1. Inguinal Hernia Laparoscopic repair
Sakib Motalib
University of Kentucky
College of Medicine, M1

2. Inguinal Hernia Repair
About the pathology
Patient Symptoms
Laparoscopic Treatment
Procedure
Types of the Procedure: TEP vs. TAPP
Steps for the repair
Post-Operative Care
Benefits of Laparoscopy vs. Open Surgery
Acknowledgements
Questions

3. About Inguinal Hernia’s
The inguinal region has anatomical and clinical significance
Inguinal canal components:
Males = spermatic cord
Females = Round ligament
Formation of the hernia involves protrusion of peritoneum through a defect, forming a sac.
Two types of hernia’s for inguinal region: direct and indirect
The inguinal region (groin), extending between the ASIS and pubic tubercle, is an important area anatomically and clinically; anatomically because it is a region where structures exit and enter the abdominal cavity and clinically because the pathways of exit and entrance are potential sites of herniation. In fact, the majority of abdominal hernias occur in this region, with inguinal hernias in particular accounting for 75% of all abdominal hernias. These hernias occur in both sexes, but most inguinal hernias (approximately 86%) occur in males because of the passage of the spermatic cord through the inguinal canal.
The inguinal canal is formed in relation to the descent of the testis during fetal development. The main occupant of the inguinal canal is the spermatic cord in males and the round ligament of the uterus in females.

4. Direct Inguinal Hernia
Hernia protruding through a weak point in the fascia medial to epigastric vessels
Structures interacted with:
hernia sac
Hesselbach’s triangle
Direct hernias are usually easier to reduce and are less prone to incarcerate or strangulate than indirect hernias

5. Indirect Inguinal Hernia
hernia protrudes thru the inguinal ring, lateral to epigastric vessels
Structures interacted with:
spermatic cord
vas deferens
testicular arteries

6. Causes of Inguinal Hernia
Increased pressure within abdomen:
Severe coughing
Straining during heavy lifting
Straining during constipation
Obesity
Pregnancy
Aging
Genetic predisposition
Pre-existing weak spot
Source: Medscape (
Don’t take care of a hernia  sliding peritoneum becomes choked  bad news bears

7. Patient Symptoms Mass/bulge in the groin
A burning sensation in the groin
Strangulated hernia:
Sudden pain, nausea, vomiting
Symptoms of an inguinal hernia may include:
A burning sensation in the groin occasionally precedes the development of a palpable hernia. Patients with hernia commonly report discovering a mass in the groin. Typically, the patient notes that the mass is gone when he awakens in the morning, but it reappears on arising. A dull sensation may be experienced as the day progresses and the patient has been upright for many hours.
Coughing or severe straining as occurs with constipation or prostatism frequently precipitates the clinical appearance of the hernia. Any sudden increase in the size of the mass suggests incarceration or the development of a sliding component.
A bulge in the groin or scrotum. The bulge may appear gradually over a period of several weeks or months, or it may form suddenly after you have been lifting heavy weights, coughing, bending, straining, or laughing. Many hernias flatten when you lie down.
Groin discomfort or pain. The discomfort may be worse when you bend or lift. Although you may have pain or discomfort in the scrotum, many hernias do not cause any pain.
You may have sudden pain, nausea, and vomiting if part of the intestine becomes trapped (strangulated) in the hernia.
Other symptoms of a hernia include:
Heaviness, swelling, and a tugging or burning sensation in the area of the hernia, scrotum, or inner thigh. Males may have a swollen scrotum, and females may have a bulge in the large fold of skin (labia) surrounding the vagina.
Discomfort and aching that are relieved only when you lie down. This is often the case as the hernia grows larger.

8. Laparoscopic treatment
Position of patient:
Trendelenburg
Surgeon positions:
Surgeon on opposite side of hernia
Camera operator opposite side of surgeon
Monitors at feet of patient
Trendelenburg = body is laid flat on the back (supine position) with the feet higher than the head. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis.
The indications for performing a laparoscopic hernia repair are essentially the same as repairing the hernia conventionally. There are, however, certain situations where laparoscopic hernia repair may offer definite benefit over conventional surgery to the patients. These include:
*Bilateral inguinal hernias *Recurrent inguinal hernias

9. Laparoscopic treatment
Trocar: 10 mm trocar for camera, 5 mm for operating devices
Camera: 30 degree laparoscope
Operating devices:
Grasper
Fine dissector
Suction-irrigation device
Curved dissector
Finger dissector
Source of image = websurg
*** LOOK UP SCOPE ***

