MY JOURNEY WITH HERNIA SURGERY

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A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.There are different kinds of hernia, each requiring a specific management or treatment.
SIGNS AND SYMPTOMS
By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm.
Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ.
Hernias are not tears in the tissue but are openings in the adipose tissue. It is possible for a hernia to come and go, but in most cases a pain will persist.
Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.
Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Strangulated hernias are always painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink.
In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately.

CAUSES OF HERNIA
Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, and incorrect posture.
Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate).

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  • By way of review, it is important to remember that a hernia is a defect in the wall that allows the extrusion of tissues normally contained by that wall. The most common types of hernias include epigastric, femoral, incisional, inguinal, umbilical, and ventral. Inguinal hernias, which can be divided into indirect and direct hernias, are by far the most common.
    Gilbert1 and Condon2 described their interpretation of the anatomy. The inguinal canal's posterior wall is a lamina of 2 layers, the transversalis fascia covered by the aponeurosisof the transversus abdominus (TAA) muscle. Defects in strands of the TAA near the lower part of the inguinal canal allow the transversalis fascia to penetrate the lamina and form direct hernias.
    It is no wonder that the inguinal canal is open to herniation. As Lichtenstein3 has explained:
    “When the internal oblique and transversus muscles are relaxed, thereis an interval between their lower border and Poupart's ligament, whichis filled by the thinned and often diaphanous transversalis fascia. Whenthese muscles contract their lower edges approximate Poupart's ligamentlike a shutter or curtain, thus diminishing the inguinal gap. Since thetransversalis fascia is the only cover bridging the gap, it is the key areaof the 'Achilles heel' of the groin. It is the only portion of the abdominalwall not protected by a musculo-aponeurotic layer. The very presence ofa hernia is proof that this fascia is inadequate.”
    References
    1. Gilbert AI. Inguinal hernia repair: biomaterials and sutureless repair. Perspectives in General Surgery.1991;2:113-129.
    2. Condon. Hernia. 4th ed. JB Lippincott Co. Philadelphia; 1995:16-72.
    3. Lichtenstein IL, Shulman AG, Amid PK, Montllor MM. The tension-free hernioplasty. Am J Surg.1989;157:188-193.
    Hiatal Hernias occur within the abdomen, not on the abdominal wall. These are hernias through the diaphragm. As a result, acid refluxes from the stomach into the esophagus causing pain, heartburn, and ulceration of the esophagus. Treatment is mostly medical, but when surgery is necessary, the TENSION FREE method is not appropriate, and these hernias are repaired either through a Laparoscope, or with a formal surgical incision.
  • Bassini repair is easy to do because of the simplicity. The thoroughness of their dissection reveals an anatomy that lends itself to reliable repair.
    Eduardo Bassini   (1844 - 1924) Professor of Surgery Padua, Italy   Early advocate Listerian antisepsis   1st to perform anatomical repair  of hernia : flush ligation of sac, 3 layer closure of posterior wall   Follow-up of post operative patients done for the 1st time  
      
    .
  • The difference between the Shouldice and Bassini repair is subtle – the essential difference is in the reconstruction of the posterior inguinal wall, which in the Bassini repair is carried out with interrupted sutures while the Shouldice uses continuous sutures back and forth (four lines), creating an overlap.
    Earl Shouldice ( 1953)   Canadian Surgeon   Specialist in Hernia Surgery   Shouldice repair became the industry standard   Recurrence rates after Shouldice repair :   Shouldice Hospital –  0.5%   Specialist centers -  1-3%   Shouldice in trials -  4-10%   Shouldice at large -   ? 15%  
  • Other potential complications may include :
    Pain - tissue damage and nerve damage
    Vascular injury
  • Still most common approach performed today (US)
    This is a tension free repair performed "open" under local anesthesia. A mesh is applied OVER the weakness and sewn in place. This surgery has the advantage of safety with the use of local anesthesia, and direct visualization of the hernia, without using a "telescope". The incision is about 3-4 inches in length. However the recurrence rate here is still a bit high, in some series as high as 4-7%. There is a great deal of surgical dissection which causes post operative pain and slightly prolonged recovery. We feel that placing the mesh "over" the weakness only is like repairing a "bubble in a tire" by patching it on the outside. A recurrent hernia may eventually LIFT the mesh up. We strongly believe that if mesh is used, it should be placed inside of the weakness, under the muscle, not on top.
