Should I Do Laparoscopic Or Open Hernia Repair

Prof. Dr. R. K. Mishra

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Introduction.

Inguinal hernia results from a hole or defect in the muscles, through which the peritoneum protrudes, forming the sac. Inguinal herniorrhaphy is i of the most common operations that full general surgeons perform. Laparoscopic herniorrhaphy is being washed at a fourth dimension when laparoscopic cholecystectomy has shown definite benefits over the open technique. But different laparoscopic cholecystectomy, laparoscopic hernia repair is an advanced laparoscopic procedure and has a longer learning curve. In addition, TEP requires college technical expertise for successful results

Laparoscopic Anatomy

In the lower abdomen at that place are five peritoneal folds or ligaments which are seen through the laparoscope in umbilicus. These ligaments are generally disregarded at the time of open up surgery.

1. One Median Umbilical Ligament

In the midline in that location is median umbilical ligament extends from the mid of urinary bladder upwardly to the omphalus. Median umbilical ligament is obliterated urachus.

two. Two Medial Umbilical Ligament ane on either side

The paired medial umbilical ligament is obliterated umbilical artery except where the superior vesical arteries are found in the pelvic portion. The medial umbilical ligaments are the most prominent fold of the peritoneum. Quondam, hangs downwards and obscure the vision of lateral pelvic wall. These ligaments are important landmark for the lateral extent of the urinary bladder.

3. Ii Lateral Umbilical Ligaments

Lateral to the medial umbilical ligament, the less prominent paired lateral umbilical fold contains the Inferior epigastric vessels. The inferior epigastric artery is lateral border of Hesselbach's triangle and hence is useful landmark for differentiating between direct and indirect hernia. Whatsoever defect lateral to the lateral umbilical ligament is indirect hernia and medial to it is directly inguinal hernia.

The femoral hernia is beneath and slightly medial to the lateral inguinal fossa, separated from it by the medial cease of the iliopubic tract internally and the inguinal ligament externally.

Of import landmarks for extraperitoneal hernia autopsy include the musculo-aponeurotic layers of the abdominal wall, the float, coopers ligament and the iliopubic tract. The inferior epigastric artery and vein, the gonadal vessels and vas deferens should also be recognized. The space of Retzius lies between the vesicoumbilical fascia posteriorly and the posterior rectus sheath and pubic bone, anteriorly. This is the space showtime entered in extraperitoneal repair of hernia.

1. TRIANGLE OF DOOM: The triangle of doom is defined be vas deferens medially, spermatic vessels laterally and external iliac vessels inferiorly. This triangle contains external iliac artery and vessels, the deep circumflex iliac vein, the genital branch of genitofemoral nerve and hidden by fascia the femoral nervus. Staple should not be applied in this triangle otherwise; chances of mortality are there if these great vessels are injured.

2. TRIANGLE OF Pain: Triangle of pain is defined as spermatic vessel medially, the iliopubic tract laterally and inferiorly the inferior edge of pare incision. This triangle contains lateral femoral cutaneous nervus and anterior femoral cutaneous nerve of thigh. The staple in this area should be less because nerve entrapment can crusade neuralgia.

three. Circumvolve OF DETH: This is also called as corona mortis and refers to vascular band course past the anastomosis of an abnormal avenue with the normal obturator artery arising from a branch of the internal iliac artery. At the time of laparoscopic hernia this vessel is torn both terminate of vessel can bleed profusely, because both ascend from a major artery.

The surgeon should remember these anatomic landmarks and the point of mesh fixation should be selected superiorly, laterally and medially.

Indications of Laparoscopic Repair of Hernia.

The indications for performing a laparoscopic hernia repair are essentially the aforementioned every bit repairing the hernia conventionally. There are, however, certain situations where laparoscopic hernia repair may offer definite benefit over conventionalsurgery to the patients. These include:

Bilateral inguinal hernias
Recurrent inguinal hernias

In recurrent hernia, surgery failure rate is as high equally 25 to xxx percentage, if again repaired by open surgery. The distorted anatomy after repeated surgery makes it more prone to recurrence and other complications like ischemic orchitis. In recurrent hernia, the laparoscopic arroyo offers repair through the inner salubrious tissues with clear anatomical planes and thus, a lower failure rate. In laparoscopic bilateral repair with iii ports technique, in that location is simultaneous access to both sides without whatsoever boosted trocar placement. Even in patients with clinically unilateral defect later on inbound inside the intestinal cavity there is 20-50 percentage incidence of a contra lateral asymptomatic hernia beingness found which can be repaired, simultaneously, without any additional morbidity of the patient?

