Laparoscopic Repair of Inguinal Hernias Description

Laparoscopic Repair of Laparoscopic Repair of

Inguinal HerniasInguinal Hernias

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LAPAROSCOPIC SURGEONS GROUP

33rdrd August, 2005 August, 2005

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LAPAROSCOPIC SURGEONS GROUP OverviewOverview Laparoscopic repairs have had to compete with the current gold Laparoscopic repairs have had to compete with the current gold

standard for anterior or conventional inguinal hernia repairs. standard for anterior or conventional inguinal hernia repairs. Initially, some of these laparoscopic repairs, such as the "plug and Initially, some of these laparoscopic repairs, such as the "plug and patch" (PAP) and "on lay technique" (IPOM ), failed to demonstrate patch" (PAP) and "on lay technique" (IPOM ), failed to demonstrate good results and were abandoned. Only two laparoscopic repairs good results and were abandoned. Only two laparoscopic repairs have proven to be viable with early results comparable or superior to have proven to be viable with early results comparable or superior to the Liechtenstein repair. These repairs are the the Liechtenstein repair. These repairs are the Extraperitoneal Extraperitoneal Laparoscopic RepairLaparoscopic Repair (TEP) and the (TEP) and the Trans-Abdominal Trans-Abdominal Preperitoneal RepairPreperitoneal Repair (TAPP). Some authors are now claiming (TAPP). Some authors are now claiming newer and simpler open laparoscopic inguinal hernia repairs such as newer and simpler open laparoscopic inguinal hernia repairs such as "Plug" or "Klug" Repair are effectively competing with the "Plug" or "Klug" Repair are effectively competing with the laparoscopic inguinal hernia repairs without the increased cost. On laparoscopic inguinal hernia repairs without the increased cost. On our surgical service, the laparoscopic inguinal hernia repair remain our surgical service, the laparoscopic inguinal hernia repair remain the best surgical modality for the management of inguinal hernia. It the best surgical modality for the management of inguinal hernia. It is however a sophisticated technique whose performance remains is however a sophisticated technique whose performance remains linked to the laparoscopic experience of performing the surgeon. linked to the laparoscopic experience of performing the surgeon.


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LAPAROSCOPIC SURGEONS GROUP OverviewOverview Currently, the two most popular laparoscopic techniques are the Currently, the two most popular laparoscopic techniques are the

TAPP and the TEP. TAPP and the TEP. The most ardent critique of the TAPP procedure is that it is an intra-The most ardent critique of the TAPP procedure is that it is an intra-

abdominal procedure with significant potential morbidity. On the abdominal procedure with significant potential morbidity. On the other hand, the TEP procedure avoids intra-abdominal access. other hand, the TEP procedure avoids intra-abdominal access.

The most persuasive argument for using this procedure is the same The most persuasive argument for using this procedure is the same argument favoring all laparoscopic procedures: the postoperative argument favoring all laparoscopic procedures: the postoperative benefits to the patients, i.e., less postoperative pain, decreased benefits to the patients, i.e., less postoperative pain, decreased disability and small incisions. disability and small incisions.

However, it continues to be a procedure with limited long term However, it continues to be a procedure with limited long term follow-up and analysis. follow-up and analysis.

Surgeons performing laparoscopic inguinal hernia repair should be Surgeons performing laparoscopic inguinal hernia repair should be familiar with the TEP and TAPP Repair.familiar with the TEP and TAPP Repair.