  • We are now convinced that this technique is truly the "STATE OF THE ART" in hernia surgery, providing the safest, most effective repair with the least post-operative pain. This technique is done under safe, local anesthesia via a small incision ( about 2 inches in most average patients). Once the hernia (bulge) is freed up by gentle dissection, it is returned through the hole or weakness into its proper position. Rather than just covering the weakness at this point, a specially designed mesh system is gently placed through the defect. It opens to cover and effectively repair the defect from the inside, the best place for mesh to be positioned. After this, an additional sheet of mesh is included over the defect as an insurance reinforcement. This is placed in a completely tension free fashion, being held in place by a "VELCRO-Like" effect of the mesh itself. Since there is no tension and only a minimal amount of surgical dissection, there is little post operative pain, and patients return to NORMAL ACTIVITY in DAYS. With recurrence rates of Less than 1/2 %, lower than any other technique including the conventional suture repairs, (TENSION REPAIR), or the Laparoscopic "Keyhole"Approach.
  • Laparoscopic Repair   Ger - intraperitoneal closure of deep ring only  (1982) Franklin -  TAPP repair  (1990) Fitzgibbons - IPOM repair  (1992) McKernan - TEP repair  (1993 ) 
    Primary hernia – consider open mesh repair  ( Open mesh repair is becoming the industry standard)  Recurrent or bilateral - consider TEP    Laparoscopic repair must be done only by trained teams doing them regularly  
    This operation involves placing a mesh onto the hernia defect from inside the abdomen. It requires GENERAL ANESTHESIA (patient goes to sleep) which is associated with definite risk. Instruments and telescope are stabbed through the abdominal wall, risking injury to the intestine. These instruments are used to position the mesh over the weakness, held in place with staples. While the post operative discomfort is relatively small, the recurrence rate approaches 10-11% or more in recent published reports, which we believe is entirely too high. This landmark study published in the highly respected New England Journal of Medicine in April 2004 (vol. 350 no. 18), concluded that "The open technique is superior to the laparoscopic technique for mesh repair of primary hernias (L. Neumayer, A. Giobbie-Hurder, O. Jonasson, R. Fitzgibbons, D. Dunlop, et al. 2004)". Moreover, "the laparoscopic technique requires general anesthesia (because the abdominal cavity has to be inflated with air) and it is more often associated with serious intra-operative complications than is open repair...( Lancet 1999;354: 185-90)."
  • In the transabdominal preperitoneal (TAPP) repair, the peritoneal cavity is entered, the peritoneum is dissected from the myopectineal orifice, mesh prosthesis is secured, and the peritoneal defect is closed. This technique has been criticized for exposing intra-abdominal organs to potential complications, including small bowel injury and obstruction.
    Following induction of anesthesia, the supine patient is placed on the operating table with the arms to the side and in a 10-20° Trendelenburg position. This helps with the reduction of hernias and allows the intestines to gravitate into the upper abdomen. The TV monitors are placed at the patient’s feet and the Surgeon and Assistant stand on either side. A Verres needle is inserted through a small supra-umbilical incision and a pneumoperitoneum formed. A midline camera trocar (Ethicon 10mm dilating tip port) is inserted and the groins assessed. In younger patients (below 30 years) or in patients with previous abdominal surgery, an optical trocar (Visiport Auto-Suture) is used to enter the peritoneal cavity. This instrument is blunt ended with a single spring-loaded blade which cuts through tissues 1 mm at a time. With the camera inserted this allows entry into the peritoneal cavity under direct vision and avoidance of underlying or adherent structures. Following the successful placement of the camera port, a telescope is placed to trans-illuminate the abdominal wall. This allows mapping of the abdominal wall vessels and the placement of lateral ports in an avascular area. The lateral ports are usually placed in the mid-clavicular line in the region of the umbilicus, the exact placement depending upon whether the repair is to be unilateral or bilateral. The pre-peritoneal space is then entered by incising the peritoneum transversely from the region of the medial umbilical ligament laterally and anterior to the hernia defect. Peritoneal flaps are then developed. Direct sacs and small indirect sacs are fully reduced. Larger indirect sacs are part dissected and having freed the cord structures posteriorly, circumcised,. The distal part of a large sac is left insitu. The anatomy is then defined and the posterior flap fully developed, the dissection going at least 5cms posterior to the internal ring. Medially the dissection is carried to the symphysis pubis. A 15 x 10 cm mesh is then fashioned and inserted. The medial border of the mesh is adjacent to the symphysis pubis and the posterior part is placed well behind the internal ring. When the mesh is satisfactorily placed, it is stapled in place, staples being applied to the pubic bone and Cooper’s ligament. Further staples are placed into the muscle layers anteriorly but none into the ileo-pubic tract or posterior to this. If the hernia is bilateral, the same procedure is performed on the contra-lateral side, a second mesh being used. The peritoneum is then reconstituted by stapling and the operation completed by closing the external oblique at the port sites and placing subcutaneous sutures to the skin.
