1. Role of Laparoscopy in Management of Hernias

2. 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

3. 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

4. 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: , Cormack K, The Cochrane Library

5. Laparoscopic approach
Transabdominal Preperitoneal approach
TAPP
Totally extra peritoneal approach
TEP

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

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

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

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

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

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

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

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

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

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

16. 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

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

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

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

20. 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: Schmedt CG et al , Surg Endosc 2002;16: Schwab JR et al , Surg Endosc 2002;16:

21. 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

22. Thanks