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    Laparoscopic Transabdominal Preperitoneal Hernia Surgery

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    mokhtar

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    Laparoscopic Transabdominal Preperitoneal Hernia Surgery

    Uploaded by

    mokhtar
    23 views52 pages

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    laparoscopic-transabdominal-preperitoneal-hernia-surgery

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    23 views52 pages

    Laparoscopic Transabdominal Preperitoneal Hernia Surgery

    Uploaded by

    mokhtar

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    © All Rights Reserved
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    Download as pdf or txt
    of 52

    APPROACH TO HERNIA

    Dr. R. K. Mishra

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    PRICE BEING
    PAID BY
    MANKIND FOR
    THE ERRECT
    POSTURE

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    HISTORY

     Operations began as early


    as 800 BC in India.
     19th century - Edoardo
    Bassini - Italian
     1983 – Tension Free
    Repair
     1987 – Laparoscopic
    Repair

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    CLASSIFICATION

    SITE:
    Inguinal, Femoral, Umbilical,
    Epigastric, Hiatal, Lumbar etc.
    OCCURRENCE:
    Primary, Recurrent, Incisional
    CLINICAL:
    Reducible, Irreducible, Obstructed,
    Strangulated

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    TREATMENT OF
    HERNIA AS OLD
    AS HISTORY OF
    MEDICINE

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    TREATMENT

     Conservative
    seldom indicated
     Surgery
     Open
     Laparoscopic
     Totally Extra
    Peritoneal (TEP)
     Trans Abdominal
    Pre Peritoneal
    (TAPP)

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    TAPP Versus TEP

    Currently, Total
    extraperitoneal repair of
    hernia is considered the
    method of choice.
    Transabdominal
    preperitoneal repair is
    technically easier then
    Total extraperitoneal
    repair.

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    HERNIA

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Laparoscopic repair is better

    Open herniorrhaphy results


    in more complications than
    the laparoscopic approach,
    according to the results of
    a five-year follow-up of a
    randomized trial published
    in the May 10 2003 issue
    of the British Medical
    Journal.
    BMJ. 2003;326:1012-1013
    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Advantages

    1. Tension free repair that


    reinforces the entire myo-
    pectineal orifice.
    2. Less tissue dissection and
    disruption of tissue planes
    3. Less pain postoperatively.
    4. Low intra & post-operative
    complications.
    5. Early return to work.

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Indication

     Bilateral Hernia
     Recurrent Hernia
     Multiple Hernias
     Femoral Hernia
     Primary Inguinal
    Hernia (Direct or
    Indirect)

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Contraindications

     Massive Scrotal hernia


     Non reducible,
    Incarcerated Inguinal
    Hernia
     Prior laparoscopic
    herniorrhaphy
     Prior pelvic lymph node
    resection
     Prior Groin Irradiation

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    RECOMMENDATIONS

    FIT FOR GA UNFIT FOR GA


     BILATERAL – LS SPINAL
     RECURRENT – LS  SMALL – LS/OS
     UNILATERAL –  LARGE – OS
    LS/OS
    LOCAL
     STRANGULATED –
    OS  OS

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Anatomy
    Median Umblical Ligament
    Medial Umblical Ligament

    Lateral Umblical Ligament


    Inf. Epigastric V
    EXT.ILIAC VESSELS
    URETER

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Anatomy
    LIGAMENTS:
     1. Median Umbilical
    Ligament-Obliterated
    Urachus
     2 Medial Umbilical
    Ligament-
    Obliterated umbilical
    arteries
     3. Lateral Umbilical
    Ligament- Inferior
    epigastric vessels.

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Anatomy

    First Identify Medial Umbilical Ligament


    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Anatomy

    Then Identify Lateral Umbilical ligament for Inferior epigastric vessels


    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Anatomy

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Triangle of Doom

    1 3
    2 7
    5
    4

    1.Medial umbilical ligament, 2.Inferiar Epigastric vessels, 3.Spermatic


    vessels, 4.Vas deferens, 5.External iliac vessels in “Triangle of Doom”,
    7.Indirect defect,

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Left side Anatomy

    Key landmark to differentiate between direct


    and indirect inguinal hernia
    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Anatomy

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Femoral and Sliding Hernia

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Pantaloon Hernia

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Laparoscopic Classification

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Mesh

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Anatomy

    •TRIANGLE OF DOOM
    •Iliac Vessels

    •TRIANGLE OF PAIN
    •GFN and LFCN

    •TRAPEZOID OF DISASATER
    •abnormal Obturator
    artery.

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Anatomy

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Diagnosis

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Position of surgical team

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Position of surgical team

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Port Position

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Port position

    Trans abdominal Pre Peritoneal

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Steps of TAPP
    Opening the pre-peritoneal space

    •Incision begins just above and 4 cm


    lateral to the outer margin of the deep
    ring

    •Peritoneum incised medially almost up


    to the midline

    •Epigastric vessels should be safe


    guarded

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Hernia sac Dissection

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Steps of TAPP
    Dissection of pre-peritoneal space
     Dissect the peritoneal flap
    towards the iliac vessels
    inferiorly & towards anterior
    abdominal wall superiorly.
     Cooper’s ligament, arch of
    transverses abdominus,
    conjoint tendon & iliopubic
    tract should be seen.
     Separate the elements of the
    spermatic cord from the
    peritoneal sac.

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    View at the end of
    Hernia sac dissection

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    View at the end of
    Hernia sac dissection

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Voluminous Hernia

    Endoloop is
    applied in case of
    voluminous hernia

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Steps of TAPP
    Placement of Mesh
     Cut the mesh in appropriate
    Size usually 7 - 11 Cm.
     Roll the mesh and load
    backward in one of the port.
     Unroll it when it reaches in
    Peritoneal cavity
     Fix the mesh by stapling or
    suturing first its middle part
    3 finger above the superior
    limit of the internal ring

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Closure of Peritoneum

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Closure of Peritoneum

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Procedure

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Complication
     Immediate
     Visceral Injury
     Vascular Injury
     Injury to Vas, Spermatic
    vessels
     Late
     Bowel Adhesions to
    mesh
     Intestinal Obstruction
     Fistulisation
     Orchitis
     Testicular atrophy
     Nerve entrapment
     Incisional Hernia
     Recurrence

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Recurrent Hernia

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Excessive Use of Implant

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Complication
    •Vascular Injury
    •Injury to Iliac Vessels: Chances
    of Mortality
    •Inferior Epigastric Vessel:
    Haematoma
    •Iliopubic vein and artery which
    travers the lacunar ligament:
    Haematoma
    •Injury to Spermatic vessels:
    Postoperative scrotal
    haematoma

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Complication
     Lateral cutaneous nerve Injury
     Most common nerve injured is lateral
    femoral cutaneous nerve (2%):
    Hyperesthesia or Paraesthesia of upper
    aspect of thigh and hip.
     If pain start days after surgery will
    recover within 2-4 weeks (or
    percutaneous steroid)
     If pain starts within 24 hour of surgery
    there is permanent nerve damage
     Cryotherapy with destruction of sensory
    branch is indicated
     Lifelong numbness
    World Laparoscopy Hospital Essentials of Laparoscopic Surgery
    Complication

     Genitofemoral nerve injury


     Genitofemoral nerve injury
    (1%): Hyperesthesia or
    Paraesthesia of scrotum
     Not significant
     With time it will subside

     Other complication
     Migration of Mesh
     Rejection of Mesh (Rare)
     Bowel adhesion

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery


    Dubai Course
    March 2007

    Dr Mishra’s Training in Dubai

    World Laparoscopy Hospital Essentials of Laparoscopic Surgery

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