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

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.

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

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”

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.
- Above the pubic arch ( 5 mm )
- Medial to anterior superior iliac spine or the side of hernia (5 mm )

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.

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.

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

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

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.

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.

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

14. THANK YOU