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Laparoscopic Laparoscopic Inguinal AnatomyInguinal Anatomy

The anatomy of the inguino-femoral region viewed via a telescope placed in intra-The anatomy of the inguino-femoral region viewed via a telescope placed in intra-abdominal position differs radically from the anatomy observed via an open or abdominal position differs radically from the anatomy observed via an open or anterior approach. The laparoscopic surgeon needs to become familiar with the anterior approach. The laparoscopic surgeon needs to become familiar with the anatomical structure of this region. As all anatomical landmarks are covered with anatomical structure of this region. As all anatomical landmarks are covered with peritoneum, in the TAPP technique the peritoneum has to be first incised and a peritoneum, in the TAPP technique the peritoneum has to be first incised and a lower flap developed in order to expose the region adequately. In the TEP repair, lower flap developed in order to expose the region adequately. In the TEP repair, the anatomical landmarks need to be meticulously exposed with blunt dissection. the anatomical landmarks need to be meticulously exposed with blunt dissection.

Guidelines for the performance of a safe and secure laparoscopic inguinal hernia Guidelines for the performance of a safe and secure laparoscopic inguinal hernia repair, mandate the following structures should be clearly and unequivocally repair, mandate the following structures should be clearly and unequivocally identified:identified:• Cooper's Ligament Cooper's Ligament • The Epigastric Vessels The Epigastric Vessels • The Spermatic Cord or the Round Ligament The Spermatic Cord or the Round Ligament • The Femoral Canal and the Iliac Vessels The Femoral Canal and the Iliac Vessels • In addition, the laparoscopic anatomical distinction between direct, indirect In addition, the laparoscopic anatomical distinction between direct, indirect

inguinal and femoral hernias should be well understood. Before a surgeon inguinal and femoral hernias should be well understood. Before a surgeon attempts to perform a laparoscopic inguinal or femoral hernia repair, he should attempts to perform a laparoscopic inguinal or femoral hernia repair, he should memorize and be very familiar with the following diagrams. memorize and be very familiar with the following diagrams.


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Anatomy with & without Anatomy with & without Peritoneal CoveragePeritoneal Coverage


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Actual Views – TAPP RepActual Views – TAPP Rep


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Actual Views - TEP RepairActual Views - TEP Repair


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Recurrent Inguinal Hernia from an Recurrent Inguinal Hernia from an Open RepairOpen Repair


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Candidates and SelectionCandidates and Selection

The surgeon decides on a per case basis if an extensive, The surgeon decides on a per case basis if an extensive, lengthy enterolysis is in the best interest of the patient or if a lengthy enterolysis is in the best interest of the patient or if a TEP technique should be used. It has been reported that the TEP technique should be used. It has been reported that the major indications of this technique are recurrent inguinal major indications of this technique are recurrent inguinal hernias and bilateral inguinal hernias. We recommended that hernias and bilateral inguinal hernias. We recommended that all inguino-femoral hernias including single, unilateral defects all inguino-femoral hernias including single, unilateral defects

be repaired via laparoscopybe repaired via laparoscopy. .


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Choice of Repair: TEP vs TAPPChoice of Repair: TEP vs TAPP

The TEP and TAPP laparoscopic techniques are identical techniques with The TEP and TAPP laparoscopic techniques are identical techniques with different, anatomical access routesdifferent, anatomical access routes. The TAPP is a Trans-Abdominal route, . The TAPP is a Trans-Abdominal route, the TEP a Pro-Peritoneal route (see technique). There is no increase in the the TEP a Pro-Peritoneal route (see technique). There is no increase in the rate of intra-operative injuries with the TEP or TAPP technique when rate of intra-operative injuries with the TEP or TAPP technique when performed by experienced laparoscopic surgeons. Surgeons should performed by experienced laparoscopic surgeons. Surgeons should however take advantage of these different access routes in different clinical however take advantage of these different access routes in different clinical settings.settings.

Use these techniques in the following settings: Use these techniques in the following settings: - Incarcerated Inguinal-Femoral Hernia: TAPP Repair, - Incarcerated Inguinal-Femoral Hernia: TAPP Repair, - Inguino-Femoral Hernia / Patients with previous major lower abdominal - Inguino-Femoral Hernia / Patients with previous major lower abdominal

surgery: TEP Repair, surgery: TEP Repair, - Massive Inguinal Hernias with scrotal extension: TEP Repair or Anterior - Massive Inguinal Hernias with scrotal extension: TEP Repair or Anterior

Repair, Repair, - Bilateral Inguinal Hernias: TAPP or TEP Repair. - Bilateral Inguinal Hernias: TAPP or TEP Repair.


