Latest in Laparoscopic Hernia surgery

All about Laparoscopy & Hernia - TAPP, TEP, Complications, Mesh Infection, Parastomal hernia, Hiatus hernia, Rare hernias, recuurence

1. LAPAROSCOPIC HERNIA SURGERY Dr. K. Sendhilkumar , Chief Surgical Gastroenterologist Dr. Piyush Patwa , Consultant Laparoscopic Surgeon Gateway Clinics, Coimbatore, India

2. HERNIA SURGERY OPEN LAPAROSCOPIC TEP : TOTALLY EXTRAPERITONEAL TAPP : TRANSABDOMINAL PREPERITONEAL IPOM : INTRAPERITONEAL ONLAY MESH REPAIR Difficult Adhesiolysis , Epigastric , Parastomal , RIF, Recurrent Hernia, Sliding, Hiatus Hernia

3. LAPAROSCOPY FOR INGUINAL HERNIAS I deal for Bilateral Hernias Recurrent Hernias (Previous open) Female Hernias ? Unilateral Hernias Combined with other procedure like Lap. Cholecystectomy Learning Curve – Laparoscopy v/s Open = 250 v/s 25 cases

4. TAPP – Tips, Tricks & Technique

5. Definition Transabdominal Preperitoneal technique: 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.

6. Lets do it step by step 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

7. 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 intervention.

8. Preoperative Care The patient with unilateral groin hernia should be asked to give his/her consent to allow simultaneous repair if a contralateral occult hernia is found.

9. Table – 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.

10. TAPP STEP 1: Entering the Intra-abdominal Cavity Trocar placement Establishing the carbon dioxide pneumoperitoneum using the Veress needle. The 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 .

11. Tips The intra-abdominal cavity is visualized with the Telescope and intra-abdominal findings are reported [intra-abdominal pathology and inguinal hernia defects and sacs].           If an asymptomatic hernia sac is identified on the contralateral side, our protocol mandates its repair, even though at this time we are unsure of its exact clinical significance.

12. Preperitoneal dissection The aim of this step is to ensure the best positioning of the mesh. In this way several anatomic landmarks have to be identified, as well as a complete dissection of the hernia’s sac. 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

13. STEP 2: Creating the Peritoneal Flap

14. Incision of the peritoneum The peritoneal incision starts 2 cm above the iliac spine/ 5cm above defect using the monopolar scissors/hook.

15. Incision of the peritoneum

16. Light House Sign

17. Crossing the Midline in RIH

18. Entering the Lateral Inguinal Space

19. STEP 3: Identifying the Anatomical Landmarks Exploration and anatomical landmarks The aim of the laparoscopic exploration is to identify the anatomical landmarks, site and type of hernia In this way, the Trendelenburg tilt should be increased to 30-45°. The two dangerous “triangles”, 1) vascular triangle- Triangle of Doom and 2) Triangle of Pain has to be well identified And Corona Mortis

20. Death, Destruction,or some other terrible fate

21. “Triangle of doom" landmark does protect the surgeon from damaging the external iliac vessels , a portion of these vessels lie outside of this area.

22. Triangle of Pain The so-called "triangle of pain" & "triangle of doom“ are misnomers Not a triangle - has only two boundaries The "triangle of pain" is an inverted "V" shaped area with its apex at the internal (deep) inguinal ring. It is bound anteriorly by the iliopubic tract / inguinal ligament and by the Gonadal vessels posteromedially

23. Triangle of Pain Don’t place staples or sutures to anchor the mesh – as several nerves which usually cannot be seen as they run just deep to the Endoabdominopelvic fascia TIP – Don’t open this fascia to see nerves ! These nerves can suffer damage with electrocautery or entrapment - cause pain (hence the name of the area)

24. CORONA MORTIS Latin - [ corona ] meaning "crown' & [ mortis ] meaning "death‘ the "crown or circle of death". The  corona mortis  refers to an anatomical variation , a vascular anastomosis between the obturator & the external iliac vascular systems that passes over P ectineal (Cooper's)  ligament and posterior to the lacunar ( Gimbernat's ) ligament.

