Presentation on theme: "INGUINAL HERNIA REPAIR: OPEN vs TEP APPROACHES"— Presentation transcript:
1 INGUINAL HERNIA REPAIR: OPEN vs TEP APPROACHES Prof Dr Orhan AlimoğluDepartment of General SurgeryIstanbul Medeniyet University
2 Inguinal herniaOne of the most common surgical problem in daily practiceDifferent operations and approachesGold standard: repair with meshCurrentlyLichtenstein hernia repairEndoscopic totally extra-peritoneal (TEP) repairLaparoscopic trans-abdominal preperitoneal (TAPP) repair
3 General PrecautionsNo place for routine antibiotic and thromboembolic prophylaxis, only in selected patientsRisk factors for wound and mesh infectionAdvanced ageCorticosteroid useImmunosuppressionObesityDiabetesMalignancy
4 Characteristics of mesh Large vs smallLow-weight vs heavy weightMicropore vs macroporeConclusion: Efficiency of lighter mesh with larger pores only during the first few postoperative weeks
5 Lichtenstein Inguinal Hernia Repair Large mesh (7*15 cm)2 cm medial to the pubic tubercle, 3–4 cm above the Hesselbach’s triangle, and 5–6 cm lateral to the internal ring, trimming 3–4 cm from its lateral sideCrossing and suturing tails of mesh behind spermatic cordSecuring mesh with two interrupted sutures on upper edge and one continuous suture with no more than three to four passes on lower edge of meshKeeping mesh with a slightly relaxed, tented up, or dome-shaped configurationIdentification and protection of the ilioinguinal, iliohypogastric, and genital nerves
6 Advantages Every type of inguinal hernia Local anesthesia Easy to learn and performLow rate of recurrenceGold standard?
7 Disadvantages Postoperative chronic pain Return to daily activity Higher than TEP or TAPP ?Return to daily activityLater than TEP or TAPP ?
8 TEP Inguinal Hernia Repair TechniqueTrocarsDirect access of one subumblical 10 mm and two 5 mm at the midlinePreperitoneal dissectionDissection of hernial sacParietalization of spermatic cord and its contentPlacement of mesh
10 Technical difficulties Preperitoneal space creationBaloon dissection in early learning curve besides its costPeritoneal injuryLoss of exposureClosure of defect via pretied suture, loop ligation, endoscopic stapling or endoscopic suturingPort-site closureClosure of fascial defects larger than 10 mm
19 Controversies Preoperative urinary catheterization Preoperative emptying of urinary bladder by him/herselfCatheterization in difficult and long-standing surgeryAccess for pneumopreperitoneumSubumblical direct trocar vs suprapubic Veress
20 Technical Key PointsInversion and anchoring of direct sac to Cooper’s ligament to decrease risk of seroma and hematoma formationProximal ligation and distal division of large indirect hernia sacDrains only in selected patientsFixation of mesh in hernias greater than 4 cm
21 Recommendations Larger mesh (12*17 cm) in larger hernia (>3-4 cm) Stapled fixation of mesh to the symphysis, Cooper’s ligament and rectus muscle in larger direct hernia (>3-4 cm)Overlapping of mesh approximately 1-3 cm lateral to the spina iliaca anterior superior in large indirect hernias (>4-5)
23 Advantages of TEP repair Early return to daily activitiesLow rate of postoperative chronic painExploration of contralateral side for hidden hernias ?
24 Disadvantages of TEP repair General anesthesia; regional anesthesia in selected patientsLonger learning curveAt least 50 to 60 casesApplicability on incarcerated and scrotal herniasApplicability on patients with previous lower abdominal surgery
25 Learning Curve for TEP repair Can J Surg, 2012, 55: 33-6700 patientsLearning curve after the first 60 casesA plateau of less than 30 min for duration of surgeryA plateau of 1 day for length of stayConclusion: learning curve for TEP hernia repair as 60 cases for a beginner surgeon