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Choice of Mesh PlacementChoice of Mesh Placement

Although various prosthetic Mesh-s were used to perform Although various prosthetic Mesh-s were used to perform these repairs, we routinely use a tailored 6"x 6" USSC these repairs, we routinely use a tailored 6"x 6" USSC SurgiPro® Mesh. As we reported, we initially used a 3 x 5 SurgiPro® Mesh. As we reported, we initially used a 3 x 5 Mesh. When analyzed most of our recurrence could have Mesh. When analyzed most of our recurrence could have been prevented by using a larger 6x6 Mesh. For this been prevented by using a larger 6x6 Mesh. For this reason, we now use large SurgiPro® Mesh for all repairs. reason, we now use large SurgiPro® Mesh for all repairs.

We have used two different variations for the placement of We have used two different variations for the placement of this Mesh. Approximately 500 cases were done with the this Mesh. Approximately 500 cases were done with the graft wrapped around the spermatic cord and more than graft wrapped around the spermatic cord and more than 700 cases were on lay placement. To date, there has been 700 cases were on lay placement. To date, there has been no difference in outcome or recurrence rates with either of no difference in outcome or recurrence rates with either of these variations. As of October 1996, we now preferentially these variations. As of October 1996, we now preferentially use the on lay Mesh placement with TAPP or TEP Repairs.use the on lay Mesh placement with TAPP or TEP Repairs.


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Onlay Placement of SurgiPro® Mesh -

SurgiPro® Mesh Around Spermatic Cord


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Anchoring the MeshAnchoring the Mesh Anchoring the Mesh has been subject to most controversy. Early on Anchoring the Mesh has been subject to most controversy. Early on

in the history of this laparoscopic technique, some surgical teams in the history of this laparoscopic technique, some surgical teams claimed the anchoring or stapling of the Mesh has been responsible claimed the anchoring or stapling of the Mesh has been responsible for a significant rate of post-operative neuropathy. Compression of for a significant rate of post-operative neuropathy. Compression of branches of the genito-femoral and lateral cutaneous nerve by branches of the genito-femoral and lateral cutaneous nerve by staples or tacks on the lateral aspect of the inguinal ring may have staples or tacks on the lateral aspect of the inguinal ring may have been the cause for this post-operative complication. For these been the cause for this post-operative complication. For these reasons, authors have developed numerous techniques, i.e. "no reasons, authors have developed numerous techniques, i.e. "no anchor-staple technique" or no lateral fixation of the Mesh. Our anchor-staple technique" or no lateral fixation of the Mesh. Our experience is somewhat different. A recent analysis of 2300 experience is somewhat different. A recent analysis of 2300 laparoscopic inguinal hernia repair ( with lateral fixation of the laparoscopic inguinal hernia repair ( with lateral fixation of the Mesh) demonstrated that patients may develop a transient Mesh) demonstrated that patients may develop a transient neuropathy without any reported permanent neuropathy. In addition neuropathy without any reported permanent neuropathy. In addition we firmly believe that stapling or anchoring the Mesh is responsible we firmly believe that stapling or anchoring the Mesh is responsible for reported low recurrence rate.for reported low recurrence rate.


