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العظيم صدصد الله العظيم ق الله ق

The Role Of Narrowing Of The Internal Ring In The Outcome Of Laparoscopic Treatment Of Indirect Inguinal Hernia.

By By Mohammed Saleh Al-dawbaliMohammed Saleh Al-dawbali

MD (Egy.), MRCS (Eng.)MD (Egy.), MRCS (Eng.)Ass. Prof Of Surgery (SanaAss. Prof Of Surgery (Sana''a University)a University)

IntroductionIntroduction

-- Hernia is a frequent disease in the community so that it produce a sizable part of many general surgeons practice.

-- The success of laparoscopic cholecystectomy has resulted in the enthusiasm to modify other abdominal procedures so that they can be performed laparoscopically.

-- laparoscopic Inguinal hernioplasty is one of such procedure.

Introduction (cont.)Introduction (cont.) Over the past 20 years, several hernia repair techniques Over the past 20 years, several hernia repair techniques

have been introduced .The main cause for the have been introduced .The main cause for the development of these new techniques was development of these new techniques was to reduce the to reduce the recurrence raterecurrence rate. .

The introduction of the Lichtenstein tension-free The introduction of the Lichtenstein tension-free hernioplasty, which uses a mesh to reinforce the abdominal hernioplasty, which uses a mesh to reinforce the abdominal wall, has decreased recurrence rates greatly.wall, has decreased recurrence rates greatly.

However, certain types such as However, certain types such as recurrent,recurrent, bilateralbilateral hernias hernias are particularly suited for a laparoscopic approach .are particularly suited for a laparoscopic approach .

Laparoscopic inguinal hernioplasty is associated with Laparoscopic inguinal hernioplasty is associated with shorter recovery periods, earlier return to daily activities shorter recovery periods, earlier return to daily activities and work, and decreased postoperative pain.and work, and decreased postoperative pain.

IndicationsIndications Certain types of hernia such asCertain types of hernia such as

- - Recurrent,Recurrent,

- - BilateralBilateral, are particularly suited , are particularly suited for a laparoscopic approach .for a laparoscopic approach .

BUT BUT also it can be done for primary also it can be done for primary unilateral hernias as first patient unilateral hernias as first patient preferencepreference

ApproachApproach

Laparoscopic hernia repair can be done Laparoscopic hernia repair can be done either through:either through:

1. Transabdominal Preperitoneal 1. Transabdominal Preperitoneal Approach Approach (TAPP )(TAPP )or or

2. Total Extra-peritoneal Approach 2. Total Extra-peritoneal Approach (TEP).(TEP).

Aim Of The WorkAim Of The Work

Our study aim to assess whether the Our study aim to assess whether the addition addition of the closure of internal ring to the of the closure of internal ring to the classical TAPP has a better short outcome classical TAPP has a better short outcome on regard to post operative pain, bulging, on regard to post operative pain, bulging, seroma or haematoma formation and on the seroma or haematoma formation and on the long term outcome in regard to recurrence . long term outcome in regard to recurrence .

Patients And MethodsPatients And Methods

- - A total of 40 patients were selected from those presented to the Outpatient Clinic with indirect inguinal hernia from the period May 2009 to April 2011

Patients And MethodsPatients And Methods

Exclusion criteriaExclusion criteria for patient selection were as for patient selection were as follows:-follows:-

- younger than 12 years of age - younger than 12 years of age - severe obesity (BMI >35). - severe obesity (BMI >35). - associated medical problems that - associated medical problems that

contraindicate safe induction of general contraindicate safe induction of general anesthesia or elective surgeryanesthesia or elective surgery

Patients And MethodsPatients And Methods

The forty Patients were randomly divided The forty Patients were randomly divided into two groupsinto two groups , , group group AA contain contain 20 20 patients and were treated by closure of patients and were treated by closure of the ring and classical TAPP ,while the ring and classical TAPP ,while group group B B contain contain 2020 patients and was treated by patients and was treated by Classical TAPP Only.Classical TAPP Only.

OperationOperation

In the theater, neither nasogastric tube nor In the theater, neither nasogastric tube nor urinary catheter were needed (patient urinary catheter were needed (patient were instructed to evacuate their bladder were instructed to evacuate their bladder before coming to the theater).before coming to the theater).

Insertion Of The Trocar (open tech.)Insertion Of The Trocar (open tech.) Induction Of Pneumoperitoneum Induction Of Pneumoperitoneum (14mmHg)(14mmHg)

abdominal cavity and viscera are abdominal cavity and viscera are inspected in a systematic orderinspected in a systematic order

Op. Technique (cont.)Op. Technique (cont.)

Two working portsTwo working ports were further were further introduced at a level just caudal to the introduced at a level just caudal to the umbilicus and lateral to the rectus muscle umbilicus and lateral to the rectus muscle of both right and left lower quadrants.of both right and left lower quadrants.

