Laparoscopic inguinal hernia repair

Question 1

What are the principles of laparoscopic inguinal hernia repair?

Answer 1

Dissection of hernia sac, assessment and reduction of hernia contents and reinforcing the repair of mesh

Question 2

What is your mesh preference for laparoscopic mesh repair of inguinal hernia?

Answer 2

Preferences

Progrip - self adhesive mesh
I fold this into quarter folds. One quarter fold down, and three quarters folded up. The top edge can be unfolded at its uppermost position, then the lower portion can be unrolled.

Question 3

How do you position your patient for a laparoscopic inguinal hernia repair?

Answer 3

GA. Supine. Both arms tucked. IDC not required, but must pass urine before case

Question 4

Describe your initial incision and opening of the pre peritoneal space

Answer 4

2cm infra-umbilical incision, on the side of the hernia

Dissect subcut tissue towards rectus sheath. Then incise approx 1cm

Identify rectus muscle, use S-bends to retract muscle laterally

Expose post. Rectus sheath. Bluntly dissect to open up pre-peritoneal space

Question 5

How do you develop your preperitoneal space, and place your 5mm ports?

Answer 5

Ports

Pass 10-mm trocar and balloon (usuallly lubriate with gel) along post. Rectus sheath aim the tip until pubic symphysis

Insert the 30◦ scope, under direct vision inflate the balloon slowly- reduces bleeding, approx 30 pumps

Watch for inf. epigatric vessle to remain on roof, peritoneum blow, rectus musle ant. And public bone infront

Deflate the balloon and replace with standard hasson or 10mm port

Insufflate with gas - create working space

Insert 2x 5mm ports in the midline.

Lower port, 2 finger breaths above public symphysis

Upper port, mid ways between the two

Question 6

What are your landmarks for developing your medial and lateral spaces? How do you deal with the cord and sac?

Answer 6

Identify landmarks and bluntly dissect out preperitoneal space dissecting laterally and

Medially

Medial dissection - extent

Identify the symphysis pubis first, then Cooper’s ligament, inferior epigastric vessels, bladder, and either the spermatic cord structure in males or round ligament in female patients

Dissect 2cm between coopers ligament and bladder

Look for femoral hernia

Lateral Dissection - extent

Dissection beyong ASIS

Reduce hernia using blunt dissection/retraction. Strip vas (medial) and gonadal vessels

(lateral) off sac.

Remove any cord lipomas

Once reduced ensure no other hernias and check peritoneum stripped well back to allow mesh placement

Question 7

How do you position your mesh? What are the closing steps of your laparoscopic mesh repair?

Answer 7

Mesh Placement

15x10cm Progrip

The mesh is marked at its medial side and rolled up; a stitch can be placed to help align the mesh

Extend the mesh to cover the myopectineal orifice overlapping at least 2 cm around the hernia defect.

Tack onto pubic symphysis and anterior abdominal wall but avoid tacks below IPT and in triangles of doom and pain

Deflate gas under vision

Question 8

What are your post operative instructions for the patient?

Answer 8

No heavy lifting for six weeks

Question 9

What are the complications of a laparoscopic mesh repair? How can these be categorised?

Answer 9

Immediate
- Bleeding
- Injury to cord structures
- Laparoscopic
- Visceral injury
- Vascular injury
- Conversion to open

Early
- Haematoma
- Ischaemic orchitis
- Infection

Late
- Pain. Inguinodynia
- Recurrence

Question 10

How do you deal with the sac of a large inguinoscrotal hernia during laparoscopic repair?

Answer 10

I would consider open repair at the outset. However, one option in the case of laparoscopic repair of large inguinoscrotal hernia and unable to reduce sac, is to divide the sac and leave distal end open

Question 11

Give three techniques for managing inadvertant pneumoperitoneum during laparoscopic repair

Answer 11

Endoloop/clipping to close defect

Veres needle LUQ to decompress pneumoperitoneum

If large peritoneal defect created convert to TAPP or open hernia repair

• If bleeding during laparoscopic repair place pressure. If major convert to open or lower midline to obtain control

Question 12

How do you deal with bleeding during a laparoscopic inguinal hernia repair

Answer 12

If bleeding during laparoscopic repair place pressure. If major convert to open or lower midline to obtain control

Question 13

You reduce necrotic bowel. How do you deal with this?

Answer 13

• Convert to lower midline laparotomy to resect bowel and anastomose with handsewn

interrupted anastomosis 3-0 PDS taking seromuscular evenly spaced bites

• Repair the inguinal hernia with a suture repair, typically Bassini. This is performed by approximating the conjoint tendon to the inguinal ligament using 2/0 prolene

Question 14

List four potential pitfalls/challenges during laparoscopic inguinal hernia repair

Answer 14

1. Irreducible sac from large inguinoscrotal heria
2. Inadvertant pneumoperitoneum
3. Bleeding
4. Necrotic bowel