بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم

IN THE NAME OF ALLAH IN THE NAME OF ALLAH

THE MOST GRACEFUL THE MOST THE MOST GRACEFUL THE MOST MERCIFULMERCIFUL

LAPAROSCOPICLAPAROSCOPIC

HERNIA REPAIRHERNIA REPAIR

INSTRUMENTS REQUIREDINSTRUMENTS REQUIRED

1.1. Laparoscope 30Laparoscope 3000

2.2. Three – four Trocars (10-12 m.m.) + reducersThree – four Trocars (10-12 m.m.) + reducers

3.3. DissectorDissector

4.4. GrasperGrasper

5.5. Diathermy needleDiathermy needle

6.6. Suction tubeSuction tube

7.7. Endo-herniaEndo-hernia

8.8. Endo-Clip clipsEndo-Clip clips

9.9. Marlex, polypropylene mesh or surgipro (different Marlex, polypropylene mesh or surgipro (different sizes)sizes)

10.10. Laparoscopic needles and needle holdersLaparoscopic needles and needle holders

ANATOMY FROM ANATOMY FROM INSIDEINSIDE

Trans-peritoneal Trans-peritoneal Laparoscopic ViewLaparoscopic View

Pre-peritonealPre-peritonealSCHEMATIC VIEWSSCHEMATIC VIEWS

Pre-peritoneal Real ViewPre-peritoneal Real View

TROCARS SITINGTROCARS SITING

Types of Laparoscopic RepairTypes of Laparoscopic Repair

1.1. On-Lay mesh patchOn-Lay mesh patch

2.2. Transperitoneal:Transperitoneal:a) pre-peritoneal mesha) pre-peritoneal mesh

b) plug and meshb) plug and mesh

c) Cigarettes and meshc) Cigarettes and mesh

3.3. Extra-peritoneal approachExtra-peritoneal approach

ON-LAY MESH PATCHON-LAY MESH PATCH

Intra – peritonealIntra – peritonealWeight of viscera to fix itWeight of viscera to fix itComplications (adhesions, Complications (adhesions,

obstruction and fistulas)obstruction and fistulas)Less testicular pain and swellingLess testicular pain and swellingNot recommended by many authorsNot recommended by many authors

Trans-peritonealTrans-peritoneal(Pre-peritoneal)(Pre-peritoneal)

Mesh only mesh and plug mesh Mesh only mesh and plug mesh and cigarettesand cigarettes

MESH ONLYMESH ONLY

MESH AND PLUGMESH AND PLUG

MESH AND MESH AND CIGARRETTESCIGARRETTES

(Video – presentation)(Video – presentation)

Extra-Peritoneal Extra-Peritoneal ApproachApproach

(Video presentation)(Video presentation)

Advantages of Laparoscopic Hernia RepairAdvantages of Laparoscopic Hernia Repair

1.1. Anatomy is clear.Anatomy is clear.

2.2. Suitable for bilateral and recurrent hernias.Suitable for bilateral and recurrent hernias.

3.3. Quick convalescence (resume working Quick convalescence (resume working after 1-7 days).after 1-7 days).

4.4. Less pain and scrotal swelling post-Less pain and scrotal swelling post-operatively.operatively.

5.5. Inguinal canal is not opened (less risk of Inguinal canal is not opened (less risk of nerves and cord injuries)nerves and cord injuries)

DisadvantagesDisadvantages

1.1. A little more expensive than anterior approach.A little more expensive than anterior approach.

2.2. Higher recurrence rate (initial studies) than Higher recurrence rate (initial studies) than anterioranterior

approach Viz: Bassini’s, McVay or Litchenstien’s approach Viz: Bassini’s, McVay or Litchenstien’s repair.repair.

3.3. Requires G.A.Requires G.A.

4.4. Takes a little longer operating time ( 2 – 2 ½ Takes a little longer operating time ( 2 – 2 ½ hours)hours)

5.5. Needs experts.Needs experts.

Training requirements for Training requirements for Laparoscopic Hernia repairLaparoscopic Hernia repair

1.1. Attending basic courses in Laparoscopic surgery.Attending basic courses in Laparoscopic surgery.

2.2. Training course in Hernia repair.Training course in Hernia repair.

3.3. Surgeon should be familiar with the instruments.Surgeon should be familiar with the instruments.

4.4. Should know how to operate with both hands.Should know how to operate with both hands.

5.5. Learn how to suture laparoscopically.Learn how to suture laparoscopically.

6.6. Learning the anatomy of the region (very Learning the anatomy of the region (very important).important).

7.7. Observing experts, assisting them and operates Observing experts, assisting them and operates later on.later on.

INDICATIONSINDICATIONS

Bilateral Hernias Bilateral Hernias

(avoid long recoveries because of (avoid long recoveries because of incisions)incisions)

Recurrent Hernias Recurrent Hernias

(avoid dissecting scarred tissues, so (avoid dissecting scarred tissues, so less chance of cord and nerve less chance of cord and nerve injuries).injuries).

CONTRA-INDICATIONSCONTRA-INDICATIONS

Patients who can not tolerate G.A.Patients who can not tolerate G.A.

