Inguinal Hernia
Laparoscopic repair
Sakib Motalib
University of Kentucky
College of Medicine, M1
Inguinal Hernia Repair
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About the pathology
Patient Symptoms
Laparoscopic Treatment
Procedure
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Types of the Procedure: TEP vs. TAPP
Steps for the repair
Post-Operative Care
Benefits of Laparoscopy vs. Open Surgery
Acknowledgements
Questions
About Inguinal Hernia’s
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The inguinal region has anatomical and
clinical significance
Inguinal canal components:
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Males = spermatic cord
Females = Round ligament
Formation of the hernia involves protrusion of
peritoneum through a defect, forming a sac.
Two types of hernia’s for inguinal region:
direct and indirect
Direct Inguinal Hernia
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Hernia protruding
through a weak point
in the fascia medial
to epigastric vessels
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Structures interacted
with:
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hernia sac
Hesselbach’s triangle
Indirect Inguinal Hernia
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hernia protrudes thru
the inguinal ring,
lateral to epigastric
vessels
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Structures interacted
with:
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spermatic cord
vas deferens
testicular arteries
Causes of Inguinal Hernia
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Increased pressure within
abdomen:
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Severe coughing
Straining during heavy
lifting
Straining during
constipation
Obesity
Pregnancy
Aging
Genetic predisposition
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Pre-existing weak spot
Patient Symptoms
 Mass/bulge
in the
groin
 A burning sensation
in the groin
 Strangulated
hernia:
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Sudden pain,
nausea, vomiting
Laparoscopic treatment
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Position of patient:
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Trendelenburg
Surgeon positions:
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Surgeon on opposite
side of hernia
Camera operator
opposite side of
surgeon
Monitors at feet of
patient
Laparoscopic treatment
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Trocar: 10 mm trocar for
camera, 5 mm for
operating devices
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Camera: 30 degree
laparoscope
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Operating devices:
Grasper
Fine dissector
Suction-irrigation device
Curved dissector
Finger dissector
1.
2.
3.
4.
5.
TAPP vs. TEP
 TAPP
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trans-abdominal preperotenial repair
Pneumoperitoneum
is created by surgeon
Ports placed
bilaterally, to either
side of the camera
TAPP vs. TEP
 TEP
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Total extraperitoneal
repair
Extraperitoneal
space is created by
surgeon
 Using
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balloons
Ports placed below
camera port, along
midline
Laparoscopic Procedure
 TAPP
1.
2.
3.
4.
Make a small incision just above the
umbilicus.
Lift up abdominal wall and gently insert
Veress needle
Connect CO2 tube to needle
Switch off gas when desired
pneumoperitoneum is created and
remove the Veress needle
Laparoscopic Procedure
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TEPP:
1.
10 mm skin incision
and retract to expose
linea-alba (0:21)
2.
small incision is made
on the anterior rectus
sheath on affected
side (0:30)
3.
Start blunt dissection
to create a tunnel
(1:00)
Laparoscopic Procedure
4.
Dissection balloon
advanced down
into the pubic
tubercle (1:20)
5.
Balloon is hand
pumped with guide
of camera. (1:44)
6.
Dissection balloon
removed and
replaced with
structural balloon (3:36)
Anatomy Review
Laparoscopic Procedure
Insert ports, and
7.
inflate
extraperitoneal
space with CO2 (5:20)
Bluntly disect away
pro-perotineal fat,
identifying key
organs:
8.
•
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Cooper’s ligament
Epigastric vessels (8:08)
Spermatic cord (11:25)
Anatomy Review
Laparoscopic Procedure
Bluntly disect away
pro-perotineal fat,
identifying key
organs:
7.
•
•
Cooper’s ligament
Epigastric vessels
(8:08)
•
Spermatic cord
(11:25)
Laparoscopic Procedure
9.
Continued dissection
 After further
dissection, hernia
clearly identified –
Indirect hernia (17:55)
 Spermatic cord
teased away from
hernia sac (16:00)
 Grab edge of
peritoneal sac and
drag away from
defect and key
structures
Laparoscopic Procedure
Second hernia on
opposite side
identified – Direct
hernia
10.
•
11.
Identify the hernia sac
and dissect (28:35)
Pull down on plane
of attachment,
cleaning off fat on
the abdominal wall
so it does not get in
the way of the mesh
(32:00)
Laparoscopic Procedure
11.
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Put in the mesh
that will cover the
defect (54:00)
polypropylene mesh
Mesh is curved, with
label M
Positioning of mesh
is significant
Tack mesh in place
or no fixation
Laparoscopic Procedure
12.
Start suctioning out
the CO2 in the
peritoneum (1:12:00)
 Push
down on the
mesh with suction
13.
Remove ports,
close the patient
(close fascial
layers, then
superficial layers)
Dangers/Areas to be Avoided
 Triangle
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of doom
vas deferens
medially
gonadal vessels
laterally
peritoneum
inferiorly
Inside the triangle
are the iliac artery
and vein
Dangers/Areas to be Avoided
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Triangle of pain
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Contains cutaneous
nerves  neuralgia
Major arteries and
spermatic vessels
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Epigastric vessels
Specific example:
tension on vas
deferens
Post-Operative Care
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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
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Refrain from any heavy lifting or straining until
approved by your doctor.
Follow up appointment with doctor 2-3 weeks
after procedure.
Advantages/Disadvantages
 Advantages
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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
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Learning curve for the procedure
Acknowledgements
 James
Hoskins, Director of MIS Training
Center
 Dr. John Roth, Director of Minimally Invasive
Surgery
Sources
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http://www.websurg.com/ref/otot02en195_en.html
http://cme.medscape.com/viewarticle/420354_5
http://www.webmd.com/digestivedisorders/tc/inguinal-hernia-symptoms
http://www.centralcarolinasurgery.com/forms/JA
N/postop%20inguinal%20hernia%2001092009.pdf
Times listed for the procedure : based on
Laproscopic inguinal hernia repair DVD; instructors:
Dr. Scott Roth [S2]
Questions?