Groin hernia prof.f.villeke

Minimal invasive
groin hernia repair (not only)

Frank Willeke
St.Marien-Hospital Siegen
Teaching Hospital of the Philips-University Marburg

with Thomas Neufang and Stefan Post

Department of General-, Visceral- and Vascular Surgery

Topics

• Overview
• Hernia type and classification
• Approach and surgical technique
• Mesh: Design, Position, Fixation
• Hernia recurrence
• avoiding complications
• managing hernias – a suggestion

Klinik für Allgemein- Viszeral und Gefäßchirurgie

Hernia location
Transversusarkade
Hesselbach Triangle indirect
direct

femoral

Posterior aspect

epigastr.
NYHUS Hesselbach ∆ vessels

CONDON

iliopubic tract

Clinical examination!!!


• Overview


direct

indirect


Anatomie -
Operationstechnische
Aspekte
• Overview


Bassini
Bassini
Mc Vay anterior
anterior
Mc Vay
Shouldice
Shouldice
Lichtenstein
Lichtenstein anterior
Cutis
Subcutis
inguinal canal
posterior wall
extra-
extra-
peritonal preperit. space
peritonal
peritoneum TAPP
TAPP
Nyhus
Nyhus
posterior
Stoppa
Stoppa
EEHP
transabdominal
transabdominal
EEHP posterior
posterior

Shouldice

Lichtenstein

Transperitoneal
TAPP


Rectus sheath

Rectus muscle

Arcuate line

Peritoneum

R. genitalis
n. genitofemoralis
SHOULDICE: resection of cremaster muscle
LICHTENSTEIN: no resection
TEP / TAPP: no resection
u.a. nach Schumpelick

MESH…

• Overview


sublay
intraabd.
pressure

onlay

Lichtenstein TAPP, EEHP

SHOULDICE reconstruction:
small diameter, lateralisation

LICHTENSTEIN:
less tight, "sling" - principle na c h SHULM N
A

TAPP

preperitoneal mesh
incison

Incison = weak area

Mesh incison ...


TEP (EEHP) Neufang style:
weak area = incison = covered by “wing”

technical details I

• Scrub the lower abdomen with wide lateral margins
• Antibiotics prophylaxis, Foley catheter
• Small median subumbilical incison
• Transverse opening of the anterior rectus sheath
• Lifting the rectus muscle with a retractor
• Opening the preperitoneal space with a pean clamp with
a wet small sponge on the tip
• Introduce ballon trocar or similar device, ideally under
camera control, inflate and visualize the inflation of the
preperitoneal space


Trocar position

☺ ☺

● ☼ ● ●
= 5 mm

●

screen

mesh configuration
5 - 6 cm 6 cm

12 cm

15 cm


technical details II

• Place a special trocar or a Hassan trocar and start to
inflate CO2 with 12 mm Hg
• Place a 5mm trocar under vision in the midline
• Open the dissection plane, slowly preparing laterally,
leaving the epigastric vessels cranially at the abdominal
wall
• Place a 5 mm trocar on the side of the hernia under
vision through the abdominal wall 3 cm cranial to the
anterior iliac crest
• Carefully dissect (usually blunt) the peritoneum cranially
with reposition of the hernia sac


technical details III

• pull the lipoma out of the funiculus
• check meticulously for indirect hernia
• check the femoral region without dissection of the fatty
tissue on the iliac vessels
• reduce large medial hernias (Roeder sling, suture)
• make sure the funiculus is free for mesh placement
underneath
• prepare the mesh and introduce it into the preperitoneal
space through the 10 mm trocar (blind)
• Unfold the mesh, place it medial to the later position and
first make the pull through under the spermatic cord


technical details IV

• Relieve the stay suture at the lateral mesh and place it
correctly
• Open the stay suture at the wing and place the wing
properly over the spermatic cord structures
• Relieve some CO2 and check for bleeding
• In case of some oozing, place a redon over the lateral
trocar
• Hold the mesh in position while deflating the
preperitoneal space
• Closure of facia at the subumbilical trocar, skin closure
with resorbable suture

Recurrence…

• Overview


Typical for hernia
recurrence…

• Defect frequently in the
medial corner of
Hesselbach
• Cranial position of
iliopubic tract = opening
of femoral hernia
• Lateralization of
funiculus / inner groin
ring
• Cave! Funiculus in a
subcutaneous position


do we have complications?

• Overview


testis

• Be careful with the vessels
• Have an urologist in your team or
as a friendly consultant


many nerves in the groin region

Iliohypogastric nerve

Ilioinguinal nerve

Genital branch
genitofemoral nerve

Nerves coming anteriorly
nach AMID

Cave: ∆ of pain

?


which mode for…

Shouldice Lichtenstein EEHP TAPP

bilateral - - + -
recurrence Ø - + +
< 18 years + Ø Ø Ø
Sportive Ø - + +
femoral Ø Ø + +
female + - + +
equivocal Ø Ø - +
incarceration -/+ - Ø -/+

+ good - less good Ø not suitable

some details…

Shouldice Lichtenstein EEHP

Antibiotics* - + +
Redon - - -
Skin closure intracutan. intracutan. intracutan.

 Arguments for antibiostics:  Arguments for drainage:
- adipositas? - adipositas?
- Recurrence? - recurrence
- bilateral? (EEHP!)
* 2nd generation cephalosporins

management…
Shouldice* Lichtenstein* EEHP

demission ∼ 3. day ∼ 3. day ∼ 2. day
work 14 days 14 days 10 days
normal
physics 10 days 10 days 10 days
heavy
physics 6 - 8 weeks 14 days 10 days

* Outpatient procedure possible


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Groin hernia prof.f.villeke

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