Hernia treatment and surgery

Various types of hernia are dealt by a general or laparoscopic surgeon

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1. ESOPHAGEAL CANCER SURGERY Dr Nitin Jha (MBBS,MS,FIAGES) Consultant Laparoscopic,MIS and Bariatric surgeon FORTIS Hospital, Noida . INDIA [email protected]

2. What is a hernia? A hernia is an abnormal weakness or hole in an anatomical structure which allows something inside to protrude through. It is commonly used to describe a weakness in the abdominal wall.

3. Common types

4. NOMENCLATURE  Incomplete hernia     Bubonocele —limited within the inguinal canal    Funicular—limited just above the epididymis Complete hernia traverses to the bottom of the scrotum Littre”s hernia Richters hernia Irreducible hernia Obstructed Strangulated hernia Hernia of hydrocele Hydrocele of hernia

5. Nyhus Classification Type I: Indirect inguinal hernia I nternal inguinal ring normal (simple pediatric hernia) Type II: Indirect inguinal hernia I nternal inguinal ring dilated but posterior inguinal wall intact (inferior deep epigastric vessels not displaced)

6. Nyhus Classification Type III: Posterior wall defect A. Direct inguinal hernia B. Indirect inguinal hernia- internal inguinal ring dilated (massive scrotal or sliding hernia) C. Femoral hernia Type IV: Recurrent hernia A. Direct B. Indirect C. Femoral D. Combined

7. Gilbert’s Classification Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct. Type 1 hernias with an intact internal ring that will not admit 1 fingerbreadth (<1 cm); the posterior wall is intact. Type 2 hernias (the most common indirect hernia) have a peritoneal sac coming through a 1-fingerbreadth internal ring ( ≤ 2 cm.); the posterior wall is intact. Type 3 hernias with 2-fingerbreadth or wider internal ring (>2 cm.) Type 3 hernias begin to break down a portion of the posterior wall just medial to the internal ring. Often have a sliding component. Type 4 hernias have a full floor posterior wall breakdown or multiple defects in the posterior wall. The internal ring is intact, and there is no peritoneal sac. Type 5 hernias are pubic tubercle recurrence or primary diverticular hernias. No peritoneal sac and the internal ring remains intact. In cases where double hernias exist, both types are designated (ex. Types 2/4). Descriptors such as L, Sld., Inc., Strang . Fem . are used to designate lipoma , sliding component, incarceration, strangulation and femoral components.

8. Gilbert’s Classification In 1993, Rutkow and Robbins added type 6 to designate double inguinal hernias type 7 to designate a femoral hernia.

9. Pelvic & Inguinal Anatomy Both the ilioinguinal nerve and the genitofemoral nerve traverse the usual hernia-repair operative field. The femoral vein also runs just deep to the inguinal floor laterally.

10. Myopectineal Orifice of Fruchaud The MPO is bordered: Above by the arching fibers of the internal oblique and transversus abdominus Muscles, Medially (towards the center or to the right) by the Rectus Abdominus Muscle and its fascial R e ctus Sheath Inferiorly by Coopers Ligament, and Laterally by the Ileopsoas Muscle Running diagonally thru the MPO is the inguinal ligament

11. Myopectineal Orifice of Fruchaud

12. Ingiunal canal Contents Ilioinguinal nerve. Spermatic cord, which contains: 3 arteries : Testicular a. Ductus deferens a. Cremasteric a. 3 nerves: Cremasteric n. Genital branch of the GF n . Autonomics 3 other things : Ductus deferens Pampiniform plexus Lymphatics

13. Hesselbach's triangle Boundaries: Medial: R ectus abdominis muscle medially, Inferiorly: I nguinal ligament Laterally: Inf. E pigastric s

14. Groin Anatomy--Nerves

15. ANATOMY

16. Etiology of Hernias Congenital Hydrocele vs. indirect hernia Patency rate of processus vaginalis 60% at 2mo; 40% at 2yo; 20% in adults Connective tissue abnomalities Smoking (collagen metabolism) Malnutrition, Vitamin deficiency Increased intra-abdominal pressure COPD, dialysis, ascites , BPH Chronic constipation Strenuous labor ?