  • The totally extraperitoneal (TEP) repair maintains peritoneal integrity, theoretically eliminating these risks while allowing direct visualization of the groin anatomy, which is critical for a successful repair. The TEP hernioplasty follows the basic principles of the open preperitoneal giant mesh repair, as first described by Stoppa in 1975 for the repair of bilateral hernias.
  • It is important to understand the abdominal wall anatomy.
    Of particular note is
    Linea alba (white line)
    Rectus abdominus muscle
    Anterior layer of the rectus sheath
    Transversalis fascia
    Posterior layer of the rectus sheath
    Peritoneum
  • There are basically three types of repair for the ventral/incisional hernia
    Primary Repair (suture)
    Mesh Repair – Open
    Mesh Repair- Laparoscopic
  • This is also known as the Rives-Stoppa repair
  • The laparoscopic technique is one of the latest advances in the repair of Ventral/Incisional hernias. It is a true intraperitoneal approach done laparoscopically.
  • The reason why a prosthetic “tension free” repair will work best when used in a posterior approach is because the body’s own physical principles are acting with the prosthetic as opposed to against it or against the suture repair. When sutures are used anteriorly, abdominal pressures are acting on the suture forcing the suture apart. When a mesh is placed intra-abdominally with a 3-5cm overlap around the defect, the abdominal pressures are actually helping to keep the mesh in place.
  • These are the things to be considered in the surgeon’s choice of a prosthetic material
    Is it macroporous or microporous ( - infection potential_
    Is it going to be used intraperitoneally or pre-peritoneal ( adhesion potential)
    Is it a large amount of foreign body ( scar plate formation)
    Can the fascia be put back together (tissue integration)
  • This is just an example of the types of prosthetic devices that are on the market for ventral/incisional hernia repair, starting from the heavier weight meshes introduced in the 1950’s to the lighter weight products used today
  • MY JOURNEY WITH HERNIA SURGERY

    1. 1. A JOURNEY WITH HERNIA SURGERY Dr.Sreejoy Patnaik. Shanti Memorial Hospital.
    2. 2. • •Hippocrates used the Greek hernios for bud or bulge to describe abdominal hernias
    3. 3. Hernia
    4. 4. •Huge Inguinal Hernias
    5. 5. Definition • An abnormal protrusion of the contents of a closed cavity through a potential or an abnormal opening
    6. 6. Describing a Hernia •Femoral •Epigastric •Umbilical •Diaphragmatic •(Hiatal Hernia) •Incisional/Vent ral •Inguinal
    7. 7. THE HISTORY OF SURGERY IS ALMOST AS OLD AS LIFE ITSELF
    8. 8. Famous hernia patient Galileo Galilei (15641642) was incapacitated by an irreducible hernia in his later life.
    9. 9. Medical causes for the formation of HERNIAS CAUSES OF HERNIAS INCREASED PRESSURE INSIDE WEAKNESS OF THE WALLS
    10. 10. Causes Of Increased Pressure IN C R E A S E D PR ESSU R E F at P U T T IN G O N W E IG H T F F F a e ce s & la t u s SEV ERE C O N S T IP A T IO N lu id D IF IC U L T Y IN U R IN A T IO N & F L U ID IN A B D O M E N F o rc e S M O K IN G & A S T H M A H E A V Y W E IG H T S F o e tu s PR EG N AN C Y
    11. 11. Causes of Weakness in the Covering Layers W EAKNESS AG E O P E R A T IV E SCARS M USCLE BULK LO SS S t a rv a tio n e t c .
    12. 12. So I Have a Hernia. Why Should I Have Surgery? Operation ? • There is pressure at the neck of the sac which can cut off the blood supply causing strangulation.
