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7/26/2019 Surgicaloptionsinthemanagementofherniarepair 090528073720 Phpapp01 (2)

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SURGICAL OPTIONS IN

THE MANAGEMENT OFINGUINAL HERNIAS

Mohammed Al-Safar


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outlines

Denition

Epidemiology

Anatomy

Surgical management options


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Hernia

A hernia is dened as an abnormalprotrusion o an organ or tissue througha deect in its surrounding walls.

roin hernia !nguinal

Direct !ndirect

emoral


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Epidemiology


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Epidemiology


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"redisposing actors


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Epidemiology

#imodal pea$ age % & ' year then ( )*years

+ight-sided groin hernias are more

common than those on the let.


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,ypes o hernia - ondition


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!nguinal anal Anatomy

o disease of the human body/belonging to the pro0ince of the

surgeon/ re1uires in its treatment abetter combination of accurate/

anatomical $nowledge with surgical s$illthan Hernia in all its 0arieties.

Sir Astley Cooper, 1804


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!nguinal anal Anatomy

,he inguinal canal is an obli1ue spacemeasuring ) cm in length that lies abo0ethe medial hal o the inguinal ligament.

!nguinal canal has ) walls % anterior/posterior/ roo/ and 2oor


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!mportant ligaments


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ontents o the inguinal canal

Males % spermatic cord and ilioinguinalner0e

3emales % round ligament and theilioinguinal ner0e


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,he spermatic cord

!t consists o ,hree co0erings

,hree arteries

,hree other structures. er0es


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,he Spermatic ord


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"reperitoneal space

Space o +et4ius

Space o #ogros

!n. Epigastric

5as deerens

the lateralemoral

cutaneous ner0e the genitoemoral

ner0e.


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Management

6ncomplicated hernias re1uire either % o treatment

Support with a truss

7perati0e treatment

complicated hernias %

alwaysre1uire surgery/ oten urgently.


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Should we repair?

!nguinal hernia %should we repair 8


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!nguinal hernia % should we repair?


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Surgical approaches

3or any hernia the surgical optioncomprises 9 components % Herniotomy

Herniorrhaphy or hernioplasty

!t is either %

7pen repair :aparascopic repair


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Surgery

Surgery aims to +educe the hernial contents

E;cise the sac


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omponents o the hernia


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Hernial Sac Dissection


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,ypes o open repair

+epairing the 2oor o the inguinal canal % #assini repair

Shouldice repair

,ension ree mesh repair


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#assini repair

,he con>oined tendon is retracted upward

the aponeurosis o the trans0ersus abdominismuscle is appro;imated to the iliopubic tract

that lies ad>acent to the inguinal ligament withse0eral interrupted ?-* sil$ sutures.

,he second layer o the repair in0ol0es suturingthe con>oined tendon to the inguinal ligamentwith interrupted 9-* sil$ sutures.

,his suture line e;tends rom the pubic tubercle

to the medial border o the internal ring.


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Shouldice +epair

@ith a no. ' scalpel an incision is madein the trans0ersalis ascia. ,his incision ise;tended rom the internal ring to the

pubic tubercle.

,he repair in0ol0es placing our lines o

sutures.


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Shouldice repair

,he rst suture line is started at the pubic tubercle using ?-*

continuous polypropylene/ and the white line isappro;imated to the ree edge o the ineriortrans0ersalis ascial 2ap.

,he 9ndsuture line % At the internal ring the suture is tied and then

continued medially by appro;imating the reeedge o the superior 2ap to the shel0ing edge othe inguinal ligament. @hen the pubic tubercleis reached/ the suture is tied and di0ided.


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Shouldice repair

,he third suture line is started at thele0el o the internal ring where thecon>oined tendon is appro;imated to the

inguinal ligament and tied when thepubic tubercle is reached.

6sing the same suture/ the ourth sutureline attaches these same structures toone another and is tied at the le0el othe internal ring.


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Shouldice repair

,he cord is replaced within the inguinalcanal/ and the e;ternal inguinalaponeurosis is reappro;imated with

continuous 9-* absorbable sutures


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,ension B ree repair

,here are se0eral options or placemento mesh during anterior inguinalherniorrhaphy/ including

,he :ichtenstein approach ,he plug-and-patch techni1ue

,he sandwich techni1ue with both ananterior and preperitoneal piece o mesh.


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"rolene hernial system


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omparison o open approachs


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+ecurrence rate C "


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:aparoscopic +epair


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!ndications or laparoscopic repair

#ilateral inguinal hernia

@hen the diagnosis o inguinal hernia isuncertain

@hen the patient want to return tonormal physical lie


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ontraindications

,he patient medical condition ma$esgeneral anesthesia more ris$y

"atient who ha0e planned pel0ic or

e;traperitoneal operations


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Ad0antages o laparoscopic

:ess acute postoperati0e pain

Shorter con0alescence

Earlier return to wor$


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Disad0antages

increased ris$ o emoral ner0e in>uryand

!ncreased ris$ o spermatic cord damage

ris$ o de0eloping intraperitonealadhesions with the ,A""

greater cost and duration o the

operation.


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:aparoscopic Approaches

:aparoscopic repair is done by 9approaches %

'. ,ransabdominal preperitoneal C,A""

9. ,otally e;traperitoneally C,E"


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,ransabdominal "reperitoneal

,he ,A"" approach/ rst described byArregui and colleagues in 'FF9

!t re1uires laparoscopic access into theperitoneal ca0ity and placement o meshin the preperitoneal space ater reducingthe hernia sac.


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,otally e;traperitoneally

,he rst ,E" inguinal hernia repair wasdescribed by McGernan and :awsin'FF?.

,his approach in0ol0es preperitonealdissection and mesh placement withoutentering into the abdominal ca0ity.


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,he Mercedes #en4 sign


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,han$ ou


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omplication

6rinary retention

er0e in>ury

,esticular ischemia and atrophy

!n>ury to 0as deerens

recurrence

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