Large incarcerated sliding herniaLarge incarcerated sliding hernia

POTENTIAL COMPLICATIONS OF POTENTIAL COMPLICATIONS OF Laparoscopic hernia repairLaparoscopic hernia repair

1.1. Complications related to the Complications related to the laparoscope:laparoscope:

a) Gas embolisma) Gas embolism

b) Trocar injury (Bl. Vessels, bladder, bowel)b) Trocar injury (Bl. Vessels, bladder, bowel)

c) Cautery injury (bladder, bowel)c) Cautery injury (bladder, bowel)

2. Complications related to the repair:2. Complications related to the repair:a) Vascular injurya) Vascular injuryb) Bladder / bowel injury b) Bladder / bowel injury c) Injury to vas deferensc) Injury to vas deferensd) nerve injuryd) nerve injurye) migration or infection of e) migration or infection of prosthesisprosthesisf) adhesions and bowel obstructionf) adhesions and bowel obstructiong) Seroma formationg) Seroma formationh) Recurrenceh) Recurrence

PERSONAL EXPERIENCEPERSONAL EXPERIENCE59 Cases59 Cases

Al-Salama Hospital, JeddahAl-Salama Hospital, Jeddah

October,1991 – JUNE,1998October,1991 – JUNE,1998

Total no. 59 casesTotal no. 59 cases( OCT. 1991- JUNE 1998 )( OCT. 1991- JUNE 1998 )

ANALYSED 47 CASESANALYSED 47 CASES( OCT. 1991- FEB. 1996 )( OCT. 1991- FEB. 1996 ) Unilateral Bilateral Unilateral Bilateral

PantalloonPantalloon(38) (6) (3) (38) (6) (3)

Indirect 17 (one recurrent)Indirect 17 (one recurrent) Rt Rt Direct 1 Direct 1

Patalloon 2 Patalloon 2

Indirect 16 (one sliding Indirect 16 (one sliding sigmoid) sigmoid)

Lt. Direct 4 Lt. Direct 4 Patalloon 1 Patalloon 1 Bilateral 6 Bilateral 6

Sides

Males 45Males 45

SEXSEX Females 2Females 2 (unilateral (unilateral

left side left side indirect)indirect)

AGEAGE 18 - 78 years18 - 78 years (mean 37 years)(mean 37 years)

Types of operationTypes of operation

Mesh patch only 7Mesh patch only 7

1.1. Pre-peritoneal Pre-peritoneal Mesh and cig. 18 (2-Mesh and cig. 18 (2-7 cig)7 cig)

Mesh and plugs 6Mesh and plugs 6

2.2. Extraperitoneal Extraperitoneal 1616

Marlex Marlex 2424

Material usedMaterial used Surgipro Surgipro 7 7

polypropylene polypropylene 1616

Anaesthesia timeAnaesthesia time

UnilateralUnilateral (1.30 – 4 hrs) (1.30 – 4 hrs) fatty patient, big defectfatty patient, big defect

Bilateral Bilateral (3 – 3.15 hrs)(3 – 3.15 hrs)

Post-op follow-upPost-op follow-up

PainPain : : Patient given I.M Voltaren and Nubain 4-6 hourly for 24 Patient given I.M Voltaren and Nubain 4-6 hourly for 24 hours.hours.

All received prophylactic antibiotics for 3 doses post-op.All received prophylactic antibiotics for 3 doses post-op.

All discharged with pain killers to be taken PRN.All discharged with pain killers to be taken PRN.

Same day of op 4Same day of op 4

AmbulationAmbulation 1st post-op day 40 1st post-op day 40

2nd post –op day 32nd post –op day 3

Hospital stayHospital stay: : (1-7 days) average 2 (1-7 days) average 2 days days

( 7 days for that with ( 7 days for that with D.V.T.)D.V.T.)

Return to workReturn to work:: 3 days to 5 weeks 3 days to 5 weeks (D.V.T.) (D.V.T.)

( Average 7 days)( Average 7 days)

Lifting heavy objectsLifting heavy objects : : 6 weeks 6 weeks

ComplicationsComplications

I.I. During SurgeryDuring Surgery: : One case, injury to U.B. stitched One case, injury to U.B. stitched

with Vicryl + catheter for 10 with Vicryl + catheter for 10 daysdays

ContinuationContinuation: Complications: Complications

II. Post-op: II. Post-op:

- - Retension of urineRetension of urine: One case responded to urinary catheterization for : One case responded to urinary catheterization for

24 hrs.24 hrs.

- Neuralgia of upper medial part of thigh (staples)- Neuralgia of upper medial part of thigh (staples)

- - Seroma Seroma – one case detected by U/S and aspirated from inguinal – one case detected by U/S and aspirated from inguinal

region.region.

- - Recurrence (4.2%)Recurrence (4.2%) = 2 one after 3 months + one after 15 months = 2 one after 3 months + one after 15 months

post-op.post-op.

- - Trocar HerniaTrocar Hernia - One at umbilical port repaired later on - One at umbilical port repaired later on

ContinuationContinuation: : ComplicationsComplications

II. Post-OpII. Post-Op- BleedingBleeding- InfectionInfection- HydroceleHydrocele- Orchitis Orchitis NONENONE- Pelvic collectionPelvic collection- Bowel injuryBowel injury

Length of follow-upLength of follow-up

OCT. 1991 – JUNE 1998OCT. 1991 – JUNE 1998( 6 YEARS + 8 MONTHS )( 6 YEARS + 8 MONTHS )

( 80 MONTHS ) ( 80 MONTHS )

THANKTHANK YOUYOU