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

2. 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.

3. 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.

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

5. Types of Hernia
Direct inguinal hernia

6. Types of Hernia
Femoral hernia

7. Types of Hernia
Indirect inguinal hernia

8. Anatomy
Types of Hernia:
Direct
Indirect
Femoral
Obturator

9. 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

10. Anatomy
TRIANGLE OF DOOM
TRIANGLE OF PAIN

11. 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.

12. 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.

13. Patient Position and Room Setup

14. Port Position:
LIH

15. Port Position:
BIH

16. Port Position:
RIH

17. 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.

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

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

20. TAPP Procedure:
Medial Dissection

21. TAPP Procedure:
Hernia sac Dissection

22. 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.

23. 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.

24. TAPP Procedure:
Fixation of Mesh:

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

26. 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.

27. Thank You