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SURGICAL ANATOMY

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LAPAROSCOPIC
INGUINAL HERNIA REPAIR
TRANSABDOMINAL APPROAH
By
Prof.Doctor
Mahmoud Shaker
M.D, FRCSI, FICS
AHMED MAHER
TEACHING HOSPITAL
INGUINAL CANAL
пЃ±SURGICAL ANATOMY
ILIAC CREST
ANT.SUP.ILIAC SPINE
MUSCLES
PUBIS
INGUINAL CANAL
- oblique intramuscular split of 4cm long in the lower
part of abdominal wall.
- it passes downward and medially from internal
inguinal ring to external inguinal ring.
INGUINAL CANAL
пЃ±EXTERNAL
INGUINAL RING.
пЃ¶V shaped split in the
external oblique
aponurosis.
пЃ¶ВЅ inch above and
lateral to the pubic
tubercle.
INGUINAL CANAL
пЃ±INTERNAL INUINAL
RING.
U – shaped defect
in fascia transversalis.
1/2 inch above
midinguinal point.
( midway between
ASIS and SP ).
INGUINAL CANAL
пЃ±BOUNDARIES
пЃ¶anterior wall.
пЃ¶ whole length:
external
oblique apponeurosis
пЃ¶ lat.1/3:
lowest fibers of
internal oblique muscle
INGUINAL CANAL
*POSTERIOR WALL.
*transversalis fascia.
*medial ВЅ : conj. Tendon.
*medial Вј : reflected part
of inguinal ligament.
INGUINAL CANAL
*ROOF
lower border of internal
oblique and transversus.
*FLOOR
upper grooved surface of
inguinal ligament.
upper surface of lacunar
ligament.
INGUINAL CANAL
пЃ±HASSELBACH TRIANGLE .
(inguinal. Triangle).
*weak part of the posterior wall.
*covered only by fascia
transversalis and peritoneum.
INGUINAL CANAL
пЃ±HASSELBACH TRIANGLE
*BOUNDARIES.
*lateral border of the rectus
muscle. medially
*inf. Epigastria. art. laterally.
*med ВЅ of inguinal. Ligament.
inferiorly.
INGUINAL HERNIA
пЃ±DEFINITION
Protrusion of part of the contents of the abdomen
through the inguinal region of the abdominal wall
TYPES OF INGUINAL HERNIA.
пЃ±Indirect.
*most common.
*any age.
*male or female 20:1
*bilat. in 30 % of cases
Direct.
*10-20 % of hernias
* old patients
*always male
*bilat. in 50 %
Direct
hernia
Indirect
hernia
INGUINAL HERNIA
пЃ±ETIOLOGY.
пЃ¶Congenital = patent proscus vaginal.
пЃ¶Acquired = true protrusion of parietal
peritoneal.
CLINICAL PICTURE
пЃ±Symptoms:
пЃ±sings
*swelling
*pain
пЃ¶ Swelling
пЃ¶ Expansile impulses
пЃ¶ Gurgling on reduction
пЃ¶ Consistency
*soft
*doughy
пЃ¶ Percussion
*resonant
*dull
пЃ¶ Trans illumination.
*opaque
пЃ¶ Not hot, red, tender ,nor tense in uncomplicated.
SPECIAL TESTS
пЃ±Internal ring test.
пЃ¶Indirect
=not appear
пЃ¶Direct
= descend but
above inguinal ligament
пЃ¶Femoral =descend but
below inguinal ligament
SPECIAL TESTS
пЃ±External ring test.
пЃ¶-painful (not usually done )
пЃ¶-tip of finger пѓ indirect
пЃ¶-medial aspect of finger пѓ direct
TREATMENT
пЃ±Conventional technique
Principle:
пЃ¶
Excision or reduction of the sac
пЃ¶
Repair of the posterior wall
пЃ¶
Mesh hernioplasty
пЃ±laparoscopic hernia repair
TREATMENT
пЃ±Direct hernia:
пЃ¶
пЃ¶
пЃ¶
Reduction of the sac
Repair of the posterior wall (F. T)
Looking for indirect sac
TREATMENT
пЃ±Indirect hernia
пЃ¶Excision of the sac
пЃ¶Repair of the posterior wall
TREATMENT
пЃ±Repair of the posterior wall
пЃ¶
пЃ¶
Approximation
Reinforcement
*Darns
*Shouldice
*Graft
APPROXIMATION
REINFORCEMENT
пЃ±DARNS
REINFORCEMENT
пЃ±SHOULDICE
REINFORCEMENT
пЃ±Grafts
пЃ¶Fascia lata (gallies operation )
пЃ¶Skin graft ( mair )
пЃ¶Synthetic mesh implants
пЃ±ADVATAGES
пЃ¶Can be done by local anesthesia
пЃ¶No need to enter the abdominal cavity
пЃ¶Less risk for injury of intra-abdominal structures
пЃ±DISADVATAGES
пЃ¶Wound infection 5%
пЃ¶Recurrence rate
*indirect
3%
*direct up to 27%
пЃ¶Bilateral hernias need 2 sittings
пЃ¶Missed sac
пЃ¶pain
Laparoscopic hernia repair
пЃ±Principle: *sac
*mesh
пЃ±Indications *all hernias especially
in elderly
*bilateral cases
*recurrent cases
пЃ±Procedure *Transabdominal Preperitoneal
approach (TAPP)
*Totally preperitoneal approach
(TOPP)
Transabdominal
preperitoneal
approach
пЃ¶Position
of the patient
пЃ¶Position
of surgeon
пЃ¶Position
of trocars
SURGICAL ANATOMY
Internal ring
Sac
Testicular vessels
Vas difference
Iliac vessels
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ADVANTAGES
пЃ±less pain (minimally invasive)
пЃ± rapid return to work (cost effective)
пЃ±identification of contra lateral hernia
пЃ±incarcerated hernia is more easily handled
пЃ±umbilical hernia
пЃ±possible concomitant pathology can be
diagnosed
пЃ±female hernia (easily dissected)
DISADVANTAGES
пЃ±Necessity to enter the abdominal cavity
пЃ±The need of general anesthesia
пЃ±The risk of intra abdominal injury
CONCLUSION
Laparoscopic
hernia repair is the first choice
for treatment of
inguinal hernia
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