Hernia Repair: Open or Laparoscopic?
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Transcript of Hernia Repair: Open or Laparoscopic?
DR. MOHAMAD AL-GAILANI FRCS .الكيالني محمد د
Consultant Surgeon استش*اري جراح
KSA الس*عودية العربية المملكةTEL: 00966 11 4250000
WWW.ALHAMMADIHOSPITAL.COM
Hernia Repair: Open or
Laparoscopic?
OUTLINE Hernia Repair Milestones Update on Hernia repair Guidelines Case photos & videos Take Home Message &
RecommendationsDR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد2 الكيالني
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد3 الكيالني
HERNIADEFINITION
• Hippocrates used the Greek “hernios” for bud or bulge to describe abdominal hernias.
• A hernia is protrusion of an organ or part of it through the wall of the cavity in which it is normally contained.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد4 الكيالني
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد5 الكيالني
Epigastric
Umbilical Incisional
Direct inguinalIndirect inguinal
Femoral
HERNIA TYPES
Spigelian
Lumbar
Obturator
75% of all abdominal wall hernias occur in the Groin.
HERNIA PREVALENCE & COMPLICATIONS
The overall lifetime risk of developing a groin hernia is 15% in men and < 5% in women.
Age standardized hernia surgery rate is 100/100,000 population per annum.
Risk of strangulation and obstruction can be life threatening.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد6 الكيالني
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد7 الكيالني
COMPLICATED HERNIA GANGRENE SMALL BOWEL
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد الكيالني
5. Internal Oblique Aponeurosis
6. Transversalis Fascia
7. Cremasteric Fascia 8. Pubic Tubercle
GROIN ANATOMY1. Inguinal ligament
2. Muscular part of Transversus Abdominis
3. Transversus Abdominis Aponeurosis
4. Muscular part of Internal Oblique
8
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد9 الكيالني
Inguinal ligament
Spermatic cord
Site for a femoral hernia
Site for an indirect inguinal hernia
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد الكيالني
10
Left Femoral herniaRight
Direct Inguinal /Femoral? hernia
Open or Laparoscopic?
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد11 الكيالني
RIGHT INGUINO- SCROTAL HERNIA
Open or Laparoscopic?
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد12 الكيالني
0PEN OR LAPAROSCOPIC?
VENTRAL-INCISIONAL HERNIA
HERNIA REPAIR MILESTONES
1. OPEN REPAIR:Eduardo Bassini
(1844-1924) Italy
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد14 الكيالني
Eduardo Bassini
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد15 الكيالني
2. TENSION FREE MESH REPAIR: Irving L. Lichtenstein
(1920-1980) USA
Irving L. Lichtenstein
3. LAPAROSCOPIC REPAIR (1989)Sergei Bogojavlensky
(1941-2013) USA
A (Gynaecologist) from Alaskareported the first case of Laparoscopic (Plug) mesh hernia repair in 1989.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد16 الكيالني
Sergei Bogojavlens
ky
THE “DAM” EFFECT PRINCIPLE
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد17 الكيالني
Open
Laparoscopic
LAPAROSCOPIC HERNIA REPAIR TYPES:
• Inguinal: Trans Abdominal Pre Peritoneal (TAPP)
• Inguinal: Total Extra Peritoneal (TEP)• Intra Peritoneal Onlay Mesh (IPOM)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد18 الكيالني
VENTRAL (INCISIONAL) OPEN HERNIA REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد19 الكيالني
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد20 الكيالني
ANATOMY OF THE ANT. ABDOMINAL WALL AS SEEN IN LAPAROSCOPY
MEDIAL UMBILICAL LIGAMENT
LATERAL UMBILICAL LIGAMENT
DIRECT INGUINAL HERNIA
INDIRECT INGUINAL HERNIA
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA 21 د. محمد الكيالني
FEMORAL
DIRECT INGUINAL
INDIRECT INGUINAL
MESH
LAPAROSCOPIC INGUINAL HERNIA REPAIR ANATOMY
RIGHT INDIRECT INGUINAL HERNIA
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد22 الكيالني
Lateral Umbilical Ligament
Right Indirect inguinal hernia
MEDIAL UMBILICAL LIGAMENT
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد23 الكيالني
INGUINAL HERNIA RECURRENCE
FOLLOWING (TAPP) REPAIRELEVATED LOWER
BORDER OF MESH
RECURRENT HERNIA
Author’s Modification (Al-Gailani) “OVERLAP”
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد24 الكيالني
Right Spermatic Cord
OVERLAP Spermatic Cord
by mesh
VIDEO 1:LAPAROSCOPIC (TAPP) (R) INGUINAL HERNIA REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد25 الكيالني
PARA UMBILICAL HERNIA(PUH)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد26 الكيالني
Greater Omentum herniated
PUHRELEASE OF HERNIA CONTAINTS
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد27 الكيالني
PUHMESH FIXATION
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد28 الكيالني
PUH Mesh In Situ
Repair Completed
