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By Surgeon Dr. Tariq Saeed Akhunzada
Associate Professor Surgical “E” Ward
KMC/KTH
 PER-OPERATIVE COMPLICATIONS
 General Anesthesia & Laparoscopy Complications
 Primary Hemorrhage
 Nerve Injuries
 Vis...
 Nausea and vomiting
 Intubation problems: Damage to
teeth/Sore throat/ laryngeal
damage.
 Anaphylaxis/ idiosyncratic r...
 Injuries to the inferior epigastric vessels
 Bleeding originating from the spermatic cord
 Injury to the iliac artery ...
 Knowledge of laparoscopic anatomy
 Placement of secondary cannulas under direct
vision with prior trans illumination of...
 laparoscopic herniorrhaphy = 1.6% incidence of
neuralgias = open approaches
 There are 6 nerves in the groin that your
...
 Lateral femoral cutaneous nerve – =most common
nerve irritated= pain or hypersensitivity experienced
along the lateral t...
 Ilio hypogastric nerve – This nerve may only be
injured rarely during a laparoscopic repair if a tack
were to penetrate ...
 Knowledge of laparoscopic anatomy ( triangle of pain )
 Avoidance of deep tacking in the abdominal wall muscles
 mesh ...
 Injuries to the lateral cutaneous nerve and to
the genital branch of the genito-femoral nerve
can be minimized by using ...
 Bowel injury is the third cause of death from a
laparoscopic procedure after major vascular injury and
anesthesia.
 Bow...
Urinary bladder injury is common during
reduction of direct hernias
 the vas deferens injury is very rare = testicular
discomfort, infertility, or be completely
asymptomatic.
 If the arter...
 Avoid laparoscopy in patients with hx of
previous abdominal surgery
 Avoid laparoscopic approach in irreducible
hernias...
 Urinary Retention
 Gastro intestinal problems
 Inguino-Scrotal Swelling
 Wound Seroma, Hematoma & Infections
 Urinary retention is seen in approximately 2%
of patients
 Preoperative placement of a catheter may
actually increase t...
 Ask the patient to void before getting on the
operation table
 If retention occurs post op, it can usually be
managed o...
 Inguinal and scrotal seromas: Some may mistake
it for a recurrent hernia.
 Scrotal ecchymosis and inguinal hematoma due...
 Scrotal elastic support for 3-4 weeks
postoperatively.
 Restricted physical activity.
 Anti-inflammatory medication ma...
 The rate of infection in the skin orifice is less
than 1%, according to several studies.
Treatment is simple, consisting...
 Less frequent in endoscopic hernia repair than
in open repairs, with a rate of about 8%
 Small-bowel obstruction after a laparoscopic
hernia repair can occur. It is the result of
adhesions to inadequately cove...
 Chronic Groin Pain
 Port-Site Hernia
 Recurrence
 Mesh infection and mesh migration
 The groin discomfort may be secondary to the
gas used during surgery and the dissection
 rarely the mesh material or ta...
 If pain persists despite conservative measures
and the pain is isolated to a specific point on
the abdominal wall or the...
 It is extremely rare for mesh to become primarily
infected if it is completely extra peritoneal.
 isolated incidences o...
 Cases in which the mesh has eroded into the
bladder have also been seen (purulent
urocystitis)
 Even rare cases of mesh...
 Result from inadequate surgical technique.
 The inadequate fixation of Marlex mesh,
 Inadequate size of the mesh (smal...
 A new complication after inguinal hernia
repair, the late development of a trocar hernia
has been seen after the TAPP ap...
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
Complications of TAPP
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Complications of TAPP

