absite review: inguinal and femoralinguinal and … hernias.pdfabsite review: inguinal and...

ABSITE Review:Inguinal and FemoralInguinal and Femoral HerniasSybile Val M.D.SUNY Downstate Medical CenterSUNY Downstate Medical CenterDepartment of SurgeryJune 27, 2008

www.downstatesurgery.org

Obj tiObjectivesCorrectly identify anatomical landmarksCorrectly identify anatomical landmarks intra-operativelyDiff ti t b t f l d i i lDifferentiate between femoral and inguinal herniasUnderstand different approaches at surgical repairCompare operative approaches

Q tiQuestions1. From which muscle layer is the inguinal ligament y g g

derived? a. Transversus abdominusb. External obliquec. Internal obliqued. None of the above

2. What are the borders of the femoral canal? a. External oblique, femoral vein, empty spaceb. external oblique, femoral vein, empty space iliopubic tract and

f l ifemoral veinc. iliopubic, cooper’s, femoral vein and junction of iliopubic and

cooper’s ligamentd None of the aboved. None of the above

Q tiQuestions3 A McVay repair3. A McVay repair

a. May be used to repair femoral herniasb. Entails suturing Poupart’s to the conjoined tendonc. Is no longer performedd. Does not require a relaxing incision

4 TAPP4. TAPPa. Is contraindicated in the elderlyb. Requires traversing the peritoneal cavityc. Is totally extraperitoneald. Has a low learning curve

Q tiQuestions5 The base of Hasselbach’s triangle is5. The base of Hasselbach’s triangle is

a. Derived from the external obliqueb. Cooper’s ligamentc. There is no based. The inferior epigastric

I t d tiIntroduction

In the US ~1 million abdominal wall hernia repairs/yearp y

750,000 – inguinal25,000 - femoral25,000 femoral

I t d tiIntroductionFrom latin word meaning ruptureFrom latin word meaning ruptureDefinition: Abnormal protrusion

Occur at sites where the aponeurosis and fascia are not covered by striated muscle

Male preponderance (7:1)Presentation:

Groin bulge/painRight more common than leftg

I t d tiIntroduction

Risk Factors:AgeOb itObesityCOPDChronic constipationChronic constipationStrainingPregnancyAscitesPeritoneal dialysis

I i l H iInguinal HerniaDirectIndirect Direct

Weakness in the transversalis fascia

IndirectMost common typeWeakness in the transversalis fascia

Due to “wear and tear”Weakness in the internal inguinal ringAssociated with patent

i liprocessus vaginalis

Abd i l W ll A tAbdominal Wall AnatomyMuscles

External obliqueInternal obliqueTransversalis abdominus

NervesIlioinguinalGenitofemoral

Blood supplySuperior epigastricInferior epigastricDeep circumflexPosterior intercostal L bLumbar

G i A tGroin Anatomy

I i l C lInguinal CanalAllows passage b/wAllows passage b/w abdomen and testesTransmits ilioinguinal nerveParallel to inguinal ligamentWalls:

Anterior- external obliquePosterior – transversalisPosterior transversalis fasciaInferior – inguinal ligamentSuperior – int oblique &Superior int oblique & trans abd

G i A tGroin Anatomy

Femoral CanalMedial compartmentBlind pouchBlind pouchBorders:

superiorly: iliopubic tractinferiorly – cooper’s ligamentlaterally – femoral vein

di ll j ti fmedially – junction of iliopubic tract and cooper’s ligament

O ti R iOperative RepairIndicated for all symptomatic herniasBased on surgeon’s experienceMay be:

Via anterior or posterior approachP iPrimary:

Preferred in presence of contaminationBest choice in female patientspAccomplished using: Bassini, McVay or Shouldice technique

O ti R iOperative Repair

Prosthetic Mesh Repair technique:Onlay versus preperitonealMesh bridges inguinal defectForeign body reaction incitedCommon strategy entails:

Minimal tissue dissection Anchoring of mesh with interrupted suturesg p

O ti R iOperative Repair

Laparoscopic technique:Based on reconstruction of weakened posterior abdominal wallSteep learning curveTwo approaches:Two approaches:

Totally extraperitonealTransabdominal preperitoneal (Intraperitoneal Onlay Mesh)

