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Inguinal Hernia Laparoscopic repair Sakib Motalib University of Kentucky College of Medicine, M1.

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Presentation on theme: "Inguinal Hernia Laparoscopic repair Sakib Motalib University of Kentucky College of Medicine, M1."— Presentation transcript:

1 Inguinal Hernia Laparoscopic repair Sakib Motalib University of Kentucky College of Medicine, M1

2 Inguinal Hernia Repair  About the pathology  Patient Symptoms  Laparoscopic Treatment  Procedure  Types of the Procedure: TEP vs. TAPP  Steps for the repair  Post-Operative Care  Benefits of Laparoscopy vs. Open Surgery  Acknowledgements  Questions

3 About Inguinal Hernia’s  The inguinal region has anatomical and clinical significance  Inguinal canal components:  Males = spermatic cord  Females = Round ligament  Formation of the hernia involves protrusion of peritoneum through a defect, forming a sac.  Two types of hernia’s for inguinal region: direct and indirect

4 Direct Inguinal Hernia  Hernia protruding through a weak point in the fascia medial to epigastric vessels  Structures interacted with:  hernia sac  Hesselbach’s triangle

5 Indirect Inguinal Hernia  hernia protrudes thru the inguinal ring, lateral to epigastric vessels  Structures interacted with:  spermatic cord  vas deferens  testicular arteries

6 Causes of Inguinal Hernia  Increased pressure within abdomen:  Severe coughing  Straining during heavy lifting  Straining during constipation  Obesity  Pregnancy  Aging  Genetic predisposition  Pre-existing weak spot

7 Patient Symptoms  Mass/bulge in the groin  A burning sensation in the groin  Strangulated hernia:  Sudden pain, nausea, vomiting

8 Laparoscopic treatment  Position of patient:  Trendelenburg  Surgeon positions:  Surgeon on opposite side of hernia  Camera operator opposite side of surgeon  Monitors at feet of patient

9 Laparoscopic treatment  Trocar: 10 mm trocar for camera, 5 mm for operating devices  Camera: 30 degree laparoscope  Operating devices: 1. Grasper 2. Fine dissector 3. Suction-irrigation device 4. Curved dissector 5. Finger dissector

10 TAPP vs. TEP  TAPP  trans-abdominal pre- perotenial repair  Pneumoperitoneum is created by surgeon  Ports placed bilaterally, to either side of the camera

11 TAPP vs. TEP  TEP  Total extraperitoneal repair  Extraperitoneal space is created by surgeon  Using balloons  Ports placed below camera port, along midline

12 Laparoscopic Procedure  TAPP 1. Make a small incision just above the umbilicus. 2. Lift up abdominal wall and gently insert Veress needle 3. Connect CO2 tube to needle 4. Switch off gas when desired pneumoperitoneum is created and remove the Veress needle

13 Laparoscopic Procedure  TEPP: mm skin incision and retract to expose linea-alba (0:21) 2. small incision is made on the anterior rectus sheath on affected side (0:30) 3. Start blunt dissection to create a tunnel (1:00)

14 Laparoscopic Procedure 4. Dissection balloon advanced down into the pubic tubercle (1:20) 5. Balloon is hand pumped with guide of camera. (1:44) 6. Dissection balloon removed and replaced with structural balloon (3:36)

15 Anatomy Review

16 Laparoscopic Procedure 7. Ins ert ports, and inflate extraperitoneal space with CO2 (5:20) 8. Bluntly disect away pro-perotineal fat, identifying key organs: Cooper’s ligament Epigastric vessels (8:08) Spermatic cord (11:25)

17 Anatomy Review

18 Laparoscopic Procedure 7. Bluntly disect away pro-perotineal fat, identifying key organs: Cooper’s ligament Epigastric vessels (8:08) Spermatic cord (11:25)

19 Laparoscopic Procedure 9. Continued dissection  After 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 structures

20 Laparoscopic Procedure 10. Second hernia on opposite side identified – Direct hernia Identify the hernia sac and dissect (28:35) 11. 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)

21 Laparoscopic Procedure 11. Put in the mesh that will cover the defect (54:00) polypropylene mesh Mesh is curved, with label M Positioning of mesh is significant Tack mesh in place or no fixation

22 Laparoscopic Procedure 12. Start suctioning out the CO2 in the peritoneum (1:12:00)  Push down on the mesh with suction 13. Remove ports, close the patient (close fascial layers, then superficial layers)

23 Dangers/Areas to be Avoided  Triangle of doom  vas deferens medially  gonadal vessels laterally  peritoneum inferiorly  Inside the triangle are the iliac artery and vein

24 Dangers/Areas to be Avoided  Triangle of pain  Contains cutaneous nerves  neuralgia  Major arteries and spermatic vessels  Epigastric vessels  Specific example: tension on vas deferens

25 Post-Operative Care  A prescription for pain medication is given to you upon discharge  Light diet the first 24 hours after surgery  resume regular (light) daily activities beginning the next day  Refrain from any heavy lifting or straining until approved by your doctor.  Follow up appointment with doctor 2-3 weeks after procedure.

26 Advantages/Disadvantages  Advantages  less tissue dissection and disruption of tissue planes  smaller incisions just for the trocars  Less pain postoperatively  earlier return to normal activities for the patient  Disadvantages  Learning curve for the procedure

27 Acknowledgements  James Hoskins, Director of MIS Training Center  Dr. John Roth, Director of Minimally Invasive Surgery

28 Sources  ot02en195_en.html ot02en195_en.html   disorders/tc/inguinal-hernia-symptoms disorders/tc/inguinal-hernia-symptoms  N/postop%20inguinal%20hernia% pdf N/postop%20inguinal%20hernia% pdf  Times listed for the procedure : based on Laproscopic inguinal hernia repair DVD; instructors: Dr. Scott Roth [S2]

29 Questions?


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