Inguinal hernia repair

hernia, surgical treatment of inguinal hernia
laparoscopic treatment

1. MANAGEMENT OF INGUINAL HERNIA Dr Rojan Adhikari FCPS Resident

2. Father of Modern Inguinal Hernia Repair - 1884 EDUARDO BASSINI

3. Investigation USG abdomen and pelvis defines defect and content In old age – BPH , size and to calculate post voidal urine (>100ml significant ) To find any mass

4. Investigation CT scan – helpful in complex incisional hernia determining the number and size of muscle defects, identifying the content as well as intra abdominal pathology MRI -- helpful in diagnosing sportsman’s groin where pain is the presenting feature and to distinguish occult hernia from orthopedic injury

5. Investigation Laparoscopy – useful to identify occult contralateral hernia

6. Investigation HERNIOGRAPHY Suspected hernia, but clinical diagnosis unclear Procedure done under flouroscopy following injection of contrast medium in peritoneum Frontal and oblique radiographs are taken with and without increased intra-abdominal pressur e

7. H er n iograp hy Right direct inguinal hernia Left indirect inguinal hernia

8. Investigation ROUTINE Complete blood count Coagulation profile PT/INR Urine Routine B lood sugar Renal function test Blood grouping/typing ECG and Chest X-ray

9. Historical Perspective 15 th century - Castration with wound cauterization or hernial sac debridement

10. Principle of hernia repair Reduction of hernia content into the abdominal cavity with removal of any non-viable tissue and bowel repair if necessary, Excision and closure of a peritoneal sac if present or replacing it deep to the muscle, Reapproximation of the walls of the neck of the hernia if possible, Permanent reinforcement of the abdominal wall defect with suture or mesh, anatomical repair Tension free

11. Treating precipitating factors Chronic Bronchitis / Bronchial asthma BPH Uretheral stricture Chronic Constipation

12. T R U S S Not curative Hernia should be reducible Contraindicated in case of irreducible hernia , undesended testis , associated huge hydrocele

13. T R U S S

14. T R U S S

15. SURGERIES FOR HERNIA HERNIOTOMY HE RN I O R R HAP Y HERNIOPLASTY

16. INDICATIONS OF HERNIOTOMY Congenital hernia Congenital hydrocoele (patent processus vaginalis) All paediatric age group & young adults

17. INDICATIONS OF HERNIORRHAPHY Young adults with good muscle tone Weak posterior wall Dilated internal ring

18. INDICATIONS OF HERNIOPLASTY Old age with poor muscle tone Direct hernia Huge indirect complete hernia

19. INDICATION OF LAPAROSCOPIC HERNIA REPAIR Recurent hernia : avoid scar tissue and visualizes occult hernia Bilateral hernia: decrease pain and early mobilization Obese and athletic patient: diagnostic and therapetic

20. HERNIOTOMY Opening up the inguinal canal Separation of sac from cord structures Reducing the content Transfixation and high ligation of sac Excision of sac

21. herniotomy

22. herniotomy

23. HERNIORRHAPHY Herniotomy Approximation of conjoint tendon with inguinal ligament

24. Types of herniorrhaphy

25. BASSINI’S REPAIR Opening the fascia transversalis from pubic tubercle to deep ring Approximation with interrupted stitches Approximation of conjoint tendon & upper leaf of fascia transversalis with inguinal ligament & lower leaf of fascia transversalis

26. MODIFIED BASSINI Approximation with continuou s interlocking stitch with prolene Sutures are placed between the conjoint tendon above and the inguinal ligament below, extending from the pubic tubercle to the deep inguinal ring.

27. SHOULDICE TECHNIQUE Additional strength is given to the posterior wall by “DOUBLE BREASTING” the fascia transversalis Lower flap of fascia is sutured to posterior part of upper flap and upper flap is sutured to inguinal ligament. Best among all anatomical repairs ( Herniorrhaphy) d/t Least recurrence

28. LYTLE’S REPAIR Narrowing of the deep ring by placing interrupted sutures over the medial side of the ring to the transversalis fascia

29. Tanner Slide Operation Reduces the tension in the repair area Relaxing incision is given over the lower rectus sheath so that conjoined tendon is allowed to slide downward

30. Darning Continuous interventing network of nonabsorbable sutures are placed between conjoint and inguinal ligament to give good support to posterior wall of inguinal hernia

31. McVay Operation Interrupted suture is aplied between transversalis fascia to copper’s ligament starting from pubic tubercle medially towards femoral sheath and later continued as suture repair between transversalis fascia and iliopubic tract laterally upto entrance of cord Covers all three groin defects- indirect, direct, and femoral.