Hi t i l R iHistorical Review

Edoardo Bassini (1844-1924)Father of modern hernia repair

Performed and published a novel anatomical dissection (1884)

Repair empasized:Repair empasized:High ligation Reconstruction of the inguinal floorgOpening the transversalis fascia

Preparation for deep repair in three layer repair

B i i R iBassini Repair

Opening of inguinal floorSuture Poupart’s ligament:

lateral border of internal oblique or conjoint tendonconjoint tendon

Sh ldi R iShouldice Repair

Complete dissection & reconstruction of inguinal floorImbricated layered

irepairFour layers

M V R iMcVay Repair

Suturing transversus abdominus to Cooper’s ligamentTransition stitch in f l h thfemoral sheathRelaxing incision in

t l bliexternal oblique

Li ht t i R iLichtenstein RepairGold standard by ACSGold standard by ACSTransversalis fascia is notopenedFi k l tFive key elements:

Large sheet of meshCross tailsSecure to rectus, int oblique and inguinal ligamentKeep mesh relaxedKeep mesh relaxedProtect nerves

PK Amid Groin hernia repair – open technique. World J Surg 29;1046-1051 2005

Gilb t “ l d h” R iGilbert “plug and mesh” Repair

Originally described by LichtensteinModified to include indirect herniasRutkow and Robbins included direct h ihernias

PK Amid Groin hernia repair – open technique. World J Surg 29;1046-1051 2005

O P it l M h R iOpen Preperitoneal Mesh Repair

ApproachesTrans-inguinalParamedianLower midlinePfannensteil

O P it l M h R iOpen Preperitoneal Mesh Repair

Associated with injuries to:

BladderBowelV lVascular

Recurrence rate compared to in frontcompared to in front of TF are the same

PHS S t R iPHS System Repair

Combines Lichtenstein and preperitoneal repair2 layers:

Deep Superficial

L i H i R iLaparoscopic Hernia RepairTransabdominal preperitoneal (TAPP)

Mesh along anterior bd i l llabdominal wall

IdentifyMedian & medial umbilical ligamentgLateral umbilical fold

Parietal peritoneum incised and reflectedMesh placed b/Mesh placed b/w peritoneum and tranversalis fascia

L i H i R iLaparoscopic Hernia Repair

Totally extraperitonealRepair via posterior approachEntirely w/in preperitoneal spaceMesh positioned deep to hernia defect

F l H i R iFemoral Hernia Repair

Low Groin ApproachLichtenstein technique

Inguinal ApproachMcVay repair

Preperitoneal Approach

C li tiComplications

RecurrencePostherniorrhaphy

HemorrhageOsteitis pubisp y

painIschemic orchitis

pInfectionProsthesis-related

Testicular atrophy complication

Q ti f th hQuestions of the hour…

1. Is there a superior open repair technique?q

2. Is laparoscopic repair superior to open repair?repair?

3. Chronic pain, is it avoidable?

Open vs. Open

SS Awad et al. Improved outcomes with the prolene hernia system mesh p p ycompared to the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair. Am J of Surgery 2007;193:697-701

Li ht t i PHSLichtenstein vs. PHSLichtensteinLichtenstein

Gold standardLow learning curve

PHS systemCombines benefits of anterior and posterioranterior and posterior repairOnly open repair to

ti lcover myopectineal orifice

SS Awad et al. Improved outcomes with the prolene hernia system mesh compared to the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair. Am J of Surgery 2007;193:697-701

Li ht t i PHSLichtenstein vs. PHSRetrospective study with 622 ptsRetrospective study with 622 pts

321 – PHS repair302 LMR302 – LMR

Follow up was 20 monthsAssessed:

Difference in operating timeComplicationsRecurrence

SS Awad et al. Improved outcomes with the prolene hernia system mesh compared to the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair. Am J of Surgery 2007;193:697-701

Li ht t i PHSLichtenstein vs. PHS

Li ht t i PHSLichtenstein vs. PHSConclusion:Conclusion:

PHS was superior to LMR due to:Lower recurrence ratesLower recurrence ratesDecreased complicationsLess post operative painp p pEarlier return to normal activity

SS Awad et al. Improved outcomes with the prolene hernia system mesh p p ycompared to the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair. Am J of Surgery 2007;193:697-701

