First laparoscopic inguinal hernia repair performed by Ger in 1970s (published in 1982) Schultz described the TAPP repair in 1990

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2 Introduction First laparoscopic inguinal hernia repair performed by Ger in 1970s (published in 1982) Schultz described the TAPP repair in 1990 McKernon and Laws described the TEP repair in 1993 Currently, 10-15% of all inguinal hernias are being fixed laparoscopically

3 Right groin anatomy

4 Sites of the groin hernias image from

5 Laparoscopic View of a Right Pantaloon Hernia MEDIAL umbilical fold LATERAL umbilical fold (contains the inferior epigastric vessels)

6 Triangle of Doom

7 Triangle of Pain

8 Location of nerves that may be injured during laparoscopic inguinal hernia repair

9 The defect that needs to be covered

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12 OR positioning

13 TAPP port locations

14 TAPP Developing peritoneal flaps to expose preperitoneal space

15 Placement of mesh Page 15

16 TEP port locations

17 TEP Initial incision

18 TEP Use of the S retractor for exposure

19 TEP Manual dissection of the preperitoneal space

20 TEP Placement of the balloon dissector/dilator

21 TEP Additional Port Placements The second port (5- or a 10mm) is placed at the line of Douglas. The third port (5mm) is placed 3-fingerbreadth below the second port.

22 TAPP (TransAbdominal PrePeritoneal) vs TEP ( Total ExtraPeritoneal) TAPP Advantages - larger working space - allows for immediate identification of groin anatomy - can perform diagnostic laparoscopy - can perform concurrent laparoscopic procedure (i.e. adhesiolysis, cholecystectomy) Disadvantages - increased risk of injury to visceral organs - complications associated with improper closure of the peritoneum (i.e. fistula, bowel obstruction)

23 TAPP (TransAbdominal PrePeritoneal) vs TEP ( Total ExtraPeritoneal) CONT TEP Advantages - minimizes all complications associated with entering the peritoneal cavity - quicker preperitoneal dissection Disadvantages - small working space (can become even smaller if a peritoneal tear is made) - increased cost from using commercially-available balloon dissector/ port system - not feasible in patients with prior preperitoneal dissection/surgery

24 TAPP (TransAbdominal PrePeritoneal) vs TEP ( Total ExtraPeritoneal) CONT Based on a meta-analysis of the RCTs, the recurrence rates are equivalent, but the learning curve may be steeper for the TEP repair. 1 TEP repair more popular because it avoid entering the peritoneal cavity. 1 Leibel BJ et al. Langenbecks Arch Surg 2005; 390: 77 82

25 Laparoscopic approach is not the favored approach for inguinal hernias. the laparoscopic approach has a variable recurrence rate (dependent on the learning curve of the surgeon) the laparoscopic approach is more difficult to master the laparoscopic approach may take longer to perform and use more costly instruments/devices the post-operative benefits are minimal

26 But that may change. advanced laparoscopic training is becoming a part of core general surgery training new generation of general surgeons will be just as comfortable with the laparoscopic repair as the open repair (if not more) (the lap appy story) sensitivity of diagnosing an inguinal hernia by physical exam is ~75% 1 - in obese individuals? - in possible recurrent cases where hernia not palpable? 1 Korenkov, M et al. J Ultrasound Med, 1999; 18(8):

27 Standardizing approach to inguinal hernia repairs The TEP approach is more popular, but there are advantages to the TAPP approach Why choose when you can have both? Effort should be made to address some of the disadvantages of the laparoscopic approach - longer operative time - increase cost of procedure - steep learning curve

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29 Study Design / Method Retrospective analysis Outcomes - immediate complications - advantages over the TAPP and TEP techniques 15 consecutive patients who presented with inguinal hernias at the DVAMC and at Duke All patients were examined and operated on by a single surgeon.

30 Algorithm for the Hybrid Approach

31 Placement of the 5mm ports

32 Diagnostic laparoscopy lateral umbilical ligament INDIRECT Hernia medial umbilical ligament

33 Preperitoneal view with left inguinal region dissected out pubic tubercle lacunar ligament gonadal vessels vas deferens

34 Placement of MESH (laparoscopic view of left inguinal region) medial umbilical ligament

35 Results No immediate complications peri-operatively or at time of follow-up. In general, operative time took min. 11/15 patients underwent lap inguinal hernia repair.

36 Results CONT 4 patients did not have an inguinal hernia. Two of these patients had previous open repair on the symptomatic side only peritoneal adhesions were found. The post-operative Dx (and the planned procedure) changed in 7/15 patients based on the diagnostic laparoscopy.

37 The Change in Post- opera1ve Diagnosis and Planned Procedure By Using the Hybrid Approach Pa1ent Pre- op Dx Post- op Dx Change in Procedure 1 Bilateral inguinal hernia - No inguinal hernia - Omental adhesions Stopped a6er diagnos7c laparoscopy (a6er adhesiolysis) 2 Bilateral inguinal hernia Le6 inguinal hernia only (incarcerated sigmoid colon) Converted to a TAPP repair 3 Le6 inguinal hernia Incidental umbilical hernia Also performed umbilical hernia repair 4 Le6 inguinal hernia No inguinal hernia Stopped a6er diagnos7c laparoscopy 5 Bilateral inguinal hernia Le6 inguinal hernia only Avoided right groin dissec7on 6 Right inguinal hernia - No inguinal hernia - Omental adhesions Stopped a6er diagnos7c laparoscopy (a6er adhesiolysis)

38 Results CONT If these cases were performed using the standard TEP repair, the hybrid approach would have been advantageous in 11/15 cases (mostly minimizing unnecessary dissection). If these cases were performed using the standard TAPP repair, the hybrid approach would not have been advantageous in any cases (except avoiding the risk of operating in the peritoneal cavity and closing the peritoneal defect).

39 Results CONT Steps made to decrease cost of procedure 1) reduction of OR time - avoided unnecessary dissection - used only 5-mm ports (no fascia closure) 2) did not use the commercial balloon dissector/port system for standard TEP repair

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41 SILS TEP port locations Page 41

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43 SILS TEP Inguinal Hernia Repair Use either a flexible tip 5 mm scope (or a 5 mm, 45 degree scope) The key to driving the scope successfully - don t move around too much (stay in one location) - use the Medusa technique look away with the camera from the side you are operating on and than turn back at it (do NOT look directly at it)

44 SILS TEP Inguinal Hernia Repair CONT Patient set-up exactly the same as standard TEP inguinal hernia repair - both arms tucked - foley catheter - periumbilical incision (on the side opposite side of repair) - same exposure and preperitoneal dissection

45 SILS TEP Inguinal Hernia Repair CONT PART 1: general dissection PART 2: fine dissection PART 3: placement of mesh

46 My secret weapon Richard Wolf Catalog Number Shaft OD Shaft Length Page 46

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48 Onlay Placement of Mesh

49 Keyhole Placement of Mesh

50 IPOM Placement of Mesh

51 MESH Preparation (Rattner) Scheme for creating a 6 4-inch patch from a standard 6 6-inch piece of polypropylene mesh.

52 MESH Placement (Rattner) This diagram illustrates the final position of the mesh with the cut angle accommodating the Cooper ligament and the iliac vessels. The mesh is secured using four spiral tacks

53 Covidien ParietexTM Mesh Anatomic Mesh Page 53

54 Covidien Parietex TM Mesh Anatomic Mesh Page 54 Covidien website 12/09

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