N.BN.B This array of trocars was used in This array of trocars was used in either unilateral or bilateral cases.either unilateral or bilateral cases.

EXPLORATION EXPLORATION

Peritoneal incision (Right)Peritoneal incision (Right)

Left peritoneal incisionLeft peritoneal incision

Right side dissectionRight side dissection

Left side dissectionLeft side dissection

Ring closureRing closure

Mesh fixationMesh fixation

Peritoneal closurePeritoneal closure

ResultsResults

Patients characteristics:Patients characteristics: The patient’s ages ranged from 25→55 The patient’s ages ranged from 25→55

years oldyears old The mean age was 33 years in Group A and The mean age was 33 years in Group A and

30 years in Group B30 years in Group B All of our pt were male (no female)All of our pt were male (no female)

Distribution of Hernia siteDistribution of Hernia site

24 cases (60%) were 24 cases (60%) were rightright side , 6 cases side , 6 cases ( 15%) were ( 15%) were left left side and 10 cases (25 %) side and 10 cases (25 %) were were bilateralbilateral . . Hernia Site

60%15%

25%

0%

1

2

3

4

Average Operative TimeAverage Operative Time

Intra-Operative ComplicationsIntra-Operative Complications

Intra-operative complication occur in a single Intra-operative complication occur in a single case (2.5 %) in the form of case (2.5 %) in the form of urinary bladder injuryurinary bladder injury during reduction of the structure from a left during reduction of the structure from a left hernia defect in a patient with bilateral hernia. hernia defect in a patient with bilateral hernia. The injury was recognized at the time of The injury was recognized at the time of operation and dealing with it was done in the operation and dealing with it was done in the form of repair in two layer after putting of urinary form of repair in two layer after putting of urinary catheter. The hernia repair was completed then catheter. The hernia repair was completed then as usual .The patient recover post operatively as usual .The patient recover post operatively without further complication without further complication

Post Operative Care.Post Operative Care.

The patients were shifted from the operating theater to The patients were shifted from the operating theater to the surgical ward and were discharged in the next day the surgical ward and were discharged in the next day (except when complications were suspected). In the (except when complications were suspected). In the surgical ward recording of the postoperative pain using surgical ward recording of the postoperative pain using the the Visual analogue scale Visual analogue scale (VAS)(VAS) was used was used . .

Patients were seen after Patients were seen after 1 week1 week , then after , then after 1 month1 month and and then after then after 6th months6th months postoperatively and they were told postoperatively and they were told to contact us if they face any problem regarding their to contact us if they face any problem regarding their hernia. During the follow up of these patients they were hernia. During the follow up of these patients they were examined clinically to assess the post operative pain examined clinically to assess the post operative pain and to look for the presence of odema, seroma , and to look for the presence of odema, seroma , hematoma , wound infection ,post operative bulge, hematoma , wound infection ,post operative bulge, recurrence or any other complications.recurrence or any other complications.

Hospital StayHospital Stay

-All patient of both group were ambulated in -All patient of both group were ambulated in the same day of operation and discharged the same day of operation and discharged in the next day of the operation.in the next day of the operation.

-Only 1 case (2.5 %) who discharged in the -Only 1 case (2.5 %) who discharged in the 33rdrd POD. POD.

Follow upFollow up

Postoperative painPostoperative pain . there was no . there was no significant difference between patients of significant difference between patients of both groups (P value < 0.01) and the pain both groups (P value < 0.01) and the pain score was ranged from VAS 1 to VAS 3 score was ranged from VAS 1 to VAS 3 (mild ) and in more than 90% of cases (mild ) and in more than 90% of cases pain was overcomed with simple pain was overcomed with simple analgesics . The causes of pain seems to analgesics . The causes of pain seems to be multifactorial (dissection , fixation of the be multifactorial (dissection , fixation of the mesh, foreign body reaction……etc) mesh, foreign body reaction……etc)

Visual analogue scale (VAS)Visual analogue scale (VAS)

- - SeromaSeroma occur in two cases (10 %) of the occur in two cases (10 %) of the second group and was treated second group and was treated conservatively . conservatively . NoNo seroma occur in pts of seroma occur in pts of the first group the first group

Post operative bulgingPost operative bulging was noted in 16 was noted in 16 case (80 %) of the second group and it case (80 %) of the second group and it last for a period of around two months last for a period of around two months postoperatively , while in the first group postoperatively , while in the first group there were there were NoNo bulging neither in the early bulging neither in the early nor in the late postoperative period. This nor in the late postoperative period. This make the patients of the first group more make the patients of the first group more satisfy . satisfy .

The follow-up period ranged from 1 to 1.5 The follow-up period ranged from 1 to 1.5 year postoperatively ( average 1 year)year postoperatively ( average 1 year)

The results of follow up show:The results of follow up show:

On clinical basis all patients of both groups On clinical basis all patients of both groups were were relived of the symptomsrelived of the symptoms of hernia of hernia

No recurrenceNo recurrence have been reported in all have been reported in all cases of both group. cases of both group.

