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Laparoscopic Inguinal Hernia Repair: Art or Evil

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Laparoscopic Inguinal Hernia Repair: Art or Evil

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    1. Laparoscopic Inguinal Hernia Repair: Art or Evil

    2. Inguinal Hernias How common are they? - ~ 700,000 inguinal hernia repairs performed in the US per year

    3. Inguinal Hernia Types: Indirect & Direct -- separated by inf epigastric vessels

    4. Open Inguinal Hernia Repairs Bassini McVay Shouldice Lichtenstein Plug & patch

    5. Lichtenstein Repair Popularized the use of polypropylene mesh in primary hernia repairs Mesh is laid over the undisturbed inguinal floor, posterior to the spermatic cord sutured to the shelving edge of the inguinal ligament, internal oblique fascia and the pubis

    7. Laparoscopic Hernia Repair

    8. When is laparoscopy appropriate? Recurrent hernias - avoid a prev operated field Bilateral hernias - one set of incisions better than two inguinal incisions; one mesh to cover both overlay bladder

    9. Types of Laparoscopic Inguinal Hernia Repair IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned. TAPP  (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized. TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs

    10. Trochar placement for both TEP & TAPP

    11. Anatomy

    14. What does the literature say ?

    15. Multicenter randomized prospective trial Sample: 487 (TEP-mesh); 507 (open-no mesh) Postop f/u 1 & 6 weeks, 6 mo, 1 & 2 years

    20. Patients with inguinal hernias who undergo laparoscopic repair recover more rapidly and have fewer recurrences than those who undergo open surgical repair

    26. Conclusions Higher recurrences in laparoscopic group for primary (same for recurrence repairs) Increased intra-op/postop complications in the laparoscopic group Earlier return to usual activities in lap. Group **Recurrence rates for lap surgeons threshold was 250 repairs**

    27. Limitations VA population Variability among surgeons performance Surgeons experience was self-reported

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