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Don’t take care of a hernia sliding peritoneum becomes choked bad news bears
Symptoms of an inguinal hernia may include: A burning sensation in the groin occasionally precedes the development of a palpable hernia. Patients with hernia commonly report discovering a mass in the groin. Typically, the patient notes that the mass is gone when he awakens in the morning, but it reappears on arising. A dull sensation may be experienced as the day progresses and the patient has been upright for many hours. Coughing or severe straining as occurs with constipation or prostatism frequently precipitates the clinical appearance of the hernia. Any sudden increase in the size of the mass suggests incarceration or the development of a sliding component.
A bulge in the groin or scrotum. The bulge may appear gradually over a period of several weeks or months, or it may form suddenly after you have been lifting heavy weights, coughing, bending, straining, or laughing. Many hernias flatten when you lie down. Groin discomfort or pain. The discomfort may be worse when you bend or lift. Although you may have pain or discomfort in the scrotum, many hernias do not cause any pain. You may have sudden pain, nausea, and vomiting if part of the intestine becomes trapped (strangulated) in the hernia.
Other symptoms of a hernia include:
Heaviness, swelling, and a tugging or burning sensation in the area of the hernia, scrotum, or inner thigh. Males may have a swollen scrotum, and females may have a bulge in the large fold of skin (labia) surrounding the vagina. Discomfort and aching that are relieved only when you lie down. This is often the case as the hernia grows larger.
Trendelenburg = body is laid flat on the back (supine position) with the feet higher than the head. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis.
The indications for performing a laparoscopic hernia repair are essentially the same as repairing the hernia conventionally. There are, however, certain situations where laparoscopic hernia repair may offer definite benefit over conventional surgery to the patients. These include: *Bilateral inguinal hernias*Recurrent inguinal hernias
1. Incised anterior layer of rectus sheath2. Posterior layer of rectus sheath3. Arcuate line4. Peritoneum
Inflate balloon under view of scope
1st pic = ID cooper’s lig and show the plane of view (first from outside in, then inside out) Cooper’s lig = an extension of the lacunar ligament that runs on the pectineal line of the pubic bone
Pneumoperitoneum is created by surgeon: Insert needle with CO2 tube below abdominal wall. Switch off gas when desired size of pneumoperitoneum has been created.
This technique has been criticized for exposing intra-abdominal organs to potential complications, including small bowel injury and obstruction
The beginning steps in creating the peritoneal space are different between the TEP and TAPP procedures. Main concern for the TEP is to make an extraperitoneal space. The extraperitoneal space is made possible by the fact that the peritoneum in suprapubic region can easily be separated from anterior abdominal wall, hereby creating enough space for dissection. For the TAPP a pneumoperitoneum is created by surgeon. A needle is inserted with CO2 tube below abdominal wall. The pneumoperiotneum is inflated until desired size has been created.
Continued dissection Spermatic cord teased away from hernia sac (16:35) Hernia identified (18:10) Hernia pseudo-sac identified (18:40). Looks like big white area. Will go back into abdominal wall After further dissection, hernia clearly identified (pt 2- 1:35) Hernia sac identified (4:44) Grab edge of peritoneal sac and drag away from vas deferens
Mesh its permanent for a permanent hole! Can contract. It’s a foreign body
Put in graft Grab top edge, roll around the mesh so when it ends up in the peritoneal cavity it will unroll putting the lateral edge laterally and you pull the mesh up and push it in medially. Roll tight enough so it can go down the port (53:47) Pull the lateral edge laterally in perotonium (53:53) Pull up superiorly covering cord and ensuring the perotineum is beneath the mesh, and then tuck in laterally Medialize the mesh
Tack mesh in position (1:07:42) While tacking, ensure you are clear of the epigastric vessels
Start sucking out the CO2 in the peritoneum Push down on the mesh with suction to ensure it stays in desired position as the peritoneum collapses Remove ports, close the patient (close fascial layers, then superficial layers)
The main area that needs to be avoided is the triangle of doom. The triangle consists of vas deferens medially, gonadals vesels laterally, inferiorly by peritoneum. Inside the triangle are the iliac artery and vein, which absolutely must be avoided as it is the largest and most significant blood supply to lower half of the body.
Other major arteries such as the inferior epigastric vessels should be avoided. Furthermore, putting increased tension on any blood vessels or spermatic chord can cause increased recovery time and increased post-operative pain. Specifically, the tension on the vas deferens can cause ischemic testicles.
Diet: You should follow a light diet the first 24 hours after surgery, such as soup, crackers, pudding, etc. Resume your normal diet the day after surgery.
Laparoscopic inguinal hernia repair (TAPP)
• Hernia protruding
through a weak point
in the fascia medial to
• Structures interacted
– hernia sac
– Hesselbach’s triangle
• hernia protrudes thru
the inguinal ring,
lateral to epigastric
• Structures interacted
– spermatic cord
– vas deferens
– testicular arteries
Causes of Inguinal Hernia
• Increased pressure
• Mass/bulge in the
• A burning sensation
in the groin
• Strangulated hernia:
– Sudden pain,
• Position of patient:
• Surgeon positions:
– Surgeon on opposite side
– Camera operator opposite
side of surgeon
– Monitors at feet of patient
• Existence of an inguinal hernia
• Recurrent hernias
• Bilateral hernias
• Absolute contraindications
Inability to tolerate general anesthesia
Intra-abdominal infections that limit the use of
Previous abdominal surgery, especially pelvic surgery
– After further
clearly identified –
– Spermatic cord teased
away from hernia sac
– Grab edge of
peritoneal sac and drag
away from defect and
• Identify the hernia
sac and dissect
• Pull down on plane of
off fat on the
abdominal wall so it
does not get in the
way of the mesh
• Put in the mesh that
will cover the defect
• polypropylene mesh
• Mesh is curved, with
• Positioning of mesh
• Tack mesh in place or
• Start suctioning
out the CO2 in the
• Push down on the
mesh with suction
• Remove ports,
close the patient
• 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
Dangers/Areas to be Avoided
• Triangle of doom
– vas deferens
– gonadal vessels
– Inside the triangle
are the iliac artery
Dangers/Areas to be Avoided
• Triangle of pain
– Contains cutaneous
• Major arteries and
– Epigastric vessels
– Specific example:
tension on vas
• 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
– less tissue dissection and disruption of tissue
– smaller incisions just for the trocars
– Less pain postoperatively
– earlier return to normal activities for the patient
– Learning curve for the procedure