Contraindications of Laparoscopic Repair of Hernia

Not-reducible, Incarcerated Inguinal Hernia
Prior laparoscopic herniorrhaphy
Massive Scrotal hernia
Prior pelvic lymph node resection
Prior groin irradiation

Advantages of Laparoscopic Arroyo

Tension free repair that reinforces the entire myo-pectoneal orifice.
Less tissue dissection and disruption of tissue planes
Iii ports are acceptable for all blazon of hernias
Less pain postoperatively.
Depression intra-operatively and postoperative complications.
Early render to work.

Disadvantages of Open Method

Requires 4 to 6 inches of incision at the groin.
Generally very painful, because of muscle spasm.
Considerable post-operative swelling of tissues in groin, effectually the wound.
Requires cut through the skin, fatty, and good muscles in order to proceeds access for repair, which in itself causes damage.
Frequent complications of wound hematomas, wound infection, scrotal hematomas and neuroma.
Usually takes 6 to eight weeks for recovery.
Sometimes long term disability, may follow east.g. neuralgia, neuroma and testicular ischemia.
Whether a apartment mesh or a plug is used from the front, they don't hold themselves in place; what holds them in place are stitches, and then the force of the repair still depends on the stitches, non so much on the mesh or plug.
Bilateral inguinal hernias require 2 incisions, doubling the pain; or ii operations.
Recurrent inguinal hernias are very difficult to operate open, and more than liable to complications.
The size of mesh used in open methods is limited past natural fusion of muscles.
All meshes and plugs compress with time, and this works against all open up methods.

Whatever method of repair must accomplish ii cardinal goals, removal of the sac from the defect and durable closure of the defect. In addition the platonic method should achieve these with the least invasion, pain or disturbance of normal anatomy. Laparoscopic repair in expert hands is at present quite safe and effective, and is an fantabulous alternative for patients with inguinal hernia. Information technology is confusion that laparoscopic repair is more circuitous and is not widely available. The public needs to be educated as to its advantages. All surgeons agree that for bilateral or recurrent inguinal hernias, laparoscopic repair is unquestionably the method of choice. The argument against its use for unilateral or primary inguinal hernias is unfounded if it is the all-time for bilateral or recurrent hernias.

Types of Laparoscopic Hernia Repair

Many techniques were used to repair hernia like
Simple closure of the internal rings
Plug and patch repair
Intraperitoneal onlay mesh repair
Transabdominal preperitoneal mesh repair (TAPP)
Total extraperitoneal repair (TEP)

The technique of transabdominal preperitoneal repair was outset described by Arregui in 1991. In the Transabdominal Preperitoneal (TAPP) repair, the peritoneal cavity is entered, the peritoneum is dissected from the myopectineal orifice, mesh prosthesis is secured, and the peritoneal defect is airtight. This technique has been criticized for exposing intra-abdominal organs to potential complications, including small bowel injury and obstruction.

The Totally Extraperitoneal (TEP) repair maintains peritoneal integrity, theoretically eliminating these risks while assuasive direct visualization of the groin anatomy, which is critical for a successful repair. The TEP hernioplasty follows the basic principles of the open up preperitoneal giant mesh repair, every bit first described by Stoppa in 1975 for the repair of bilateral hernias.

Patient Choice

The general anaesthesia and the pneumoperitoneum required as part of the laparoscopic process practice increment the risk in certain groups of patients. Most surgeons would non recommend laparoscopic hernia repair in those with pre-existing disease conditions. Patients with cardiac diseases and COPD should not be considered a practiced candidate for laparoscopy. The laparoscopic hernia repair may also be more than difficult in patients who have had previous lower abdominal surgery. The elderly may also be at increased risk for complications with full general anaesthesia combined with pneumoperitoneum.

If the patient is young or the hernia minor, information technology does non matter how the hernia is repaired. Many surgeons agree that for bilateral or recurrent inguinal hernias, laparoscopic repair is unquestionably the method of selection.

Laparoscopic surgery is not recommended for big irreducible and incarcerated hernia. Hernia repair should non be performed under local anaesthesia. Small straight hernia tin can be performed under spinal Anaesthesia if TEP is planned but all-time anaesthesia for laparoscopic hernia repair is Grand.A.

Trans-abdominal Pre-peritoneal Repair of Inguinal Hernia

Position of Surgical Squad

Surgeon stands towards the contrary side of the shoulder. Cameral assistant should stand either right to the patient or on the opposite side of the patient.