25. Corona Mortis on left side

26. In some cases, the corona mortis is the actual obturator artery- arises from the inferior epigastric artery instead of the internal iliac artery It can also arise from the external iliac artery. In both cases, it has been called an " aberrant obturator artery "

27. The Preperitoneal dissection ends when the anatomic landmarks previous described are well exposed and the two dangerous triangles (vascular and pain triangle) can be identified

28. STEP 4: Dissecting the Hernia Sac The indirect inguinal hernia sac should be dissected  carefully  from the  Spermatic Cord   It is essential to expose and know at all times where the spermatic cord is located. Direct hernia sacs are easily dissected Particular 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

29. The hernia sac dissection is performed using traction contra-traction maneuvers and fine coagulation . To avoid the injuries of the ductus deferens and spermatic vessels the sac dissection always starts anteriorly

30. Pseudosac dissection in a Direct Hernia

31. A large indirect sac may be ligated proximally and divided distally without the risk of a higher postoperative pain & recurrence rate, but with an increased postoperative seroma rate * * Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society) Surg Endosc (2015) 29:289–321

32. When performing inguinal hernia repair in women , extra effort should be undertaken to reveal and treat occult synchronous femoral hernia

33. STEP 5: Deploying and Anchoring the Mesh A large ( 15x12 cm ) polypropylene mesh. The mesh is inserted from the Camera trocar . Then, the mesh is placed in the appropriate position and fixed by 1 Polypropylene sutures (or tacking staples, glue in some centres ). The first suture is at the level of pubis The mesh is fixed on the upper and internal edge The mesh shouldn’t be sutured/stapled at the level of dangerous triangles and epigastric vessels

34. Mesh is inserted from the Camera Trocar

35. The 15X12 cm Mesh is folded & inserted 

36. The Mesh should cover Myopectineal orifice When the mesh is smoothed out, it overlaps the pubic bone & crosses midline TIP – wrinkles or folds should not be seen

37. The Mesh is secured to  Cooper's Ligament , 

38. The mesh is fixed on the upper and internal edge

39. 3 Point Fixation

40. STEP 6 - The peritoneal closure A thorough closure of peritoneal incision or bigger peritoneal tears should be achieved The peritoneum is closed by a running suture using a 2-0 vicryl Look - Mesh is not exposed now to abdominal organs

41. The peritoneum is closed by a running 2-0 vicryl suture TIP – Far to Near

42. To improve postoperative pain control, trocar wounds can be infiltrated by local anaesthetic drug

43. TEP REPAIR

44. Contraindications for TEP Multiple prior lower abdominal surgeries Large Irreducible Hernias Previous Pre-peritoneal Surgeries (prostate / inguinal hernia) Patient not fit for GA

45. INSTRUMENTS Trocar tip Retractor

46. Retractor

47. INCISION

48. INCISION Umbilicus Starting point – from the depth of the umbilicus Length

49. ANTERIOR RECTUS SHEATH

50. WHICH RECTUS SHEATH? Right Hernia Left Hernia Bilateral Hernia Level of exposure

51. POSTERIOR RECTUS SHEATH

52. PROBLEMS Air leak Trocar slippage

53. PREVENTION OF AIR LEAK

54. CREATING SPACE Telescopic dissection Balloon tipped trocars

55. Various Balloons

56. WHERE TO GO?

57. Loose Areolar Tissues - CORRECT PLANE

58. PREPARATION FOR 1 st WORKING PORT

59. FIRST WORKING TROCAR Midline vs lateral ports Risk of injury to the inferior epigastric artery Risk of injury to the peritoneum