  1. 1. By Surgeon Dr. Tariq Saeed Akhunzada Associate Professor Surgical “E” Ward KMC/KTH
  2. 2.  PER-OPERATIVE COMPLICATIONS  General Anesthesia & Laparoscopy Complications  Primary Hemorrhage  Nerve Injuries  Visceral Injuries  Spermatic Cord Injuries  EARLY POST-OPERATIVE COMPLICATIONS  Pain  Urinary Retention  Scrotal Swelling/Hydroceles  Constipation  Wound Seroma , Hematoma & Infections  LATE COMPLICATIONS  Chronic Groin Pain  Mesh ‘Plug’ Migration  Port-Site Hernia  Recurrence  Internal Herniation & Adhesions
  3. 3.  Nausea and vomiting  Intubation problems: Damage to teeth/Sore throat/ laryngeal damage.  Anaphylaxis/ idiosyncratic reactions to anesthetic agents (malignant hyperpyrexia)  CVS collapse and Respiratory depression.  Aspiration pneumonitis  Hypothermia and Hypoxic brain damage.  Nerve injury  Awareness during anesthesia  Embolism – air/thrombus/venous/arterial.  Backache / Headache.  Death.  Trocar Injuries  Electrical Burns = Perforated Organs = Peritonitis.  Complications Due To Pneumo peritonium  Hypothermia  Shoulder Tip Pain
  4. 4.  Injuries to the inferior epigastric vessels  Bleeding originating from the spermatic cord  Injury to the iliac artery occurred during clip fixation “triangle of doom.”  The distal aorta and right common iliac artery are particularly prone to injury during trocar and port insertion in thin lean patients
  5. 5.  Knowledge of laparoscopic anatomy  Placement of secondary cannulas under direct vision with prior trans illumination of the abdominal wall.  The decision to open must be made quickly if the bleeding cannot be controlled laparoscopically, and compression of the bleeding site must be maintained with a laparoscopic instrument while opening.
  6. 6.  laparoscopic herniorrhaphy = 1.6% incidence of neuralgias = open approaches  There are 6 nerves in the groin that your surgeon is aware of and will avoid harm to.
  7. 7.  Lateral femoral cutaneous nerve – =most common nerve irritated= pain or hypersensitivity experienced along the lateral thigh.  Genitofemoral nerve : Its irritation is usually perceived by a hypersensitive scrotum in males and hypersensitive labia majora in females. The femoral branch innervates the anterior thigh, and irritation can lead to pain or hypersensitivity of the upper anterior thigh.  Femoral nerve (and its anterior cutaneous branches) – Rather rarely, it at risk to be irritated or injured by use of a tack below the illio pubic tract. Even rarer, mesh can irritate this nerve. If irritated or injured, leg muscles may feel heavy or weak, or pain along the leg may result.
  8. 8.  Ilio hypogastric nerve – This nerve may only be injured rarely during a laparoscopic repair if a tack were to penetrate through the muscle and into the nerve.Pain or hypersensitivity to the suprapubic region or groin may occur.  Ilioinguinal nerve –Its injury during a laparoscopic repair is extraordinarily rare. Irritation causes pain or hypersensitivity to the medial thigh, shaft of the penis, or groin  Paravasal nerve fibers (tiny nerves along the vas deferens in a male) – irritation of these may cause temporary testicular discomfort.
  9. 9.  Knowledge of laparoscopic anatomy ( triangle of pain )  Avoidance of deep tacking in the abdominal wall muscles  mesh repairs that do not require fixation or have chosen adhesive fixation.  and correct placement ( don’t tack below the llliopubic tract)  The tract can be identified visually as a fibrous band at the lower edge of the internal ring or manually by placing one’s hand on the abdominal wall and palpating an instrument placed laparoscopically at the level of the iliopubic tract.  If the surgeon cannot feel the instrument, the point of contact of the probe is below the iliopubic tract. Because the nerves usually enter the thigh below this line, placing fixation
  10. 10.  Injuries to the lateral cutaneous nerve and to the genital branch of the genito-femoral nerve can be minimized by using simple maneuvers.  Do not use abdominal wall counter pressure when placing a tack  Dissect the abdominal wall meticulously and try to identify obvious neural branches  Do not place and tack the Mesh under tension  Make all patients exercise starting the day after the procedure [minimal exercise: a 1 to 3 miles, daily walk].
  11. 11.  Bowel injury is the third cause of death from a laparoscopic procedure after major vascular injury and anesthesia.  Bowel injury is common during trocar insertion in a patient with prior adhesions and during reducing an incarcerated or strangulated hernia  Unlike major vascular injuries where the risk and presentation are immediate, many bowel injuries go unrecognized at the time of the procedure. Consequently, patients present postoperatively, often after discharge with peritonitis. This delay makes it a significant cause of morbidity and mortality.
  12. 12. Urinary bladder injury is common during reduction of direct hernias
  13. 13.  the vas deferens injury is very rare = testicular discomfort, infertility, or be completely asymptomatic.  If the arterial supply to the testicle is divided =ischemic orchitis and testicular atrophy= 0.36% of primary hernias and 5% in recurrent ones.  If the venous blood supply from the testicle is potentially compromised, this can lead to vague testicular discomfort or a varicocele.  Most cases occur after repair of large indirect hernias and are related to the extent of surgical trauma in dissection of the hernial sac.