Port Position

The Position of Port is Laparoscopic repair of trans-abdominal hernia repair should be again according to base ball diamond concept.

The telescopic port should exist in belly button. A 10 mm umbilical port is used. Two other ports, commonly ten mm for dominant paw and 5 mm for non dominant manus, are placed lateral to the umbilicus. In a left sided hernia the right lateral port should be in left iliac fossa and left port in left hypochondrium then that both the instrument should brand a manipulation angle of threescore degree. In right sided hernia surgery right port should motility up towards hypochondrium and left port will come up down to make the triangle.

Procedure of TAPP

After Admission a diagnostic laparoscopy is performed to rule out any adhesion or other intra-abdominal lesion. All the important anatomical landmark of hernia surgery is identifies with the help of telescope and one atraumatic grasper. The defect should be seen carefully and if any content is present inside the sac it should be reduced gently. A sliding hernia of colon should be advisedly reduced because chances of perforation of big bowel are more than other viscus. Any adhesion between bowel and omentum should exist divided carefully using bipolar and scissors.

The next step of transabdominal preperitoneal repair of hernia is creation of preperitoneal infinite. Many surgeons like to do hydro dissection to create this preperitoneal space but it is easy to create with sharp dissection equally well. The peritoneum is cut 4cm lateral to the outer margin of deep ring. The flap of peritoneum is separated from in a higher place downward equally soon equally information technology will accomplish at the site of internal ring the hernia sac will be encountered.

Dissection should be started with opening the peritoneum lateral to the medial umbilical fold in social club to identify Cooper's ligament. Stopa's parietalization technique should be used for dissection of the spermatic string from the peritoneum by separating the elements of the spermatic cord from the peritoneum and peritoneal sac.

In case of indirect defect the hernial sac has to be either gently dissected free or inverted or if it is completely adhered with the transversalis fascia and cord structure it can be transected. The important landmarks of laparoscopic hernia repair are the pubic bone and inferior epigastric vessels. Surgeons should employ both blunt and sharp dissection and the sac is dissected off the inductive abdominal wall. After beingness reduced partially it is ligated using an endo-loop and then transected with pair of scissors. In case of bilateral hernias, the process is repeated on the other side. The vas and spermatic vessels has been separated from sac. Once the sac is separated, the next step is separation of sac from string structures and autopsy for creation of proper lateral space for placement of mesh. Lateral limit of dissection is the antero-superior iliac spine while inferior limit laterally is the psoas muscle. Dissection should exist avoided in the "triangle of doom" which is divisional medially by the vas deferens and laterally by the gonadal vessels. A large hernial sac creates multiple planes and it is easy for the beginners to get disoriented with sac vas and vessel. The best mode to avoid this confusion is that surgeon should continue himself equally close every bit possible to the outer surface of peritoneum. If the spermatic vessels are injured accidentally it tin be clipped. Fifty-fifty if the testicular vessel is injured, the testes will become the blood supply from collateral vessels developed through cremasteric.

In direct hernias the cosmos of preperitoneal infinite is insufficiently easy as there is no chance of injury of spermatic vessels and vas. The bulge in the transversalis fascia may exist repaired by suturing or stapling.

The tacker application and awarding of electrosurgery should be very careful at the triangle of doom, triangle of pain and trapezoid of disaster. In case of massive consummate indirect scrotal hernias, no endeavor should be made to reduce the sac completely equally it may increases the risk of testicular nerve injury and haematoma germination.

Placement of the Mesh

Criteria for Laparoscopic Mesh

Non Absorbable
Adequate size
Adequate retentiveness

A proline mesh of appropriate size, usually 15X15 cm should be taken and one corner of Mesh should be tailored. Mesh should be rolled and loaded backward in one of the port. Mesh is placed inside the intestinal cavity through 12mm port. If surgery is being performed by 10mm port but the port should be removed and rolled mesh should exist introduced though the port wound direct. Subsequently introduction of mesh information technology is unrolled when it reaches in peritoneal cavity. Mesh is fixed medially over the Cooper'south ligament and pubic os using a tacker or ballast. Tailored corner of mesh should be positioned infero-medially. No lateral slit should exist made in the mesh and it should not be fixed lateral to string structures to prevent injury to lateral cutaneous nerve of thigh. The mesh in this position covers the directly, indirect and femoral defects. It is essential that mesh should extend below the pubic tubercle then that it covers the femoral orifice. Mesh should as well extend medially to cover all the possible orifices of hernia. Laterally mesh should project at least 2 to three cm beyond the margin of deep ring. If mesh is not of appropriate size, the hazard of recurrence is high. Former, surgeon may be disoriented and mesh is placed with its long axis vertical instead of transverse. If mesh is cut at one of the corner chances of this disorientation is minimum.

