1. بسم الله الرحمن الرحيم IN THE NAME OF ALLAH
THE MOST GRACEFUL THE MOST MERCIFUL

2. LAPAROSCOPIC
HERNIA REPAIR

3. INSTRUMENTS REQUIRED Laparoscope 300
Three – four Trocars (10-12 m.m.) + reducers
Dissector
Grasper
Diathermy needle
Suction tube
Endo-hernia
Endo-Clip clips
Marlex, polypropylene mesh or surgipro (different sizes)
Laparoscopic needles and needle holders

4. ANATOMY FROM INSIDE

5. Trans-peritoneal Laparoscopic View

6. Pre-peritoneal SCHEMATIC VIEWS

7. Pre-peritoneal Real View

9. TROCARS SITING

10. Types of Laparoscopic Repair
On-Lay mesh patch
Transperitoneal:
a) pre-peritoneal mesh
b) plug and mesh
c) Cigarettes and mesh
Extra-peritoneal approach

11. ON-LAY MESH PATCH Intra – peritoneal Weight of viscera to fix it
Complications (adhesions, obstruction and fistulas)
Less testicular pain and swelling
Not recommended by many authors

12. Trans-peritoneal (Pre-peritoneal) Mesh only mesh and plug mesh and cigarettes

13. MESH ONLY

14. MESH AND PLUG

15. (Video – presentation)
MESH AND CIGARRETTES
(Video – presentation)

17. Extra-Peritoneal Approach
(Video presentation)

19. Advantages of Laparoscopic Hernia Repair
Anatomy is clear.
Suitable for bilateral and recurrent hernias.
Quick convalescence (resume working after 1-7 days).
Less pain and scrotal swelling post-operatively.
Inguinal canal is not opened (less risk of nerves and cord injuries)

20. Disadvantages A little more expensive than anterior approach.
Higher recurrence rate (initial studies) than anterior
approach Viz: Bassini’s, McVay or Litchenstien’s repair.
Requires G.A.
Takes a little longer operating time ( 2 – 2 ½ hours)
Needs experts.

21. Training requirements for Laparoscopic Hernia repair
Attending basic courses in Laparoscopic surgery.
Training course in Hernia repair.
Surgeon should be familiar with the instruments.
Should know how to operate with both hands.
Learn how to suture laparoscopically.
Learning the anatomy of the region (very important).
Observing experts, assisting them and operates later on.

22. INDICATIONS Bilateral Hernias
(avoid long recoveries because of incisions)
Recurrent Hernias
(avoid dissecting scarred tissues, so less chance of cord and nerve injuries).

23. CONTRA-INDICATIONS Patients who can not tolerate G.A.
Large incarcerated sliding hernia

24. POTENTIAL COMPLICATIONS OF Laparoscopic hernia repair
Complications related to the laparoscope:
a) Gas embolism
b) Trocar injury (Bl. Vessels, bladder, bowel)
c) Cautery injury (bladder, bowel)

25. 2. Complications related to the repair: a) Vascular injury b) Bladder / bowel injury c) Injury to vas deferens d) nerve injury e) migration or infection of prosthesis f) adhesions and bowel obstruction g) Seroma formation h) Recurrence

26. PERSONAL EXPERIENCE 59 Cases
Al-Salama Hospital, Jeddah
October,1991 – JUNE,1998

27. Total no. 59 cases ( OCT. 1991- JUNE 1998 ) ANALYSED 47 CASES ( OCT
Total no. 59 cases ( OCT JUNE 1998 ) ANALYSED 47 CASES ( OCT FEB ) Unilateral Bilateral Pantalloon (38) (6) (3)

28. Sides
Indirect (one recurrent) Rt Direct Patalloon Indirect (one sliding sigmoid) Lt Direct Patalloon Bilateral

29. Males 45 SEX Females 2 (unilateral left side indirect)

30. AGE 18 - 78 years (mean 37 years)

31. Types of operation Mesh patch only 7
Pre-peritoneal Mesh and cig (2-7 cig)
Mesh and plugs
Extraperitoneal

32. Marlex 24 Material used Surgipro 7 polypropylene 16

33. Anaesthesia time Unilateral (1
Anaesthesia time Unilateral (1.30 – 4 hrs) fatty patient, big defect Bilateral (3 – 3.15 hrs)

34. Post-op follow-up
Pain : Patient given I.M Voltaren and Nubain 4-6 hourly for 24 hours.
All received prophylactic antibiotics for 3 doses post-op.
All discharged with pain killers to be taken PRN.
Same day of op
Ambulation st post-op day
2nd post –op day

35. Hospital stay: (1-7 days) average 2 days
( 7 days for that with D.V.T.)
Return to work: days to 5 weeks (D.V.T.)
( Average 7 days)
Lifting heavy objects : 6 weeks

36. Complications During Surgery:
One case, injury to U.B. stitched with Vicryl + catheter for 10 days

37. Continuation: Complications
II. Post-op:
- Retension of urine: One case responded to urinary catheterization for
24 hrs.
- Neuralgia of upper medial part of thigh (staples)
- Seroma – one case detected by U/S and aspirated from inguinal
region.
- Recurrence (4.2%) = 2 one after 3 months + one after 15 months
post-op.
- Trocar Hernia - One at umbilical port repaired later on

38. Continuation: Complications
II. Post-Op
Bleeding
Infection
Hydrocele
Orchitis NONE
Pelvic collection
Bowel injury

39. Length of follow-up OCT. 1991 – JUNE 1998 ( 6 YEARS + 8 MONTHS )

40. THANK YOU