TEP: ISSUES FOR DEBATE

Andrew Bowker Laparoscopy Auckland New Zealand

Poland October 2012

ISSUES FOR DEBATE: AN INTRODUCTION

Evidence-based practice not necessarily best practice Any approach to hernia repair can be defended through literature search My way is the best way! Based on Experience (6280 lap hernias) Thought about technique Observation of other surgeons

TOPICS TO BE DISCUSSED (i)

Laparoscopic vs. Open
TEP vs. TAPP Technical aspects: Balloon dissection / Port placement / 0 vs. 30 laparoscope Mesh: Type / Shape / Size

Fixation: none / tacs / titanium vs. absorbable / glue

Recovery advice

Use of ultrasound for hernias

TOPICS TO BE DISCUSSED (ii)

Particular situations
Abdominal wall scarring Irreducible hernias Femoral hernias Spigellian hernias TEP for sports hernia/groin strain Masterclass Hernia recurrence after previous laparoscopic repair TEP after radical prostatectomy

LAPAROSCOPIC VS. OPEN

For Makes mechanical sense Avoids muscle trauma Avoids ilioinguinal and iliohypogastric nerves Less post operative pain (short and long term) Earlier return to full activity Low recurrence rate Against General anaesthesia required More expensive: GA, disposables Long learning curve Not suitable for all surgeons

TEP VS TAPP
For TEP Intra abdominal adhesions = no problem No peritoneal incision No peritoneal closure Faster Incisional hernia not possible Against TEP Anatomy more difficult to recognise Harder to learn/teach

LEARNING LAPAROSCOPIC TECHNIQUE

Believe = ideal way to repair inguinal hernias Attend course Observe experts Be mentored

KEEP TRYING! Observe experts (again)

BALLOON DISSECTION
Gives clean initial space Expensive if commercial balloon used Home-made option low cost

BALLOON DISSECTION
Can strip inferior epigastric vessels from rectus muscle

PORT PLACEMENT
In midline Comfortable, if operating room set up properly Avoids dissection of contralateral side Lateral (both sides of midline)

Requires wider dissection Awkward angles Violates contralateral side

0 vs 30 LAPAROSCOPE
30 Makes orientation difficult Gets in the way when working close to the midline , with the ports placed in the midline 0 makes it difficult to see around corners; need to learn tricks Is easier to keep orientated (still need care)

LIGHTWEIGHT VS.HEAVYWEIGHT MESH

Heavyweight, small pore Cheaper Good handling characteristics Contraction up to 30% Lightweight, large pore More expensive Less scarring, less shrinkage Less pain?? Poor handling (floppy) Increased recurrences??

MESH: FLAT VS. MODIFIED

Flat Should sit well if dissection complete Shaped mesh Easier to position (especially when learning)

Slit in mesh (around cord) More pain?? Potential for recurrence through slit

MESH: SIZE
Size: 15x10cm Smaller associated with increased recurrence rate (particularly with shrinkage)

MESH: PLAIN VS.BARRIER

Barrier mesh (anti-adhesion) May improve handling of lightweight mesh Expensive Barrier provides no benefit in TEP

FIXATION VS. NO FIXATION

Fixation with tacks Secures mesh, especially medial edge Allows reduction of direct hernia defect Fixation with glue More expensive with fibrin glue Less expensive with cyanoacrylate Less pain potential No fixation Cheaper Less pain potential Increased recurrence (especially direct hernias)

FIXATION: BONE OR SOFT TISSUE?

Bone: no soft tissue injury Strong fixation Soft tissue (muscle / ligament): cause of chronic pain?

FIXATION: TITANIUM OR ABSORBABLE?

Titanium tacks: penetrate bone / periosteum Absorbable tacks: suitable for soft tissue only More expensive

RECOVERY ADVICE
No restrictions More activity = better recovery Analgesics as necessary Early return to heavy activity not associated with increased risk of recurrence

Patients are stronger than they ever have been immediately after the operation!

ULTRASOUND
Limited value If hernia clinically, adds no further information If no hernia clinically, probably no hernia Ultrasound hernia usually just cord lipoma But patient believes hernia..

TOPICS TO BE DISCUSSED (ii)

Particular situations
Abdominal wall scarring Irreducible hernias Femoral hernias Spigellian hernias TEP for sportsmans hernia/groin strain Masterclass Herniation post previous laparoscopic repair TEP post radical prostatectomy

TEP : ABDOMINAL WALL SCARRING

Midline scars (including Pfannensteil) Ignore for unilateral repairs Separate dissection either side of midline for bilateral repairs Transverse scars (appendicectomy) Careful dissection to avoid / minimise peritoneal tearing

PERITONEAL TEAR R

ENDOLOOP PERITONEAL TEAR L IIH

IRREDUCIBLE HERNIA
Options: (i) Manual reduction under general anaesthesia (ii) Laparoscopic TAPP reduction (iii) Open reduction via skin crease incision in groin and mobilise sac

Then TEP

IRREDUCIBLE RIIH

REDUCTION OF FEMORAL HERNIA

Defect has tight neck: hernia difficult to reduce

Disrupt Lacuna ligament medially Diathermy hook = ideal Abnormal obturator vessels easily avoided

FEMORAL HERNIA L

SPIGELLIAN HERNIA
TEP approach Dissect further cephalad Reduce hernia Cover with mesh Fix mesh

SPIGELLIAN HERNIA R

SPORTS HERNIA/GROIN STRAIN

Chronic pain in inguinal area without hernia Tender over conjoint tendon Pathology uncertain Anatomy at surgery looks normal Support with mesh from within can help

No guarantees

FURTHER LAPAROSCOPIC REPAIR FOR RECURRENCE AFTER LAPAROSCOPIC REPAIR

Why laparoscopic? Surgeon education Benefits of lap repair

TAPP required Leave existing mesh in situ Dissect sac and adjacent peritoneum Insert new mesh, overlapping existing mesh Cover new mesh with mobilised peritoneum / sac

RECURRENCE POST TEP REPAIR

TEP AFTER RADICAL PROSTATECTOMY

Scarring from radical prostatectomy Open repair = good option If TEP No balloon Start laterally Sharp + blunt dissection of scar tissue Keep to abdominal wall Hernia sac always = free Modify mesh size

TEP POST RADICAL PROSTATECTOMY

Perseverance..

breeds success

END