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The Learning Curve PhenomenonThe Learning Curve Phenomenon

The laparoscopic inguinal hernia repair remains a difficult The laparoscopic inguinal hernia repair remains a difficult surgical repair. It is best demonstrated by the analysis of our surgical repair. It is best demonstrated by the analysis of our mean operating time versus the number of cases performed. mean operating time versus the number of cases performed. Our mean operative time was 1 hour and 39 minutes Our mean operative time was 1 hour and 39 minutes for our for our first ten patientsfirst ten patients. For . For the last 50 patientsthe last 50 patients, it was 27 minutes. , it was 27 minutes. We strongly believe these repairs are best done by surgeons We strongly believe these repairs are best done by surgeons who have performed at least 40 procedures assisting other who have performed at least 40 procedures assisting other laparoscopic surgeons well-trained in this procedure. laparoscopic surgeons well-trained in this procedure. Neophyte operators performing this repair without the proper Neophyte operators performing this repair without the proper training or guidance may generate an inordinate and training or guidance may generate an inordinate and inappropriate morbidity rate.inappropriate morbidity rate.


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LAPAROSCOPIC SURGEONS GROUP InstrumentsInstruments TelescopeTelescope Straight Forward Straight Forward

10 mm O Deg. 10 mm O Deg. CameraCamera Storz 3C High Def. CameraStorz 3C High Def. Camera InsufflatorInsufflator High Flow High Flow

InsufflatorInsufflator Video OutVideo Out OptionalOptional

The TEP Repair Dilating Trocar


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Operating Room Operating Room Set-upSet-up

This set-up is the same for TAPP or This set-up is the same for TAPP or TEP Repair TEP Repair

PPrroocceedduurraall VViiddeeooss

> > FFuullll TTAAPPPP RReeppaaiirr [[FFeemmaallee}}

>>FFuullll TTAAPPPP RReeppaaiirr [[MMaallee]]>>FFuullll TTEEPP RReeppaaiirr [[MMaallee]]>>RReeppaaiirr ooff CCoommpplliiccaattiioonnss iinn TTEEPP RReeppaaiirrss> > RReeppaaiirr ooff CCoommpplliiccaattiioonnss iinn TTAAPPPP RReeppaaiirr> > IInnsseerrttiinngg aanndd UUssiinngg tthhee TTEEPP BBaalllloooonn aanndd SSttrruuccttuurraall TrTrooccaarr..>>AAnncchhoorriinngg tthhee MMeesshh TTeecchhnniiqquueess iinn TTAAPPPP aanndd TTEEPP RReeppaaiirr> > TTEEPP oorr TTAAPPPP:: HHooww ttoo ddeecciiddee??


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LAPAROSCOPIC SURGEONS GROUP Trocars PlacementTrocars Placement

Favor the same trocar insertion sites for TEP and TAPP repair. In some cases, the Favor the same trocar insertion sites for TEP and TAPP repair. In some cases, the two 5 mm trocars are placed in midline position below the umbilicus for the TEP two 5 mm trocars are placed in midline position below the umbilicus for the TEP repair. repair.

TROCARS

Sub-Sub-uummbbiilliiccaall aarreeaa -- 1100 mmmm oorr SSttrruuccttuurraall TTrrooccaarr

RRiigghhtt LLaatteerraall -- 55 mmmm RReegg.. VVeerrssaappoorrtt™™ TTrrooccaarr -- [[SShhoorrtt TTrrooccaarr mmaayy bbee uusseedd]]

LLeefftt LLaatteerraall -- 55 mmmm RReegg.. VVeerrssaappoorrtt™™ TTrrooccaarr -- [[SShhoorrtt TTrrooccaarr mmaayy bbee uusseedd]]

SSuubb--uummbbiilliiccaall aarreeaa -- 1100 mmmm oorr SSttrruuccttuurraall TTrrooccaarr

RRiigghhtt LLaatteerraall -- 55 mmmm RReegg.. VVeerrssaappoorrtt™™ TTrrooccaarr -- [[SShhoorrtt TTrrooccaarr mmaayy bbee uusseedd]]

LLeefftt LLaatteerraall -- 55 mmmm RReegg.. VVeerrssaappoorrtt™™ TTrrooccaarr -- [[SShhoorrtt TTrrooccaarr mmaayy bbee uusseedd]]

Sub-umbilical area - 10 mm

Left Lateral - 5 mm

Right Lateral - 5 mm


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TAPP Repair: TAPP Repair: The TechniqueThe Technique


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A pneumoperitoneum is created in the usual fashion (sub-A pneumoperitoneum is created in the usual fashion (sub-umbilical position). The first trocar is inserted [11-5mm umbilical position). The first trocar is inserted [11-5mm Versaport™] in sub-umbilical position. Versaport™] in sub-umbilical position.

