1. Hernia Repair; TEP, Incisional, and Umbilical
By Chayse Thompson

2. TEP (Totally Extraperitoneal)

3. Relevant Anatomy Skin and SubQ Scarpa’s fascia Innominate fascia
Ext. oblique muscle
Inguinal ligament
Interparietal fascia
Int. oblique muscle
Trans. Abdominis muscle
Transversalis fascia
Cooper’s ligament
Rectus abdominis muscle
Peritoneum
Inguinal canal
Epigastric vessels
Iliofemoral vessels
Spermatic cord
Iliohypogastric and Ilioinguinal nerves
Cremaster muscle

4. Physiology and Pathophysiology
The transversalis fascia is the main source of herniation, it’s weak and a hernia occurs through a tear or weakness here.

5. Diagnostic Exams Hx&Px Observation of hernia-inguinal bulge
Scrotal digital exam

6. Surgical Intervention
Implication of polypropylene mesh(laparoscopically) to secure and reinforce abdominal wall to prevent herniation of bowel and other tissues.

7. Special Considerations
Age
Weight
Comorbidities

8. Anesthesia and Positioning
General
Spinal and conscious sedation
Epidural
Local
The pt will be placed in the supine position

9. Skin Prep
The pt will be prepped with a wide abdominal prep mid chest to the symphysis pubis, and as laterally as far as possible

10. Draping
The surgical site will be squared off with four towels using the same anatomical points of reference as the skin prep.
Abdominal laparoscopy drape
Some facilities may have specialty laparoscopic hernia drapes available

11. Incision An infraumbilical incision is made using a #15 blade
Transverse or vertical incisions, four

12. Supplies Dissecting balloon Polypropylene mesh and suture
Loop ligature

13. Equipment and Instruments
30 degree laparoscope
Laparoscopic stapling device
Major laparotomy set
You can see by the light produced by the laparoscope on the right that the end is angled.
Linear stapler (left)

14. Procedure Steps Infraumbilical incision-#15 blade
Anterior rectus sheath is incised, then the ipsilateral rectus abdominis muscle is retracted laterally
Blunt dissection-creates space beneath the rectus abdominis muscle
Dissection balloon is inserted and placed on the posterior rectus(anterior side). The balloon is then moved to create a tunnel into the pubic symphysis in the preperitoneal space. After, its inflated to create a cavity, and then it’s removed and replaced with a blunt tipped trocar.
The preperitoneal space gets insufflated and followed up with the insertion of additional trocars. 30 degree scopes are then used to complete the procedure.

15. Procedure Steps (continued)
The inf. Epigastric vessels are identified and retracted anteriorly
Cooper’s ligament is identified and dissected so that it’s free from the pubic symphysis medially to the level of the ext. Iliac vein
Then the iliopubic tract, genitofemoral, and lateral femoral cutaneous nerves are identified-prevents damage to the nerves
Lateral dissection occurs on the anterior iliac spine, and the spermatic cord is dissected free

16. Procedure Steps (continued)
Direct hernia- reduced by traction Indirect hernia (small)-freed from the spermatic cord and reduced into the peritoneal cavity Indirect hernia (large)-divided with cautery near the inguinal ring, then the proximal peritoneal sac is closed with loop ligature
During reduction of the hernia, polypropylene mesh is inserted through a trocar to cover the direct, indirect, femoral spaces, and the spermatic cord.
The mesh is then secured by a tacking stapler
The balloon, laparoscope, and trocars are removed. This is then followed with closure, either suture or closure strips.

17. Counts and Specimen Initial count
Count as the laparoscopic equipment is being removed from the abdomen
Count as the subcutaneous layer is being closed
Final count
Anaerobic and aerobic

18. Dressings and Prognosis
Small pressure dressings
Suture
Steri-strips
If no complications, the pt can be discharged the same day of Sx.
The pt will be able to return to normal activities in 2-4 weeks.

19. Complications Hernia recurrence Nerve damage
Fluid build up at the site of the mesh implant
Postop SSI

20. Wound Classification/Management
Clean case, unless an entrance is made into the alimentary tract.
The pt must avoid putting strain on the abdomen

21. Ventral (Incisional)

22. Relevant Anatomy Anatomy is the same as the TEP herniorrhaphy
Anatomy will change based on the site of the incision
Most common site of incision; vertical midline
Linea alba

23. Physiology and Pathophysiology
Ventral hernia weakened area that occurs along a primary abdominal incision Identified by a bulge in the abdomen.

24. Diagnostic Exams and Surgical Intervention
Hx&Px
An incision is made with a #10 blade(most commonly) in the abdomen and the hernia is repaired either with a mesh implant or suture the laparoscopic equipment.