    13. 13. Inguinal Hernia Repair Techniques • Tension Repair – Bassini – Shouldice • Tension-free Repair – Open • Lichtenstein • Devices – Laparoscopic • TAPP • TEP
    14. 14. Tissue Repair – Bassini •Defect repaired by stitches •Tension – Pain - Recurrence
    15. 15. •Bassini Repair • • • Established - the end of the nineteenth century The prototype of the purest tissue repair 3 Layers of suturing: Superiorly: – internal oblique muscle – transversus abdominis muscle – transversalis fascia and Inferiorly: – the inguinal ligament and the iliopubic tract The spermatic cord lies against the newly reconstructed posterior inguinal wall, with the external oblique aponeurosis closed over it.
    16. 16. Shouldice Repair • Shouldice repair – the Canadian repair (Toronto) • Established in 1952 • Similar to the Bassini Repair – The essential difference is in the reconstruction of the posterior inguinal wall, which in the Bassini repair is carried out with interrupted sutures (three lines) while the Shouldice uses continuous sutures back and forth (four lines), creating an overlap.
    17. 17. Advantages of Tension Repair • Easy to perform • Cost effective
    18. 18. Disadvantages of Tension Repairs High recurrence rates • 10% to 30% recurrence rate with primary inguinal hernia repair • Estimated 35% or higher recurrence rate with recurrent hernia repairs 4 5 Patient discomfort Other potential complications • 4. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11. • 5. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.
    19. 19. Tension-Free Repairs
    20. 20. •Lichtenstein (Onlay) Repair Introduced in 1984 •Improved results over prior methods of repair •Open anterior approach •Steps • – deal with the sac – mesh sutured to floor and around spermatic cord (between transversalis fascia and external oblique) – running or interrupted sutures
    21. 21. Tension Free – Lichtenstein • Pioneered in 1984. • Covering the defect of the hernia with a patch of mesh, instead of sewing the edges together • PAIN FREE repair • Return to full activities at the earliest
    22. 22. Lichtenstein Technique • Advantages – Tension-Free Anterior Mesh Repair – Quick and Easy – Easily Teachable • Disadvantages – No Posterior Repair – No “Plugging” of the defect – Extensive continuous or interrupted suturing
    23. 23. Hernia repaired by plug • Results often compromised with incidences of recurrence •3 plugs in one patient with a recurrence. Image courtesy of Karl LeBlanc, MD. •Problem often of mesh migration •Defect repaired by Plug •Erosion of a shrunken soft Marlex™ plug into the bladder wall. Image courtesy of Parviz K. Amid, MD.
    24. 24. The PROLENE Hernia System • Introduced in 1998 • A secure posterior repair from a simple anterior approach • Lowest reported recurrence rates 8 • Low cost • 3 points of protection •8. Combined Anterior and Posterior Inguinal Hernia Repair: Intermediate recurrence rates with three groups of surgeons •Gilbert, AI et al. Hernia, 2004:8: 203-207
    25. 25. Lichtenstein Tension Free Single• FlatofMesh Ease use. • Tension-free repair. • Dramatic reduction in the incidence of recurrence. • However, the mesh was situated above the defect. • Recurrence could occur between the mesh and the defect.
    26. 26. Laparoscopic Herniorrhaphy
    27. 27. TAPP • TAPP = TransAbdominal PrePeritoneal • Laparoscopic Approach • Posterior Repair •Transversalis Fascia •Preperitoneal Space •Mes h •Incisio n •Trocar
    28. 28. TEP • • • • TEP = Totally ExtraPeritoneal Laparoscopic Approach Posterior Repair Steps of Repair •Transversalis Fascia •Preperitoneal • Space •Mes h •Trocar •Peritoneum
    29. 29. Ventral / Incisional Hernia
    30. 30. Ventral / Incisional Hernias • Develop as the result of a thinning, separation or tear in the muscle or tendon closure from prior surgery • Often due to too much tension placed on the closure itself • Hernias may be small but can enlarge and become problematic • Surgical repair is best performed early when first diagnosed
    31. 31. Ventral/Incisional Hernias • The problem: – – – – 3-13% of laparotomy incisions develop hernias 90,000 ventral/incisional hernia repairs per year Recurrence rates of 25-50% Prostethic mesh reduces recurrences, but.. • Increases wound complications • Has been associated with chronic pain from poor compliance
    32. 32. Ventral / Incisional Hernias • Facts: – Most hernias occur in the midline – Transverse incision tends to herniate where they cross the midline – Initial closure is very important – Faulty technique universally leads to development of herniation •YOU NEED TO KNOW THE ANATOMY !!!
