The document discusses inguinal hernia repair techniques. It notes that inguinal hernias are very common, with over 20 million repairs performed worldwide each year. There are several open and laparoscopic repair options, but the optimal technique is unknown. The document argues that the Lichtenstein open mesh repair technique is the gold standard, as it has low recurrence and complication rates, a short learning curve, and can be performed under local anesthesia. In contrast, laparoscopic repair has a long learning curve, higher costs, and risks of serious complications. The document concludes that open repair is best for most patients due to its safety, low cost, and technical simplicity.

1. Dr. Vinay H D
Dept. of Surgery,
RIMS, Imphal
11th OCT, ASIMANICON 2015

2. Hi, Hands up for Open Hernia Surgery……….
11th October, ASIMANICON 2015

3. Disclosures
No Disclosures
11th OCT, ASIMANICON 2015

4. Why is this a hot topic ?
Surgical repair of inguinal hernias is a common
procedure.
However, recurrence of hernias has been reported to
occur after repair in 15 % or more cases, and
postoperative pain and diability are frequent.
But the most effective surgical technique is unknown.
11th OCT, ASIMANICON 2015

5. What’s the burden ?
• Abdominal wall hernias are common(occur in at least
2% of men1)
• USA 15 per 1000 population (1.5%).2
• >20 million hernias are repaired every year around the
world.3
• Per year 800,000 hernia repairs are carried out in the
USA,4 and over 100,000 in the UK.
11th OCT, ASIMANICON 2015

6. Inguinal Hernia - epidemiology
• Very Common
• Life Time Risk: % : 27 M :3 F
• >20million Repairs/yr/worldwide
• 100-300 / 100000 / yr
• 100,000 in UK /yr
• 800,000 in US
• Approx > ?? in India /yr
1. Primatesta P, Goldacre MJ. Inguinal hernia repair: incidence of elective and
emergency surgery, readmission and mortality. Int J Epidemiol 1996;25:835-9.
2. Kingsnorth AN, LeBlanc KA. Management of abdominal hernias. 3rd ed.London,
New York: Edward Arnold, 2003:40-7.
3.Samir S A, Shawn P F .Current Approach to Inguinal Hernia Repair. Am J Surg
2004;188-6;9-16
4. Richard Burnley: http://online.epocrates.com/u/2942723/inguinal+hernia 2012
Dec: BMJ Content

7. Are there complications ?
In general, patients with uncomplicated inguinal and
abdominal wall hernias do well.
Hernia can lead
• incarcerated and often obstructed bowel
• strangulated bowel,
• can result in bowel perforation and peritonitis.
• Mortality is 10% for those who have hernias with
associated strangulation.
11th OCT, ASIMANICON 2015

8. Inguinal Hernia Repair
options a complex choice
• Open primary suture repair
Shouldice, Bassins
• Openmesh Repair
Lichtenstein, Kugal, PHS, Plug/Patch
• Laparoscopic Repair
TEP, TAPP, IPOM
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9. Lichtenstein
• Open incision
• Mesh placed anteriorly
• Adequate fixation
• Gold Standard by which
tension free repairs are
measured
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10. kugel
• Open / laparoscopic
• Limited visualization
• Mesh (heavy weight polypropylene) may migrate and
shrink
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11. Plug and Patch
• Open incision
• Limited mesh coverage
• Fixation varies
• Plug (heavy weight
polypropylene) may
migrate and contract
• May lead to increased
chronic pain
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12. Prolene Hernia System
• Open incision
• Mesh coverage preperitoneal
and anterior to defect
• Heavy weight polypropylene
• Some learning curve
(knowledge of preperitoneal
anatomy similar to the Kugel
& laparoscopic approaches)
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13. Primary Suture Repair
• Open incision
• Repair under tension
• Recurrence can occur over time
• Has decreased in popularity (not dead yet)
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14. Ideal method of hernia repair
• Minimal discomfort both during the surgery &
post op.
• Technically simple to perform & easy to learn
• Low rate of complication & recurrence
• Require only a short period of convalescence
• Finally cost effective is important.
11th OCT, ASIMANICON 2015

15. Lichtenstein Open Hernia Surgery
• Suitable for all adults, irrespective of age, weight,
general health, medical problems.
• Time tested procedure
• Can be done under local anaesthesia
• Considered as Criterion Standard, Gold Standard
by which tension free repairs are measured
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16. Lichtenstein Open Hernia Surgery
Preferred:
• Large Scrotal (irreducible) Hernia
• Major Lower Abdominal Surgery
• No General Anaesthesia – C/I
• Learning curve 5 cases
• Time tested safe & economical
• Low operation time
• Low complication
• Gold standard
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17. Laparoscopic Hernia Surgery
“Laparoscopy is only an approach, not a procedure”
Laparoscopic complications:
Disastrous like
– Laparoscopic injuries
– Bowel obstruction
Effect of GA/ Pneumo-peritoneum/ ACS/ Cardio Pulmonary
effects, Retention
More Expensive
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18. It is not Minimally
Invasive Surgery,
Its Minimally
Access Surgery
only.
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19. Laparoscopic Hernia Surgery
• Learning curve (200-300 cases)
• Long term recurrence are lacking.
• Longer operation time.
• C/I in strangulated hernia, sliding hernia,
irreducible hernia & patients who are elderly or have
co-morbid conditions.
• Laparoscopic hernia repair can be not be
performed as day care surgery or under local
anesthesia
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28. To Conclude
• Open Mesh Repair is economical, easy to teach & learn
without any steep learning curve.
• Doesn’t need any specialized training.
• Results same in all centers.
• Does not carry any risk of serious visceral or bowel injuries.
• Is suitable for all types of groin hernias including
strangulated, irreducible, sliding hernia or elderly patients
and patients with co-morbidity.
• Is ideal for day-care surgery, especially under local
anesthesia.
11th OCT, ASIMANICON 2015

29. To Conclude
• Laparoscopic Hernia Repair is more costly; difficult to
learn, steep learning curve.
• Risk of serious visceral and or vascular injuries.
• All cases of groin hernia are not suitable for laparoscopic
hernia repair as it is contraindicated in strangulated, sliding,
irreducible and patients who are elderly or have co-morbid
conditions.
• Laparoscopic hernia repair can be not be
performed as day care surgery or under local anesthesia.
11th OCT, ASIMANICON 2015

30. Lets contact: drvinayhd@gmail.com
Thank You
No disease of the human body, belonging to the province of the
surgeon, requires in its treatment a greater combination of accurate
anatomical knowledge with surgical skill than hernia in all it’s
varieties.