3. Direct Inguinal
Hernia
• Hernia protruding
through a weak point
in the fascia medial to
epigastric vessels
• Structures interacted
with:
– hernia sac
– Hesselbach’s triangle
4. Indirect
Inguinal
Hernia
• hernia protrudes thru
the inguinal ring,
lateral to epigastric
vessels
• Structures interacted
with:
– spermatic cord
– vas deferens
– testicular arteries
5. Causes of Inguinal Hernia
• Increased pressure
within abdomen:
• Aging
• Genetic
predisposition
6. Patient Symptoms
• Mass/bulge in the
groin
• A burning sensation
in the groin
• Strangulated hernia:
– Sudden pain,
nausea, vomiting
7. Laparoscopic treatment
• Position of patient:
– Trendelenburg
• Surgeon positions:
– Surgeon on opposite side
of hernia
– Camera operator opposite
side of surgeon
– Monitors at feet of patient
8. Indications
• Existence of an inguinal hernia
Symptomatic patients
• Recurrent hernias
• Bilateral hernias
27. Laparoscopic Procedure
Continued dissection
– After further
dissection, hernia
clearly identified –
Indirect hernia
– Spermatic cord teased
away from hernia sac
– Grab edge of
peritoneal sac and drag
away from defect and
key structures
28. Laparoscopic Procedure
Direct hernia
• Identify the hernia
sac and dissect
• Pull down on plane of
attachment, cleaning
off fat on the
abdominal wall so it
does not get in the
way of the mesh
29.
30. Laparoscopic Procedure
• Put in the mesh that
will cover the defect
• polypropylene mesh
• Mesh is curved, with
label M
• Positioning of mesh
is significant
• Tack mesh in place or
no fixation
31. Laparoscopic Procedure
• Start suctioning
out the CO2 in the
peritoneum
• Push down on the
mesh with suction
• Remove ports,
close the patient
(close fascial
layers, then
superficial layers)
32.
33. Approach Considerations
• TACKING THE MESH
Tacks should be placed only above the iliopubic tract.
Proper placement may be ensured by drawing a line from
the pubic tubercle to the anterior superior iliac spine
(ASIS) at the start of the procedure
Before firing each tack, carefully palpate the tacker head
through the abdominal wall to ensure that it is above this
line
34.
35. Dangers/Areas to be Avoided
• Triangle of doom
– vas deferens
medially
– gonadal vessels
laterally
– peritoneum
inferiorly
– Inside the triangle
are the iliac artery
and vein
36. Dangers/Areas to be Avoided
• Triangle of pain
– Contains cutaneous
nerves neuralgia
• Major arteries and
spermatic vessels
– Epigastric vessels
– Specific example:
tension on vas
deferens
37.
38. Post-Operative Care
• A prescription for pain medication is given to
you upon discharge
• Light diet the first 24 hours after surgery
• resume regular (light) daily activities
beginning the next day
• Follow up appointment with doctor 2-3 weeks
after procedure.
39. Advantages/Disadvantages
• Advantages
– less tissue dissection and disruption of tissue
planes
– smaller incisions just for the trocars
– Less pain postoperatively
– earlier return to normal activities for the patient
• Disadvantages
– Learning curve for the procedure
