Informed consent

1. Inguinal hernia repair / inquinal
herniorrhaphy
Consent checklist
Raimundas Lunevicius, MD, PhD, FRCS (Engl.)

2. • What is hernia ?
– Hernias are areas of weakness or frank disruption of the fibromuscular tissues of
the body wall through which intracavity structures pass.
• What is the best treatment?
– Surgery is the only effective treatment; however, the optimal therapeutic
procedure is controversial
– Incarceration and strangulation of hernia: absolute indication for emergency surg
• rarely bowel resection required in the emergency setting for strangulated bowel
• What are benefits of surgery ?
– You should no longer have the hernia.
– Elective surgery should prevent you from having any serious complications that a
hernia can cause
• How do you do inguinal hernia repair ?
– The main principles of hernia repair for adults are
• to reinforce the floor of the inguinal canal and & tighten the internal inguinal ring.
– All surgeons agree that repairs must be tension free to minimize recurrences

3. Classification of surgical techniques for
groin hernia repair
• tissue approximation repairs
– such as the Bassini
– the McVay repair
• tension free repairs using mesh
– the Lichtenstein open tension-free hernioplasty
– a plug and patch (the Rutkow for femoral hernia)
– a preperitoneal approach
• open
• laparoscopic
– the totally extraperitoneal hernia repair (TEP)
– the transabdominal preperitoneal hernia repair (TAPP)

4. Inguinal herniorrhaphy for adults:
the choice
• Conventional anterior nonprosthetic repair: Shouldice
– Bassini, Marcy repair, Maloney darn, McVay Cooper’s ligament
repair (for femoral hernia)
• Conventional anterior prosthetic repair: Lichtenstein
• Preperitoneal prosthetic repair
– Anterior approach (Read – Rives repair)
– Posterior approach:
giant prosthetic reinforcement of visceral sac = Stoppa-Rignault-Wantz repair
– Kugel and Ugahary repairs  minimal invasive alternative

5. Are there any alternatives to elective
surgery?
• WATCHFUL WAITING
– Patients can sometimes control the hernia
with a truss (padded support belt) or
– simply leave it alone.

6. Uncomplicated postoperative
period: for majority of patients
• Day case/ over night stay
• Mild / moderate analgesia for 2 weeks
– Pain from port sites (4-5 days) or groin
incision (2 weeks)
• Full recovery
– within 4-6 weeks for open
– 2-3 weeks for laparoscopic procedures

7. What complications can
happen?
• General complications of any operation
– bleeding, blood clots, infection in the surgical
wound, unsightly scarring
• Specific complications of this operation

8. The risks associated this procedure: 7
possible complications & its’ likelihood
• Chr. postherniorrhapy (postoper)groin pain
Discomfort or pain in the groin
• Ischemic orchitis & testicular atrophyDiscomfort
or pain in the testicle on the side of the operation (orchitis)
• Hemorrhage
• Osteitis pubis
• Prosthesis-related complications
• Infection
• Urinary retention difficulty passing urine / in men

9. The risks:
Chronic postherniorrhapy groin pain
Chronic pain is defined as pain present in the groin, scrotum, or medial part of the thigh with or
without a disturbed sense of touch at the yearly follow-up visit, or discomfort with a disturbed
sense of touch found at physical examination.
• Moderate / severe pain occur in 10% of pts
• Some degree of restriction of activity is 25%
• Occurs without regard to the type of repair performed
• It can be classified into 3 types:
– Somatic (scar, reaction to mesh, osteitis..)
– Neuropathic direct nerve damage (4 +2):
• ilioinguinal, iliohypogastric, both branches of genitofemoral
n., lateral cutaneous n. of the thigh)
– Visceral (pain with urination, dysejaculation syndr.)

10. The risks:
Ischemic orchitis and testicular atrophy
• May result if a testicular blood supply is compromised
– Most likely attributable to thrombosis of veins draining
the testicle
• Orchitis: postoper inflammation of the testicle within the
first 2 postop. days  enlargement + pain
• May last several weeks / months and result in testicular
atrophy (unpredictable)
• Most pts have no history of any testicular problems
associated with the index herniorrhaphy
• The incidence at the Souldice Hospital: 0.04% - 0.5%

11. Other risks
• Postherniorrhaphy haemorrhage
– The result of delayed bleeding
– Consequences:
• a wound or scrotal hematoma
– the cremaster a, the internal spermatic artery, branches
of inferior epigastric vessels
• a large retroperitoneal hematoma
– deep circumflex a., the corona mortis, the external iliac
vessels
• Osteitis pubis:
• do not place sutures and staples through the periosteum

12. Other risks
• Prosthetic-related complications
– Tissue response is variable and unpredictive
• If it is intense  deformity, contraction of the mesh, etc..
• Surgical emphysema: for TEP
• Infections: rare
• An allergic response: extremely rare
• Contraindications to use of prosthesis:
• Patient preference, systemic infection, local infection (?),
allergy

13. Recurrence rate – most important outcome
The recurrence rate of an inguinal hernia following a primary herniorrhaphy or
hernioplasty ranges from 0.5 to 15 percent, depending upon the type of repair and
duration of follow-up (UpToDate)
• Conventional open surgery:
– at 2 years 6 %
– at 4 years 10 %
• Laparoscopic group
(totally extraperitoneal technique in which an unsplit 10 × 15-cm polypropylene mesh was placed
without fixing it):
– at 2 years 4%
– at 4 years 5%
Liem MSM, et al. Recurrences After Conventional Anterior and Laparoscopic Inguinal Hernia Repair. A Randomized Comparison. Annals of Surgery 2003; 237: 136-141.

14. Patient-related risk factors for recurrent hernia
• Clinical characteristics of patients at an increased risk of
recurrent hernias following a repair include
– Smoking
– Older age at initial hernia presentation
– Arteriosclerosis
– Diabetes mellitus
– Metabolic disorders including obesity and renal insufficiency
– Deficiency of coagulation factor VIII or vitamin C
– Steroids and chemotherapeutic agents
– Increased intra-abdominal pressure caused by postoperative
chronic cough, constipation, and bowel distention