Unformatted text preview: Laparoscopic Inguinal Hernia
Laparoscopic Inguinal Hernia
Repair: Art or Evil Inguinal Hernias
How common are they?
~ 700,000 inguinal hernia repairs performed in the US per year Inguinal Hernia
Inguinal Hernia Types: Indirect & Direct separated by inf epigastric vessels Open Inguinal Hernia Repairs
Open Inguinal Hernia Repairs Bassini
Plug & patch Lichtenstein Repair
Lichtenstein Repair Popularized the use of polypropylene mesh in primary hernia repairs
Mesh is laid over the undisturbed inguinal floor, posterior to the spermatic cord sutured to the shelving edge of the inguinal ligament, internal oblique fascia and the pubis Laparoscopic Hernia Repair
Laparoscopic Hernia Repair When is laparoscopy When is laparoscopy appropriate? Recurrent hernias avoid a prev operated field Bilateral hernias one set of incisions better than two inguinal incisions; one mesh to cover both overlay bladder Types of Laparoscopic Inguinal Types of Laparoscopic Inguinal Hernia Repair IPOM (IntraPeritoneal Onlay Mesh) repair. A mesh is placed intra TAPP (Trans Abdominal PrePeritoneal) repair. With this technique, the TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned.
preperitoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized. retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs Trochar placement for both Trochar placement for both TEP & TAPP Anatomy
Anatomy What does the literature say ?
What does the literature say ? Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for InguinalHernia Repair Mike S.L. Liem, M.D., Yolanda van der Graaf, M.D., Cees J. van Steensel, M.D., Roelof U. Boelhouwer, M.D., GeertJan Clevers, M.D., Willem S. Meijer, M.D., Laurents P.S. Stassen, M.D., Johannes P. Vente, M.D., Wibo F. Weidema, M.D., Augustinus J.P. Schrijvers, Ph.D., and Theo J.M.V. van Vroonhoven, M.D. Multicenter randomized prospective trial Sample: 487 (TEPmesh); 507 (openno mesh) Postop f/u 1 & 6 weeks, 6 mo, 1 & 2 years Conclusion: Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair Liem et al. Comparison of Conventional Anterior Surgery and Laparoscopic Surgery for InguinalHernia Repair. NEJM. 1997. 336. 15417. Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia Leigh Neumayer, M.D., Anita GiobbieHurder, M.S., Olga Jonasson, M.D., Robert Fitzgibbons, Jr., M.D., Dorothy Dunlop, Ph.D., James Gibbs, Ph.D., Domenic Reda, Ph.D., William Henderson, Ph.D., for the Veterans Affairs Cooperative Studies Program 456 Investigators VA Multicenter randomized prospective study N: 3518 (eligible) 2164 (randomization) 1983 (surgery) 1696 (2 yr f/u) Conclusions
Conclusions Higher recurrences in laparoscopic group for primary (same for recurrence repairs)
Increased intraop/postop complications in the laparoscopic group
Earlier return to usual activities in lap. Group
**Recurrence rates for lap surgeons threshold was 250 repairs** Leigh Neumayer, M.D Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia. NEJM. 2004; 350:181927 Limitations
Limitations VA population
Variability among surgeons performance
Surgeons experience was selfreported Leigh Neumayer, M.D Open Mesh versus Laparoscopic Mesh Repair of Inguinal Hernia. NEJM. 2004; 350:181927 ...
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- Fall '11
- Conclusion, Inguinal hernia, inguinal hernia repairs, Laparoscopic Inguinal Hernia