60. 1 st WORKING TROCAR

61. 1st WORKING TROCAR ENTRY

62. CROSSING THE MIDLINE

63. Entering into the opposite side

64. 2 nd WORKING PORT

65. IMPORTANT LANDMARK

66. PUBIC ARCH

67. PREPARATION TO GO TO LATERAL INGUINAL SPACE

68. PREPARATION TO GO TO LATERAL INGUINAL SPACE

69. PREPARATION TO GO TO LATERAL INGUINAL SPACE

70. PREPARATION TO GO TO LATERAL INGUINAL SPACE

71. PERITONEUM

72. EXPOSURE OF THE SAC

73. FASCIA TRANSVERSALIS SLING

74. SAC DISSECTION

75. SAC ISOLATION

76. SAC DIVISION

77. LIGATION OF THE SAC

78. MEDIAL DISSECTION OBTURATOR NERVE

79. OBTURATOR NERVE

80. PERITONEAL INJURY

81. POSTERIOR MOBILISATION OF THE PERITONEUM

82. VAS DEFERENS

83. TRIANGLE OF DOOM AND PAIN

84. THE HERNIA ANATOMY

85. MESH PLACEMENT

86. MESH FIXATION

87. MESH FIXATION

88. PROPERLY PLACED MESH

89. Other Ways Of Fixation TACKERS

90. DEFLATION

91. PORT PLACEMENT

92. HIATUS HERNIA

93. TYPES OF HIATUS HERNIAS

94. FIRST LOOK STOMACH LEFT LOBE LIVER

95. EXPOSURE LEFT LOBE LIVER UNDER SURFACE OF DIAPHRAGM STOMACH HEPATIC BRANCH OF VAGUS

96. ANATOMY OF THE HIATAL REGION CAUDATE LOBE LEFT GASTRIC PEDICLE STOMACH LEFT LOBE LIVER HEPATIC BRANCH OF VAGUS

97. ENTERING THE LESSER SAC GASTRO HEPATIC LIGAMENT KUTZNER WINDOW LEFT LOBE LIVER UNDER SURFACE OF DIAPHRAGM

98. ANATOMY AFTER GHL DIVISION LEFT LOBE LIVER CAUDATE LOBE LEFT GASTRIC ARTERY LEFT GASTRIC VEIN RT CRUS

99. RIGHT CRUS RT CRUS. WHITE LINE CAUDATE LOBE ESOPHAGUS

100. ANTERIOR VAGUS STOMACH SPLEEN ESOPHAGUS RT CRUS LEFT LOBE LIVER CAUDATE LOBE

101. GOING BEHIND THE ESOPHAGUS PHRENO ESOPHAGEAL MEMBRANE ESOPHAGUS RT CRUS

102. DEFINING THE LEFT CRUS FROM ABOVE BARE AREA OF STOMACH STOMACH ESOPHAGUS

103. EXPOSURE OF THE LEFT CRUS FROM ABOVE INFERIOR PHRENIC VESSEL STOMACH ESOPHAGUS BARE AREA OF STOMACH

104. DIVISION OF SHORT GASTRIC VESSELS SPLENIC ARTERY SPLEEN GASTRO SPLENIC LIGAMENT STOMACH

105. RETRO ESOPHAGEAL WINDOW RETRO ESOPHAGEAL WINDOW RT CRUS

106. POSTERIOR VAGUS ESOPHAGUS RT CRUS LEFT CRUS

107. CRURAL REPAIR AORTA RT CRUS LT CRUS ESOPHAGUS SPLEEN

108. CRURAL CLOSURE

109. FUNDAL WRAP CAUDATE LOBE ESOPHAGUS FUNDUS

110. Large Hiatus Hernia.(Laparoscopic Nissen’s Fundoplication)

111. DISSECTING AND EXCISINS THE SAC

112. LARGE HIATAL OPENING

113. DIAPHRAGMATIC HERNIA

114. Laparoscopic Repair of Incarcerated Bochdalek Hernia in Elderly : A rare emergency easily overlooked

115. CXR(PA)

116. Upper GI Endoscopy

117. Barium Swallow

118. HRCT

119. Diagnosis Left sided Bochdalek hernia with stomach herniating into left chest. PLAN Laparoscopic repair of Bochdalek hernia with reinforcement by dual mesh.

120. LEFT POSTERIOR LATERAL DEFECT

121. CONTENTS ADHERANT TO THE SAC

122. EXPOSURE OF THE HIATUS

123. DEFECT CLOSURE

124. MESH PLACEMENT

125. MESH PLACEMENT

126. Left Posterolateral D efect I n Adult

127. DEFECT CLOSURE AND MESH PLACEMENT

128. MANAGEMENT Misdiagnosis of BH is common, as reported in this case, and may be fatal Clinician should take great care during the management of patients with persistent pulmonary symptoms and abnormal chest findings CT Scan are the only way to direct visualize the focal defect of diaphragm, and also helps in establishes a definitive diagnosis

129. MANAGEMENT Very few cases of Laparoscopic management of incarcerated BHs in elderly have been reported The ideal technique is not yet determined because of lack of randomized trials comparing the procedures Procedure of choice depends on the surgeons