  14. 14.  Avoid laparoscopy in patients with hx of previous abdominal surgery  Avoid laparoscopic approach in irreducible hernias if not adequately experienced  Urinary bladder injury does not cause significant morbidity if immediately corrected with primary suture in association with decompression with a Foley catheter.
  15. 15.  Urinary Retention  Gastro intestinal problems  Inguino-Scrotal Swelling  Wound Seroma, Hematoma & Infections
  16. 16.  Urinary retention is seen in approximately 2% of patients  Preoperative placement of a catheter may actually increase the incidence of retention and is avoided unless one feels that the bladder has not been emptied preoperatively or that the length of the procedure may be extended
  17. 17.  Ask the patient to void before getting on the operation table  If retention occurs post op, it can usually be managed on an outpatient basis. Catheterize and give adequate analgesia  A temporary insertion of a urinary catheter which is usually removed after one to three days. All patients eventually regain their baseline control of initiating a urinary stream.
  18. 18.  Inguinal and scrotal seromas: Some may mistake it for a recurrent hernia.  Scrotal ecchymosis and inguinal hematoma due to small vessel injuries  Testicular edema normally occurs when the closure of the internal inguinal ring is excessively tight around the spermatic cord.  Hydrocele= represents a persistence of the vaginalis process, which loses its drainage into the peritoneal cavity when the indirect sac is disconnected. Most cases are resolved with a single aspiration
  19. 19.  Scrotal elastic support for 3-4 weeks postoperatively.  Restricted physical activity.  Anti-inflammatory medication may be used.  If left alone, the seroma spontaneously resolves in 90% patients.  If, however, the seroma is large or symptomatic, a single aspiration usually eliminates the problem.
  20. 20.  The rate of infection in the skin orifice is less than 1%, according to several studies. Treatment is simple, consisting of drainage and dressings. Antibiotics are used only when there are systemic repercussions
  21. 21.  Less frequent in endoscopic hernia repair than in open repairs, with a rate of about 8%
  22. 22.  Small-bowel obstruction after a laparoscopic hernia repair can occur. It is the result of adhesions to inadequately covered mesh or due to intestines being entrapped in a defect left in the peritoneum.  can be avoided by suturing the peritoneal defect instead of tacking it.  constipation is common with the use of narcotic pain medication, and can be managed with a stool softener or laxatives.
  23. 23.  Chronic Groin Pain  Port-Site Hernia  Recurrence  Mesh infection and mesh migration
  24. 24.  The groin discomfort may be secondary to the gas used during surgery and the dissection  rarely the mesh material or tacks (if used) can cause chronic pain  There are a variety of mesh fixation materials that surgeons may choose to use, and all have a rare, but possible association with causing groin pain. These fixation options include (staples, permanent tacks, absorbable tacks, or glues). Some surgeons do repair without using mesh fixation materials at all.
  25. 25.  If pain persists despite conservative measures and the pain is isolated to a specific point on the abdominal wall or the distribution of a specific nerve, exploration is warranted. the surgeon should explore the posterior wall laparoscopically, looking for the offending staple to remove it
  26. 26.  It is extremely rare for mesh to become primarily infected if it is completely extra peritoneal.  isolated incidences of extra peritoneal mesh secondary infection due to a ruptured appendix or perforated diverticulum of the colon.  In these cases, the patient can present with an indolent chronic infection years after the repair that is difficult to eradicate without removing the mesh thus Mesh infections should be treated with mesh removal  A biologic mesh may be substituted for the original mesh if the resulting defect is a concern.
  27. 27.  Cases in which the mesh has eroded into the bladder have also been seen (purulent urocystitis)  Even rare cases of mesh migrating into scrotum have been reported  Spiral tacks have also been reported to erode into adjacent viscera.
  28. 28.  Result from inadequate surgical technique.  The inadequate fixation of Marlex mesh,  Inadequate size of the mesh (small)  and a flaw in covering unidentified hernial defects (hernias which had never been repaired) are the main reasons for early recurrence of hernia.  Use of incised mesh  Inadequate dissection and missed cord lipoma  Displacement of mesh  The causes of late recurrence of hernia could be stress on the tissues and the intrinsic weakness of the collagen.
  29. 29.  A new complication after inguinal hernia repair, the late development of a trocar hernia has been seen after the TAPP approach.  They may be Richter hernias or typical incarcerated hernias.  They usually occur in ports that are ≥10mm in size but have been reported in 5-mm ports
  • aasthahospital

    Nov. 28, 2019
  • DurgaYadav2

    Feb. 10, 2019

transabdominal preperitoneal mesh hernioplasty

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