Implant for Fixing Mesh

Foe fixing mesh in hernia surgery many preloaded devices are available. Mesh is stock-still medially over the Cooper's ligament and pubic bone using an implant.

Currently three popular brands of implants to fix the mesh are available. These are Tacker, Protack or Ballast. The comparative chart of these implant is shown in table beneath.

ESS Endoanchor
Tyco Protack
Tyco Tacker

Number of Implants

Geometry of Implant

Ballast
Helical Fastener
Helical Fastener

Implant Textile

Nitinol
Titanium
Titaneum

Implant Length

5.9mm
3.8mm
3.6mm

Implant Width

6.7mm
4mm
3.4mm

Port size required

Shaft length

360mm
356mm
356mm

Trigger burn down orientation

Release to deploy
Depress to deploy
Depress to deploy

Afterwards adjusting the mesh properly it should be fixed past stapling get-go its centre part 3 figure higher up the superior limit of the internal ring. With mesh duly stapled pneumoperitoneum is reduced to 9 mmHg. Information technology is important to avoid pricking of the inferior epigastric artery or the testicular vessels. Intracorporeal suturing can as well be used for fixation of mesh if surgeon has sufficient suturing skill.

Closure of the Peritoneum

Peritonization

Afterward fixing the mesh properly the peritoneum flap is replaced over the mesh and it is closed either by staples or suture. It is important that mesh should be completely covered by the peritoneum. Ideally peritoneum should exist opposed past overlap fashion and peritoneum defect is closed either by staples or past continuous suturing and Aberdeen termination.

Repair of Bilateral Inguinal Hernia

In laparoscopic surgery postoperative recovery of bilateral hernia is same every bit that of unilateral hernia. The technique of bilateral laparoscopic repair of hernia is aforementioned as that of unilateral hernia. Patients with bilateral hernia are good candidate of laparoscopy. The ii sides may be repaired using two meshes only single long mesh as well can be used and it is pushed across from one side behind the bladder, and across the inguinal orifice on the opposite side. The size of the mesh for bilateral hernia should be 30cm X 15cm. Surgeon should avoid twisting of mesh. Later on placing the mesh in bilateral hernia surgery it should wait just like a bow tie.

Repair of Recurrent Inguinal Hernia

Recurrent laparoscopic hernia after open surgery is better to repair laparoscopically, because external anatomy is disrupted and open repair have more than chance of recurrence. Laparoscopy is method of pick for recurrent hernia. The defect is unremarkably straight and more than ane in recurrent hernia. The result of laparoscopic repair is excellent even in case of multiple hernias.

Laparoscopic Hernia in Children

Laparoscopy has been tried in lilliputian children'due south. Only closure of ring and herniotomy is possible in pediatric age grouping. The sac is simply inverted and tied internally. The care should exist taken that the vas or vessels should not be caught in the ligature.

Ending of the Operation

At the terminate of surgery, the abdomen should be examined for any possible bowel injury or haemorrhage. The entire instrument should be removed and so all the port. Each port should exist removed under direct observation through telescope. Ports larger then 10mm should be sutured. Telescope should be removed at terminal after releasing all the gas keeping in mind that final port should non be pulled without putting telescope or whatsoever blunt musical instrument in, to prevent entrapment of bowel or omentum and germination of adhesion or intestinal adhesion. Wound should exist airtight with suture, especially ten mm wound.

Totally Extra-peritoneal Hernia Repair

The technique of totally extra-peritoneal repair (TEP) of inguinal hernia was described even before the TAPP technique; however, technical difficulties of working in closed space and beefcake with the limited working infinite hindered its popular acceptance. The effectiveness of this blazon of repair has been well established by the open functioning of Stoppa.

Advantage of TEP

Pneumoperitoneum is non required
Less chance of dangerous vessel injury or bowel injury
The view of groin is improve for dissection effectually the cervix of sac
Continuity of peritoneum is not breached then demand not to be closed

Disadvantage of Preperitoneal repair

The identification of correct plane of dissection is difficult
The landmarks of hernia autopsy tin only be identified when they are encountered
Reduction of content of sac is difficult to ensure
Sliding hernia is hard to recognize from outside of sac
If the sac is cut it is difficult to close information technology again
In recurrent hernia all-encompassing adhesion make the dissection difficult because peritoneum may be adherent to the under surface of scar.
There is always a chance of breach of peritoneum continuity and this will reduce the view.
4 ports generally are necessary for bilateral hernia surgery. Whereas, in TAPP but three ports are sufficient.

