Inguinal herniorrhaphy

hernia, herniorhaphy, inguinal hernia,

1. INGUINAL HERNIORRHAPHY DR BASHIR YUNUS SURGERY RESIDENT 04-Feb-15 [email protected] 1

2. OUTLINE DEFINITION INDICATIONS TYPES PREOPERATIVE PREP PROCEDURE COMPLICATIONS 04-Feb-15 [email protected] 2

3. DEFINITION Surgical repair of a hernia INDICATIONS Emergency Obstruction Strangulation Elective Risk of complication Cosmesis Discomfort- pain, pressure necrosis Career choice 04-Feb-15 [email protected] 3

4. TYPES OPEN LAPAROSCOPIC 04-Feb-15 [email protected] 4

5. PRE-OP PREPARATION Treatment of exacerbating factors- causes of chronic straining- Chronic cough, constipation, bladder outlet obstruction CXR, ABD USS, Weight reduction Hernia with loss of domain requires intermittent abdominal pneumoperitoneum to prevent post-op respiratory embarrassment. Obstructed or strangulated requires resuscitation- iv fluids, iv antibiotics, NG tube and urethral catheterization Obtain an informed consent. 04-Feb-15 [email protected] 5

6. PROCEDURE POSITION Supine Routine cleaning(nipple line to mid-thigh) and draping(exposing the umbilicus, ASIS, pubic symphysis ) Surgeon stand on the side of the hernia and the assistant at the opposite ANAESTHESIA local anasthesia (60ml of 0.5%lidocain + adrenaline) with sedation for elective Ilioinguinal and hypogastric nerve block Intradermal and the subcutaneous tissues are infiltrated at the site of the proposed incision At the deep ring (peritoneal pain) Pubic tubercle medially General anasthesia for emergency Spinal for elderly with co-morbidity OR bilateral, recurrent hernia 04-Feb-15 [email protected] 6

7. Local anasthesia Ilioinguinal and iliohypogastric blocks Surface landmarks for ilioinguinal block. The point of needle insertion ismarked 2 cm medial and 2 cm superior from the anterior superior iliac spine. 04-Feb-15 [email protected] 7

8. Needle maneuvers to block to ilioinguoinal nerve. Shown is perpendicular needle insertion (1), lateral (2), and medial (3) redirections (fan technique ) 04-Feb-15 [email protected] 8

9. INCISION An incision is usually made parallel to and approximately 2 cm above the inguinal ligament . Extend from the level of the pubic tubercle to the internal ring at the level of the femoral pulse . (medial two-third of the inguinal ligament) 04-Feb-15 [email protected] 9

10. EXPOSURE The subcutaneous tissue is incised The blood vessels – superficial Epigastric vein and external pudenda vein- are ligated and divided A self-retaining Weitlaner retractor is placed The external oblique aponeurosis is exposed Further local anesthetic agent is infiltrated beneath the external obligue . 04-Feb-15 [email protected] 10

11. Small incision is made on the direction of the fibers of the external oblique and extended into the medial side of the external ring . The cut edges of the external oblique held away to prevent injury to the underlying nerves. The two nerves ( ilioinguinal and genitofemoral nerves ) are then preserved and retracted out of the way 04-Feb-15 [email protected] 11

12. The cord is then freed from the floor of the canal(best started from the pubic tubercle)and held with a hernia ring. The crimaster muscle is grasped with toothed forceps and divided to approach the sac. The sac is white membrane anteriomedial to the cord. Vas difference can be felt by palpation because is firmer than other structures of the cord. 04-Feb-15 [email protected] 12

13. The crimaster is dissected of the off the sac and dissect the sac and cord apart. The sac separated upto the deep ring, with exposure of preperitoneal fat or inferior Epigastric vessels The wall of the sac is picked is lifted up gently and opened at the apex with care to avoid injury to the content. The content is inspected and reduced. Transfix the sac at the deep ring and excise the redundant sac. 04-Feb-15 [email protected] 13

14. Re-enforcement of the posterior wall 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 . Tanner slide can be made to reduce tension Lytle’s repair; tighting the internal ring on the medial side if it is too wide. 04-Feb-15 [email protected] 14

15. Shouldice repair; four layered repair Lichtenstein repair; mesh repair 04-Feb-15 [email protected] 15

16. CLOSURE The external oblique fascia is reapproximated starting at the external ring using 2-0 absorbable sutures . The subcutaneous tissue is irrigated, and any debris is removed. The skin is approximated with subcuticular 4-0 absorbable sutures, and the testis is gently drawn into the scrotum to avoid iatrogenic undescended testis . 04-Feb-15 [email protected] 16

17. COMPLICATION INTRA-OPERATIVE Injury to the external iliac or femoral vessels Injury the vas deferens Injury to the bladder and colon esp in sliding hernia Injury to the inferior epigastric vessel Injury to the content of the sac Injury to the testicular artery EARLY POST-OP Retention of urine Haematoma of cord and scrotum Wound infection 04-Feb-15 [email protected] 17

18. LATE POST-OP Recurrence Sinuses Neuralgic pain- ilioinguinal nerve – hyperasthesia over the medial side of the inguinal canal Painful scar Atrophy of the testis due to injury to testicular artery Ostetis pubis Mesh extrusion with or without foreign body reaction Epidermoid cyst 04-Feb-15 [email protected] 18

19. Causes of recurrence Inadequate pre-op preparation Persistent causes of straining Infection Intra-operative Tension repair Low ligation of sac Inadequate lytle’s repair (in huge long standing hernia) Treatment of recurrence is via preperitoneal repair(there is fibrosis of the previous site). Can be open or laparoscopic(gold standard). 04-Feb-15 [email protected] 19

20. Special situations Sliding hernia Strangulated hernia Madyl’s hernia(hernia N-W) 04-Feb-15 [email protected] 20

21. References Vijay P chatri ; operative surgery manual. 1 st edition 2003 Zollinger ; atlas of surgical operations. 9 th edition Graeme J Poston. Principles of operative surgery. 2 nd edition S.K Bhattacharya; short cases in surgery. Sixth edition Youtube . www.nysora.com 04-Feb-15 [email protected] 21