    33. 33. Ventral / Incisional Hernia Anatomy Abdominal Wall Defect Adhesions Bowel
    34. 34. Ventral Hernia Anatomy •Incisional/Ventral •Umbilica l •Epigastric
    35. 35. Ventral Hernia Anatomy
    36. 36. Ventral/Incisional Hernia Repair Procedural Options
    37. 37. • • • • • • Ventral/Incisional Hernia Repair Techniques Tissue to tissue Onlay Inlay Retromuscular/Preperitoneal Open Intra-abdominal Laparoscopic
    38. 38. Tissue to Tissue Technique • Approximation of fascia under tension
    39. 39. Tissue to Tissue Technique • Approximation of fascia with suture (under tension) – Strengths • Inexpensive • Easy to perform • No foreign body – Weaknesses • Tension on suture line • High recurrence rates (43%-58%) • Not suitable for large defects •* Data on file • Difficult to identify multiple defects
    40. 40. Onlay Technique • Approximation of fascia with suture (under tension). Polypropylene mesh placed on top of fascia and fixated circumferentially
    41. 41. Onlay Technique
    42. 42. Onlay Technique • Approximation of fascia with suture (under tension). Polypropylene mesh placed on top of fascia and fixated circumferentially. – Strengths • Inexpensive • Easy to perform – Weaknesses • May not be able to use on large hernias • High recurrence rates (20%-24%)2 • Intra-abdominal pressure working against repair • Chance for strangulation and incarceration • High incidence of seromas (subcutaneous dissection) • Need for drains • Chance of infection • Difficult to identify multiple defects •* Data on file
    43. 43. Inlay Technique
    44. 44. Retromuscular Technique
    45. 45. Retromuscular/Preperitoneal Technique • Development of a preperitoneal pocket. Mesh placed into this pocket and fixated to the rectus sheath – Strengths • Lower recurrence rates <10% • Intra-abdominal pressure working for the repair – Weaknesses •* Data on file • Extensive lateral dissection • Creating the pocket may be difficult; ripping the peritoneum • High incidence of seromas • High incidence of infections 18.5%
    46. 46. Open Intra-Abdominal Technique • Open Intra-abdominal – Hernia sac removed, intra-abdominal cavity entered, mesh fixated to the abdominal wall – Strengths • Lower recurrence rates <5% • Intra-abdominal pressure working for the repair • Less likely chance of seroma formation • Less likely chance of infection • Can easily identify multiple defects – Weaknesses • Adhesions and fistula formation to prosthetic materials • Chance of enterotomy • Usually large incisions – Must Use TSM •* Data on file
    47. 47. Laparoscopic Technique
    48. 48. Laparoscopic Technique • Insufflation of the intra-abdominal cavity. Use of 5mm & 10mm ports and instruments to reduce hernia contents. Mesh placed in the intra-abdominal cavity, adjacent to viscera. – – – •* Data on file Strengths • Low recurrence rates <3% • Low infection rate <1% • Intra-abdominal pressure working for the repair • Minimally invasive (small scars) • Can easily identify multiple defects Weaknesses • Expensive (tacker, Disposable instruments) • Difficult to perform • High learning curve • Chance of enterotomy Must Use TSM
    49. 49. Pascal’s Principle
    50. 50. What mesh should be used? CONSIDER: • Infection • Where is it going to be placed? • Adhesions • Shrinkage • Integration • Pain • Loss of domain
    51. 51. Many Meshes • • • • • • Marlex knitted polypropylene Prolene woven polypropylene Mersilene woven polyester Gore-Tex ePTFE Vicryl knitted polyglactin Dexon knitted polyglactin • • • • • • • • • Composix Kugel Composix Sepramesh Surgisis Alloderm Permacol ULTRAPRO Parietex PROCEED
    52. 52. Advantage of Lap Hernia Rep. • It offers minimal access approach to preperitoneal hernia repair. • Lap Preperitoneal Repair provides much better views of what one is doing than open repair and avoid large incision & large mesh to cover the incision in order to prevent incisional hernia. • Cost effectiveness of Lap Hernia com to Open . • Patients can back to normal life as soon as possible as compared to Open Hernia.

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