The intra-abdominal cavity is visualized with the Telescope The intra-abdominal cavity is visualized with the Telescope and intra-abdominal findings are reported [intra-abdominal and intra-abdominal findings are reported [intra-abdominal pathology and inguinal hernia defects and sacs]. pathology and inguinal hernia defects and sacs].

If an asymptomatic hernia sac is identified on the contralateral If an asymptomatic hernia sac is identified on the contralateral side, our protocol mandates its repair, even though at this time side, our protocol mandates its repair, even though at this time we are unsure of its exact clinical significance. we are unsure of its exact clinical significance.

The two additional 5 mm VersaPort ™ Trocars are inserted The two additional 5 mm VersaPort ™ Trocars are inserted under direct vision.under direct vision.

STEP 1: STEP 1: Entering the Intra-abdominal CavityEntering the Intra-abdominal Cavity


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STEP 2: Creating the Peritoneal STEP 2: Creating the Peritoneal FlapFlap

The repair is initiated. The The repair is initiated. The laparoscope is pointed toward the laparoscope is pointed toward the afflicted inguinal canal. The afflicted inguinal canal. The peritoneal defect or hernia is peritoneal defect or hernia is identified. The identified. The Lateral Umbilical Lateral Umbilical LigamentLigament is located as well as the is located as well as the Inferior Epigastric Artery and VeinInferior Epigastric Artery and Vein . . A peritoneal incision is made using A peritoneal incision is made using scissors or the EndoShear* scissors or the EndoShear* Instrument. The incision is extended Instrument. The incision is extended from the lateral aspect of the from the lateral aspect of the inguinal region to the inguinal region to the Lateral Lateral Umbilical LigamentUmbilical Ligament. .

For obese patients, this ligament may have to be transected in order to obtain For obese patients, this ligament may have to be transected in order to obtain additional exposure. The operator should be meticulous in making this incision as additional exposure. The operator should be meticulous in making this incision as high as possible to maximize the exposure of the region high as possible to maximize the exposure of the region


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STEP 3:STEP 3: Identifying the Anatomical Landmarks Identifying the Anatomical Landmarks

With blunt dissection, With blunt dissection, Cooper's LigamentCooper's Ligament is exposed as well as the is exposed as well as the Inferior Epigastric Inferior Epigastric VesselsVessels and the and the Spermatic CordSpermatic Cord. The iliac vessels are not dissected but their positions . The iliac vessels are not dissected but their positions is clearly identified. It is essential to expose the uncovered abdominal wall is clearly identified. It is essential to expose the uncovered abdominal wall meticulously (without peritoneum) and remove all fatty layers. meticulously (without peritoneum) and remove all fatty layers.


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STEP 4:STEP 4: Dissecting the Hernia Sac Dissecting the Hernia Sac

The indirect inguinal hernia sac should be dissected carefully from the The indirect inguinal hernia sac should be dissected carefully from the Spermatic CordSpermatic Cord. The most difficult hernia sacs to dissect are large, indirect . The most difficult hernia sacs to dissect are large, indirect inguinal sacs where iatrogenic injuries to the spermatic cord can occur. For inguinal sacs where iatrogenic injuries to the spermatic cord can occur. For this reason it is essential to expose and know at all times where the this reason it is essential to expose and know at all times where the spermatic cord is located. Direct hernia sacs are easily dissected. spermatic cord is located. Direct hernia sacs are easily dissected.

