Direct Inguinal Hernia

• Hernia protruding through a weak point in the fascia medial to epigastric vessels

• Structures interacted with:– hernia sac – Hesselbach’s triangle

Indirect Inguinal Hernia

• hernia protrudes thru the inguinal ring, lateral to epigastric vessels

• Structures interacted with:– spermatic cord– vas deferens– testicular arteries

Causes of Inguinal Hernia

• Increased pressure within abdomen:

• Aging

• Genetic predisposition

Patient Symptoms

• Mass/bulge in the groin

• A burning sensation in the groin

• Strangulated hernia:– Sudden pain, nausea,

vomiting

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

Indications

• Existence of an inguinal hernia Symptomatic patients

• Recurrent hernias• Bilateral hernias

Contraindications

• Absolute contraindications Inability to tolerate general anesthesia

coagulopathy

Intra-abdominal infections that limit the use of prosthetic meshes

Relative contraindications

Previous abdominal surgery, especially pelvic surgery

Anatomy Review

Anatomy Review

TAPP

• TAPPSteps

Make a small incision just above the umbilicus.

Lift up abdominal wall and gently insert Veress needle

Connect CO2 tube to needle

Switch off gas when desired pneumoperitoneum is created and remove the Veress needle

• Sharp dissection to take down peritoneum for access to inguinal region

How much to dissect?

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

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

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

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)

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

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

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

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.

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

A SHORT REVIEW OF THE PROCEDURE

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

Questions?