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LAPAROSCOPIC INGUINAL HERNIA SURGERY TECHNICAL ASPECTS, CASE SELECTION Asoc. Prof.Dr. Orhan Yalçın Ministry of Health Okmeydanı Education and Research.

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Presentation on theme: "LAPAROSCOPIC INGUINAL HERNIA SURGERY TECHNICAL ASPECTS, CASE SELECTION Asoc. Prof.Dr. Orhan Yalçın Ministry of Health Okmeydanı Education and Research."— Presentation transcript:

1 LAPAROSCOPIC INGUINAL HERNIA SURGERY TECHNICAL ASPECTS, CASE SELECTION Asoc. Prof.Dr. Orhan Yalçın Ministry of Health Okmeydanı Education and Research Hospital İstanbul / Turkey 1

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3 There are three techniques 1-Intra peritoneal only mesh ( IPOM ) 2-Trans abdominal pre peritoneal ( TAPP ) 3-Totally extra peritoneal ( TEP ) In all techniques, three trocars are used. 3

4 IPOM TECHNIQUE -One from umbilicus -Other two trocars, lateral to rectus muscles -Mesh is placed to overlap the defect -Fixed with tacks, sutures or combination -It is not used in routine practice 4

5 TAPP TECHNIQUE -Trocar sites are same for IPOM -Periton is incised 2 cm above to hernia defect at the medial umbilical ligament and peritoneal flaps are created -Dissection of hernia sac -Placement of mesh -Closure of peritoneum -In TAPP and TEP, dissection area and mesh placement area the same. Difference is to approach to the pre peritoneal area 5

6 TEP TECHNIQUE Trocar position : There are two techniques 1. -Umbilicus ( 10 mm ) -Above the pubic arch ( 5 mm ) -Midway between two trocars ( 5 mm) 2. -Umbilicus ( 10 mm ) -Above the pubic arch ( 5 mm ) -Medial to anterior superior iliac spine or the side of hernia (5 mm ) 6

7 TEP –CONT. A-First trocar is applied in a plane between posterior surface of rectus muscle and posterior rectus sheath and peritoneum with balloon – preperitoneal retzius area are dissected B-Second and third trocars are inserted C- 1-First landmark is pubic bone and Cooper ligament 2-Medially direct hernia reduction 3-Laterally indirect hernia sac: superio-laterally from spermatic vessels. Medially vas deferens is dissected. 7

8 TEP CONT. -Cord parietalization to a point that crosses iliac vessels Preperitoneal dissection should be so big that When preperitoneal area is closed, prosthesis should lie flat in the preperitoneal space and should not roll up. D-Placement of mesh ( 12 x 15 cm polypropilen, polyester from umbilical port ) E-Fixation with tacks, staples, biologic glue. Fixation should be applied superior to iliopectineal ligament. 8

9 IN GENERAL IPOM Advantages -Minimal dissection -Minimal postoperative pain Disadvantages -Risk of bowel injury -Adhesive complications or herniations 9

10 TAPP Advantages -Easier to learn, anatomy is more familiar for the surgen. -The work space is larger than TEP -Allows to see the hernia sac contents Disadvantages -Potential intra abdominal injury risk -More time consuming than TEP -Potential adhesive complication at where peritoneum has been closed 10

11 TEP ADVANTAGES -reduced risk of potential intra abdominal injury -reduced risk of adhesive complications -operation time is less than TAPP DISADVANTAGES -learning curve is longer than TAPP -the working space is limited - inadvertently peritoneum can be torn. 11

12 CASE SELECTION TAPP preference - Recurrence after TEP -Patients in who had radical prostatectomy operation -Patients who has midline incision for major surgery -In the absence of this two conditions TEP is preferred technique. 12

13 LAPAROSCOPY CONTRINDICATIONS Absolute -Infection -Coagulopathy -In whom general anesthesia has increased risk Relative -Previous surgery in Retzius space -Incarcerated sliding scrotal hernia 13

14 THANK YOU 14


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