ConclusionConclusion

Laparoscopic surgery is becoming widely Laparoscopic surgery is becoming widely accepted as an alternative to conventional accepted as an alternative to conventional procedures. With-miniaturization of instrument it procedures. With-miniaturization of instrument it isis becoming more and more evident that becoming more and more evident that laparoscopic techniques can be applied safely laparoscopic techniques can be applied safely and successfully to hernia patients. The selection and successfully to hernia patients. The selection criteria for patients who are eligible for criteria for patients who are eligible for laparoscopic procedures is dynamic and as skills laparoscopic procedures is dynamic and as skills and technologies improve and technologies improve fewer patients are fewer patients are found to have absolute exclusion criteriafound to have absolute exclusion criteria

Result showResult show that Laparoscopic that Laparoscopic narrowing of the internal inguinal ring narrowing of the internal inguinal ring was found to be safe , effective and was found to be safe , effective and low cost procedure for treatment of low cost procedure for treatment of oblique inguinal hernia with better oblique inguinal hernia with better outcome regarding post operative outcome regarding post operative serohematoma and postoperative serohematoma and postoperative bulging which are annoying problem bulging which are annoying problem to hernia patients . to hernia patients .

However, the important Question However, the important Question isis Whether the closure of the internal Whether the closure of the internal ring will be an auxiliary step in the ring will be an auxiliary step in the classical TAPP procedures in the light classical TAPP procedures in the light of these substantial benefits as regard of these substantial benefits as regard to less postoperative complications.to less postoperative complications. More studies needed to answer this More studies needed to answer this question but in our study narrowing of question but in our study narrowing of the internal ring with hernioplasty the internal ring with hernioplasty was simple, sufficient and effective .was simple, sufficient and effective .

Thank you !Thank you !

Numerical rating scale (NRS)

Faces rating scale (FRS)Faces rating scale (FRS)

Pain rating scales instructionsPain rating scales instructionsSubjective pain scoreSubjective pain score All patients are to have a functional activity score recorded in addition to the chosen subjective All patients are to have a functional activity score recorded in addition to the chosen subjective

score.score.Visual analogue scale (VAS)Visual analogue scale (VAS) Instruct the patient to point to the position on the line between the faces to indicate how much pain Instruct the patient to point to the position on the line between the faces to indicate how much pain

they are currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst they are currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst pain ever’.pain ever’.

Numerical rating scale (NRS)Numerical rating scale (NRS) Instruct the patient to choose a number from 0 to 10 that best describes their current pain. 0 would Instruct the patient to choose a number from 0 to 10 that best describes their current pain. 0 would

mean ‘No pain’ and 10 would mean ‘Worst possible pain’.mean ‘No pain’ and 10 would mean ‘Worst possible pain’.Faces rating scale (FRS)Faces rating scale (FRS) Adults who have difficulty using the numbers on the visual/numerical rating scales can be assisted Adults who have difficulty using the numbers on the visual/numerical rating scales can be assisted

with the use of the six facial expressions suggesting various pain intensities. Ask the patient to with the use of the six facial expressions suggesting various pain intensities. Ask the patient to choose the face that best describes how they feel. The far left face indicates ‘No hurt’ and the far choose the face that best describes how they feel. The far left face indicates ‘No hurt’ and the far right face indicates ‘Hurts worst’. Document number below the face chosen.right face indicates ‘Hurts worst’. Document number below the face chosen.

Behavioural rating scaleBehavioural rating scale The behavioural pain assessment scale is designed for use with non-verbal patients unable to The behavioural pain assessment scale is designed for use with non-verbal patients unable to

provide self-reports of pain.provide self-reports of pain. Rate each of the five measurement categories (0,1 or 2).Rate each of the five measurement categories (0,1 or 2). Add these together.Add these together. Document the total pain score out of 10.Document the total pain score out of 10.Functional activity scoreFunctional activity score This is an activity-related score. Ask your patient to perform an activity related to their painful area This is an activity-related score. Ask your patient to perform an activity related to their painful area

(for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain).(for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain). Observe your patient during the chosen activity and score A, B or C.Observe your patient during the chosen activity and score A, B or C. A – No limitation meaning the patient’s activity is unrestricted by painA – No limitation meaning the patient’s activity is unrestricted by pain B – Mild limitation means the patient’s activity is mild to moderately restricted by painB – Mild limitation means the patient’s activity is mild to moderately restricted by pain C - Severe limitation means the patient ability to perform the activity is severely limited by pain C - Severe limitation means the patient ability to perform the activity is severely limited by pain *Relative to baseline refers to any restriction above any pre–existing condition the patient may *Relative to baseline refers to any restriction above any pre–existing condition the patient may

already have.already have.