بسم الله الرحمن الرحيم IN THE NAME OF ALLAH THE MOST GRACEFUL THE MOST MERCIFUL

LAPAROSCOPIC HERNIA REPAIR

INSTRUMENTS REQUIRED Laparoscope 300 Three – four Trocars (10-12 m.m.) + reducers Dissector Grasper Diathermy needle Suction tube Endo-hernia Endo-Clip clips Marlex, polypropylene mesh or surgipro (different sizes) Laparoscopic needles and needle holders

ANATOMY FROM INSIDE

Trans-peritoneal Laparoscopic View

Pre-peritoneal SCHEMATIC VIEWS

Pre-peritoneal Real View

TROCARS SITING

Types of Laparoscopic Repair On-Lay mesh patch Transperitoneal: a) pre-peritoneal mesh b) plug and mesh c) Cigarettes and mesh Extra-peritoneal approach

ON-LAY MESH PATCH Intra – peritoneal Weight of viscera to fix it Complications (adhesions, obstruction and fistulas) Less testicular pain and swelling Not recommended by many authors

Trans-peritoneal (Pre-peritoneal) Mesh only mesh and plug mesh and cigarettes

MESH ONLY

MESH AND PLUG

(Video – presentation) MESH AND CIGARRETTES (Video – presentation)

Extra-Peritoneal Approach (Video presentation)

Advantages of Laparoscopic Hernia Repair Anatomy is clear. Suitable for bilateral and recurrent hernias. Quick convalescence (resume working after 1-7 days). Less pain and scrotal swelling post-operatively. Inguinal canal is not opened (less risk of nerves and cord injuries)

Disadvantages A little more expensive than anterior approach. Higher recurrence rate (initial studies) than anterior approach Viz: Bassini’s, McVay or Litchenstien’s repair. Requires G.A. Takes a little longer operating time ( 2 – 2 ½ hours) Needs experts.

Training requirements for Laparoscopic Hernia repair Attending basic courses in Laparoscopic surgery. Training course in Hernia repair. Surgeon should be familiar with the instruments. Should know how to operate with both hands. Learn how to suture laparoscopically. Learning the anatomy of the region (very important). Observing experts, assisting them and operates later on.

INDICATIONS Bilateral Hernias (avoid long recoveries because of incisions) Recurrent Hernias (avoid dissecting scarred tissues, so less chance of cord and nerve injuries).

CONTRA-INDICATIONS Patients who can not tolerate G.A. Large incarcerated sliding hernia

POTENTIAL COMPLICATIONS OF Laparoscopic hernia repair Complications related to the laparoscope: a) Gas embolism b) Trocar injury (Bl. Vessels, bladder, bowel) c) Cautery injury (bladder, bowel)

2. Complications related to the repair: a) Vascular injury b) Bladder / bowel injury c) Injury to vas deferens d) nerve injury e) migration or infection of prosthesis f) adhesions and bowel obstruction g) Seroma formation h) Recurrence

PERSONAL EXPERIENCE 59 Cases Al-Salama Hospital, Jeddah October,1991 – JUNE,1998

Total no. 59 cases ( OCT. 1991- JUNE 1998 ) ANALYSED 47 CASES ( OCT Total no. 59 cases ( OCT. 1991- JUNE 1998 ) ANALYSED 47 CASES ( OCT. 1991- FEB. 1996 ) Unilateral Bilateral Pantalloon (38) (6) (3)

Sides Indirect 17 (one recurrent) Rt Direct 1 Patalloon 2 Indirect 16 (one sliding sigmoid) Lt. Direct 4 Patalloon 1 Bilateral 6

Males 45 SEX Females 2 (unilateral left side indirect)

AGE 18 - 78 years (mean 37 years)

Types of operation Mesh patch only 7 Pre-peritoneal Mesh and cig. 18 (2-7 cig) Mesh and plugs 6 Extraperitoneal 16

Marlex 24 Material used Surgipro 7 polypropylene 16

Anaesthesia time Unilateral (1 Anaesthesia time Unilateral (1.30 – 4 hrs) fatty patient, big defect Bilateral (3 – 3.15 hrs)

Post-op follow-up Pain : Patient given I.M Voltaren and Nubain 4-6 hourly for 24 hours. All received prophylactic antibiotics for 3 doses post-op. All discharged with pain killers to be taken PRN. Same day of op 4 Ambulation 1st post-op day 40 2nd post –op day 3

Hospital stay: (1-7 days) average 2 days ( 7 days for that with D.V.T.) Return to work: 3 days to 5 weeks (D.V.T.) ( Average 7 days) Lifting heavy objects : 6 weeks

Complications During Surgery: One case, injury to U.B. stitched with Vicryl + catheter for 10 days

Continuation: Complications II. Post-op: - Retension of urine: One case responded to urinary catheterization for 24 hrs. - Neuralgia of upper medial part of thigh (staples) - Seroma – one case detected by U/S and aspirated from inguinal region. - Recurrence (4.2%) = 2 one after 3 months + one after 15 months post-op. - Trocar Hernia - One at umbilical port repaired later on

Continuation: Complications II. Post-Op Bleeding Infection Hydrocele Orchitis NONE Pelvic collection Bowel injury

Length of follow-up OCT. 1991 – JUNE 1998 ( 6 YEARS + 8 MONTHS )

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