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...
Epidemiology
Epidemiology
Predisposing factors
Epidemiology
   Bimodal peak age : < 1 year then > 40
    years
   Right-sided groin hernias are more
    common than th...
Types of hernia - Condition
Inguinal Canal Anatomy

   No disease of the human body, belonging
    to the province of the surgeon, requires in
      ...
Inguinal Canal Anatomy
   The inguinal canal is an oblique space
    measuring 4 cm in length that lies above
    the med...
Important ligaments
Contents of the inguinal canal

   Males : spermatic cord and ilioinguinal
    nerve

   Females : round ligament and th...
The spermatic cord
   It consists of
     Three coverings
     Three arteries

     Three other structures.

     Ner...
The Spermatic Cord
Preperitoneal space
   Space of Retzius
   Space of Bogros
   Inf. Epigastric
   Vas deferens
   the lateral femoral
...
Management
   Uncomplicated hernias require either :
     No treatment
     Support with a truss

     Operative treat...
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

     Herniorrha...
Surgery
   Surgery aims to
     Reduce   the hernial contents
     Excise the sac (herniotomy) in most cases

     Rep...
Components of the hernia
Hernial Sac Dissection
Types of open repair
   Repairing the floor of the inguinal canal :
     Bassinirepair
     Shouldice repair

     Ten...
Bassini repair
   The conjoined tendon is retracted upward
   the aponeurosis of the transversus abdominis
    muscle is...
Shouldice Repair
   With a no. 15 scalpel an incision is made in
    the transversalis fascia. This incision is
    exten...
Shouldice repair
   The first suture line
       is started at the pubic tubercle using 3-0
        continuous polypropy...
Shouldice repair
   The third suture line is started at the level of
    the internal ring where the conjoined
    tendon...
Shouldice repair
   The cord is replaced within the inguinal
    canal, and the external inguinal
    aponeurosis is reap...
Tension – free repair
   There are several options for placement of
    mesh during anterior inguinal
    herniorrhaphy, ...
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
    uncerta...
Contraindications
   The patient medical condition makes
    general anesthesia more risky
   Patient who have planned p...
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 devel...
Laparoscopic Approaches
   Laparoscopic repair is done by 2
    approaches :
    1.   Transabdominal preperitoneal “TAPP”...
Transabdominal Preperitoneal

   The TAPP approach, first described by
    Arregui and colleagues in 1992

   It require...
Totally extraperitoneally
   The first TEP inguinal hernia repair was
    described by McKernan and Laws in1993.

   Thi...
The Mercedes Benz sign
Thank You
Complication
   Urinary retention
   Nerve injury
   Testicular ischemia and atrophy
   Injury to vas deferens
   rec...
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
Surgical Options In The Management Of Hernia Repair
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Surgical Options In The Management Of Hernia Repair

  1. 1. SURGICAL OPTIONS IN THE MANAGEMENT OF INGUINAL HERNIAS Mohammed Al-Saffar
  2. 2. outlines  Definition  Epidemiology  Anatomy  Surgical management options
  3. 3. 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
  4. 4. Epidemiology
  5. 5. Epidemiology
  6. 6. Predisposing factors
  7. 7. Epidemiology  Bimodal peak age : < 1 year then > 40 years  Right-sided groin hernias are more common than those on the left.
  8. 8. Types of hernia - Condition
  9. 9. 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
  10. 10. 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
  11. 11. Important ligaments
  12. 12. Contents of the inguinal canal  Males : spermatic cord and ilioinguinal nerve  Females : round ligament and the ilioinguinal nerve
  13. 13. The spermatic cord  It consists of  Three coverings  Three arteries  Three other structures.  Nerves
  14. 14. The Spermatic Cord
  15. 15. Preperitoneal space  Space of Retzius  Space of Bogros  Inf. Epigastric  Vas deferens  the lateral femoral cutaneous nerve  the genitofemoral nerve.
  16. 16. Management  Uncomplicated hernias require either :  No treatment  Support with a truss  Operative treatment  complicated hernias :  always require surgery, often urgently.
  17. 17. Should we repair ? Inguinal hernia : should we repair ?
  18. 18. Inguinal hernia : should we repair ?
  19. 19. Surgical approaches  For any hernia the surgical option comprises 2 components :  Herniotomy  Herniorrhaphy or hernioplasty  It is either :  Open repair  Laparascopic repair
  20. 20. 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
  21. 21. Components of the hernia
  22. 22. Hernial Sac Dissection
  23. 23. Types of open repair  Repairing the floor of the inguinal canal :  Bassinirepair  Shouldice repair  Tension free mesh repair
  24. 24. 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.
  25. 25. 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.
  26. 26. 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.
  27. 27. 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.
  28. 28. Shouldice repair  The cord is replaced within the inguinal canal, and the external inguinal aponeurosis is reapproximated with continuous 2-0 absorbable sutures
  29. 29. 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.
  30. 30. Tension – free repair
  31. 31. Tension – free repair
  32. 32. Prolene hernial system
  33. 33. Comparison of open approachs
  34. 34. Recurrence rate “ PGY “
  35. 35. Laparoscopic Repair
  36. 36. 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
  37. 37. 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
  38. 38. Advantages of laparoscopic  Less acute postoperative pain  Shorter convalescence  Earlier return to work
  39. 39. 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.
  40. 40. Laparoscopic Approaches  Laparoscopic repair is done by 2 approaches : 1. Transabdominal preperitoneal “TAPP” 2. Totally extraperitoneally “TEP”
  41. 41. 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.
  42. 42. 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.
  43. 43. The Mercedes Benz sign
  44. 44. Thank You
  45. 45. Complication  Urinary retention  Nerve injury  Testicular ischemia and atrophy  Injury to vas deferens  recurrence
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