Preparation of the Patient

Training of the patient in totally preperitoneal hernia repair is same as of the trans abdominal hernia repair. Knowledge of the beefcake of the intestinal wall muscle and recognition of the transition zone that occur at the arcuate line of Douglas is very important for totally pre-peritoneal hernia repair.

Arroyo to Preperitoneal Infinite

In totally extraperitoneal repair of hernia, the main business is to make an extraperitoneal space. The extraperitoneal space is made possible past the fact that the peritoneum in suprapubic region tin can easily be separated from anterior abdominal wall, thereby creating enough infinite for autopsy.

A 2cm longitudinal peel incision is made just beneath the umbilicus 1cm lateral to the midline on the side of hernia. The incision is deepened down to attain upward to the anterior rectus sheath. All the subcutaneous fatty is cleared and the rectus is opened nether direct vision. Two-stay suture on each leaf of rectus sheath is placed and the rectus musculus is retracted by 2 retractors downward towards symphysis pubis in an oblique style; we should never cross the posterior fascia of the rectus muscle while dissecting.

By fingered or swab towards the hernia autopsy should perform carefully, preperitoneal space volition be found below the arcuate line of Douglas.

Insertion of Port

A balloon dissector should exist introduced with telescope and airship is inflated for farther dissection of the pre-peritoneal space. An11mm port is introduced without its sharp tip with a laparoscope in thirty degree. A Small pre peritoneal pocket is created by manipulating laparoscope in sweeping mode.

If balloon dissector is not available the glove finger can be tied effectually the suction irrigation instrument and can exist used to create some preperitoneal space.

Sweeping Motility of Telescope

Once the telescope is placed properly a 10mm port is inserted nether direct view approximately halfway between the symphysis pubis and the umbilicus. Some other 5mm port should be placed two fingers below and medial to the correct inductive iliac spine. If the secondary port site is not seen conspicuously though the telescope 1 tin infiltrate the port site with local anaesthetic and expect for the tip of the needle internally. This will insure the verbal placement of port and permit the tip of trocar to be seen by telescope at the fourth dimension of insertion.

Autopsy of Preperitoneal Infinite and Cord Structures in TEP.

In totally extraperitoneal repair of hernia Stopa'southward parietalization technique is used for dissection of the spermatic string from the peritoneum past separating the elements of the spermatic string from the peritoneum and peritoneal sac should be done. The dissection is started by tracing the inferior epigastric vessels towards the deep ring. The upper border of the hernia sac readily recognized considering indirect hernia is lateral to the junior epigastric vessels and straight hernia is medial to that.

As the inguinal region is approached, the dissection is continued all around the sac to encircle the neck. The surgeon should effort to remain close to peritoneum and dissection continues medially to separate vas from the sac. Under the neck of the sac care should be taken to avoid injury of iliac vessels.

In case of directly inguinal hernia the dissection is carried out from in a higher place downwards and progressed medially to the inferior epigastric vessels. The direct sac is freed from the transversalis fascia. Autopsy should be continued until the peritoneum has reached the iliac vessels inferiorly.

Care should be taken that whatsoever hole in peritoneum should not class otherwise it will be difficult to have good working infinite because the gas volition escape into intestinal cavity. If the hole is made anyway information technology should be identified and enlarged this will equalize the pressure on both side of peritoneum and allows the peritoneum to driblet back downwardly due to gravity. A venting 5mm port or veress needle tin exist placed in the right upper quadrant at palmers point to decompress the intestinal cavity.

Introduction of Mesh in TEP

The technique of insertion of mesh in totally extraperitoneal repair of hernia is same equally tat of trans abdominal preperitoneal. Mesh in appropriate size usually 15X15 cm is used. Mesh should be rolled and load backward in 1 of the port.

Mesh should exist fixed past stapling first in its middle function three finger above the superior limit of the internal ring. In totally extraperitoneal repair some surgeon practice not utilise staple, because peritoneum is not breached and once the gas from pre-peritoneal space is removed, it volition place the mesh in its proper position. In 1 to 2% of cases of TEP conversion to open or TAPP may exist necessary due to large peritoneal tear making the vision hard or in the cases where content is not reduced completely.