Open vs. Laparoscopic

Neumayer L, Giobbie-Hurder A, jonasson O, et al. Veterans Affairs Cooperative Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med 2004; 350:1819-27

The data showsThe data shows…Laparoscopic approach gaining popularity

Prelim recurrence rates ranged from 3-10%Benefits included

Less PainQuicker return to activityQuicker return to activity

Subsided enthusiasm due to:High costSteep learning curvep gSerious complicationsNeed for general anesthesia

TAPP versus TEP:TEP preferred because:

Wide exposureAvoids abdominal entryAssociated with decrease post-op painAssociated with decrease post-op painFaster post-operative recovery

Open versus LaparoscopicOpen versus LaparoscopicGoal:

Examine perioperative outcomes and complications in both TEP and open mesh repair

345 patients345 patients198 – open mesh repair147 – TEP repair

F ll th thFollow up: three monthsCompared:

Operative timeOperative timeComplications

ER Winslow, LM Brunt Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice. Surg Endosc 2004;18:221-227

Open versus LaparoscopicOpen versus LaparoscopicResults:Results:

ER Winslow, LM Brunt Perioperative outcomes and complications of open vs laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice. Surg Endosc 18;221-227, 2004

Open versus LaparoscopicOpen versus Laparoscopic

Open versus LaparoscopicOpen versus LaparoscopicResults:Results:

Open versus LaparoscopicOpen versus LaparoscopicConclusion:Conclusion:

TEP repairs can be performed efficiently and without major complicationswithout major complicationsOperative times are shorter in the hands of experienced surgeonsexperienced surgeonsTEP associated with lower rate of post-operative numbness and prolonged groin painp p g g p

Open versus Laparoscopic

Prospective randomized controlled trial

Open versus Laparoscopic

Prospective, randomized controlled trialConducted b/w 1996-1997Follow up: 7.3 years168 patients:p

81 – TEP87 - Lichtenstein87 Lichtenstein

Hallen et al Laparoscopic extraperitoneal inguinal hernia repair versus openHallen et al. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair:long term follow-up of a randomized controlled trial. SURGERY 2008;143:313-317

O L iOpen versus Laparoscopic

O L iConclusion:

Open versus LaparoscopicConclusion:

Long term cure of hernia in patient with lap or open hernia repair is excellentope e a epa s e ce eIndividualized hernia repair yields best results and is most cost effectiveTEP is an excellent method for individuals in a working population who require short convalescenceconvalescenceTEP advantageous in recurrent hernias

Hallen et al. Laparoscopic extraperitoneal inguinal hernia repair versus open mesh repair:long term follow-up of a randomized controlled trial. SURGERY 2008143:313-317

Ch i G i P iChronic Groin Pain

Potentially incapacitating complication Cause not clear: ? Nerve EntrapmentCause not clear: ? Nerve Entrapment

Ilioinguinal IliohypogastricIliohypogastric Genital branch of genitofemoral

R ti ti d di i i hRoutine preservation and division have been advocated

Prophylactic IlioinguinalProphylactic Ilioinguinal Neurectomy in Open Hernia Repair

Double blinded randomized controlled trial100 patients b/w 18-80yoa

50: whole ilioinguinal nerve excised50: nerve preserved

P i t i id f h i i t 6Primary outcome: incidence of chronic pain at 6 monthsSecondary outcome: incidence of groin numbnessy g

Follow up: 6 months

WL Mui et al “Prohylactic ilioinguinal neurctomy in open inguinal hernia repair” Annals of Surgery 244;1, 2006

Prophylactic IlioinguinalProphylactic Ilioinguinal Neurectomy in Open Hernia Repair

Results:No significant difference in:No significant difference in:

incidence of pain at 6 monthsIncidence of groin numbness and sensation changeQuality of life

WL Mui et al “Prohylactic ilioinguinal neurctomy in open inguinal hernia repair” Annals of Surgery 244;1, 2006

C l iConclusionLi ht t i ti t b t d dLichtenstein continues to be standard although PHS and laparoscopic techniques are gaining acceptanceare gaining acceptanceSurgeon experience is key to providing good hernia repairgood hernia repairLearning curve in laparoscopic hernia repair is steep however in hands of experiencedis steep however in hands of experienced surgeons outcome comparable to open repairrepair

absite review: inguinal and femoralinguinal and … hernias.pdfabsite review: inguinal and...

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