Complications & Solutions in Laparoscopic Hernia Surgery.pptx
- 1. Dr.T.VARUN RAJU Senior advanced Laparoscopic Surgeon D.N.B (Surgery) FIAGES,FMAS & FALS (H.P.B) Director Laparoscopy Course TVR Laparoscopy Center H.O.D General & Laparoscopic Surgery ST.Theresa Hospital Hyderanbad
- 2. HYDERABAD
- 3. 1.Learning curve 2.T.A.P.P( inguinal) complications & Solutions 3. T.E.P/E-T.E.P (Inguinal) complications & Solutions 4.E-TEP –RS (Ventral) complications & Solutions complications & Solutions 5.TARM –(Incisional) complications & Solutions 6.E-TEP TAR (Incisional) complications & Solutions 7.IPOM + (Umbilical) complications & Solutions 8.Conclusions
- 5. Many studies in the literature Basic laparoscopic training, around 13–15 cases are required initially to become well versed with both TEP andTAPP No significant difference in the learning curve between the two procedures. Learning Curve in Laparoscopic Inguinal Hernia Repair: Experience at aTertiary Care Centre Virinder Kumar Bansal, Asuri Krishna, Mahesh C. Misra, and Subodh Kumar Indian J Surg. 2016 Jun; 78(3): 197–202.
- 7. 1.The rate of infection in the port site is less than 1% Drainage and dressings.Antibiotic when there are systemic involvement 2.Evidence of 0.2%. major bleeding during inguinal hernia repair - not a usual complication, inferior epigastric vessels . Bleeding must be controlled with sutures or clips; electrocautery 3.The spermatic vessels suffer injury @ dissecting the spermatic cord, especially in the technique using split mesh for repair. The cord must be dissected and subsequently repaired. Special care must be taken in handling the spermatic cord. It should not undergo excessive traction, and hemostasis of bleeding cord vessels should be accurately secured
- 8. 4.Vascular injury -Iliac vessels can be severe and generally occurs because of staples placed in the region of the so-called “Triangle of Doom.” 5.Ischemic orchitis –rare-occur after large indirect hernias repair. Found in 0.36% of primary hernias and 5% in recurrent ones. 6.Inguinal seromas, - 1.1% of laparoscopic repair, when mesh is used – more often in fully extraperitoneal repairs, presumably because the serous collection cannot drain to the peritoneal cavity. Damage control" options for these severely injured vessels are either ligation or temporary intravascular shunts (TIVSs).Complications of ligation include a 50% amputation rate and up to 90% mortality Conservative - 56 % Scrotal exloration -44% Orchidectomy/Hematoma evacuation Loosening the mesh /adhesiolysis around the card Conservative management/ Drain/aspirations/ Sclerotherapy/exploration
- 9. 7.TAPP technique - 1.6% cases of hydrocele formation - Completely extraperitoneal correctionsTEP in 0.50/0. 8.Nerve injuries - 1.6% incidence of neuralgias- the iliopubic tract is an important anatomic point. Lateral to the spermatic vessels, and immediately below the fibers of the iliopubic tract, are the genital and femoral branches of the genito-femoral nerve, the femoral nerve and the lateral femoral cutaneous nerve- LFCN. Clips placed below the iliopubic tract and lateral to the femoral vessels may cause temporary or permanent neuralgias, involving one or more of the nerve branches Conservative management Erly nerve decompression – best way .Laparoscopic re operation provides adequate visualization,assessment the injury .Trans abdominal ? the challenge is to identify which patients have injury that will not improve without treatment and to direct appropriate and prompt treatment . Interventional radiology-YES
- 10. The iliohypogastric and ilioinguinal nerves may be injured if the clips are applied too deep in the muscles of the anterior abdominal wall. 9.Bowel injury- Incarcerated hernias In strangulated hernias, the laparoscopic approach can accurately evaluate the viability of the bowel loop involved. 10.Urinary bladder injury This injury does not cause significant morbidity if immediately corrected with primary suture in association with decompression of the urinary bladder with a Foley catheter. TAPP appears to be safe in acutely incarcerated/strangulated inguinal hernias. Should be performed by experienced surgeons in laparoscopic techniques. World J Emerg Surg. 2021; 16: 5 Bowel repair Suture entrapment of sensory fibers - resolved by removal of the suture. Prompt recognition and treatment prevent subsequent development of chronic abdomino- pelvic pain.