Laparoscopic Repair of Femoral Hernia

Laparoscopic repair of femoral hernia is same equally that of laparoscopic direct or indirect hernia. Information technology can be performed by both TAPP and TEP methods. In case of Laparoscopic femoral hernia repair the sac should be carefully excised because rigid femoral band make it difficult to mobilize the sac. The dissection should be careful because there is increased risk of injury of abnormal obturator avenue on lateral to the sac. In femoral hernia defect is between the iliopubictract and pubic ramus and can be hands identified. Repair of the femoral culvert should be washed by approximating iliopubic tract to the Cooper's ligament past proline stitches.

Catastrophe of the Functioning

At the cease of surgery the belly should exist examined for any possible bowel injury or haemorrhage. The unabridged musical instrument should exist removed and then all the port. We mostly apply Vicryl for rectus and un-absorbable intra-dermal or Stapler for skin. Adhesive sterile dressing should be applied over the wound.

Complications of Laparoscopic Hernia Repair

Like any other laparoscopic procedures, complications have been recorded during the learning curve. The major bug include:

Recurrence
Neurovascular injury
Urinary tract injury
Injury to vas
Testicular complications
Issues due to mesh.

The mechanism of recurrence tin can be related to lack of understanding of the difficult laparoscopic anatomy, wrong hernia repair technique or the wrong prosthesis. These include incomplete dissection without proper pocket germination, missed sac, migration of mesh due to minor sized mesh which may be decumbent to displaced once fixed, inadequate fixation with rolling upwardly of the mesh and haematoma formation leading to infection.

The complication of laparoscopic hernia repair can be summarized equally follows:

Immediate: Visceral Injury, Vascular Injury, Injury to Vas, Spermatic vessels
Late: Bowel Adhesions to mesh, Intestinal Obstruction, Fistulization, Orchitis, Testicular atrophy, Nervus entrapment, Incisional hernia recurrence

Vascular Injury

The incidence of vascular injury has been documented to exist most 0.five-1 percent and inferior epigastric artery is the one most commonly traumatized.

Injury to Iliac Vessels: Chances of Mortality
Inferior Epigastric Vessel: Haematoma
Iliopubic vein and artery which traverse the lacunar ligament: Haematoma
Injury to Spermatic vessels: Postoperative scrotal haematoma

Mail service-operative scrotal haematoma

Nervus Entrapment and Injury

The lateral cutaneous nervus of thigh and the femoral branch of genitofemoral nerve are the two nerves vulnerable to trauma due to indiscriminate placement of staplers lateral to the spermatic string on the iliopubic tract.

Injury of lateral cutaneous nerve injury
Most common nerve injured is lateral femoral cutaneous nervus (2%): Hyperesthesia or Paraesthesia of upper aspect of thigh and hip.
If pain showtime days after surgery will recover within 2-4 weeks (or Percutaneous steroid)
If pain starts within 24 60 minutes of surgery in that location is permanent nerve damage
Cryotherapy with devastation of sensory branch is indicated
Lifelong numbness

Nervus entrapment should be avoided in laparoscopic repair of Hernia

Genitofemoral nerve injury
Genitofemoral nerve injury (i%): Hyperesthesia or Paraesthesia of scrotum
Not meaning
With time it will subside

Other Complications

Migration of Mesh
Rejection of Mesh (Rare)
Bowel adhesion

Complete transaction of vas requires firsthand anastomosis. Other complications include testicular pain, orchitis, epididymitis, swelling due to seromas or haematoma. The treatment is supportive and incidence of all these complications is similar to that in conventional surgery.

Decision

After some experience most cases of inguinal hernia can be treated laparoscopically. Several prospective randomized trials comparing open versus laparoscopic repair have reported. Reduced postoperative hurting, earlier render to work and fewer complications and less take chances of recurrences for the laparoscopic approach are some of the crucial advantages. Although the procedural price for laparoscopic hernia repair is more compared to conventional repair simply overall expense for open repair is high if we summate number of working days lost and medication is taken into consideration. Information is at present available which documents the totally extraperitoneal repair to have distinct reward over the Trans-abdominal preperitoneal repair in terms of lesser postoperative complications and lower recurrence charge per unit. TAPP has been stated to violate the peritoneal cavity with all its known possible complication of pneumoperitoneum, vessel or bowel injury. In that location is no dubiety that the laparoscopic hernia repair is a proven technique and volition become more popular over a flow of fourth dimension

Prof. Dr. R. K. Mishra

Minimal Access Surgeon

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