Editing Inguinal hernia (section)

== '''Laparoscopic repairs''' ==

* Comparison to open
** Quicker recovery
** Less pain
** Better visualisation of anatomy
** Ease of fixing all hernias
** Longer operative times
** Technical challenges
** Increased risk of recurrence
** Increased cost
** 0.3% risk of visceral or vascular injury
* TAPP vs TEP 
** Although TEP has demonstrated slightly lower recurrence rates, on the whole, there isn't any evidence to prefer one over the other definitively
** Both suitable choices
** TEP has a longer learning curve but doesn't violate as many tissue planes
** TAPP allows visualisation of both sides, and intra-peritoneal structures
** '''Liechtenstein and TAPP and TEP are thought to have similar recurrence rates overall'''
** rTAPP has shown reasonably similar recurrence rates to TAPP/TEP although no clear data
* Critical view of myopectineal orifice
** Dissect 2cm across midline
** Display direct hernia space
** Dissect 2cm posterior pectineal ligament
** Display femoral hernia space
** Dissect indirect sac
** Reduce all cord lipomas
** Posterior lateral dissection to expose psoas (why?)
** Mesh coverage and fixation
** Minimum mesh size 10 x 15cm



=== '''TAPP''' ===

* First performed 1990 by Schultz
* Supine, GA, prep, drape, Abx
* Hasson entry at umbilicus with 10mm port, then two 5mm ports bilaterally in a horizontal plane with the umbilicus
* Landmarks - umbilical ligaments, bladder, inferior epigastrics, vas def, spermatic cord, iliac vessels, hernia defects.
* Incise peritoneum from lateral edge of median umbilical ligament (at level of ASIS bilaterally) and extend 8-10cm laterally, to about 2cm medial to ASIS. Allow enough room above hernia for mesh placement! Need 2-3cm!
* '''Zone 1:''' First work laterally to IEVs, pushing transversalis and fat away from the peritoneum, which allows nerves to retain their fascial coverings (thin peritoneal flap)
* '''Zone 2:''' Then move medially to IEVs, and dissect directly on the posterior rectus sheath, with fat being pushed down with the peritoneum, which avoids damage to bladder or peri-vesical structures (thick peritoneal flap). Continue the dissection 2cm below pubic symphysis, and 2cm across midline to the contralateral side.
* '''Zone 3:''' Then dissect out around the IEVs, and triangle of doom
* Continue dissection until 'critical view of safety' is obtained
* Reduce hernia with gentle traction
* Insert mesh (e.g. Bard 3D Max ideally large) to cover the entire myopectineal orifice and fix in place with sutures/tacks (don’t use self-fixating mesh). 5-6 tacks is usually enough to fix it. Don't tack to bone. Often use fibrin glue on posterior aspect of mesh in triangles of doom and pain.
* Close peritoneum
* Close fascia, skin
** The 'inverted Y': inferior epigastrics (red), vas deferens (white), spermatic vessels (blue).
** Iliopubic tract in blue
*

=== '''TEP''' ===

* First performed 1993 by McKernan
* Contraindications
** Obliteration of retroperitoneal plane from previous surgery (prostate) or radiotherapy
* Pitfalls
** Missed hernia/inadequate mesh fixation
** Injury to bladder
** Nerve or major vessel injury
* Setup
** Both arms tucked
** May need Trendelenburg
** Monitor at foot of table
** Surgeon on side opposite to hernia
* Technique
** Transverse para-umbilical incision (give yourself more room, if there is a short lower abdomen)
*** Can also do infra-umbilical
*** Generally orient the incision on the ipsilateral side, to give better access to that rectus sheath
** Dissect through fat with scissors to get straight down to linea alba (don't need to stay close to cicatrix). Expose 2cm of ipsilateral anterior sheath to the hernia. Make a transverse 1cm incision in the anterior sheath. Elevate and lateralise ipsilateral rectus abdominis to expose posterior rectus sheath, using blunt dissection. 
** Use the S retractor to keep muscle elevated, and slide the dilating balloon in, aiming directly for symphysis pubis. Under vision (often use straight scope), inflate the dilating balloon manually with the white end (no specific number of pumps - use judgment) and hold inflated for 1-2 minutes, then deflate with the black end and swap to the structural balloon. Pump up the sealing balloon, which is the button closest to symphysis. Then attach gas, pressure 12mmHg, straight to high flow.
*** If using a regular Hasson port instead of the dissecting balloon, use the camera itself to push in and dissect down to symphysis pubis
** Two additional 5mm ports just off midline. Top one as high as possible whilst not interfering with the balloon on the camera port, the other one halfway between umbilicus and symphysis pubis. The lower one should be slightly contralateral to the hernia, but it doesn't really matter.
** Need to dissect peritoneum off transversalis fascia (same plane as TAPP)
*** Start with pubic tubercle
*** Look for the plane just above the peritoneal reflection, using both hands in an up-down chopsticks motion
*** Expose inferior epigastric vessels (key landmark), and expose ipsilateral pubic tubercle, Cooper's ligament, and the iliopubic tract (avoid going below iliopubic tract)
*** Expose as far laterally as ASIS
*** Look for the whitish hernia sac
*** Be wary of femoral vein/artery
** Hernia reduced (may require some cord skeletonization)
*** Small indirect sacs should reduce easily
*** Larger chronic sacs may have adhesions distally - may need to divide the sac just distal to the internal ring, by entering from the opposite side to the cord structures. If so, may need to close the proximal sac with clips or EndoLoop to prevent pneumoperitoneum from occurring.
*** Direct hernias should be able to be easily reduced with gentle traction
** Mesh placed over direct, indirect and femoral spaces
*** Can use a polypropylene mesh such as Bard 3D, or just any 12x14cm polypropylene
*** Need to cover entire myopectineal orifice - direct, indirect and femoral spaces, and resting over cord structures
*** No need to cut a slit for the cord (Chassin), but need to ensure peritoneum has been dissected at least 4cm off cord structures, to prevent subsequent encroachment and recurrence under mesh.
** Secure mesh with tacks - avoid triangle of doom and pain
*** Single tack medially to soft tissue above pubic tubercle
*** Medial inferior border fastened just above Cooper's ligament
*** Don't tack directly into the pubic symphysis - although many surgeons do
*** Also secure mesh along the superior border to the posterior rectus sheath and transversalis fascia, at least 2cm above the hernia defect, and laterally to iliopubic tract
*** Respect the triangles of doom (medial) and pain (lateral)
**** If the tacking device cannot be palpated on the anterior abdominal wall, assume it is below the iliopubic tract
**** Can only tack below the iliopubic tract if you are medial to external iliac vessels
**** See below
** Allow space to close under vision to ensure sac stays on top of the mesh and doesn't slip under the edge
** Close fascia with single figure-of-eight
*** If peritoneum was opened, release pneumoperitoneum with a cutdown
* Problems
** Pneumoperitoneum
*** Insert a 5mm optical port in LUQ with tap open to decompress
*** If still unable to get space, convert to TAPP or open



=== '''Fixation in laparoscopic repairs''' ===

* Controversial topic
* Tacks (absorbable and permanent), suture, adhesives
* If used, limit to the region of Cooper's ligament, medial to femoral space and anterior abdominal wall
* Do not place tacks posterior to ASIS
* Triangles: apex is internal ring, with doom medially and pain laterally
** Triangle of pain - femoral and lateral femoral cutaneous nerves and femoral branch of genitofemoral nerve.
** Triangle of doom - medial - femoral vessels, vas def medially, spermatic vessels laterally