Inguinal hernia repair Laparoscopic Inguinal hernia repair S.Darabi,M.D, Fellowship in Advanced MIS and Bariatric Surgery

Indications: For many patients, either a laparoscopic or open approach to inguinal hernia repair is appropriate to consider. In experienced hands, outcomes are similar in terms of hernia recurrence.

The advantages of the laparoscopic approach are more apparent in the following situations: 1. Bilateral inguinal hernias. 2. Recurrent inguinal hernia after a prior open anterior approach. 3. Patients who are undergoing another laparoscopic procedure who also have an inguinal hernia.

Laparoscopic approach: Totally Extra Peritoneal (TEP) Trans Abdominal Pre Peritoneal (TAPP)

Types of Hernia Direct inguinal hernia

Types of Hernia Femoral hernia

Types of Hernia Indirect inguinal hernia

Anatomy Types of Hernia: Direct Indirect Femoral Obturator

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

Anatomy TRIANGLE OF DOOM TRIANGLE OF PAIN

Anatomy . Preperitoneal anatomy for right inguinal hernia displaying vital structures and their structures and their relationships to indirect, direct, and femoral hernia spaces. I indirect space, D direct space, F femoral space, EV epigastric vessels, R rectus muscle, P pubic bone, IT iliopubic tract, CL Cooper’s ligament, V vas deferens, CVcord vessels, IV iliac vessels, LFN lateral femoral cutaneous nerve.

Patient Position and Room Setup: 1. The patient is supine with both arms tucked. 2. Surgeon stands on the side opposite of the hernia. 3. The monitor should be positioned at the foot of the bed.

Patient Position and Room Setup

Port Position: LIH

Port Position: BIH

Port Position: RIH

TAPP Procedure: Incision of Peritoneum incise the peritoneum laterally by the anterior superior iliac spine at a distance of approximately 3 cm over the internal ring all the way to the median umbilical ligament.

TAPP Procedure: Lateral Dissection Sweep the peritoneum down to view the preperitoneal space.

TAPP Procedure: Medial Dissection Sweep the peritoneum down to view the preperitoneal space

TAPP Procedure: Medial Dissection

TAPP Procedure: Hernia sac Dissection

TAPP Procedure: Fixation of Mesh: Select a large (10 cm by 15 cm) piece of mesh (usually polypropylene or polyester based) and place it into the abdomen via the10-mm port.

TAPP Procedure: Fixation of Mesh: Position the mesh so that the entire myopectineal orifice is covered with good superior, medial, and lateral overlap. The mesh necessarily overlaps the cord structures in order to cover the indirect space completely. It is important that the peritoneum and sac be reduced proximal to where the inferior border of the mesh will lie so that it cannot slip back under the mesh and lead to a recurrence.

TAPP Procedure: Fixation of Mesh:

Bilateral Hernia For bilateral hernias, perform a similar dissection and mesh placement on the contralateral side.

Closure of Peritoneum: TAPP Procedure: Closure of Peritoneum: The peritoneal flap is closed back over the mesh either using a staple fixation device or an absorbable suture. It is important that there be no gaps in the peritoneal closure through which bowel could herniate.

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