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد29 الكيالني
VIDEO 2:LAPAROSCOPIC (PUH) REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد30 الكيالني
INCISIONAL HERNIA REPAIR following
Kocher Incision (Open Cholecystectomy)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد31 الكيالني
Omental Adhesions to
Incisional Hernia
INCISIONAL HERNIA RELEASE OF ADHESIONS
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد32 الكيالني
INCISIONAL HERNIA Adhesolysis Completed
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد33 الكيالني
Old nylon suture of previous Kocher incision closure
INCISIONAL HERNIA Mesh Fixation with “Protac”
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد34 الكيالني
Recommended Mesh Overlap (5 cm)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد35 الكيالني
OVERLAP 5CM (ALL AROUND)DEFECTOVERLAP 5CM
(ALL AROUND)
VIDEO 3:LAPAROSCOPIC INCISIONAL HERNIA REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد36 الكيالني
HERNIA REPAIR GUIDELINES
2001NATIONAL INSTITUTE CLINICAL EXCELLENCE (NICE)
HERNIA REPAIR GUIDELINES
• Only 4.1% of repairs done laparoscopically
• Only to be done by trained surgeons• Laparoscopic hernia repair for bilateral and recurrent hernias
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد38 الكيالني
2004NICE GUIDELINES
1. Reduced postoperative pain2. Earlier return to normal activities 3. Repair of bilateral hernias 4. Occult hernias
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد39 الكيالني
2004NICE GUIDELINES
Reduction in long term pain and numbness
Recurrence rates similar to open repair
Associated with fewer Surgical Site I & Haematoma
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد40 الكيالني
2008ETHICON: U.K Hernia Repairs • 15-20% of inguinal hernias repaired Laparoscopically (4.1% 2001)
• 20% of Incisional hernias repaired Laparoscopically
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد41 الكيالني
2013ASSOCIATION of SURGEONS GB &
IRELAND (ASGBI)INDICATIONS
LAPAROSCOPICPatients at risk of Chronic Pain
Groin hernias in Women (may be Femoral?)
OPEN (L.A)Older patientsSignificant Co-morbidity
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA 42 د. محمد الكيالني
2013ASGBI
Recurrent Inguinal Hernia:
• Recurrence after Open Repair Laparoscopic Repair
• Recurrence after Laparoscopic Repair Open Repair
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد43 الكيالني
2016SOCIETY AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
VENTRAL HERNIALaparoscopic V Open Repair:
• Lower rate of wound infections.• Recurrence rates and post-operative pain are
similar • Contraindications: 1. The need to remove previously placed prosthetic
mesh2. Large abdominal wall defects
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد44 الكيالني
2016SAGES
(LAP) CLOSURE OF HERNIA DEFECT
• Theoretical advantage• Not proven by good quality comparative studies
• Undertaken at the surgeon’s discretion
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد45 الكيالني
2016SAGES
SEROMA POST OPERATIVE (LAP)• Common and should be anticipated!• Reduced by:1. Cauterization of the hernia sac2. Use of pressure dressings 3. Suture closure of the hernia defect
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد46 الكيالني
LAPAROSCOPIC HERNIA REPAIR COMPLICATIONS
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA 47 د. محمد الكيالني
LAPAROSCOPIC HERNIA REPAIR COMPLICATIONS
• Visceral injury• Vascular injury• Injury to vas, spermatic vessels
• Port site hernia
• Bowel adhesions to mesh
• Intestinal obstruction
• Persistent groin pain
• Mesh infectionDR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد48 الكيالني
IMMEDIATE LATE
SUMMARYLAPAROSCOPIC
HERNIA REPAIR
Less postoperative painFewer wound
complicationsFaster return to work Improved cosmesis
LOWER INCIDENCE OF CHRONIC GROIN PAIN
BILATERAL THROUGH ONE SET OF INCISIONS
LONGER LEARNING CURVE
COST
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA 49 د. محمد الكيالني
TAKE HOME MESSAGE
WHICH HERNIA REPAIR?
INGUINAL Hernia Repair
LAPAROSCOPIC Bilateral Unilateral (choice)Women Recurrent following Open repair
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد51 الكيالني
INGUINAL Hernia RepairOPEN MESH
Unfit for GA (Spinal or Local anaesthesia)
Recurrent following LaparoscopicLarge Inguino-ScrotalDR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد52 الكيالني
VENTRAL Hernia Repair
Open Mesh: Large Ventral or Infected Mesh
Laparoscopic: Recurrent OpenSurgeon’s experience!
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد53 الكيالني
Customized Surgery…
according to Patient’s Needs!
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد54 الكيالني
Which Hernia Repair?
CONSULTANT BREAST & GENERAL SURGEON
WWW.ALHAMMADIHOSPITAL.COM
TEL: 00966 11 4250000