Presentation on theme: "Inguinal Hernia Laparoscopic repair"— Presentation transcript:
1Inguinal Hernia Laparoscopic repair Sakib MotalibUniversity of KentuckyCollege of Medicine, M1
2Inguinal Hernia Repair About the pathologyPatient SymptomsLaparoscopic TreatmentProcedureTypes of the Procedure: TEP vs. TAPPSteps for the repairPost-Operative CareBenefits of Laparoscopy vs. Open SurgeryAcknowledgementsQuestions
3About Inguinal Hernia’s The inguinal region has anatomical and clinical significanceInguinal canal components:Males = spermatic cordFemales = Round ligamentFormation of the hernia involves protrusion of peritoneum through a defect, forming a sac.Two types of hernia’s for inguinal region: direct and indirectThe inguinal region (groin), extending between the ASIS and pubic tubercle, is an important area anatomically and clinically; anatomically because it is a region where structures exit and enter the abdominal cavity and clinically because the pathways of exit and entrance are potential sites of herniation. In fact, the majority of abdominal hernias occur in this region, with inguinal hernias in particular accounting for 75% of all abdominal hernias. These hernias occur in both sexes, but most inguinal hernias (approximately 86%) occur in males because of the passage of the spermatic cord through the inguinal canal.The inguinal canal is formed in relation to the descent of the testis during fetal development. The main occupant of the inguinal canal is the spermatic cord in males and the round ligament of the uterus in females.
4Direct Inguinal Hernia Hernia protruding through a weak point in the fascia medial to epigastric vesselsStructures interacted with:hernia sacHesselbach’s triangleDirect hernias are usually easier to reduce and are less prone to incarcerate or strangulate than indirect hernias
5Indirect Inguinal Hernia hernia protrudes thru the inguinal ring, lateral to epigastric vesselsStructures interacted with:spermatic cordvas deferenstesticular arteries
6Causes of Inguinal Hernia Increased pressure within abdomen:Severe coughingStraining during heavy liftingStraining during constipationObesityPregnancyAgingGenetic predispositionPre-existing weak spotSource: Medscape (http://cme.medscape.com/viewarticle/420354_5)Don’t take care of a hernia sliding peritoneum becomes choked bad news bears
7Patient Symptoms Mass/bulge in the groin A burning sensation in the groinStrangulated hernia:Sudden pain, nausea, vomitingSymptoms of an inguinal hernia may include:A burning sensation in the groin occasionally precedes the development of a palpable hernia. Patients with hernia commonly report discovering a mass in the groin. Typically, the patient notes that the mass is gone when he awakens in the morning, but it reappears on arising. A dull sensation may be experienced as the day progresses and the patient has been upright for many hours.Coughing or severe straining as occurs with constipation or prostatism frequently precipitates the clinical appearance of the hernia. Any sudden increase in the size of the mass suggests incarceration or the development of a sliding component.A bulge in the groin or scrotum. The bulge may appear gradually over a period of several weeks or months, or it may form suddenly after you have been lifting heavy weights, coughing, bending, straining, or laughing. Many hernias flatten when you lie down.Groin discomfort or pain. The discomfort may be worse when you bend or lift. Although you may have pain or discomfort in the scrotum, many hernias do not cause any pain.You may have sudden pain, nausea, and vomiting if part of the intestine becomes trapped (strangulated) in the hernia.Other symptoms of a hernia include:Heaviness, swelling, and a tugging or burning sensation in the area of the hernia, scrotum, or inner thigh. Males may have a swollen scrotum, and females may have a bulge in the large fold of skin (labia) surrounding the vagina.Discomfort and aching that are relieved only when you lie down. This is often the case as the hernia grows larger.
