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Direct Inguinal
Hernia
• Hernia protruding
through a weak point
in the fascia medial to
epigastric vessels
• Structures in...
Indirect
Inguinal
Hernia
• hernia protrudes thru
the inguinal ring,
lateral to epigastric
vessels
• Structures interacted
...
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...
Laparoscopic treatment
• Position of patient:
– Trendelenburg
• Surgeon positions:
– Surgeon on opposite side
of hernia
– ...
Indications
• Existence of an inguinal hernia
Symptomatic patients
• Recurrent hernias
• Bilateral hernias
Contraindications
• Absolute contraindications
Inability to tolerate general anesthesia
coagulopathy
Intra-abdominal in...
Relative contraindications
Previous abdominal surgery, especially pelvic surgery
Anatomy Review
Anatomy Review
TAPP
• TAPP
Steps
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
– Sper...
Laparoscopic Procedure
Direct hernia
• Identify the hernia
sac and dissect
• Pull down on plane of
attachment, cleaning
of...
Laparoscopic Procedure
• Put in the mesh that
will cover the defect
• polypropylene mesh
• Mesh is curved, with
label M
• ...
Laparoscopic Procedure
• Start suctioning
out the CO2 in the
peritoneum
• Push down on the
mesh with suction
• Remove port...
Approach Considerations
• TACKING THE MESH
Tacks should be placed only above the iliopubic tract.
Proper placement may b...
Dangers/Areas to be Avoided
• Triangle of doom
– vas deferens
medially
– gonadal vessels
laterally
– peritoneum
inferiorly...
Dangers/Areas to be Avoided
• Triangle of pain
– Contains cutaneous
nerves  neuralgia
• Major arteries and
spermatic vess...
Post-Operative Care
• A prescription for pain medication is given to
you upon discharge
• Light diet the first 24 hours af...
Advantages/Disadvantages
• Advantages
– less tissue dissection and disruption of tissue
planes
– smaller incisions just fo...
A SHORT REVIEW OF THE PROCEDURE
SOURCES
• http://www.websurg.com/ref/ot-
ot02en195_en.h
• http://cme.medscape.com/viewarticle/42035
4_5
• http://www.webmd...
Questions?
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
Laparoscopic inguinal hernia repair (TAPP)
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Laparoscopic inguinal hernia repair (TAPP)

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Laparoscopic inguinal hernia repair (TAPP)

  1. 1. Direct Inguinal Hernia • Hernia protruding through a weak point in the fascia medial to epigastric vessels • Structures interacted with: – hernia sac – Hesselbach’s triangle
  2. 2. Indirect Inguinal Hernia • hernia protrudes thru the inguinal ring, lateral to epigastric vessels • Structures interacted with: – spermatic cord – vas deferens – testicular arteries
  3. 3. Causes of Inguinal Hernia • Increased pressure within abdomen: • Aging • Genetic predisposition
  4. 4. Patient Symptoms • Mass/bulge in the groin • A burning sensation in the groin • Strangulated hernia: – Sudden pain, nausea, vomiting
  5. 5. 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
  6. 6. Indications • Existence of an inguinal hernia Symptomatic patients • Recurrent hernias • Bilateral hernias
  7. 7. Contraindications • Absolute contraindications Inability to tolerate general anesthesia coagulopathy Intra-abdominal infections that limit the use of prosthetic meshes
  8. 8. Relative contraindications Previous abdominal surgery, especially pelvic surgery
  9. 9. Anatomy Review
  10. 10. Anatomy Review
  11. 11. TAPP
  12. 12. • TAPP Steps Make a small incision just above the umbilicus.
  13. 13. Lift up abdominal wall and gently insert Veress needle
  14. 14. Connect CO2 tube to needle
  15. 15. Switch off gas when desired pneumoperitoneum is created and remove the Veress needle
  16. 16. • Sharp dissection to take down peritoneum for access to inguinal region
  17. 17. How much to dissect?
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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)
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. 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.
  26. 26. 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
  27. 27. A SHORT REVIEW OF THE PROCEDURE
  28. 28. SOURCES • http://www.websurg.com/ref/ot- ot02en195_en.h • http://cme.medscape.com/viewarticle/42035 4_5 • http://www.webmd.com/digestive- disorders/tc/inguinal-hernia-symptoms • http://www.centralcarolinasurgery.com/forms /JAN/postop%20inguinal%20hernia%2001092 009.pdf
  29. 29. Questions?
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Laparoscopic inguinal hernia repair (TAPP)

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