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How to prevent Recurrences in Laparoscopy for Hernia
Dr John ThanakumarMBBS (Vellore), MS (Vel), MNAMS (Vel), FRCS, FRCS, Dip MIS, FALS
Chairman, ANURGAG HOSPITALCoimbatore.
President IAGES 2012-14.
Dr Pravin Hector John MS
Light Weight Mesh Heavy Weight Mesh
Elasticity
Flexibility
Shrinking
Inflammation
Pain
LW Mesh
Recurrence Adhesions
Infection
BUTLWM
Choice of patientCollagen disease
Smoking
Obesity
Malnutrition
Diabetes Type II
Chronic lung disease
Coagulopathy
Steroids
Radiotherapy Chemotherapy
Jaundice
Male genderAnemia
Choice of hernia
• Surgeon’s inexperience in laparoscopy
• Surgeon’s inexperience in technique
• Giant hernias
• Recurrences after laparoscopy
Dissection• Do not miss out hernial sacs
• Do not miss out lipomas of cord
• Dissect medially across midline
• Dissect medial, posterior and lateral margins well
• Good hemostasis
• Difficulty- convert
Dissect Across Midline and Down to Bladder
Dissect Sac and Ligate
Center fix mesh,fix, unroll
Dissection of Borders
MedialAcross midline
LateralUpto ASIS
Nerves
PosteriorUpto Psoas
Peritonealize the Cord
Choice of Mesh
• Large hernia- use standard prolene mesh
• Large hernia do not use LWM
• Not too small mesh for large hernias
• Do not slit meshes
• No infolding of the mesh at corners
• While desufflating, hold the mesh (TEP)
Mesh• Size 15X 12 cm
• No slitting of mesh
• Blunten the corners
• Center of mesh to be against center of defect
• Mesh to cover 5 cm all around defect
• Mesh to cover the Myopectineal orifice of Fruchaud
• Apply wrinkle free
Fixation of Mesh
• Use 1 stapler at Cooper for fixation; 2nd for prevention of rotation of mesh in hernias
• Large hernia, use fixation near Cooper, medial and laterally above the ilio pubic tract
• Sutures / fixation as good
Tips to prevent recurrence
• Best knowledge & display of anatomy
• Always meshes for adult hernias
• Awareness of one’s limitations
• Advanced laparoscopic skills
• Strict and standardized principles of dissection
• Anurag Hospital,
• 8, Krishna Nagar,Sowripalayam
• Coimbatore - 641028.
• Tel: 0422- 6587871
• www.anuraghospital.com
• Email: [email protected]
With the best compliments of
Centre for Advanced Laparoscopy and Bariatric Surgery
