Hernia 2015

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GENERAL SURGERY HERNIA – DR. WALLACE MEDINA

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75% of all hernias are inguinal

o 50% are Indirect (M:F= 7:1), with a right

side predominance, and 25% are direct

o 3% are inguinal hernias have sliding

component most often on the left side

(left to right ratio = 4.5:1)

14% of hernias are umbilical

10% of hernias are incisional or ventral (F:M

2:1)

3-5% of hernias are femoral

Femoral hernia least common type of groin hernia, more

commonly seen in females due to broader pelvis of female

and wider femoral space.

*minimum risk of developing hernia is about 10% (highest

=27%)*inherited hernia= 4x increase in patient with Family history

of hernia, due to Type III Collagen leads to weakening of

transversalis fascia

DIAGNOSIS REMAINS CLINICAL

1. If an incarcerated or strangulated hernia is

suspected the following imaging studies may be

helpful

2.

Upright chest radiograph to exclude free air

(extremely rare)

3. Flat and upright abdominal films to diagnose a

small bowel obstruction (neither sensitive nor

specific) or to identify areas of bowel outside

the abdominal cavity

ASYMPTOMATIC HERNIA

1.

Swelling or fullness at the hernia site

2.

Aching sensation (radiates to the areas of the

hernia)

3. No true pain or tenderness upon examination

4. Enlarges with increasing intra-abdominal

pressure and/or standing

INCARCERATED HERNIA

Painful enlargement of a previous hernia or

defect

Cannot be manipulated (either spontaneously

or manually) through the fascial defect.

Nausea, vomiting, and symptoms of bowe

obstruction (possible)

STRANGULATED HERNIA

Patients have symptoms of an incarcerated

hernia

Systemic toxicity secondary to ischemic bowel is

possible

Strangulation is probable if pain and tenderness

of an incarcerated hernia persist after reduction

Strangulated hernia are differentiated from

incarcerated hernia by the following

Pain out of proportion to examination findings

Fever or toxic appearance

Pain that persist after reduction of hernia

DIFFERENTIAL DIAGNOSES

Lipoma

Orchitis

Lymph node

Abscess

Hematoma

Hydrocele

Cysts

Varicocele

GOALS OF HERNIA SURGERY

Provide long lasting secure closure of pelvic

floor defect

Reduce pain

Improve quality of life

(MC cause of chronic pain = use of mesh)

Classically the existence of an inguinal hernia has been

reason enough for operative intervention. However

recent studies have shown that the presence o

reducible hernia is not, in itself. An indication of surgery

and the risk of incarceration is less than 1%

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The question of observation versus surgical intervention

in this asymptomatic or minimally symptomatic

population was recently addressed in 2 randomized

clinical trials. The trials found similar results, namely

that after after long-term follow-up, no significant

difference in hernia-related symptomology was noted,

and that watchful waiting did not increase the

complication rate. (Annals of Surgery, 2013)

A clinically accepted practice in elected hernia repair

1. Physically fit for surgery

2. Symptomatic patients

*No urgency in doing repair, unless incarceration

episode

*High risk with perioperative complications, and

minimal symptoms, watchful waiting is a safe option

Current indication for tissue repair

1. Male young adult patient

2. Risk of mesh infection Hernia is a clean

operation, however the presence of

strangulated hernia or the possibility of bowel

resection may contaminate the operation.

3. High risk individuals to develop pain

e.g. Female, may develop gynecologic

problems perform tissue repair

4. History of chronic pain

*bowel resection – not supported by data.

MANAGEMENT

All hernias must be repaired because they don’t

resolve spontaneously.

”En masse”reduction

Components of repair:

o Dissection of cord

o

Ligation of hernia sac (MC site:

anteromedia )

o Repair of the floor

NYHUS CLASSIFICATION

Based on

1. Patency of processus vaginalis

2. Displacement of epigastric vessel

(*hesselbach’s triangle)

3. Weakness of floor (transversalis fascia)

Type I Indirect hernia (IH) with paten

processus vaginalis onlyType II IH with enlarged internal ring only

Type III With defect (weakness) of the inguina

floor

Type IIIA Direct hernia

Type IIIB Massive IH, pantaloon and sliding

hernia

Type IIIC Femoral hernia

Type IV Recurrent hernia

Early recurrent hernia – always attributed to technica

reasons or secondary to tension

Late recurrent – metabolic type

TYPES OF HERNIA SURGERY

1. Herniotomy

Closure of processus vaginalis (defect)

Ligation of hernia sac.

Pediatric hernia

2. Herniorrhaphy

Closure of the defect, repair of pelvic

floor using tissues

3. Hernioplasty

Closure of the defect, repair of the

pelvic floor using mesh

TYPES OF REPAIR OF THE FLOOR

1. TISSUE REPAIR

Use of patient’s own tissue to create a

new floor.

Non-anatomical

15-20% recurrence

2.

MESH REPAIR

Use of prosthetic mesh in the creation

of the new floor

Serves as a bridge between two tissues

Anatomical

1-5% recurrence

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MARCY – closure of internal ring type I & II

BASSINI – approx TAA with IL, IPT; types II & III; 10% RR

McVAY - Cooper ligament – TAA; Types II,III & IV

SHOULDICE – gold standard; similar with bassini but

using continuous suturing (imbrications), 1.1% RR

APPROACH TO GROIN HERNIA

1. ANTERIOR APPROACH (all anterior repair is

herniorrhapy)

Creation of the new floor above the

transversalis fascia

Types (a-c = tissue repair)

a. Bassini

b.