8Laparoscopic treatment Position of patient:TrendelenburgSurgeon positions:Surgeon on opposite side of herniaCamera operator opposite side of surgeonMonitors at feet of patientTrendelenburg = body is laid flat on the back (supine position) with the feet higher than the head. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis.The indications for performing a laparoscopic hernia repair are essentially the same as repairing the hernia conventionally. There are, however, certain situations where laparoscopic hernia repair may offer definite benefit over conventional surgery to the patients. These include:*Bilateral inguinal hernias *Recurrent inguinal hernias
9Laparoscopic treatment Trocar: 10 mm trocar for camera, 5 mm for operating devicesCamera: 30 degree laparoscopeOperating devices:GrasperFine dissectorSuction-irrigation deviceCurved dissectorFinger dissectorSource of image = websurg*** LOOK UP SCOPE ***
10TAPP vs. TEP TAPP trans-abdominal pre-perotenial repair Pneumoperitoneum is created by surgeonPorts placed bilaterally, to either side of the cameraPneumoperitoneum is created by surgeon: Insert needle with CO2 tube below abdominal wall. Switch off gas when desired size of pneumoperitoneum has been created.This technique has been criticized for exposing intra-abdominal organs to potential complications, including small bowel injury and obstruction
11TAPP vs. TEP TEP Total extraperitoneal repair Extraperitoneal space is created by surgeonUsing balloonsPorts placed below camera port, along midlineMain concern is to make an extraperitoneal space. The extraperitoneal space is made possible by the fact that the peritoneum in suprapubic region can easily be separated from anterior abdominal wall, hereby creating enough space for dissectionmaintains peritoneal integrity, theoretically eliminating these risks while allowing direct visualization of the groin anatomy, which is critical for a successful repair.Pre-peritoneal space is a little bit large than TAPP.
12Laparoscopic Procedure TAPPMake a small incision just above the umbilicus.Lift up abdominal wall and gently insert Veress needleConnect CO2 tube to needleSwitch off gas when desired pneumoperitoneum is created and remove the Veress needleThe beginning steps in creating the peritoneal space are different between the TEP and TAPP procedures. Main concern for the TEP is to make an extraperitoneal space. The extraperitoneal space is made possible by the fact that the peritoneum in suprapubic region can easily be separated from anterior abdominal wall, hereby creating enough space for dissection. For the TAPP a pneumoperitoneum is created by surgeon. A needle is inserted with CO2 tube below abdominal wall. The pneumoperiotneum is inflated until desired size has been created.
13Laparoscopic Procedure TEPP:10 mm skin incision and retract to expose linea-alba (0:21)small incision is made on the anterior rectus sheath on affected side (0:30)Start blunt dissection to create a tunnel (1:00)1. 10 mm skin incision is made at the inferior portion of the umbilicus. If dissection is unilateral, the dissection is done on the side of the hernia2. Use army-navy retractors to retract the sub cutaneous planes and to bluntly dissect the fascia until linea-alba and the anterior rectus sheaths are exposed3. A small incision is made on the anterior rectus sheath on affected side, cutting along and lateral to the midline. Pick up anterior rectus sheath so muscle is not cut. Now in pro-peritoneal space3. Start blunt dissection to create a tunnel
14Laparoscopic Procedure Dissection balloon advanced down into the pubic tubercle (1:20)Balloon is hand pumped with guide of camera. (1:44)Dissection balloon removed and replaced with structural balloon (3:36)5. Dissection balloon (dipped in saline/goop) advanced down into the pubic tubercle6. The insert of the trochar is removed and replaced with a zero degree laproscope. Balloon is hand pumped with guide of the laparoscopic camera. **40 pumps** Put pressure along ipsilateral side to inflate balloon in place.7. Structural balloon on an umbilical trochar is inserted at same place as the dilating trochar. 3 full hand pumps to inflate the balloon. Then it is secured by sliding down the adjustable outer ring of the trocar to seal the entry site. Once sealed, use gas to inflate and create a pneumo-pro-peritoneum.
