1. Avoiding and Managing Complications for Lap Inguinal Hernia Repair
Bruce Ramshaw MD FACS
Consultant, Halifax Health
Daytona Beach, FL

2. TEP (Total Extraperitoneal)

3. ANATOMY Very complex Unfamiliar to most open surgeons Consistent
Need to see over and over

7. Access to Extraperitoneal Space
Unfamiliar Anatomy
Consistent Anatomy
Obesity
Previous Surgery

8. Abdominal Wall Anatomy

9. Skin Incision

11. Balloon Dissection Different Types of Balloon Dissectors
Degree of Balloon Distention
Previous Surgery
Bleeding

12. Balloon Shapes

13. Lateral View

15. View Through the Balloon

16. Trocar Placement

17. Medial Dissection Usually accomplished by the balloon
Direct hernia may obscure view
Previous surgery
Obesity
Look for direct, femoral, and obturator hernias

19. Inferior Epigastric
Vessels

20. Direct Hernia

23. Lateral Dissection The most difficult part of the dissection
Stay just posterior to inferior epigastrics
Look for lateral abdominal wall
Avoid posterior structures

27. Cord

28. Cutaneous Nerve

30. Exploration of the Cord
Indirect sac located anteriomedial
Lipoma located anteriolateral
Vas located posteriomedial
Cord vessels located posteriolateral

33. Lipoma of the Cord

36. Mesh Placement Large mesh- at least 4 x 6 inches Slit or no slit
Anatomic or Flat
Memory

41. Inguinodynia – The Problem
Chronic groin pain after any type of inguinal hernia repair is potentially disabling
Neuralgia, parasthesia, hypoesthesia, hyperesthesia
Unable to work, limited physical & social activities, sleep disturbances, psychic distress
5-7% of patients experiencing post-hernia repair groin pain begin litigation. Most cases are settled. (General Surgery News, Feb 2004)

42. Inguinodynia Prospective series of open Lichtenstein hernia repairs:
At 1 yr f/u 19% of patients had pain, 6% moderate or severe
Callesen, Bech & Kehlet Br J Surg 1999
Scottish population based study
43% respondents with mild pain
3% severe, very severe pain
Courtney, Duffy, Serpell & O’Dwyer. Br J Surg 2002

43. Inguinodynia Pain 1 year s/p hernia repair – over 800 patients:
Pain present in 28.7% lap and 36.7% open
3 patients reported severe pain in open group
MRC Laparoscopic Groin Hernia Trial Group, Lancet 1999
Pain present at one year in 28.7% of patients in Danish National Hernia Database study
11% pain impaired work or leisure activity
4.5% sought treatment
Bay-Neilsen, Perkins & Kehlet, Ann Surg 2001

44. The cutaneous nerves
Anterior view Posterior view

46. Inguinodynia Algorithm
Failure of conservative treatment
Diagnostic laparoscopy
Intrabdominal Findings:
Adhesions or Hernia recurrence?
Adhesiolysis and/or
Mesh hernia repair
yes
TAPP dissection (peritoneal take-down): 4 steps
Evaluate laterally for cutaneous nerve entrapment
Evaluate medially for canal/cord nerve entrapment
Remove offending tacks or mesh lateral to epigastric vessels
Look for interstitial hernia and/or lipoma of the cord
No pathology noted &
Continuation of symptoms post-operatively
Open mesh excision/neurectomy

47. Adhesions

48. Recurrent Hernia

49. Tacks

50. Plugs

51. Previous mesh slit

52. Inguinodynia- Case study
280 lb ex-NFL football player (40 y.o)
Lap LIH (3-D max, minimal fixation)
Severe pain almost immediately
Three operations over three years
- two by primary surgeon
- one for open neurectomy by expert
100 lb wt. loss, loss of all employment, severe depression, NFL permanent disability

53. Previous mesh- no slit

54. Open mesh excision

55. THANK YOU
Questions?