- 11. 11.Small bowel obstruction due to preperitoneal herniation following laparoscopic inguinal hernia repairTAPP Int J Surg Case Rep. 2021 Nov; 88: 106532. Emergency laparoscopic revision is necessary to avoid bowel ischaemia. Adequate closure of the peritoneum during the primary procedure mandatory to avoid preperitoneal herniation after TAPP. 12.Testicular edema - Closure of the internal inguinal ring - excessively tight around the spermatic cord- venous or lymphatic injury. Treatment - with suspension of scrotal sac and restricted physical activity. Anti-inflammatory medication
- 12. 13.Port sites,cannulas, look for possible bleeding, -injury to the epigastric artery with hypovolemic shock . 14.Scrotal ecchymosis and inguinal hematoma by small bleeding vessels - the most frequent complications following inguinal hernia repair. 15.Mesh infection/abscess Prevented using an elastic support for 3-4 weeks postoperatively. Control under the vision Ports of sizes 10 mm and 12 mm trocars, should be closed to prevent future herniation. I&D Mesh explantation
- 13. 16.Recurrence Various series, using technique (TAPP), appears to result from inadequate surgical technique. The inadequate fixation of mesh, inadequate size of the mesh (small) and a flaw in covering unidentified hernial defects are the main reasons for early recurrence of hernia. Late recurrence of hernia - stress on the tissues –mesh contraction - intrinsic weakness of the collagen. A recurrence rates of up to 12% have been reported with <50% being reoperated. 1.Observation 2.Elective surgical repair: (excessive pain or discomfort) 3.Emergency surgical repair
- 14. Immediate complications 1.Visceral injury (bowel and bladder) 2.Vascular injury 3. Injury to the vas deferens and the spermatic cords. 4.Wound complications, bruising, scrotal swelling, seroma formation and hematomas. Delayed or late complications 1. Adhesions (to mesh as well as adhesional bowel obstruction) 2. Fistula formation /Mesh infection 3. Testicular atrophy 4. Nerve entrapment 5. Incisional hernia or a recurrence 6. Chronic pain
- 15. 1.Overlooked defects or rupture of the posterior layer can possibly cause internal hernias risk of incarceration and strangulation of the bowel 2.Essential complications related to the method A.Rupture or dehiscence of the posterior layer B.Damage to the linea alba while crossing C.Unintentional injury to the neurovascular bundle D.Disruption of the linea semilunaris while performing lateral dissection. Good understanding of an appropriate endoscopic anatomy and meticulous dissection in the retromuscular plane prevent these events Khetan M, DeyA, BindalV, Suviraj J, MittalT, Kalhan S, MalikVK, Ramana B (2021) e-TEP repair for midline primary and incisional hernia: technical considerations and initial experience. Hernia 25(6):1635–1646. https://doi.org/10.1007/s10029-021-02397-6
- 16. 1. Blood loss and length of stay 2.Convertion due to dense bowel adhesions. 3.Mesh infection 4.Hernia recurrence 5.PRS suture-line disruption LaparoscopicTrans-Abdominal Retromuscular (TARM) Repair forVentral Hernia:A Novel, Low-CostTechnique for Sublay and Posterior Component Separation Ashwin A. Masurkar WorldJournal of Surgery volume SOLUTIONS
- 17. Hematoma Seroma Surgical site infection – divided into superficial deep and organ- related Pulmonary thromboembolism Hernia recurrence There was no statistically significant association found in the multivariate analysis. Factors associated with higher recurrence rates described in the literature are – Obesity (BMI greater than 25 kg/m2) - smoking history - T2DM - corticosteroid use - procedure performed in an emergency context In terms of postoperative complications such as seroma, hematoma, and SSI, a clear association has been determined with smoking history,T2DM, and COPD Parker SG, Mallett S, Quinn L, Wood CPJ, Boulton RW, Jamshaid S, et al. Identifying predictors of ventral hernia recurrence: Systematic review and meta-analysis. BJS Open. 2021;5(2):zraa071. doi: 10.1093/bjsopen/zraa071. Landin M, Kubasiak JC, Schimpke S, Poirier J, Myers JA, Millikan KW, Luu MB.The effect of tobacco use on outcomes of laparoscopic and open inguinal hernia repairs:A review of the NSQIP dataset. Surg. Endosc.
- 18. Seroma Surgical site infection Intraoperative complications Bleeding Bowel injuries Port-site hernia Intestinal obstruction Intestinal perforation Chronic sinus formation SOLUTIONS
- 19. Learning curve is carefully followed Endoscopic anatomy – knowledge and experience – essential Recognize the complication early to tackle it carefully Any gadget can not guarantee the surgeon with less complications Damage control is the key to solve a complication Surgeon is the key factor for the immediate post surgery complication Prevention is always better than the cure
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