SURGICAL OPTIONS IN THE MANAGEMENT OF INGUINAL HERNIAS

Mohammed Al-Saffar

outlines

Definition Epidemiology Anatomy Surgical management options

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

femoral

Epidemiology

Epidemiology

Predisposing factors

Epidemiology

Bimodal peak age : < 1 year then > 40 years

Right-sided groin hernias are more common than those on the left.

Types of hernia - Condition

Inguinal Canal Anatomy

No disease of the human body, belonging to the province of the

surgeon, requires in its treatment a better combination of accurate,

anatomical knowledge with surgical skill than Hernia in all its varieties.

Sir Astley Cooper, 1804

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

Important ligaments

Contents of the inguinal canal

Males : spermatic cord and ilioinguinal nerve

Females : round ligament and the ilioinguinal nerve

The spermatic cord

It consists of Three coverings Three arteries Three other structures. Nerves

The Spermatic Cord

Preperitoneal space

Space of Retzius Space of Bogros Inf. Epigastric Vas deferens the lateral

femoral cutaneous nerve

the genitofemoral nerve.

Management

Uncomplicated hernias require either : No treatment Support with a truss Operative treatment

complicated hernias : always require surgery, often urgently.

Should we repair ?

Inguinal hernia : should we repair ?

Inguinal hernia : should we repair?

Surgical approaches

For any hernia the surgical option comprises 2 components : Herniotomy Herniorrhaphy or hernioplasty

It is either : Open repair Laparascopic repair

Surgery

Surgery aims to Reduce the hernial contents Excise the sac (herniotomy) in most cases Repair and close the defect either by

herniorrhaphy or hernioplasty

Components of the hernia

Hernial Sac Dissection

Types of open repair

Repairing the floor of the inguinal canal : Bassini repair Shouldice repair Tension free mesh repair

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.

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.

Shouldice repair

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.

The 2nd 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.

Shouldice repair

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.

Shouldice repair

The cord is replaced within the inguinal canal, and the external inguinal aponeurosis is reapproximated with continuous 2-0 absorbable sutures

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.

Tension – free repair

Tension – free repair

Prolene hernial system

Comparison of open approachs

Recurrence rate “ PGY“

Laparoscopic Repair

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

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

Advantages of laparoscopic

Less acute postoperative pain Shorter convalescence Earlier return to work

Disadvantages

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.

Laparoscopic Approaches

Laparoscopic repair is done by 2 approaches :1. Transabdominal preperitoneal “TAPP”2. Totally extraperitoneally “TEP”

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.

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.

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Thank You

Complication

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