McVay

c.

Shouldice d. Lichtenstein gold standard

2. POSTERIOR APPROACH

Creation of the new floor below the

transversalis fascia, preperitoneal layer

(space of Bogros)

Types

a. Nyhus repair

b. Laparascopic repair

- TAPP

- TEP

-

IPOM no longer done due to a lot

of complications

OPEN VERSUS LAPAROSCOPIC HERNIA SURGERY

A 2014 meta-analysis of seven studies comparing

laparoscopic repair with Lichtenstein technique fo

treatment of recurrent inguinal hernia concluded tha

despite the advantages to be expected with the forme

(e.g. Reduced pain and earlier return to norma

activities), operating time was significantly longer with

the minimally invasive technique and the choicebetween the two approaches depended largely on the

availability of local expertise.

COMPLICATIONS OF REPAIR

1. Recurrence (MC site? Assign#1)

2. Nerve entrapment

3. Ischemic orchitis, testicular atrophy, injury to

vas deferens

4. Bowel obstruction, adhesions

5.

Vascular injury

6. Wound infection

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Groin Anatomy

Two important openings of inguinal area

1. Internal inguinal ring – area of indirect inguinal

hernia

2. Superficial inguinal ring – direct inguinal hernia

Important to identify, because this is where thespermatic cord is located

Area of inguinal canal

MC site of sac: anteromedial, followed by anterolateral

Space of Bogros: vascular and avascular

Hesselbach’s triangle - to differentiate IH and DH

o base is the inguinal ligament

o lateral border is formed by the inferior epigastric

vessels

o Medial border is the lateral edge of the rectus

sheath.

*No hernia will close, it will remain as is or it will grow

bigger. Hernia is different from defect.

SURGICAL ANATOMY

ABDOMINAL WALL LAYER SPERMATIC CORD

1. Skin Scrotum

2. Camper’s Superficial spermatic

fascia

3. Scarpa’s External spermatic fascia

forms inguinal ligament

4.

External oblique

aponeurosis

Cremaster muscle

5. Internal oblique No derivative, forms arch

of internal inguinal ring

6. Transversus abdominis Internal spermatic fascia

7. Transversalis fascia Processus vaginalis (M)

Canal of Nuck (F)

Hernia sac

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8. Preperitoneal layer

9. peritoneum

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Hesselbach and Femoral canal

Nerves of Groin area

ILIOINGUINAL NERVE

runs medially through the inguinal canal along

with the cord structures traveling from the

internal ring to the external ring.

It innervates the upper and medial parts of the

thigh, the anterior scrotum, and the base of the

penis

ILIOHYPOGASTRIC NERVE

Runs below the external oblique aponeurosibut cranial to the spermatic cord then

perforates the external oblique cranial to the

superficial ring

It innervates the skin above the pubis

GENITAL BRANCH OF THE GENITOFEMORAL NERVE

This branch travels with the cremasteric vessels

through the inguinal canal

It innervates the cremaster muscle and provides

sensory innervations to the scrotum

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SENSORY DISTRIBUTION

LIGAMENTS OF THE INHUINO-FEMORAL CANAL

1.

ILIOINGUINAL LIGAMENT (IL) From external oblique aponeurosis; ASIS –

pubic tubercle

Crural arch, fallopian arch, femoral arch,

Poupart’s ligamentum inguinale

2. ILIOPUBIC TRACT (IPT)

Thickened lateral extension of transversalis

fascia between Cooper’s and IL

3.

Lacunar ligament Forms medial border of femoral canal

Gimbernat, ligamentum lacunae

4. Cooper’s ligament

Union of transversalis fascia and

periosteum of superior pubic ramus joins

IPT and lacunar ligament into the pubis.

LIGAMENTS OF INGUINO-FEMORAL CANAL

Inguinal hernia is a pathologic hole within the

Transversalis fascia that occurs within the area of a

poorly reinforced and ___ hernia prone anatomic hole

___ called the MYOPECTINEAL ORIFICE

MYOPECTINEAL ORIFICE OF FRUCHAUD

Boundaries

Superior: transverse abdominis, internal oblique

muscle

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Lateral: Iliopsoas muscle

Inferior: Pectin pubis (Cooper’s ligament)

Medial: Rectus muscle

This orifice is lined entirely by Tranversalis fascia

INGUINAL ANATOMY: POSTERIOR VIEW

UMBILICAL LIGAMENTS

TRIANGLE OF PAIN

Region bordered by the IPT and gonadal

vessels, and it encompassesthe lateral femoral

cutaneous, femoral branch of genitofemoral

and the femoral nerves

TRIANGLE OF DOOM

Bordered medially by vas deferens and

laterally by the vessels of the spermatic cord.

The contents of the space include the externa

iliac vessels, deep circumflex vein, femora

nerve and genital branch of genitofemora

nerve.

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Highlighted in the PPT

Recording from Dr. Medina’s lecture

Hernia 2015

Documents

Transcript of Hernia 2015