15Anatomy Review1. Incised anterior layer of rectus sheath 2. Posterior layer of rectus sheath 3. Arcuate line 4. PeritoneumInflate balloon under view of scope
16Laparoscopic Procedure Insert ports, and inflate extraperitoneal space with CO2 (5:20)Bluntly disect away pro-perotineal fat, identifying key organs:Cooper’s ligamentEpigastric vessels (8:08)Spermatic cord (11:25)(pre-emptive analgesisa) - Before ports are inserted, local anesthetic is delivered to areas where ports are to be inserted. Numb nerves near trocharInsert ports:Lowest port goes 3 finger breadths (4 cms) above pubic tubercle (so port doesn’t get in way of mesh)Second port goes as high as possible without popping a hole in the balloonWhy use CO2 = it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic proceduresBegin bluntly dissecting away pro-perotanial fat, identifying key organs. Start isolating things away from hernia sacEpigastric vesselsSpermatic cordCooper’s ligement
17Anatomy Review1st pic = ID cooper’s lig and show the plane of view (first from outside in, then inside out)Cooper’s lig = an extension of the lacunar ligament that runs on the pectineal line of the pubic bone
18Laparoscopic Procedure Bluntly disect away pro-perotineal fat, identifying key organs:Cooper’s ligamentEpigastric vessels (8:08)Spermatic cord (11:25)Insert ports (6:55):Lowest port goes 3 finger breadths (4 cms) above pubic tubercle (so port doesn’t get in way of mesh)Second port goes as high as possible without popping a hole in the balloonBegin bluntly dissecting away pro-perotanial fat, identifying key organs. Start isolating things away from hernia sacEpigastric vessels (9:08)Spermatic cord (11:25)Cooper’s ligement
19Laparoscopic Procedure Continued dissectionAfter further dissection, hernia clearly identified – Indirect hernia (17:55)Spermatic cord teased away from hernia sac (16:00)Grab edge of peritoneal sac and drag away from defect and key structuresContinued dissectionSpermatic cord teased away from hernia sac (16:35)Hernia identified (18:10)Hernia pseudo-sac identified (18:40). Looks like big white area. Will go back into abdominal wallAfter further dissection, hernia clearly identified (pt 2- 1:35)Hernia sac identified (4:44)Grab edge of peritoneal sac and drag away from vas deferens
20Laparoscopic Procedure Second hernia on opposite side identified – Direct herniaIdentify the hernia sac and dissect (28:35)Pull down on plane of attachment, cleaning off fat on the abdominal wall so it does not get in the way of the mesh (32:00)
21Laparoscopic Procedure Put in the mesh that will cover the defect (54:00)polypropylene meshMesh is curved, with label MPositioning of mesh is significantTack mesh in place or no fixationMeshits permanent for a permanent hole!Can contract. It’s a foreign bodyPut in graftGrab top edge, roll around the mesh so when it ends up in the peritoneal cavity it will unroll putting the lateral edge laterally and you pull the mesh up and push it in medially. Roll tight enough so it can go down the port (53:47)Pull the lateral edge laterally in perotonium (53:53)Pull up superiorly covering cord and ensuring the perotineum is beneath the mesh, and then tuck in laterallyMedialize the meshTack mesh in position (1:07:42)While tacking, ensure you are clear of the epigastric vessels
22Laparoscopic Procedure Start suctioning out the CO2 in the peritoneum (1:12:00)Push down on the mesh with suctionRemove ports, close the patient (close fascial layers, then superficial layers)Start sucking out the CO2 in the peritoneumPush down on the mesh with suction to ensure it stays in desired position as the peritoneum collapsesRemove ports, close the patient (close fascial layers, then superficial layers)
23Dangers/Areas to be Avoided Triangle of doomvas deferens mediallygonadal vessels laterallyperitoneum inferiorlyInside the triangle are the iliac artery and veinThe main area that needs to be avoided is the triangle of doom. The triangle consists of vas deferens medially, gonadals vesels laterally, inferiorly by peritoneum. Inside the triangle are the iliac artery and vein, which absolutely must be avoided as it is the largest and most significant blood supply to lower half of the body.
24Dangers/Areas to be Avoided Triangle of painContains cutaneous nerves neuralgiaMajor arteries and spermatic vesselsEpigastric vesselsSpecific example: tension on vas deferensOther major arteries such as the inferior epigastric vessels should be avoided. Furthermore, putting increased tension on any blood vessels or spermatic chord can cause increased recovery time and increased post-operative pain. Specifically, the tension on the vas deferens can cause ischemic testicles.
25Post-Operative CareA prescription for pain medication is given to you upon dischargeLight diet the first 24 hours after surgeryresume regular (light) daily activities beginning the next dayRefrain from any heavy lifting or straining until approved by your doctor.Follow up appointment with doctor 2-3 weeks after procedure.Diet: You should follow a light diet the first 24 hours after surgery, such as soup,crackers, pudding, etc. Resume your normal diet the day after surgery.
26Advantages/Disadvantages less tissue dissection and disruption of tissue planessmaller incisions just for the trocarsLess pain postoperativelyearlier return to normal activities for the patientDisadvantagesLearning curve for the procedure
27Acknowledgements James Hoskins, Director of MIS Training Center Dr. John Roth, Director of Minimally Invasive Surgery
28Sources http://www.websurg.com/ref/ot-ot02en195_en.html Times listed for the procedure : based on Laproscopic inguinal hernia repair DVD; instructors: Dr. Scott Roth [S2]