130. Conclusion BHs are uncommon clinical findings in adult population and cases presenting with incarceration are even less common CT is preferred diagnostic tool for BHs Laparoscopic repair of an incarcerated BH is an excellent option because of the advantages of its unique, minimally invasive nature

131. VENTRAL HERNIA

132. Recurrent Incisional Hernia

133. Multiple Defect W ith B owel A dhesion (Ventral Hernia)

134. Ventral Hernia W ith Bowel Adhesions

135. Parastomal H ernia Repair(Post APR)

136. Parastomal HerniaTechnique -Keyhole (direct) 151 |

137. Parastomal Hernia Technique- Sugar-baker (indirect) 152 |

138. DEFECT CLOSURE AND MESH PLACEMENT

139. Hernia in Paediatric age Group

140. Laparoscopic hernia repair also allows contralateral patent process vaginalis (PPV) hernias to be defined and repaired in the same operation *F. Schier , P. Montupet , and C. Esposito, “Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs,” Journal of Pediatric Surgery, vol. 37, no. 3, pp. 395–397, 2002.

141. Epigastric Hernia

142. Port Placement – Epigastric Hernia

143. Reducing the contents

144. Defect

145. Defect Closure  Stomach

146. 20x15 cms Elliptical Dual Mesh

147. Sliding Hernia

148. RIF region hernia after Bone graft Surgery

149. Position

150. Eventration of Diaphragm

151. MRI

152. Goal of Hernia Repair Minimal operative and post operative discomfort Effective repair Lowest possible recurrence rate Rapid return to normal activities Cost effective Reproducible among Hernia Specialists and General Surgeons 210

153. Ideal Prosthesis Chemically inert Minimal inflammatory or foreign body reaction Non-carcinogenic Does not induce a state of allergy or hypersensitivity Resists infection Minimal shrinkage Capable of resisting mechanical strains Strong enough to prevent recurrence Easy to handle and use Provides for appropriate tissue in-growth 211

154. Prosthetic Materials Meshes Anchor Tacker 212

155. Meshes Single Layered Double Layered Biological 213

156. What is the ideal mesh? Covidien? Ethicon? Bard? Gore? Atrium? Dynamesh ? GFE?... Lightweight? Ultra-light? Heavyweight?... Polyester? Polypropylene? ePTFE?... Weaved? Braided? Knitted?... Permanent? Absorbable? Semi-absorbable? Monofilament? Multifilament? ? 214

157. H + or H - , Surface, absorbable, Non absorbable, mixed mesh, foil, knitted, braided, woven expanded monofilament, Xfilament, elasticity , weight Macroporosity Microporosity Effective porosity Construction Material Porosity 3 main criteria’s to consider in mesh selection 215

158. 1mm 1.5mm The porosity of a mesh influences capsule formation and shrinkage of the mesh Optimal porosity provide sufficient space for tissue ingrowth Poor porosity leads to capsule formation and shrinkage 3 216

159. Currently used Prosthetic Meshes Polyester (Dacron)Mesh Polypropylene Mesh e PTFE mesh (Expanded Polytetra fluoroethylene ) Composite Mesh 217

160. Polypropylene Mesh Thermoplast based on propane with MW of 100000 Resists physical decay after years As strong as steel but 1/8 the density High bending stiffness is a disadvantage Causes sub-acute inflammatory reaction causes fibrosis and stability Direct contact with bowel can lead to intestinal adhesions and fistulas 218

161. Polypropylene Mesh Considerable shrinkage (20% in length to 40% in area) Leads to early edema (2-7 days), so needs drains Intense fibrosis embedding the mesh into scar leads to restriction of wall mobility In case of infections leave the mesh and give antibiotics If not settled the mesh should be removed 219

162. Traditional Weight Mesh Used for over 30 years Secure repair BUT…. Does it optimize wound healing? Patient complaints Loss of abdominal wall mobility Post-operative discomfort Ability to feel the edge of the mesh 220

163. Lightweight Mesh The lightweight mesh hypothesis: Alter construction of the mesh in such a way as to allow handling characteristics of a traditional mesh while delivering: More natural abdominal wall compliance Improved patient comfort Less foreign body implanted over the lifetime of the patient A secure repair 221

164. Traditional weight meshes allow for scar tissue to form a bridge from filament to filament. This results in what is called bridging fibrosis and consequently, a rigid scar plate. The lighter weight polypropylene encourages an orderly ingrowth of tissue and allows for healthy, flexible collagen to form between the filaments…resulting in a flexible, more compliant scar plate. 222

