Different types of laparoscopic hernia repair

Definition, Types, Risk Factors, Laparoscopic Repair, TAPP and TEP.

1. Different types of Laparoscopic Hernia Repair Advanced Laparoscopic in Robotic and Bariatric Surgery King Saud University Medical City 3 rd December, 2018 Ibrahim Abunohaiah R1, Urology

2. Objectives To discuss the definition of a hernia . To discuss hernia types . To discuss laparoscopic repair options.

3. Definition of Hernia A hernia is an abnormal protrusion of an organ or tissue through a defect in the fascia or muscles that contain it.

4. Types of Hernias Inguinal (Indirect and Direct) & Femoral Hernias Ventral , Epigastric, and Incisional Hernias Umbilical and Para-Umbilical Hernias Hiatus and Paraesophageal Hernias Congenital Diaphragmatic Hernias Spigelian Hernia Others (Richter’s, Littre’s, Lumbar, Obturator Hernias)

5. Risk Factors Smoking Obesity Steroid Diabetes mellitus

6. Inguinal and Femoral Hernias Inguinal hernias: Indirect and Direct Femoral hernias.

7. Incisional Hernias

8. Umbilical and Para-Umbilical Hernias

9. Hiatal and Paraesophageal Hernias

10. Congenital Diaphragmatic Hernias

11. Spigelian Hernia Surgical Anatomy It occurs through slit like defects in the anterior abdominal wall adjacent to the semilunar line Diagnosis Often Clinical Confirmed by CT or MRI imaging Treatment As Ventral Hernias

12. Richter’s Hernia Richter hernia (partial enterocele) is the protrusion and/or strangulation of only part of the circumference of the intestine's antimesenteric border through a rigid small defect of the abdominal wall

13. Hernia Surgical Repair

14. Hernia Surgical Repair Laparoscopic Open

15. Laparoscopic Inguinal Hernia Repair

16. Background Laparoscopic inguinal hernia repair originated in the early 1990s. Inguinal hernias account for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women. Repair of these hernias is one of the most commonly performed surgical procedures in the world.  1   In the United States, approximately 800,000 inguinal herniorrhaphies are performed annually.  2 Jenkins JT, O'Dwyer PJ. Inguinal hernias.  BMJ . 2008 Feb 2. 336(7638):269-72 Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003.  Surg Clin North Am . 2003 Oct. 83(5):1045-51, v-vi

17. Laparoscopic Options Totally extraperitoneal (TEP) repair Transabdominal preperitoneal (TAPP) repair Intraperitoneal onlay mesh (IPOM) repair

18. TAPP vs TEP

19. Laparoscopic repair Preferred in: Bilateral Hernias Recurrent Hernias (Previous open) Female Hernias Combined with other procedure like Lap. Cholecystectomy Learning Curve: Laparoscopy v/s Open = 250 v/s 25 cases

20. Anatomy Adapted from Schwartzs Principles of Surgery, 10th Edition.

21. Anatomy, cont. Adapted from Schwartzs Principles of Surgery, 10th Edition. Posterior view of intraperitoneal folds and associated fossa

22. Anatomy, cont. Adapted from Schwartzs Principles of Surgery, 10th Edition. Anatomy of the groin region from the posterior perspective.

23. Anatomy, cont. Triangle of doom: Is an anatomical triangle defined by the vas deferens medially, spermatic vessels laterally and peritoneal fold inferiorly. This triangle contains external iliac artery and vein, the deep circumflex iliac vein, the genital branch of genitofemoral nerve and hidden by fascia, the femoral nerve.

24. Anatomy, cont. Triangle of doom Adapted from Schwartzs Principles of Surgery, 10th Edition.

25. Anatomy, cont. Triangle of Pain: The region bordered by the iliopubic tract and gonadal vessels, and it encompasses the lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral nerves.

26. Anatomy, cont. Adapted from Schwartzs Principles of Surgery, 10th Edition. Triangle of Pain

27. Anatomy, cont. Corona Mortis: The circle of death is a vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric, and external iliac vessels..

28. Anatomy, cont. Circle of Death

29. TAPP - Transabdominal Preperitoneal technique

30. TAPP: Definition A laparoscopic repair procedure wherein the surgeon enters the peritoneal cavity, incises the peritoneum, enters the preperitoneal space, and places the mesh over the hernia; the peritoneum is then sutured or tacked.

31. TAPP: Steps • STEP 1: Entering the Intra-abdominal Cavity • STEP 2: Creating the Peritoneal Flap • STEP 3: Identifying the Anatomical Landmarks • STEP 4: Dissecting the Hernia Sac • STEP 5: Deploying and Anchoring the Mesh • STEP 6: Closing the Peritoneum • STEP 7: Taking out Sutures & Port Closure

32. TAPP: Preoperative Care It is recommended that the patient empty his/her bladder before the operation. Restrictive per- and postoperative intravenous fluid administration reduces the risk of postoperative urinary retention. If you expect technical difficulties (e.g., after prostatic surgery, Scrotal hernia) or an extended operating time , consider using a urinary catheter during the operation. Patient with unilateral groin hernia should be asked to give his/her consent to allow simultaneous repair if a contralateral occult hernia is found.