10. TAPP vs. TEP TAPP trans-abdominal pre-perotenial repair
Pneumoperitoneum is created by surgeon
Ports placed bilaterally, to either side of the camera
Pneumoperitoneum is created by surgeon: Insert needle with CO2 tube below abdominal wall. Switch off gas when desired size of pneumoperitoneum has been created.
This technique has been criticized for exposing intra-abdominal organs to potential complications, including small bowel injury and obstruction

11. TAPP vs. TEP TEP Total extraperitoneal repair
Extraperitoneal space is created by surgeon
Using balloons
Ports placed below camera port, along midline
Main concern is to make an extraperitoneal space. The extraperitoneal space is made possible by the fact that the peritoneum in suprapubic region can easily be separated from anterior abdominal wall, hereby creating enough space for dissection
maintains peritoneal integrity, theoretically eliminating these risks while allowing direct visualization of the groin anatomy, which is critical for a successful repair.
Pre-peritoneal space is a little bit large than TAPP.

12. Laparoscopic Procedure
TAPP
Make a small incision just above the umbilicus.
Lift up abdominal wall and gently insert Veress needle
Connect CO2 tube to needle
Switch off gas when desired pneumoperitoneum is created and remove the Veress needle
The beginning steps in creating the peritoneal space are different between the TEP and TAPP procedures. Main concern for the TEP is to make an extraperitoneal space. The extraperitoneal space is made possible by the fact that the peritoneum in suprapubic region can easily be separated from anterior abdominal wall, hereby creating enough space for dissection. For the TAPP a pneumoperitoneum is created by surgeon. A needle is inserted with CO2 tube below abdominal wall. The pneumoperiotneum is inflated until desired size has been created.

13. Laparoscopic Procedure
TEPP:
10 mm skin incision and retract to expose linea-alba (0:21)
small incision is made on the anterior rectus sheath on affected side (0:30)
Start blunt dissection to create a tunnel (1:00)
1. 10 mm skin incision is made at the inferior portion of the umbilicus. If dissection is unilateral, the dissection is done on the side of the hernia
2. Use army-navy retractors to retract the sub cutaneous planes and to bluntly dissect the fascia until linea-alba and the anterior rectus sheaths are exposed
3. A small incision is made on the anterior rectus sheath on affected side, cutting along and lateral to the midline. Pick up anterior rectus sheath so muscle is not cut. Now in pro-peritoneal space
3. Start blunt dissection to create a tunnel

14. Laparoscopic Procedure
Dissection balloon advanced down into the pubic tubercle (1:20)
Balloon is hand pumped with guide of camera. (1:44)
Dissection balloon removed and replaced with structural balloon (3:36)
5. Dissection balloon (dipped in saline/goop) advanced down into the pubic tubercle
6. The insert of the trochar is removed and replaced with a zero degree laproscope. Balloon is hand pumped with guide of the laparoscopic camera. **40 pumps** Put pressure along ipsilateral side to inflate balloon in place.
7. Structural balloon on an umbilical trochar is inserted at same place as the dilating trochar. 3 full hand pumps to inflate the balloon. Then it is secured by sliding down the adjustable outer ring of the trocar to seal the entry site. Once sealed, use gas to inflate and create a pneumo-pro-peritoneum.

15. Anatomy Review
1. Incised anterior layer of rectus sheath 2. Posterior layer of rectus sheath 3. Arcuate line 4. Peritoneum
Inflate balloon under view of scope

16. Laparoscopic Procedure
Insert ports, and inflate extraperitoneal space with CO2 (5:20)
Bluntly disect away pro-perotineal fat, identifying key organs:
Cooper’s ligament
Epigastric vessels (8:08)
Spermatic cord (11:25)
(pre-emptive analgesisa) - Before ports are inserted, local anesthetic is delivered to areas where ports are to be inserted. Numb nerves near trochar
Insert ports:
Lowest port goes 3 finger breadths (4 cms) above pubic tubercle (so port doesn’t get in way of mesh)
Second port goes as high as possible without popping a hole in the balloon
Why use CO2 =  it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures
Begin bluntly dissecting away pro-perotanial fat, identifying key organs. Start isolating things away from hernia sac
Epigastric vessels
Spermatic cord
Cooper’s ligement

17. Anatomy Review
1st pic = ID cooper’s lig and show the plane of view (first from outside in, then inside out)
Cooper’s lig = an extension of the lacunar ligament that runs on the pectineal line of the pubic bone

