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LAPAROSCOPIC

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LAPAROSCOPIC Powered By Docstoc
					        IN THE NAME OF ALLAH
THE MOST GRACEFUL THE MOST MERCIFUL
LAPAROSCOPIC

 HERNIA REPAIR
         INSTRUMENTS REQUIRED

1.    Laparoscope 300
2.    Three – four Trocars (10-12 m.m.) + reducers
3.    Dissector
4.    Grasper
5.    Diathermy needle
6.    Suction tube
7.    Endo-hernia
8.    Endo-Clip clips
9.    Marlex, polypropylene mesh or surgipro (different sizes)
10.   Laparoscopic needles and needle holders
ANATOMY FROM INSIDE
Trans-peritoneal Laparoscopic
            View
  Pre-peritoneal
SCHEMATIC VIEWS
Pre-peritoneal Real View
TROCARS SITING
     Types of Laparoscopic Repair
1.   On-Lay mesh patch
2.   Transperitoneal:
     a) pre-peritoneal mesh
     b) plug and mesh
     c) Cigarettes and mesh
3.   Extra-peritoneal approach
      ON-LAY MESH PATCH
 Intra – peritoneal
 Weight of viscera to fix it
 Complications (adhesions, obstruction and
  fistulas)
 Less testicular pain and swelling
 Not recommended by many authors
            Trans-peritoneal
            (Pre-peritoneal)


Mesh only      mesh and plug   mesh and
                cigarettes
MESH ONLY
MESH AND PLUG
MESH AND CIGARRETTES

    (Video – presentation)
Extra-Peritoneal Approach

      (Video presentation)
     Advantages of Laparoscopic Hernia Repair


1.    Anatomy is clear.
2.    Suitable for bilateral and recurrent hernias.
3.    Quick convalescence (resume working after 1-7
      days).
4.    Less pain and scrotal swelling post-operatively.
5.    Inguinal canal is not opened (less risk of nerves
      and cord injuries)
                  Disadvantages
1.   A little more expensive than anterior approach.
2.   Higher recurrence rate (initial studies) than anterior
     approach Viz: Bassini’s, McVay or Litchenstien’s repair.
3.   Requires G.A.
4.   Takes a little longer operating time ( 2 – 2 ½ hours)
5.   Needs experts.
               Training requirements for
              Laparoscopic Hernia repair
1.   Attending basic courses in Laparoscopic surgery.
2.   Training course in Hernia repair.
3.   Surgeon should be familiar with the instruments.
4.   Should know how to operate with both hands.
5.   Learn how to suture laparoscopically.
6.   Learning the anatomy of the region (very important).
7.   Observing experts, assisting them and operates later
     on.
             INDICATIONS
 Bilateral Hernias
  (avoid long recoveries because of
  incisions)
 Recurrent Hernias
  (avoid dissecting scarred tissues, so less
  chance of cord and nerve injuries).
      CONTRA-INDICATIONS


   Patients who can not tolerate G.A.

   Large incarcerated sliding hernia
 POTENTIAL COMPLICATIONS OF Laparoscopic
              hernia repair


1.   Complications related to the
     laparoscope:
      a) Gas embolism
      b) Trocar injury (Bl. Vessels, bladder, bowel)
      c) Cautery injury (bladder, bowel)
2. Complications related to the repair:
     a) Vascular injury
     b) Bladder / bowel injury
     c) Injury to vas deferens
     d) nerve injury
     e) migration or infection of prosthesis
     f) adhesions and bowel obstruction
     g) Seroma formation
     h) Recurrence
PERSONAL EXPERIENCE
      59 Cases
 Al-Salama Hospital, Jeddah
 October,1991 – JUNE,1998
        Total no. 59 cases
    ( OCT. 1991- JUNE 1998 )

      ANALYSED 47 CASES
    ( OCT. 1991- FEB. 1996 )
Unilateral   Bilateral   Pantalloon
  (38)          (6)          (3)
              Sides

            Indirect      17 (one recurrent)
Rt          Direct         1
                   Patalloon     2

            Indirect      16 (one sliding sigmoid)
Lt.         Direct        4
            Patalloon     1

Bilateral                 6
      Males     45
SEX
      Females   2    (unilateral
                     left side indirect)
AGE   18 - 78 years
      (mean 37 years)
            Types of operation
                       Mesh patch only   7
1.   Pre-peritoneal    Mesh and cig.     18   (2-7 cig)
                       Mesh and plugs    6


2.   Extraperitoneal                     16
                Marlex          24
Material used   Surgipro        7
                polypropylene   16
Anaesthesia time

Unilateral (1.30 – 4 hrs)

fatty patient, big defect

Bilateral (3 – 3.15 hrs)
              Post-op follow-up

Pain :   Patient given I.M Voltaren and Nubain 4-6 hourly for 24 hours.
         All received prophylactic antibiotics for 3 doses post-op.
         All discharged with pain killers to be taken PRN.

                             Same day of op          4

Ambulation                   1st post-op day          40
                             2nd post –op day         3
   Hospital stay:      (1-7 days) average 2 days
                        ( 7 days for that with D.V.T.)



   Return to work:     3 days to 5 weeks (D.V.T.)
                        ( Average 7 days)



   Lifting heavy objects :   6 weeks
               Complications


I.   During Surgery:
       One case, injury to U.B.
     stitched                     with Vicryl +
     catheter for 10 days
                    Continuation:    Complications

II. Post-op:
  -    Retension of urine: One case responded to urinary catheterization for

       24 hrs.
   -   Neuralgia of upper medial part of thigh (staples)
   -   Seroma – one case detected by U/S and aspirated from inguinal
       region.
   -   Recurrence (4.2%) = 2 one after 3 months + one after 15 months
       post-op.
   -    Trocar Hernia - One at umbilical port repaired later on
               Continuation   :   Complications

II. Post-Op
  -   Bleeding
  -   Infection
  -   Hydrocele
  -   Orchitis                               NONE
  -   Pelvic collection
  -   Bowel injury
Length of follow-up
 OCT. 1991 – JUNE 1998
( 6 YEARS + 8 MONTHS )
     ( 80 MONTHS )
THANK YOU

				
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