33. TAPP: Patient Position Patient in Supine position. Head-down position during the operation and slightly (approximately 15°) turned toward the surgeon. The operating surgeon & the camera assistant stay on opposite sides of the hernia.

34. TAPP: STEP 1: Entering the Intra-abdominal Cavity Trocar placement Establishing pneumoperitoneum using the Veress needle. 10 mm Camera trocar – supraumbilical Under laparoscopic view - Two 5 mm operating trocars on the midclavicular line 2 cm below the level of the horizontal line from the optical trocar.

35. TAPP: STEP 1: Trocar Placement

36. TAPP: STEP 1: Tips The intra-abdominal cavity is visualized with the Telescope and intraabdominal findings are reported [intra-abdominal pathology and inguinal hernia defects and sacs]. If an asymptomatic hernia sac is identified on the contralateral side, consider repair. The bladder, median and medial umbilical ligaments, external iliac, and inferior epigastric vessels are visualized.

37. TAPP: STEP 1: Preperitoneal dissection The aim of this step is to ensure the best positioning of the mesh. An incision is made in the peritoneum at the medial umbilical ligament 3 to 4 cm superior to the hernia defect, and it is carried laterally to the anterior superior iliac spine. In this way several anatomic landmarks must be identified, as well as a complete dissection of the hernia’s sac.

38. TAPP: STEP 1: Preperitoneal dissection The inferior edge of incised peritoneum is retracted, and the preperitoneum is dissected to expose the spermatic cord. If a direct hernia is encountered, the sac is inverted and fixed to Cooper’s ligament to prevent development of hematoma or seroma.

39. TAPP: STEP 1: Anatomical Landmarks Epigastric vessels Urinary bladder Pubis Cooper’s ligament Gimbernat’s ligament Medial part of ilio-pubic tract External iliac vessels Corona mortis Vas deferens in males and Round ligament in females Spermatic vessels Internal inguinal ring

40. TAPP: STEP 1: Anatomical Landmarks

41. TAPP: STEP 2: Creating the Peritoneal Flap

42. TAPP: STEP 2: Creating the Peritoneal Flap

43. Entering the Lateral Inguinal Space

44. TAPP: STEP 3: Identifying the Anatomical Landmarks The aim of the laparoscopic exploration is to identify the anatomical landmarks, site and type of hernia. The two dangerous “triangles”: Vascular triangle- Triangle of Doom and Triangle of Pain must be well identified And Corona Mortis

45. TAPP: STEP 3: Identifying the Anatomical Landmarks

46. TAPP: STEP 3: Identifying the Anatomical Landmarks

47. TAPP: STEP 4: Dissecting the Hernia Sac The indirect inguinal hernia sac should be dissected carefully from the Spermatic Cord. It is always essential to expose and know where the spermatic cord is located. Direct hernia sacs are easily dissected. Care should be taken not to dissect lateral and inferior to Cooper’s ligament, as the Iliac Artery and Vein will enter the femoral canal at this site

48. TAPP: STEP 4: Dissecting the Hernia Sac The hernia sac dissection is performed using traction contra-traction maneuvers and fine coagulation. To avoid the injuries of the Vas deferens and spermatic vessels the sac dissection always starts anteriorly

49. TAPP: STEP 5: Deploying and Anchoring the Mesh The mesh is inserted from the Camera trocar. Then, placed in the appropriate position. It is unrolled in the preperitoneal space and secured medially to Cooper’s ligament using a spiral tacker. The mesh shouldn’t be sutured/stapled at the level of dangerous triangles and epigastric vessels.

50. TAPP: STEP 5: Deploying and Anchoring the Mesh During this fixation, the surgeon palpates the end of the tacker from the abdominal surface to ensure its proper angle and to stabilize the pelvis. The mesh is then pulled taut and fixed lateral to the anterior superior iliac spine. Tacks are placed above the iliopubic tract to avoid injury to the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve.

51. TAPP: STEP 5: Deploying and Anchoring the Mesh

52. TAPP: STEP 5: Deploying and Anchoring the Mesh

53. TAPP: STEP 6: The peritoneal closure The peritoneum should be closed completely to avoid contact between the mesh and the intestine.

54. TAPP: STEP 7: Taking out Sutures & Port Closure Local Anesthetics infiltrated to improve postoperative pain control. The abdomen is desufflated and the trocars are removed. The fascial defect of the 12-mm port and the skin incisions are appropriately closed.

55. References Laparoscopic Hernia Surgery, Gateway Clinics, Coimbatore. Medscape. Schwartzs Principles of Surgery, 10th Edition.