17. Composition of hernia Sac: a folding of peritoneum consisting of a mouth, neck, body and fundus . Body : which varies in size and is not necessarily occupied. Coverings: derived from layers of the abdominal wall. Contents: which could be anything from the omentum , intestines, ovary or urinary bladder.

18. Symptoms 1…Swelling in inguinoscrotal region Increasing on coughing,straining,walking Decreasing on lying down 2…h/o irreducibility 3…h/o obstruction pain, vomiting,obstipation distension of abdomen. 4…h/o Strangulation redness,shock,sepsis

19. Clinical Diagnosis Can you get above it? Reducibility test Expansile Cough Impulse; Invagination test Three finger test Zieman’s technique 6. Ring occlusion test

20. Relation to Pubic Tubercle INGUINAL HERNIA; The neck above and medial to the pubic tubercle FEMORAL HERNIA; The neck below and lateral to pubic tubercle

21. 1-Cough Impulse Pt. coughs to highlight hernia. May not ;if the neck is blocked by adhesions Visible & Palpable cough impulse. Reappear on straining, standing or coughing  

22. 2-Reducibility test Ask pt. to reduce hernia himselves In lying position. Thigh of the affected side should be flexed, adducted and internally rotated. Finger guard of the inguinal canal by thumb and index finger and then the scrotum is gently squeezed.

23. 3- Get above the swelling test Done in standing position At the root of the scrotum place the thumb in front and the index behind Try to reach above the swelling . Inguinal hernia; cannot get above Pure scrotal swelling; will get above

24. 4- Invagination test The scrotum on each side is inverted with the examining index finger Entering the inguinal canal along the course of the cord structures. The size of the external ring. The finger push up to the superf inguinal ring. The pulp should feel the ring. Pat is asked to cough, A palpable impulse will confirm the hernia; felt on the pulp then direct felt on the tip then indirect hernia .

25. 5-Three finger test / Zieman’s technique Index finger; deep inguinal ring (indirect hernia) Middle finger; superficial ing . Ring (direct hernia) Ring finger; saphenous opening (femoral hernia) The patient is asked to cough.

26. 6- Ring occlusion test Reduce the hernia Occlusion of the deep ring by thumb. Then holding the thumb in position ask The pt to stand then cough If no bulging; indirect If bulging; direct .

27. PRE-OP WORK UP USG abdomen to r/o BHP, All routine blood investigation for PAC X Ray Chest,ECG Written informed Consent Part preparation Antibiotic after induction of anaesthesia Bladder emptying just before surgery

28. Open Inguinal Hernia Repairs Bassini McVay Shouldice Lichtenstein Plug & patch LAPAROSCOPIC REPAIR TEP (Totally Extra Peritoneal) TAPP(Trans Abdominal Pre Peritoneal)

29. Lichtenstein Repair Popularized the use of polypropylene mesh in primary hernia repairs Mesh is laid over the undisturbed inguinal floor, posterior to the spermatic cord sutured to the shelving edge of the inguinal ligament, internal oblique fascia and the pubis

30. Bassini Repair Is frequently used for indirect inguinal hernias and small direct hernias The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

31. Bassini Repair

32. Shouldice Repair AKA: Canadian R epair A primary repair of the hernia defect with 4 overlapping layers of tissue. Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.

33. Shouldice Repair

34. When is laparoscopy appropriate? Recurrent hernias - avoid a previously operated field Bilateral hernias - one set of incisions better than two inguinal incisions; one mesh to cover both overlay bladder

35. Types of Laparoscopic Inguinal Hernia Repair IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned. TAPP  (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized. TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs

36. Laparoscopic techniques versus open techniques for inguinal hernia repair. There is no apparent difference in recurrence between laparoscopic and open mesh methods of hernia repair. The data suggests less persisting pain and numbness following laparoscopic repair Return to usual activities is faster. However, operation times are longer and there appears to be a higher risk of serious complication rate in respect of visceral (especially bladder) and vascular injuries Cochrane Database Syst Rev. 2003;(1):CD001785

37. Dangers/Areas to be Avoided Triangle of pain Contains cutaneous nerves  neuralgia Major arteries and spermatic vessels Epigastric vessels Specific example: tension on vas deferens

38. Lap TAPP Repair---- VIDEO

39. Lap TEP Repair VIDEO