3There 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.
4IPOM 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
5TAPP 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”
6TEP TECHNIQUETrocar position : There are two techniques1.- Umbilicus ( 10 mm )- Above the pubic arch ( 5 mm )- Midway between two trocars ( 5 mm)2.- Above the pubic arch ( 5 mm )- Medial to anterior superior iliac spine or the side of hernia (5 mm )
7TEP –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 dissectedB- Second and third trocars are insertedC-1- First landmark is pubic bone and Cooper ligament2- Medially direct hernia reduction3- Laterally indirect hernia sac: superio-laterally from spermatic vessels. Medially vas deferens is dissected.
8TEP CONT.- Cord parietalization to a point that crosses iliac vesselsPreperitoneal 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.
9IN GENERAL IPOM Advantages -Minimal dissection -Minimal postoperative painDisadvantages-Risk of bowel injury-Adhesive complications or herniations
10TAPPAdvantages- Easier to learn, anatomy is more familiar for the surgen.- The work space is larger than TEP- Allows to see the hernia sac contentsDisadvantages- Potential intra abdominal injury risk- More time consuming than TEP- Potential adhesive complication at where peritoneum has been closed
11TEP ADVANTAGES -reduced risk of potential intra abdominal injury -reduced risk of adhesive complications-operation time is less than TAPPDISADVANTAGES-learning curve is longer than TAPP-the working space is limited- inadvertently peritoneum can be torn.
12CASE SELECTION TAPP preference - Recurrence after TEP Patients in who had radical prostatectomy operationPatients who has midline incision for major surgeryIn the absence of this two conditions TEP is preferred technique.
13LAPAROSCOPY CONTRINDICATIONS Absolute- Infection- Coagulopathy- In whom general anesthesia has increased riskRelative- Previous surgery in Retzius space- Incarcerated sliding scrotal hernia