Role of Laparoscopy in

Management of Hernias
SIR ASTLEY COOPER 1804

No disease of the human body, belonging

to the province of the general surgeon,
requires in its treatment a greater
combination of accurate anatomical
knowledge with surgical skill, than
hernia in its all varieties
Inguinal Hernia : Changing Concepts

 1800’s : Sutured repairs

 1980’s : Mesh repairs
 1990’s : Preperitoneal mesh placement
– More physiological
– Additional support from muscles
– Pascal’s law
 Recent : Laparoscopic hernia repair
– Combines preperitoneal and lap concepts
 Advantages of Lap repair
 Faster return to normal activity
 Lower persistent pain after lap repair
 European Union (EU) Hernia Trialists Collaboration
 25 trials, 4165 patients in 20 countries
 Fewer post operative complications
 Early discharge from hospital
 Faster return to normal activities and work
 Memon et al a meta analysis
 29 trials, 5588 patients with 5989 hernias

MMemon MA, Br J Surg 2003;90:1479-92 , Cormack K, The Cochrane

Library
Laparoscopic approach

 Transabdominal Preperitoneal approach

– TAPP
 Totally extra peritoneal approach
– TEP
EVOLUTION AT GEM

 Started TAPP from 1992

 Started TEP from 1995
 From1999 onwards >95% is TEP
TAPP- INDICATIONS

 Any type of groin hernia

 Recurrent inguinal hernia
 Bilateral inguinal hernia
 Patients undergoing another lap
procedure
CONTRAINDICATIONS

 Unfit for GA
 Extensive intra abdominal adhesions
 Large sliding hernia with bowel
adhesions to the sac
 Late strangulated hernia
POSITION OF PORTS

 Umbilicus- camera- 10mm

 Right pararectus- RHWP- 5mm
 Left pararectus- LHWP – 5mm
TAPP approach

 Creation of pneumoperitoneum
 Peritoneal flap creation
 Dissection in preperitoneal space
 Placement of Mesh & fixation
 Closure of peritoneal incision
Prosthesis- mesh

 Type
 Size
 Method of folding
 Method of introduction
 Method of unfolding
 Method of placement
 Method of fixation
MESH FIXATION

 Method used
 Suture material used
 Fixed to
 Cooper’s ligament
 Rectus muscle
POST OPERATIVE PERIOD

 liquids after 6 hrs

 Mobilisation after recovering from
anaesthesia
 Discharged after 24hrs.
 Allowed to do routine work from the
next day
INTRAOPERATIVE COMPLICATIONS

 Vascular injuries
 Bowel injuries
 Bladder injuries
 Vasdeferens injuries
 Others- lost needle into the rectus
muscle
POST OP COMPLICATION

 Seroma
 haematoma
 Hydrocele
 Neuralgia
 Intestinal obstruction
 Testicular complications
 Mesh related complications
RECURRENCE-CAUSES

 Inexperience
 Incomplete dissection
 Missed hernias
 Missed lipoma
 Incomplete reduction of direct hernia
 Mesh related problems
 Smaller mesh, migration,
 Slitting, rolling
 Displacement due to hematoma, seroma
TEP approach

 Creation of extra peritoneal space

 Dissection
 Placement of Mesh & Fixation

 Peritoneal flap creation

 Closure of peritoneal incision
Advantages of TEP Approach

 No peritoneal invasion
 Less intra abdominal complications
 Less adhesions
 More physiological approach
Initial Concerns

 Superiority not proven

 High recurrence rates
 Increased complication rate
 Prohibitive cost
 Steep learning curve
Recent results

Patients Follow up Recurrence

yrs %

Felix 1998 10,053 4 0.4

Schemdt 2002 6,860 5 <1
Schwab 2002 1,903 10 0.6
Palanivelu 2004 4,050 7 0.1

Felix E et al , Surg Endosc 1998;12:226-31.

Schmedt CG et al , Surg Endosc 2002;16:240-4.
Schwab JR et al , Surg Endosc 2002;16:1201-6.
Current consensus :
Groin hernia surgery

 Laparoscopic repair is highly effective

 Extremely low recurrence & complication
 Ideal repair in all types of groin hernias
– Bilateral and recurrent hernias
 Needs adequate knowledge of preperitoneal
anatomy
 Steep learning curve
Thanks