18. Laparoscopic Procedure
Bluntly disect away pro-perotineal fat, identifying key organs:
Cooper’s ligament
Epigastric vessels (8:08)
Spermatic cord (11:25)
Insert ports (6:55):
Lowest port goes 3 finger breadths (4 cms) above pubic tubercle (so port doesn’t get in way of mesh)
Second port goes as high as possible without popping a hole in the balloon
Begin bluntly dissecting away pro-perotanial fat, identifying key organs. Start isolating things away from hernia sac
Epigastric vessels (9:08)
Spermatic cord (11:25)
Cooper’s ligement

19. Laparoscopic Procedure
Continued dissection
After further dissection, hernia clearly identified – Indirect hernia (17:55)
Spermatic cord teased away from hernia sac (16:00)
Grab edge of peritoneal sac and drag away from defect and key structures
Continued dissection
Spermatic cord teased away from hernia sac (16:35)
Hernia identified (18:10)
Hernia pseudo-sac identified (18:40). Looks like big white area. Will go back into abdominal wall
After further dissection, hernia clearly identified (pt 2- 1:35)
Hernia sac identified (4:44)
Grab edge of peritoneal sac and drag away from vas deferens

20. Laparoscopic Procedure
Second hernia on opposite side identified – Direct hernia
Identify the hernia sac and dissect (28:35)
Pull down on plane of attachment, cleaning off fat on the abdominal wall so it does not get in the way of the mesh (32:00)

21. Laparoscopic Procedure
Put in the mesh that will cover the defect (54:00)
polypropylene mesh
Mesh is curved, with label M
Positioning of mesh is significant
Tack mesh in place or no fixation
Mesh
its permanent for a permanent hole!
Can contract. It’s a foreign body
Put in graft
Grab top edge, roll around the mesh so when it ends up in the peritoneal cavity it will unroll putting the lateral edge laterally and you pull the mesh up and push it in medially. Roll tight enough so it can go down the port (53:47)
Pull the lateral edge laterally in perotonium (53:53)
Pull up superiorly covering cord and ensuring the perotineum is beneath the mesh, and then tuck in laterally
Medialize the mesh
Tack mesh in position (1:07:42)
While tacking, ensure you are clear of the epigastric vessels

22. Laparoscopic Procedure
Start suctioning out the CO2 in the peritoneum (1:12:00)
Push down on the mesh with suction
Remove ports, close the patient (close fascial layers, then superficial layers)
Start sucking out the CO2 in the peritoneum
Push down on the mesh with suction to ensure it stays in desired position as the peritoneum collapses
Remove ports, close the patient (close fascial layers, then superficial layers)

23. Dangers/Areas to be Avoided
Triangle of doom
vas deferens medially
gonadal vessels laterally
peritoneum inferiorly
Inside the triangle are the iliac artery and vein
The main area that needs to be avoided is the triangle of doom. The triangle consists of vas deferens medially, gonadals vesels laterally, inferiorly by peritoneum. Inside the triangle are the iliac artery and vein, which absolutely must be avoided as it is the largest and most significant blood supply to lower half of the body.

24. Dangers/Areas to be Avoided
Triangle of pain
Contains cutaneous nerves  neuralgia
Major arteries and spermatic vessels
Epigastric vessels
Specific example: tension on vas deferens
Other major arteries such as the inferior epigastric vessels should be avoided. Furthermore, putting increased tension on any blood vessels or spermatic chord can cause increased recovery time and increased post-operative pain. Specifically, the tension on the vas deferens can cause ischemic testicles.

25. Post-Operative Care
A prescription for pain medication is given to you upon discharge
Light diet the first 24 hours after surgery
resume regular (light) daily activities beginning the next day
Refrain from any heavy lifting or straining until approved by your doctor.
Follow up appointment with doctor 2-3 weeks after procedure.
Diet: You should follow a light diet the first 24 hours after surgery, such as soup,
crackers, pudding, etc. Resume your normal diet the day after surgery.

26. Advantages/Disadvantages
less tissue dissection and disruption of tissue planes
smaller incisions just for the trocars
Less pain postoperatively
earlier return to normal activities for the patient
Disadvantages
Learning curve for the procedure

27. Acknowledgements James Hoskins, Director of MIS Training Center
Dr. John Roth, Director of Minimally Invasive Surgery

28. Sources http://www.websurg.com/ref/ot-ot02en195_en.html
Times listed for the procedure : based on Laproscopic inguinal hernia repair DVD; instructors: Dr. Scott Roth [S2]

29. Questions?