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Laparoscopic Inguinal Hernia Repair

Contents
Overview
Anatomy
Technical Analysis
Laparoscopic Mesh
Instruments
OR Set-up
Trocars
Consent
Coding-Billing
TAPP Technique
TEP Repair
Post-op instructions
Mngt. Complications
Oucome Analysis
Photos
References

 

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Laparoscopic Repair of Inguinal & Femoral Hernias
Candidates and Selection

All patients cleared for general anesthesia were candidates for this repair. Our youngest patient was fifteen years old and our oldest 88 years old. Previous intra-abdominal surgical procedures were not a contraindication. The surgeon decides on a per case basis if an extensive, lengthy enterolysis is in the best interest of the patient or if a TEP technique should be used. It has been reported that the major indications of this technique are recurrent inguinal hernias and bilateral inguinal hernias. We recommended that all inguino-femoral hernias including single, unilateral defects be repaired via laparoscopy.

Choice of Repair: TEP vs TAPP

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

We use these  techniques in the following settings:

- Incarcerated Inguinal-Femoral Hernia: TAPP Repair,
- Inguino-Femoral Hernia / Patients with previous major lower abdominal surgery: TEP Repair,
- Massive Inguinal Hernias with scrotal extension: TEP Repair or Anterior Repair,
- Bilateral Inguinal Hernias: TAPP or TEP Repair.

 
Choice of Mesh Placement

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

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

- Onlay Placement of SurgiPro® Mesh -

- SurgiPro® Mesh Around Spermatic Cord -

 
Anchoring the Mesh

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

 
The Learning Curve Phenomenon

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

 

Procedural Videos
> Full TAPP Repair [Female}

>Full TAPP Repair [Male]

>Full TEP Repair [Male]

>Repair of Complications in TEP Repairs

> Repair of Complications in TAPP Repair

> Inserting and Using the TEP Balloon and Structural Trocar.

>Anchoring the Mesh Techniques in TAPP and TEP Repair

> TEP or TAPP: How to decide?


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