165. Abdominal Wall Compliance 0.8 mm Pore Size 4.0 mm Pore Size Heavyweight, or traditional weight mesh Lightweight, or “physiologic” weight mesh Granuloma Granuloma 223

166. In Favor of Polypropylene Mesh: Extensive fibroblast in growth , incorporation by the host and can be used in contaminated fields Franklin ME et al. Lap ventral and incisional hernial repair. Surg Lap End 8(4):294-299 1998 285 lap ventral hernia and 520 lap inguinal hernia using IPOM with polypropylene mesh. 1 fistula formation (0.14%), 4 mesh infections (0.50%), and 6 reoperations for bowel obstruction secondary to mesh adhesions (0.75%). Relaparoscopy 27 patients (19 incisional, 8 inguinal): 1/3 no adhesions, 1/3 mild adhesions, 1/3 severe. Chowbey PK et al. Lap ventral hernia repair J La Adv Surg Tech 2000; 10:79-84 Bingener J et al. Adhesion formation after laparoscopic ventral incisional hernia repair with polypropylene mesh: a study using abdominal ultrasound, JSLS (2004)8:127-131 224

167. Against polypropylene mesh: It is extremely difficult to lyse adhesions to polypropylene without causing enterotomies* Major complications with polypropylene not evident until years later 9 cases of mesh erosion fistula stainless steel (1) tantalum (1) mersilene (1) dexon (1) ppm (5). The time to the development of these fistulas ranged from 3 months to 14 years *Losanoff JE et al. Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature, Hernia 2002; 6: 144-147 225

168. In Favor of ePTFE Microporous, smooth texture minimizes tissue in-growth and limits adhesion formation and bowel injury Combined with a large pore second layer it can adhere well to the abdominal wall 226

169. Against ePTFE Microporous construction limits ability of macrophages to destroy bacteria Mesh infection is not well treated by antibiotics and requires mesh removal Does not integrate well into host tissue when not combined with a large pore mesh 227

170. Polyester Dual Mesh Parietex (polyester and atelocollagen type 1, polyethylene glycol, glycerol) Covidien , Hamilton, Bermuda Polyester mesh incorporates well into the abdominal wall Collagen covering on the visceral surface protects bowel and dissolves as the polyester is incorporated 228

171. Composite Meshes Combination of 2 materials Surface facing the peritoneal aspect Promotes tissue ingrowth Increases adhesion between mesh & parietal wall Eg. Polyproplene/Polyester Surface facing the abdominal contents Inert Prevents adhesion between mesh & bowel Absorbable or nonabsorbable 229

172. Composite Meshes Composix Peritoneal surface : Polyester Abdominal surface : ePTFE (nonabsorbable) Parietex Peritoneal surface : Polyester Abdominal surface : Hydrophilic collagen coating Gore Tex Both surface : ePTFE 230

173. Composite Meshes Proceed Polypropylene Oxidised Reinforced Collegen Atrium Polypropylene Omega 3 Fatty Acid 231

174. Proceed mesh 232

175. Parietex mesh 233

176. Composix mesh 234

177. Goretex Dual Mesh 235

178. Atrium mesh 236

179. DR. LATIF BAGWAN. GATEWAY CLINICS 237

180. Biosynthetic mesh Surgisis gold 8ply mesh - Processed porcine small intestinal submucosa Alloderm – Processed cadaveric human acellular dermis 238

181. Surgisis mesh 239

182. Advantages Resists infection well Conforms well to the abdominal wall Physiological collagen deposition Can be used in infected fields 240

183. Disadvantages Occasional severe host reaction Seroma common with surgisis mesh High incidence of post op diastasis and recurrence with alloderm Cost 241

184. Take Home message Material nature is important for cells attachment Porosity is more important than the weight of the mesh For ventral hernia, the elasticity of the mesh is key Not all materials behave the same way on long term 242

185. COMPLICATIONS

186. Mesh Infection And Removal

187. REMOVAL OF MESH AND TACKS TACK

188. EXTRACTION OF THE MESH MESH REMOVAL IN ENDOBAG

189. Entero-Cutaneous fistula Previous Open Ventral Hernia and Lap IPOM Repair for Umbilical Hernia

190. CECT- abdomen