Laparoscopic inguinal hernia repair (TAPP)
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Transcript of Laparoscopic inguinal hernia repair (TAPP)
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Direct Inguinal Hernia
• Hernia protruding through a weak point in the fascia medial to epigastric vessels
• Structures interacted with:– hernia sac – Hesselbach’s triangle
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Indirect Inguinal Hernia
• hernia protrudes thru the inguinal ring, lateral to epigastric vessels
• Structures interacted with:– spermatic cord– vas deferens– testicular arteries
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Causes of Inguinal Hernia
• Increased pressure within abdomen:
• Aging
• Genetic predisposition
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Patient Symptoms
• Mass/bulge in the groin
• A burning sensation in the groin
• Strangulated hernia:– Sudden pain, nausea,
vomiting
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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
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Indications
• Existence of an inguinal hernia Symptomatic patients
• Recurrent hernias• Bilateral hernias
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Contraindications
• Absolute contraindications Inability to tolerate general anesthesia
coagulopathy
Intra-abdominal infections that limit the use of prosthetic meshes
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Relative contraindications
Previous abdominal surgery, especially pelvic surgery
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Anatomy Review
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Anatomy Review
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TAPP
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• TAPPSteps
Make a small incision just above the umbilicus.
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Lift up abdominal wall and gently insert Veress needle
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Connect CO2 tube to needle
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Switch off gas when desired pneumoperitoneum is created and remove the Veress needle
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• Sharp dissection to take down peritoneum for access to inguinal region
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How much to dissect?
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Laparoscopic Procedure
Continued dissection– After further dissection,
hernia clearly identified – Indirect hernia
– Spermatic cord teased away from hernia sac
– Grab edge of peritoneal sac and drag away from defect and key structures
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Laparoscopic Procedure
Direct hernia• Identify the hernia sac
and dissect • Pull down on plane of
attachment, cleaning off fat on the abdominal wall so it does not get in the way of the mesh
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Laparoscopic Procedure
• Put in the mesh that will cover the defect • polypropylene mesh• Mesh is curved, with
label M• Positioning of mesh is
significant• Tack mesh in place or
no fixation
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Laparoscopic Procedure
• Start suctioning out the CO2 in the peritoneum • Push down on the
mesh with suction
• Remove ports, close the patient (close fascial layers, then superficial layers)
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Approach Considerations
• TACKING THE MESH Tacks should be placed only above the iliopubic tract.
Proper placement may be ensured by drawing a line from the pubic tubercle to the anterior superior iliac spine (ASIS) at the start of the procedure
Before firing each tack, carefully palpate the tacker head through the abdominal wall to ensure that it is above this line
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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
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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
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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
• Follow up appointment with doctor 2-3 weeks after procedure.
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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
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A SHORT REVIEW OF THE PROCEDURE
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SOURCES
• http://www.websurg.com/ref/ot-ot02en195_en.h
• http://cme.medscape.com/viewarticle/420354_5• http://www.webmd.com/digestive-disorders/tc/
inguinal-hernia-symptoms• http://www.centralcarolinasurgery.com/forms/
JAN/postop%20inguinal%20hernia%2001092009.pdf
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Questions?