Surgery hernia

Surgical management of inguinal hernia

1. Mohammed Al- Saffar Surgical Management of inguinal Hernias RAMKUMAR

2. Hernia A hernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls. Groin hernia Inguinal Direct Indirect femora L

3. Epidemiology

4. Predisposing factors

5. Types of hernia - Condition

6. Inguinal Canal Anatomy The inguinal canal is an oblique space measuring 4 cm in length that lies above the medial half of the inguinal ligament. Inguinal canal has 4 walls : anterior, posterior, roof, and floor

7. Contents of the inguinal canal Males : spermatic cord and ilioinguinal nerve Females : round ligament and the ilioinguinal nerve

8. The Spermatic Cord

9. Management Uncomplicated hernias require either : No treatment Support with a truss Operative treatment complicated hernias : always require surgery, often urgently.

10. Surgical approaches For any hernia the surgical option comprises 2 components : Herniotomy Herniorrhaphy or hernioplasty It is either : Open repair Bassini repair Shouldice repair Tension free mesh repair Laparascopic repair

11. Components of the hernia

12. Hernial Sac Dissection

13. 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. This suture line extends from the pubic tubercle to the medial border of the internal ring.

14. Shouldice repair With a no. 15 scalpel an incision is made in the transversalis fascia. This incision is extended from the internal ring to the pubic tubercle. The repair involves placing four lines of sutures. The first suture line is started at the pubic tubercle using 3-0 continuous polypropylene, and the white line is approximated to the free edge of the inferior transversalis fascial flap.

15. Shouldice repair The 2 nd suture line : At the internal ring the suture is tied and then continued medially by approximating the free edge of the superior flap to the shelving edge of the inguinal ligament. When the pubic tubercle is reached, the suture is tied and divided. The third suture line is started at the level of the internal ring where the conjoined tendon is approximated to the inguinal ligament and tied when the pubic tubercle is reached. Using the same suture, the fourth suture line attaches these same structures to one another and is tied at the level of the internal ring.

16. Tension – free repair There are several options for placement of mesh during anterior inguinal herniorrhaphy , including The Lichtenstein approach The plug-and-patch technique The sandwich technique with both an anterior and preperitoneal piece of mesh.

17. Tension – free repair

18. Tension – free repair

19. Prolene hernial system

20. Comparison of open approachs

21. Indications for laparoscopic repair Bilateral inguinal hernia When the diagnosis of inguinal hernia is uncertain When the patient want to return to normal physical life Laparoscopic repair is done by 2 approaches : Transabdominal preperitoneal “TAPP” Totally extraperitoneally “TEP”

22. Contraindications The patient medical condition makes general anesthesia more risky Patient who have planned pelvic or extraperitoneal operations ( eg , radical prostatectomy) Patient who have had a recurrence from a prior laparoscopic repair Patient presented with strangulated hernia

23. Less acute postoperative pain Shorter convalescence Earlier return to work increased risk of femoral nerve injury and Increased risk of spermatic cord damage risk of developing intraperitoneal adhesions with the TAPP greater cost and duration of the operation Advantages DISADVANTAGES

24. Transabdominal Preperitoneal The TAPP approach, first described by Arregui and colleagues in 1992 It requires laparoscopic access into the peritoneal cavity and placement of mesh in the preperitoneal space after reducing the hernia sac.

25. Totally extraperitoneally The first TEP inguinal hernia repair was described by McKernan and Laws in1993. This approach involves preperitoneal dissection and mesh placement without entering into the abdominal cavity .

26. The Mercedes Benz sign

27. Thank You

28. Complication Urinary retention Nerve injury Testicular ischemia and atrophy Injury to vas deferens recurrence