Hernia Repair (Lichtenstein) Kuliah.pptx

hernia repai

1. Hernia Essentials Open Hernia Repair, Today Issue and Update Dr. dr. Warsinggih , SpB -KBD

2. INTRODUCTION Abnormal protrusion of viscus or a part of it through a weak point in the abdominal wall

3. ANATOMY OF INGUNAL REGION Superficial inguinal ring- triangular aperture in the aponeurosis of the ext oblique muscle . Lies 1.25 cm above the pubic tubercle. Normally it doesn’t admit the tip of the little finger. Deep inguinal ring – U shaped condensation of the fascia trasversalis Lies 1.25cm above the mid inguinal point.

4. INGUNAL CANAL Oblique passage in the lower part of the anterior abdominal wall. Extends from deep inguinal ring to superficial inguinal ring. Directed downwards forwards and medially About 4 cm long

5. BOUNDARIES Anterior – Ext. oblique aponeurosis & conjoined muscle laterally. Posterior – Fascia transversalis & the conjoined tendon. Superiorly – conjoined muscle. Inferiorly – inguinal ligament.

6. PRE-OPERATIVE CONSIDERATIONS Pre-operative considerations Patient preparation Minimize predisposing factors Discuss the procedure with the patient including outcomes and complications Open (Lichtenstein) Hernia Repair

7. Anesthesia Local Regional General anesthesia Open (Lichtenstein) Hernia Repair

8. Technique of local anesthesia 50/50 mixture of xylocaine and bupivacaine Subdermal infiltration (5 ml) Intradermal injection (3ml) Deep subcutaneous injection (10ml) Subaponeurotic injection (8-10ml) Pubic tubercle and neck of hernia sac Open (Lichtenstein) Hernia Repair

9. Surgical Technique

10. Started in 1984 Reported in 1989 with zero recurrence of up to 5 year ff-up Under local anesthesia Utilizes 5 x 10 cm mesh Lichtenstein il , am j surg 1989, 157;188-193 Open (Lichtenstein) Hernia Repair

11. EVOLUTION OF TECHNIQUE LOCAL ANESTHETIC BLOCK SAC INVAGINATED OR INVERTED 5X10 CM MESH SLIT TO ACCOMMODATE THE CORD CONTINOUS SUTURE MEDIAL AND LATERAL SINGLE STITCH FOR THE CROSS TAIL LOCAL ANESTHETIC BLOCK SAC INVAGINATED OR INVERTED 8X15 CM MESH SLIT TO ACCOMMODATE THE CORD CONTINOUS SUTURE LATERAL INTERRUPTED MEDIAL SINGLE STITCH FOR THE CROSS TAIL OBSERVE OVERLAPS NERVE IDENTIFICATION Lichtenstein il , am j surg 1989, 157;188-193 Amid p, hernia 1998,2003 Open (Lichtenstein) Hernia Repair

12. EVOLUTION OF TECHNIQUE Lichtenstein il , am j surg 1989, 157;188-193 Amid p, hernia 1998,2003 Open (Lichtenstein) Hernia Repair

13. OPERATION STEPS The patient is placed in the supine position. The groin is prepared in the usual fashion. After incising the skin, subcutaneous tissue, and external oblique aponeurosis (as usually), the spermatic cord is elevated from the posterior wall of the inguinal canal. In indirect hernias, the hernial sac is identified, dissected to the internal ring and opened to allow examination of its contents. The sac is ligated and its distal portion is usually excised. Open (Lichtenstein) Hernia Repair

14. OPERATION STEPS A polypropylene mesh is trimmed to fit the floor of the inguinal canal, and its apex is first sutured to the pubic tubercle The same continuous suture then sutures the lower border of the mesh to the free edge of the inguinal ligament, after an opening is made into its lower edge to accommodate the spermatic cord. Open (Lichtenstein) Hernia Repair

15. Critical steps Use large sheet of mesh 8 x 15 cm Observe overlaps 2 cm beyond pubic tubercle Cross the tails behind the spermatic cord Mesh secured with continous suture at the inguinal ligament and two interrupted sutures at the medial side Amid p, hernia 1998,2003 Open (Lichtenstein) Hernia Repair

16. Critical steps Dome shaped configuration Identify and protect the nerves Amid p, hernia 1998,2003 Open (Lichtenstein) Hernia Repair

17. Protect the nerves Open (Lichtenstein) Hernia Repair

18. Protect the nerves Open (Lichtenstein) Hernia Repair

19. Learning Curve Open (Lichtenstein) Hernia Repair

20. Conclusion: Lichtenstein repair for an indirect inguinal hernia reduces the risk of recurrence in young men between the age of 18 and 30 years compared with a sutured repair. The use of a Lichtenstein mesh repair in young males must be balanced against the risk of chronic pain. Open (Lichtenstein) Hernia Repair

21. Mesh fixation Sutured Absorbable vs non absorbable Sutureless (self gripping mesh) Glue Tackers Open (Lichtenstein) Hernia Repair

22. Chronic inguinal pain 10-12% incidence Scoring system Management Guidelines Open (Lichtenstein) Hernia Repair

23. Carolinas comfort scale Open (Lichtenstein) Hernia Repair

24. Eurahs Done pre-operatively and post-operatively Open (Lichtenstein) Hernia Repair

25. Dermatomal mapping Open (Lichtenstein) Hernia Repair

26. Ilioinguinal nerve involvement Iliohypogastric nerve involvement Genital nerve involvement DMC Open (Lichtenstein) Hernia Repair

27. Prevention of chronic inguinal pain Use of mesh over tissue repair Use of material reduced meshes offer an advantage Identifying the nerves during surgery Prophylactic nerve resection does not prevent chronic inguinal pain EHS Guidelines 2009/2014 Open (Lichtenstein) Hernia Repair

28. Management of chronic inguinal pain Difficult to manage Observe for three months Role of dermatomal mapping Identify the exact source of the pain Role of triple neurectomies Open (Lichtenstein) Hernia Repair

29. 4D Dome Composite Prosthesis

30. 4D Dome Composite Prosthesis Advantages: Mesh structure gives maximum structural advantage Less Complication and reccurrences Reduce chronic pain Decrease the potential risk of infection Polypropylene mesh along with the three sizes of dome com- posite (10% polypropylene, 90% PLLA) that together make up the 4DDome® prosthesis. Leroy JL, Mutter D, Forgione A, Inoue H, Vix M, Bailey C, et al. The new 4DDome prosthesis: An original light and partially absorbable composite mesh for hernia repair. Hernia. 2006;10(5):401–8.

31. Operation Technique The operative technique involved conventional open The hernia sac was isolated by dissection and reduced. The dome-shaped, composite (10% polypropylene, 90% PLL A) component of the prosthesis system is available in three sizes (22, 30, and 38 mm). The one of best fit is inserted into the level of the defect and fixed by four interrupted absorbable sutures. The on-lay lightweight polypropylene was then placed to reinforce the posterior wall of the inguinal canal, with its limbs being placed around the spermatic cord at the level of the deep inguinal ring. Expanded Clinical Experience with 4DDome® Composite Prosthesis in Elective Open Inguinal Herniorrhaphy MUTTER/CALLARI/D'AGOSTINO/CAHILL/FORGIONE/ VIX/LERO Y/MARESCAUX

32. Expanded Clinical Experience with 4DDome® Composite Prosthesis in Elective Open Inguinal Herniorrhaphy MUTTER/CALLARI/D'AGOSTINO/CAHILL/FORGIONE/ VIX/LERO Y/MARESCAUX

33. Thank You