closed with tacks
 The tacks being used are absorbable to prevent future adhesions
 Ideally, tacking is performed in an overlap fashion
 If tacks are not available, a continuous running suture can be used to close the peritoneal
flap.
 After removal of the ports, the skin incisions are closed with single interrupted stitches after
careful closure of the fascia in the 10 mm trocar port.

15. LAP INGUINAL HERNIA REPAIR
TEP
• Initial entry into pre-peritoneal space via open
technique:
 Make an infra-umbilical incision vertically
 2 retractors are used to slide the lips of incision to right if
the hernia is located on the right side, or to the left if the
hernia is located on that side.
 The anterior rectus sheath on the side of the hernia is then
opened under direct vision, and two stay sutures of 2–0 vicryl
are placed
 Rectus muscle is then separated by two retractors introduced
into the rectus muscle itself so that the posterior rectus
sheath can be visualized
 At this point don’t cross the posterior rectus sheath but
instead to head downwards towards the symphysis pubis in
an oblique fashion using either the index finger or a small
peanut with an angulation of about 30°. That will lead to the
pre-peritoneal space below the arcuate line of Douglas.

16. LAP INGUINAL HERNIA REPAIR
TEP
• Dissecting the pre-peritoneal space with balloon:
 Pre-peritoneal space is dissected using a balloon spacer under direct vision with a 0° laparoscope
 One should be careful to dissect in such a way that the inferior epigastric vessels stay with the
rectus muscle.
 Next, the Hasson port is introduced with a video laparoscope, with angulation of about 30°.
 Two 5-mm ports are placed at midline between the umbilicus and the symphysis pubis
 Care should be taken not to perforate the peritoneum. Pressure should be less than 9mms of Hg,
otherwise pneumoperitoneum or subcutaneous emphysema results
 If perforated, it should be closed with an endoloop or a 5mm clip

17. LAP INGUINAL HERNIA REPAIR
TEP
• Identifying all anatomical
landmarks in pre-peritoneal space:
 Pubic bone and Cooper’s ligament are
identified by it’s glistening white colour
Light House Sign
 Don’t dissect below the level of iliac veins
 The operative field should be identical to
that seen with TAPP
 Small hernial sac can be easily reduced. If
large, after reducing the content, transact
it and leave distal end open and the
proximal end closed by endoloop or 5mm
clip.
 Introduce the mesh and spread over the
three hernial orifices
 Fix the mesh with tackers or sutures
avoiding triangle of doom and triangle of
pain

18. LAP INGUINAL HERNIA REPAIR
• Post-op Care:
Most of these repairs are day-care procedures, and patients can be
discharged with a prescription for a mild analgesic agent.
Mobility: Immediately after the procedure
Prophylactic antibiotics to prevent mesh infection
Allow fluids 4 to 6 hrs after recovering from anesthesia and then
progressively advance to solids.
Time off work: 3 to 6 days

19. THANK YOU