surgical options in the management of hernia repair
TRANSCRIPT
![Page 1: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/1.jpg)
SURGICAL OPTIONS IN THE MANAGEMENT OF INGUINAL HERNIAS
Mohammed Al-Saffar
![Page 2: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/2.jpg)
outlines
Definition Epidemiology Anatomy Surgical management options
![Page 3: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/3.jpg)
Hernia
A hernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls.
Groin hernia Inguinal
Direct Indirect
femoral
![Page 4: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/4.jpg)
Epidemiology
![Page 5: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/5.jpg)
Epidemiology
![Page 6: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/6.jpg)
Predisposing factors
![Page 7: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/7.jpg)
Epidemiology
Bimodal peak age : < 1 year then > 40 years
Right-sided groin hernias are more common than those on the left.
![Page 8: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/8.jpg)
Types of hernia - Condition
![Page 9: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/9.jpg)
Inguinal Canal Anatomy
No disease of the human body, belonging to the province of the
surgeon, requires in its treatment a better combination of accurate,
anatomical knowledge with surgical skill than Hernia in all its varieties.
Sir Astley Cooper, 1804
![Page 10: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/10.jpg)
Inguinal Canal Anatomy
The inguinal canal is an oblique space measuring 4 cm in length that lies above the medial half of the inguinal ligament.
Inguinal canal has 4 walls : anterior, posterior, roof, and floor
![Page 11: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/11.jpg)
![Page 12: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/12.jpg)
![Page 13: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/13.jpg)
![Page 14: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/14.jpg)
![Page 15: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/15.jpg)
![Page 16: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/16.jpg)
![Page 17: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/17.jpg)
Important ligaments
![Page 18: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/18.jpg)
![Page 19: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/19.jpg)
Contents of the inguinal canal
Males : spermatic cord and ilioinguinal nerve
Females : round ligament and the ilioinguinal nerve
![Page 20: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/20.jpg)
The spermatic cord
It consists of Three coverings Three arteries Three other structures. Nerves
![Page 21: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/21.jpg)
The Spermatic Cord
![Page 22: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/22.jpg)
Preperitoneal space
Space of Retzius Space of Bogros Inf. Epigastric Vas deferens the lateral
femoral cutaneous nerve
the genitofemoral nerve.
![Page 23: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/23.jpg)
Management
Uncomplicated hernias require either : No treatment Support with a truss Operative treatment
complicated hernias : always require surgery, often urgently.
![Page 24: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/24.jpg)
Should we repair ?
Inguinal hernia : should we repair ?
![Page 25: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/25.jpg)
Inguinal hernia : should we repair?
![Page 26: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/26.jpg)
Surgical approaches
For any hernia the surgical option comprises 2 components : Herniotomy Herniorrhaphy or hernioplasty
It is either : Open repair Laparascopic repair
![Page 27: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/27.jpg)
Surgery
Surgery aims to Reduce the hernial contents Excise the sac (herniotomy) in most cases Repair and close the defect either by
herniorrhaphy or hernioplasty
![Page 28: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/28.jpg)
Components of the hernia
![Page 29: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/29.jpg)
Hernial Sac Dissection
![Page 30: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/30.jpg)
Types of open repair
Repairing the floor of the inguinal canal : Bassini repair Shouldice repair Tension free mesh repair
![Page 31: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/31.jpg)
Bassini repair
The conjoined tendon is retracted upward the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract that lies adjacent to the inguinal ligament with several interrupted 3-0 silk sutures.
The second layer of the repair involves suturing the conjoined tendon to the inguinal ligament with interrupted 2-0 silk sutures.
This suture line extends from the pubic tubercle to the medial border of the internal ring.
![Page 32: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/32.jpg)
Shouldice Repair
With a no. 15 scalpel an incision is made in the transversalis fascia. This incision is extended from the internal ring to the pubic tubercle.
The repair involves placing four lines of sutures.
![Page 33: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/33.jpg)
Shouldice repair
The first suture line is started at the pubic tubercle using 3-0
continuous polypropylene, and the white line is approximated to the free edge of the inferior transversalis fascial flap.
The 2nd suture line : At the internal ring the suture is tied and then
continued medially by approximating the free edge of the superior flap to the shelving edge of the inguinal ligament. When the pubic tubercle is reached, the suture is tied and divided.
![Page 34: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/34.jpg)
Shouldice repair
The third suture line is started at the level of the internal ring where the conjoined tendon is approximated to the inguinal ligament and tied when the pubic tubercle is reached.
Using the same suture, the fourth suture line attaches these same structures to one another and is tied at the level of the internal ring.
![Page 35: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/35.jpg)
Shouldice repair
The cord is replaced within the inguinal canal, and the external inguinal aponeurosis is reapproximated with continuous 2-0 absorbable sutures
![Page 36: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/36.jpg)
![Page 37: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/37.jpg)
![Page 38: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/38.jpg)
![Page 39: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/39.jpg)
![Page 40: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/40.jpg)
![Page 41: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/41.jpg)
Tension – free repair
There are several options for placement of mesh during anterior inguinal herniorrhaphy, including The Lichtenstein approach The plug-and-patch technique The sandwich technique with both an
anterior and preperitoneal piece of mesh.
![Page 42: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/42.jpg)
Tension – free repair
![Page 43: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/43.jpg)
Tension – free repair
![Page 44: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/44.jpg)
Prolene hernial system
![Page 45: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/45.jpg)
![Page 46: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/46.jpg)
Comparison of open approachs
![Page 47: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/47.jpg)
Recurrence rate “ PGY“
![Page 48: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/48.jpg)
Laparoscopic Repair
![Page 49: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/49.jpg)
Indications for laparoscopic repair
Bilateral inguinal hernia When the diagnosis of inguinal hernia is
uncertain When the patient want to return to
normal physical life
![Page 50: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/50.jpg)
Contraindications
The patient medical condition makes general anesthesia more risky
Patient who have planned pelvic or extraperitoneal operations (eg, radical prostatectomy)
Patient who have had a recurrence from a prior laparoscopic repair
Patient presented with strangulated hernia
![Page 51: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/51.jpg)
Advantages of laparoscopic
Less acute postoperative pain Shorter convalescence Earlier return to work
![Page 52: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/52.jpg)
Disadvantages
increased risk of femoral nerve injury and
Increased risk of spermatic cord damage risk of developing intraperitoneal
adhesions with the TAPP greater cost and duration of the
operation.
![Page 53: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/53.jpg)
Laparoscopic Approaches
Laparoscopic repair is done by 2 approaches :1. Transabdominal preperitoneal “TAPP”2. Totally extraperitoneally “TEP”
![Page 54: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/54.jpg)
Transabdominal Preperitoneal
The TAPP approach, first described by Arregui and colleagues in 1992
It requires laparoscopic access into the peritoneal cavity and placement of mesh in the preperitoneal space after reducing the hernia sac.
![Page 55: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/55.jpg)
Totally extraperitoneally
The first TEP inguinal hernia repair was described by McKernan and Laws in1993.
This approach involves preperitoneal dissection and mesh placement without entering into the abdominal cavity.
![Page 56: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/56.jpg)
The Mercedes Benz sign
![Page 57: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/57.jpg)
![Page 58: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/58.jpg)
Thank You
![Page 59: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/59.jpg)
![Page 60: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/60.jpg)
![Page 61: Surgical Options In The Management Of Hernia Repair](https://reader036.vdocument.in/reader036/viewer/2022062512/554b42fcb4c905b5378b4d66/html5/thumbnails/61.jpg)
Complication
Urinary retention Nerve injury Testicular ischemia and atrophy Injury to vas deferens recurrence