32. HERNIOPLASTY Herniotomy Strenthening of the posterior wall of inguinal canal with autologous tissue or foreign material U se of PROLENE MESH to bridge the gap between inguinal ligament and conjoint tendon \

33. Types of hernioplasty

34. LICHTENSTEIN’S TENSION FREE Prolene mesh 15 X 10 cm size is taken & fixed in the inguinal ligament First bite periosteum of pubic tubercle & fix the mesh to a point beyond the deep ring Fix the mesh with inguinal ligament & conjoint tendon using 1’0 or 2’0 prolene without tension

35. LICHTENSTEIN’S TENSION FREE Used in all types of inguinal hernia Least recurrence rates

36. Mesh can be used.. To bridge a defect: simply fixed over the defect as tension free patch To plug a defect: a plug of mesh is pushed into the defect Ta augment a repair: the defect is closed with sutures and the mesh added for reinforcement.

37. Types of Mesh Synthetic mesh polymer of polypropylene, polyester or polytetrafluroethylene (PTFE) Non absorbable and provoke little tissue reaction Hydrophobic nature and monofilament microstructure of polypropylene impede bacterial ingrowth

38. Types of Mesh Biological mesh Sheets of sterilized, decellularised , non-immunogenic connective tissue Provide a scaffold to encourage neovascular ingrowth and new collagen deposition. Host enzymes eventually break down the biological implant which is replaced and remodelled with fibrous tissue It is expensive

39. Types of Mesh Absorbable mesh Also synthetic absorbable meshes, such as those made from polyglycolic acid fibres Used in temporary abdominal closure and to buttress sutured repairs No role in hernia repair as they absorb and induce minimal collagen deposition

40. Types of Mesh Tissue separating mesh Intraperitoneal use Different surfaces, one being sticky and another slippery Adherence and host tissue in growth is required on the parietal side of the mesh Bowel side needs to prevent adhesion to the bowel

41. Positioning of Mesh Onlay – just outside of the muscle in the subcutaneous space Inlay – with in the defect, only applies to mesh plugs in small defects Sublay – between fascial layers in the abdominal wall, intraparietal Immediately extraperitoneally , against muscle or fascia (also sublay ) intraperitoneally

42. Laparoscopic mesh repair TAPP – Trans a bdominal Preperitoneal Procedure TEP – Total Extraperitoneal Procedure

43. TEP Repair More popular then TAPP Through subumbilical incision (10mm) extraperitoneal space is reached After CO2 insufflation , another 5mm port created 4 cm below the 1 st port in the midline, 3 rd port on same line or RIF Disssection is carried downwards carefully, then medially upto pubic tubercle, iliopectneal line, laterally to iliac vessels and inferior epigastric vessels

44. TEP Repair Once adequate space is dissected 15x15cm mesh is placed and spread. Mesh may be sutured to iliopectinal ligament Displacement of mesh is not seen Another side can be done on single setting

45. TAPP Repair Used in large indirect or irreducible inguinal hernia Ports created Content of hernia is reduced Hernial sac dissected in preperitoneal plane after making horizental incision at the upper part of the sac opening ,

46. TAPP Repair Once sac is dissected and excised prolene mesh of 15x10cm sized or smaller is placed in preperitoneal space It is fixed with pubic bone using tacks. Peritonem is closed with continous prolene suture

47. CONCLUSION Laparoscopic and Lichtenstein open mesh repairs were associated with good long term results and a low incidence of recurrence, but laparoscopic repair caused less groin pain and permanent paraesthesia than Lichtenstein mesh repair. 

48. CONCLUSION The intraoperative and general postoperative complication rates as well as the reoperation rate for complications show no significant difference between TEP and TAPP. The higher postoperative complication rate for TAPP, which could be managed conservatively, is partly explained by larger defect sizes, more scrotal hernias and older age.

49. CONCLUSION TEP and TAPP improved clinical outcomes compared with OHR, but the network meta-analysis showed that TEP and TAPP efficacy is equivalent. TAPP was associated with a slightly longer hospital stay compared with TEP.

50. Complication- Intra operative Injury to blood vessles (inferior epigastric & femoral) Injury to bowel & bladder Injury to ilioinguinal & iliohypogastric nerves Injury to cord structures

51. Complication - Immediate post operative Urine retention Hematoma Infection Periosteitis of pubic tubercle Post herniorrhaphy hydrocele

52. Complication - Late complications Recurrence Testicular atrophy if testicular artery is damaged O bstruction

53. Complication- Lap aroscopic Hernia Repair Vascular Injuries Visceral Injuries Trocar Site Complications Bowel Obstructions Hypercarbia syndrome Abdomen Compartment Syndrome

54. References Bailey and Love’s Short Practice of Surgery Sabiston Textbook of Surgery SRB manual of Surgery UpToDate Medscape Pubmed online

55. THANK YOU