Caution:Caution: Be attentive not to injure the Vas Deferens. Be attentive not to injure the Vas Deferens. Particular care should also be taken not to dissect lateral and inferior to Particular care should also be taken not to dissect lateral and inferior to

Cooper's ligament, as the Cooper's ligament, as the Iliac Artery and VeinIliac Artery and Vein will enter the femoral canal will enter the femoral canal at this site. at this site.


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LAPAROSCOPIC SURGEONS GROUP STEP 5: STEP 5:

Deploying and Anchoring the MeshDeploying and Anchoring the Mesh

The 6x6 i Mesh is rolled like a cigarette and The 6x6 i Mesh is rolled like a cigarette and inserted uncut via the 11-5mm Versaport™ inserted uncut via the 11-5mm Versaport™ Trocar into the intra-abdominal cavity and Trocar into the intra-abdominal cavity and deployed over the inguinal region. The deployed over the inguinal region. The Mesh is attached or secured to Mesh is attached or secured to Cooper's Cooper's LigamentLigament, around and lateral to the , around and lateral to the Inferior Inferior Epigastric VesselsEpigastric Vessels using tacks delivered via using tacks delivered via the Protack® Instrument.the Protack® Instrument.

Caution: Be attentive not to place staples or Caution: Be attentive not to place staples or tacks over the inguinal vessels.tacks over the inguinal vessels.

The Protack® Instrument is dramatically The Protack® Instrument is dramatically different from the classical Multifire different from the classical Multifire EndoHernia* stapler. The tacks are EndoHernia* stapler. The tacks are inserted by rotating; these tacks are more inserted by rotating; these tacks are more secure than the endostaples, and in most secure than the endostaples, and in most cases, we use 25 to 30 tacks (one disposable cases, we use 25 to 30 tacks (one disposable instrument) to perform one repair. Again, instrument) to perform one repair. Again, the operator should be meticulous to avoid the operator should be meticulous to avoid the iliac vessels and to place tacks lateral to the iliac vessels and to place tacks lateral to the inguinal ring.the inguinal ring. Caution: Be attentive not to

grossly place staples of tacks over visible nerve branches.


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STEP 6:STEP 6: Testing the Fixation of the Mesh Testing the Fixation of the Mesh

The operator should check the Mesh is well anchored to the The operator should check the Mesh is well anchored to the surrounding structures. Using a closed grasper, pressure is surrounding structures. Using a closed grasper, pressure is applied with the end or tip of the grasper directly at the center of applied with the end or tip of the grasper directly at the center of the covered direct and indirect defect. The Mesh should not the covered direct and indirect defect. The Mesh should not migrate and remain in place.migrate and remain in place.


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STEP 8:STEP 8: Closing the Peritoneum Closing the Peritoneum

The peritoneum is closed meticulously and no defect between the The peritoneum is closed meticulously and no defect between the peritoneum and the abdominal wall should be left open. In addition, it peritoneum and the abdominal wall should be left open. In addition, it should cover the entire Mesh.should cover the entire Mesh.

The closure should be initiated on the lateral aspect of the repair. The The closure should be initiated on the lateral aspect of the repair. The peritoneal flap is held by a grasper and pulled over the upper peritoneal peritoneal flap is held by a grasper and pulled over the upper peritoneal layer. Tacks are used to close the peritoneal flap. The epigastric vessels layer. Tacks are used to close the peritoneal flap. The epigastric vessels should be meticulously visualized prior to stapling around them.should be meticulously visualized prior to stapling around them.

Caution:Caution: Be attentive not to place staples or tacks over the Epigastric Be attentive not to place staples or tacks over the Epigastric vessels.vessels.

The trocars are removed under direct vision. The fascia of the sub-The trocars are removed under direct vision. The fascia of the sub-umbilical trocar site is closed as needed.umbilical trocar site is closed as needed.

Laparoscopic Repair of Inguinal Hernias Description

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