25. Special Considerations
Age
Weight
Comorbidities
Attending surgeon’s techniques
How long it takes to heal
How much tissue/length of instruments
Types of mesh and suture used

26. Anesthesia and Positioning
Pt will be placed in the supine position
General, spinal, epidural, or local anesthesia.

27. Skin Prep and Draping Lower or upper R or L quadrant
Umbilicus down to the symphysis pubis or umbilicus up to the sternum and laterally as far as possible
Square off the surgical site with four towels
Laparotomy sheet

28. Incision
#10 blade and allis clamps for the removal of the old scar

29. Supplies
Synthetic mesh
Suture or staples for mesh

30. Equipment and Instruments
Laparoscopic equipment
Major instrument set
#10 blade for initial incision
Allis clamps for removal of old scar

31. Procedure Steps
Removal of the old abdominal scar with #10 blade *tech follows along the surgeon with the allis clamped to the scar providing gentle traction
The verres needle is then placed into the abdomen for insufflation
Three trocars are then placed laterally to the incision
An atraumatic laparoscopic clamp(curved) is used to pull the internal abdominal contents(omentum) away from the hernia site and then back into its normal anatomical position,
*Tech TIp
Middle trocar for laparoscope and other two for instruments

32. Procedure Steps (continued)
Next, lyse the adhesions either with a bovie or harmonic scalpel
A spinal is placed through the skin and visualized through the laparoscope to help with measuring the size of the hernia, and mesh required for repair.
*The mesh is then cut to size(larger than the hernia).
The surgeon will then mark the correct side of the mesh with a marking pen and place non-absorbable monofilament sutures in the corners of the mesh to serves as markers for placement.
*The mesh is then placed into the abdomen through a trocar and positioned
Tech must ensure of enough mesh before procedure starts
Prolene, Ethilon
Pass to surgeon or insert in trocar rolled up

33. Procedure Steps (continued)
A suture passer/retriever is inserted and used to grab the corners of the sutures, they are then brought and tied at the skin level. The mesh is secured to the abdominal wall using mattress sutures that were placed through different incision sites.
Tacking staples are then placed in between the sutures to secure the mesh further and prevent tissue from protruding.

34. Counts and Specimen Initial count
Count before the mesh is secured to the abdominal wall closing the herniation
Count before the subcutaneous layer is closed
Final count
Aerobic and anaerobic specimens taken
Anaerobic will die quickly, must be placed into the growth medium or vacuum quickly

35. Dressings and Prognosis
Small pressure dressing
Suture
Steri-strips
If no complications; pt is discharged the same day and can return to their normal ADL’s within two to four weeks.

36. Complications & Wound Classification/Management
Hernia recurrence
Nerve damage
Fluid build up at the site of the mesh
Postop SSI
Clean case unless entrance to the alimentary tract
Pt will be instructed to not put any strain on the abdomen

37. Umbilical

38. Physiology, Pathophysiology and Sx Intervention
The umbilicus is formed from the umbilical ring of the linea alba
The ligamentum teres(round ligament) and the paraumbilical veins combine superiorly at the umbilicus while the obliterated urachus(umbilical ligament) enters the umbilicus inferiorly
Congenital in infants and usually close spontaneously
Sx treated after age 5 most commonly

39. Diagnostic Exams
Hx&Px

40. Special Considerations
Pt’s body temperature, pediatric pt’s will need radiant heat
Age

41. Anesthesia and Positioning
Supine position
General anesthesia

42. Draping and Skin Prep Square off around the infraumbilical site
Pediatric laparotomy drape
Mid chest to symphysis pubis and laterally as far as possible

43. Incision
An infraumbilical incision is made using a #15 blade

44. Supplies, Equipment and Instruments
Synthetic mesh
Suture for mesh; monofilament, non-absorbable
Minor instrument set
Radiant overhead heater-pediatric pt’s 2 yrs and younger

45. Procedure Steps Infraumbilical incision is made with a #15 blade
Senn retractors are used to retract the skin and subcutaneous tissue in order to visualize the rectus fascia and hernia
The hernia sac is located between the rectus abdominis muscle sheaths and is bluntly dissected free
Once free, the sac may be ligated or excised
If ligated, a peanut sponge on a mosquito will be placed inside the sac to gently push down the hernia sac contents while the suture is being placed
A brown or mayo needle holder should be loaded with the suture
If excised, the hernia sac is a specimen

46. Procedure Steps (continued)
*The peritoneum is closed with suture-continuous
The rectus fascia is closed using an interrupted suturing technique; 3-0 or 4-0 non-absorbable
Then a continuous suture with a small gauge absorbable suture is used to close the subcutaneous layer
A small pressure dressing is placed
The tech should remember to follow the surgeon

47. Counts and Specimens Initial count
Count before the peritoneum is closed
Count before the rectus fascia and subcutaneous layer are closed
Final count
If the hernia sac was excised, then it will become a specimen

48. Dressings and Prognosis
If no complications the pt will be discharged the same day and can return to normal ADL’s within 2-4 weeks
Parents or gaurdians of pt will have to ensure that strain isn’t put on the wound

49. Complications
Hernia recurrence
Hemorrhaging
Postop SSI

50. Wound Classification/Management
Clean
Parents receive postop education in particular to being alert about signs and symptoms of SSI’s