Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies •...

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Its just a hernia ! Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, Hepatobiliary and Pancrea?c Surgeon Auckland City Hospital

Transcript of Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies •...

Page 1: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Its just a hernia !

Mr.SanjayPandanaboyanaMS,FRCS(UK),MPhilGeneral,HepatobiliaryandPancrea?cSurgeon

AucklandCityHospital

Page 2: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Its just a hernia !

•  Sportsman'shernia

•  Laparoscopicversusopenherniarepair• ACCandInguinalherniacover

Page 3: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Sportsman's hernia

Gilmore’sherniaIncipientherniaAthle3cPubalgiaSoccerplayergroinSportsman'sgroinHockeygroinsyndrome

Page 4: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinaldisrup-on

Page 5: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinal disrup7on Noactualhernia!!!ThepaintypicallyaHersportsac?vity,getsbeJerwithrest,returnswithsportsac?vityAbnormalincreasedtensionintheinguinalcanal1.   Posteriorwallweakness2.   Conjointtendondamage3.   TearsintheinguinalligamentGenerallyabovetheinguinalligament

Page 6: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinal disrup7on: Differen7al diagnosis

•  Acetabularinjury

•  Pubicramusfractures•  Ostei?spubis

•  PubicSymphysi?s•  Hippathology

Page 7: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinal disrup7on: Pain zones

Page 8: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

PinpointtendernessoverthepubictubercleTendernessonthedeepinguinalringTendernessonsuperficialinguinalringPainattheoriginofadductorlongustendonDiffusedullpaininthegroin,radia?ngtotheperineumandinnerthigh

Page 9: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinal disrup7on: Inves7ga7ons

• Ultrasoundoftheinguinalcanal• MRIpelvistoexcludeotherpathology

Page 10: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinal disrup7on: Is surgery always advised? Algorithm for the management of inguinal disrup7on

Page 11: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Issurgeryeffec?ve?

RandomisedintoOpera?ve(n=30)orphysiotherapygroup(n=30)Opera?verepairwasmoreeffec?vetodecreasechronicgroinpainaOer1monthandupto12monthsoffollow-up(P<0.001).90%intheopera?vegroupreturnedtosportsac?vi?esvs.27%inthenonopera?vegroup.Laparoscopicmeshreinforcementwasmoreefficientthanconserva?vetherapy

Page 12: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Laparoscopic mesh reinforcement

Page 13: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Inguinal hernia

Laparoscopicoropensurgery?

Page 14: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

•  34RCT’sincluding6804pa?ents

•  Dura?onofopera?on:Longerinthelaparoscopicgroup•  VisceralandVascularinjuriesmorefrequentintheLaparoscopicgroup4.7%per1000

•  Postopera?vepain:lowerinthelaparoscopicgroup•  Lengthofhospitalstaysimilarinbothgroups•  Recurrenceratessimilarbothgroups

•  ChronicgroinpainandnumbnessaresignificantlyreducedbyLaparoscopicapproach

Page 15: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Concomitant femoral and inguinal hernias

•  11%oflaparoscopicinguinalherniarepairshaveconcomitantfemoralhernias

•  51%ofFemoralherniarepairpa?entshaveconcomitantInguinalhernias

Page 16: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

ACC and Inguinal Hernia

Doesasinglestrenuouseventcauseainguinalhernia?

Page 17: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Does a single strenuous event cause a inguinal hernia?

Strenuousevent! Inguinalhernia!

Page 18: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

520herniarepairpa?entssentques?onnaires.62%(320)responserate.

51%oftheherniasweregradualinonsetandin42%ofherniastherewasaassocia?onbetweenastrenuouseventandsuddenonsetofhernia.91%ofpa?entsreportedgroinpainatthe?meoftheevent74%ofpa?entshadindirectherniasinthesuddenonsetgroup.

Page 19: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Other studies

•  SmithGD,CrosbyDL,LewisPA(1996)Inguinalherniaandasinglestrenuousevent.AnnRCollSurgEngl78(4):367–368

•  PathakS,PostonGJ(2006)ItishighlyunlikelythatthedevelopmentofanabdominalwallherniacanbeaYributabletoasinglestrenuousevent.AnnRCollSurgEngl88(2):168–171

•  HendryPO,Paterson-BrownS,deBeauxA(2008)Workrelatedaspectsofinguinalhernia:aliteraturereview.Surgeon.6(6):361–365

Page 20: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

ACC and RACS consensus statement 2016

•  Thepa?entreportsthatasinglestrenuouseventhascausedthehernia•  Significantgroinpainatthe?meoftheevent,enoughceaseac?vity•  Onexamina?on:Groinlump•  Diagnosisismadewithin10daysofthestrenuousevent•  Ifstrenuouseventoccurredatwork,incidentofficiallyreportedtoworkplace

Page 21: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

ACC and RACS statement

•  Imagingi.e.Ultrasoundisnotnecessary.Clinicaldiagnosisissufficient

•  Nodis?nc?onbetweendirectandindirectherniaisneeded

Accuratedocumenta3onisessen3al!

Page 22: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Indica-onforsurgery:Symptoma-chernia!

Page 23: Mr. Sanjay Pandanaboyana MS, FRCS (UK), MPhil General, … · 2019-02-24 · Other studies • Smith GD, Crosby DL, Lewis PA (1996) Inguinal hernia and a single strenuous event. Ann

Thank you


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