Role of Laparoscopy in Management of Hernias

SIR ASTLEY COOPER 1804 No disease of the human body, belonging to the province of the general surgeon, requires in its treatment a greater combination of accurate anatomical knowledge with surgical skill, than hernia in its all varieties

Inguinal Hernia : Changing Concepts 1800’s : Sutured repairs 1980’s : Mesh repairs 1990’s : Preperitoneal mesh placement More physiological Additional support from muscles Pascal’s law Recent : Laparoscopic hernia repair Combines preperitoneal and lap concepts

Advantages of Lap repair Faster return to normal activity Lower persistent pain after lap repair European Union (EU) Hernia Trialists Collaboration 25 trials, 4165 patients in 20 countries Fewer post operative complications Early discharge from hospital Faster return to normal activities and work Memon et al a meta analysis 29 trials, 5588 patients with 5989 hernias MMemon MA, Br J Surg 2003;90:1479-92 , Cormack K, The Cochrane Library

Laparoscopic approach Transabdominal Preperitoneal approach TAPP Totally extra peritoneal approach TEP

EVOLUTION AT GEM Started TAPP from 1992 Started TEP from 1995 From1999 onwards >95% is TEP

TAPP- INDICATIONS Any type of groin hernia Recurrent inguinal hernia Bilateral inguinal hernia Patients undergoing another lap procedure

CONTRAINDICATIONS Unfit for GA Extensive intra abdominal adhesions Large sliding hernia with bowel adhesions to the sac Late strangulated hernia

POSITION OF PORTS Umbilicus- camera- 10mm Right pararectus- RHWP- 5mm Left pararectus- LHWP – 5mm

TAPP approach Creation of pneumoperitoneum Peritoneal flap creation Dissection in preperitoneal space Placement of Mesh & fixation Closure of peritoneal incision

Prosthesis- mesh Type Size Method of folding Method of introduction Method of unfolding Method of placement Method of fixation

MESH FIXATION Method used Suture material used Fixed to Cooper’s ligament Rectus muscle

POST OPERATIVE PERIOD liquids after 6 hrs Mobilisation after recovering from anaesthesia Discharged after 24hrs. Allowed to do routine work from the next day

INTRAOPERATIVE COMPLICATIONS Vascular injuries Bowel injuries Bladder injuries Vasdeferens injuries Others- lost needle into the rectus muscle

POST OP COMPLICATION Seroma haematoma Hydrocele Neuralgia Intestinal obstruction Testicular complications Mesh related complications

RECURRENCE-CAUSES Inexperience Incomplete dissection Missed hernias Missed lipoma Incomplete reduction of direct hernia Mesh related problems Smaller mesh, migration, Slitting, rolling Displacement due to hematoma, seroma

TEP approach Creation of extra peritoneal space Dissection Placement of Mesh & Fixation Peritoneal flap creation Closure of peritoneal incision

Advantages of TEP Approach No peritoneal invasion Less intra abdominal complications Less adhesions More physiological approach

Initial Concerns Superiority not proven High recurrence rates Increased complication rate Prohibitive cost Steep learning curve

Recent results Patients Follow up yrs Recurrence % Felix 1998 10,053 4 0.4 Schemdt 2002 6,860 5 <1 Schwab 2002 1,903 10 0.6 Palanivelu 2004 4,050 7 0.1 Felix E et al , Surg Endosc 1998;12:226-31. Schmedt CG et al , Surg Endosc 2002;16:240-4. Schwab JR et al , Surg Endosc 2002;16:1201-6.

Current consensus : Groin hernia surgery Laparoscopic repair is highly effective Extremely low recurrence & complication Ideal repair in all types of groin hernias Bilateral and recurrent hernias Needs adequate knowledge of preperitoneal anatomy Steep learning curve

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