Avoiding and Managing Avoiding and Managing Complications for Lap Complications for Lap Inguinal Hernia RepairInguinal Hernia Repair

Bruce Ramshaw MD FACSBruce Ramshaw MD FACS

Consultant, Halifax HealthConsultant, Halifax Health

Daytona Beach, FLDaytona Beach, FL

TEP (Total Extraperitoneal)TEP (Total Extraperitoneal)

ANATOMYANATOMY

Very complexVery complex

Unfamiliar to most open surgeonsUnfamiliar to most open surgeons

ConsistentConsistent

Need to see over and overNeed to see over and over

Access to Extraperitoneal SpaceAccess to Extraperitoneal Space

Unfamiliar AnatomyUnfamiliar Anatomy

Consistent AnatomyConsistent Anatomy

ObesityObesity

Previous SurgeryPrevious Surgery

Abdominal Wall AnatomyAbdominal Wall Anatomy

Skin IncisionSkin Incision

Balloon DissectionBalloon Dissection

Different Types of Balloon DissectorsDifferent Types of Balloon Dissectors

Degree of Balloon DistentionDegree of Balloon Distention

Previous SurgeryPrevious Surgery

BleedingBleeding

Balloon ShapesBalloon Shapes

Lateral ViewLateral View

View Through the BalloonView Through the Balloon

Trocar PlacementTrocar Placement

Medial DissectionMedial Dissection

Usually accomplished by the balloonUsually accomplished by the balloon

Direct hernia may obscure viewDirect hernia may obscure view

Previous surgeryPrevious surgery

ObesityObesity

Look for direct, femoral, and obturator Look for direct, femoral, and obturator herniashernias

Inferior Epigastric Vessels

Direct HerniaDirect Hernia

Lateral DissectionLateral Dissection

The most difficult part of the dissectionThe most difficult part of the dissection

Stay just posterior to inferior epigastricsStay just posterior to inferior epigastrics

Look for lateral abdominal wallLook for lateral abdominal wall

Avoid posterior structuresAvoid posterior structures

Cord

Cutaneous NerveCutaneous Nerve

Exploration of the CordExploration of the Cord

Indirect sac located anteriomedialIndirect sac located anteriomedial

Lipoma located anteriolateralLipoma located anteriolateral

Vas located posteriomedialVas located posteriomedial

Cord vessels located posteriolateralCord vessels located posteriolateral

Lipoma of the CordLipoma of the Cord

Mesh PlacementMesh Placement

Large mesh- at least 4 x 6 inchesLarge mesh- at least 4 x 6 inches

Slit or no slitSlit or no slit

Anatomic or FlatAnatomic or Flat

MemoryMemory

Inguinodynia – The ProblemInguinodynia – The Problem

Chronic groin pain after any type of Chronic groin pain after any type of inguinal hernia repair is potentially inguinal hernia repair is potentially disablingdisabling• Neuralgia, parasthesia, hypoesthesia, Neuralgia, parasthesia, hypoesthesia,

hyperesthesiahyperesthesia• Unable to work, limited physical & social Unable to work, limited physical & social

activities, sleep disturbances, psychic activities, sleep disturbances, psychic distressdistress

5-7% of patients experiencing post-5-7% of patients experiencing post-hernia repair groin pain begin hernia repair groin pain begin litigation. Most cases are settled.litigation. Most cases are settled. (General Surgery News, Feb 2004)(General Surgery News, Feb 2004)

InguinodyniaInguinodynia

• Prospective series of open Prospective series of open Lichtenstein hernia repairs:Lichtenstein hernia repairs:

At 1 yr f/u 19% of patients had pain, 6% At 1 yr f/u 19% of patients had pain, 6% moderate or severemoderate or severe

• Callesen, Bech & Kehlet Callesen, Bech & Kehlet Br J SurgBr J Surg 1999 1999

• Scottish population based studyScottish population based study 43% respondents with mild pain43% respondents with mild pain 3% severe, very severe pain3% severe, very severe pain

• Courtney, Duffy, Serpell & O’Dwyer. Courtney, Duffy, Serpell & O’Dwyer. Br J Br J SurgSurg 2002 2002

InguinodyniaInguinodynia• Pain 1 year s/p hernia repair – over 800 Pain 1 year s/p hernia repair – over 800

patients:patients: Pain present in 28.7% lap and Pain present in 28.7% lap and 36.7%36.7% open open 3 patients reported severe pain in open group3 patients reported severe pain in open group

• MRC Laparoscopic Groin Hernia Trial Group,MRC Laparoscopic Groin Hernia Trial Group, Lancet Lancet 1999 1999

• Pain present at one year in 28.7% of patients Pain present at one year in 28.7% of patients in Danish National Hernia Database studyin Danish National Hernia Database study

11% pain impaired work or leisure activity11% pain impaired work or leisure activity 4.5% sought treatment4.5% sought treatment

• Bay-Neilsen, Perkins & Kehlet, Bay-Neilsen, Perkins & Kehlet, Ann SurgAnn Surg 2001 2001

The cutaneous nervesThe cutaneous nerves

Anterior view Posterior viewAnterior view Posterior view

Failure of conservative treatment

Diagnostic laparoscopy

Intrabdominal Findings:Adhesions or Hernia recurrence? yes

Adhesiolysis and/orMesh hernia repair

TAPP dissection (peritoneal take-down): 4 steps1. Evaluate laterally for cutaneous nerve entrapment2. Evaluate medially for canal/cord nerve entrapment3. Remove offending tacks or mesh lateral to epigastric

vessels4. Look for interstitial hernia and/or lipoma of the cord

No pathology noted &Continuation of symptoms post-

operatively

Open mesh excision/neurectomy

Inguinodynia AlgorithmInguinodynia Algorithm

AdhesionsAdhesions

Recurrent HerniaRecurrent Hernia

TacksTacks

PlugsPlugs

Previous mesh slitPrevious mesh slit

Inguinodynia- Case studyInguinodynia- Case study

280 lb ex-NFL football player (40 y.o)280 lb ex-NFL football player (40 y.o) Lap LIH (3-D max, minimal fixation)Lap LIH (3-D max, minimal fixation) Severe pain almost immediatelySevere pain almost immediately Three operations over three yearsThree operations over three years

- two by primary surgeon - two by primary surgeon

- one for open neurectomy by expert - one for open neurectomy by expert 100 lb wt. loss, loss of all employment, 100 lb wt. loss, loss of all employment,

severe depression, NFL permanent severe depression, NFL permanent disabilitydisability

Previous mesh- no slitPrevious mesh- no slit

Open mesh excisionOpen mesh excision

THANK YOUTHANK YOU

Questions?Questions?