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Evolution of inguinal hernia repair
- 1. EVOLUTION OF INGUINAL HERNIA REPAIR DR. ASIK HOSSAIN 2ND YEAR PGT , GENERAL SURGERY
- 2. LEARNING OBJECTIVE Why we need to learn the history Timeline of different treatment Current practice and perspective Gold standard of surgery of inguinal hernia
- 3. Why we need to learn the history To understand the thought process of the masters Their principle and philosophy of the treatment its interesting from this knowledge we innovate and improve the treatment and produce better result for the treatment
- 4. EVOLUTIONARY LANDMARK IN HERNIA SURGERY Hernia is one of the disease that haunted humanity from its very beginning Greek word- ‘HERNIOS’= Bud or off shoot OLDEST ERA[ Ancient Egypt to 18th century] Hernia belt Galen 130-200 CE-ligature of sac with cord Al Tasrif[936-1013]-transfix by cross stitch, orchiectomy, and drainage Gabriele & Fallopio- wide excision of hernial sac and its content and secure the neck 1735, Claudius Amyand- remove appendix from hernia sac NEW TREND IN 19TH CENTURY Introduction of antiseptics, asepsis and anesthesia Advances in anatomical knowledge lead to introduction of 2 rule of hernia surgery- 1. high ligation of sac. 2. 2. narrowing of internal ring REVOULUTION OF E BASSINI 1887- Real breakthrough in hernia repair Halsted –similar to Bassini method but post wall transfix with very strong suture During world war 2- Mc Vay repair Last biggest step by SHOULDICE Not Curative Hernia should be reducible Contraindicated in irreducible hernia
- 5. TENSIONFREE REPAIR Different prosthetic material became available Initially mesh was placed with tense repair and release were given 1984-technique of lichtension Gilbert’s plug concept Rutkow and Robbins plug and mesh repair 1999- PHS by Gilbert INTRAPERITONEAL REPAIR GPVRS by Rene Stoppa LAPROSCOPIC REPAIR Advancrement OF MIS TAAP & TEP became widespread Finally IPOM DEVELOPPED ON1991 E. Bassini SHOULDICE LICHTENSTEIN DESERDA
- 6. PRINCIPLE OF HERNIA REPAIR Reduction of hernia content into abdominal cavity with removal of any non viable tissue and bowel repair if necessary Excision and closure of hernial sack Reapproximation of wall of neck of hernia if possible Permanent reinforcement of abdominal wall defect with suture or mesh Tension free Treatment of precipitating factors
- 7. herniotomy INDICATION Congenital hernia Patent processus vaginalis All pediatric age group and young adult Principle of steps Opening up of inguinal canal Separation of sac from cord Reducing of content Transfix and ligation of sac Excision of sac
- 8. herniorraphy INDICATION Young adult and good muscle Dilated interior ring PRINCIPLE OF OPERATIVE STEPS Herniotomy Approximation of conjoint tendon with inguinal ligament Bassini Repair Modified Bassini Shouldice’S Technique Wylly Andrew Tanner s muscle slide Halsted repair Ferguson Mc vay Henley
- 9. DIFFERENT TYPES OF HERNIORRAPHY BASSINI Opening of FT from pubic tubercle Approximation of lower leaf of FT and inguinal ligament with conjoint tendon and upper leaf of FT with with interrupted suture with silk MODIFIED BASSINI Here approximation is done with continuous interlocking stitch with prolene Suture is placed between conjoint tendon above and inguinal ligament below and extend from pubic tubercle to deep inguinal ring SHOULDICE TECHNIQUE Additional strength is given to the posterior wall by DOUBLE BREASTING the FT POSTERIOR PART of upper flap of FT# LOWER FLAP of FT ANTERIOR part of upper flap of FT # INGUINAL LIGAMENT
- 10. DIFFERENT TYPES OF HERNIORRAPHY HALSTED-TANNER SLIDE OP Tension is reduced in repair area by giving RELAXING INCISION over LOWER RECTUS so that conjoint tendon is allowed to slide downward Wylly Andrew operation Overlapping of external oblique Apo neurosis ABRAHAMSON NYLON DARNING Continuous intervening network of non absorbable suture are placed between conjoint tendon and inguinal ligament
- 11. LYTLE’S REPAIR MC VAY Interrupted suture between FT to cooper ligament start from pubic tubercle narrowing femoral ring and later continued as suture between FT and ILIOPUBIC TRACT up to entrance of cord It cover all groin defect. KOONTZ OPERATION For old patient orchiectomy along with cord removal done And full closure of posterior inguinal wall
- 12. NYHUS ILIOPUBIC REPAIR Transverse incision above symphysis pubis Expose rectus sheath Anterior rectus sheath incised horizontally above the deep ring, which is confirmed by introducing finger through superficial ring Lateral part of rectus muscle is retracted Post sheath open IO,TA,FT incised along incision Reach to pre peritoneal space Sac dissected Trans apo neurotic arch [TA, FT] is sutured below to cooper ligament & iliopubic tract DESERDA TECHNIQUE By prof Mohan Desarda, Pune,India. This is no mesh tension free repair Live EX Ob tissue flap reconstruction
- 13. hernioplasty Types 1. Lichtenstein 2. Gilbert plug 3. Kugel 4. Nyhus codon 5. Stoppa 6. Laparoscopic mesh repair Indication Old age and poor muscle tone Direct hernia Huge indirect hernia Principle Operative steps Herniotromy Strengthening of posterior wall of inguinal canal with prolene to bridge the gap.
- 14. TYPES OF MESH POSITIONING OF MESH SUBLAY • Mesh is placed in preperitoneal space • E.g.- Nyhus Codon • ,Reed Rives, • STOPPA/GPRVS/Wantz procedure • GILBERT PHS • Kugel repair INLAY •Eg- Gilbert mesh repair[plug and patch] ONLAY • E.g.- Lichtenstein • Gilbert PHS • Gilbert mesh repair[patch and plug] • 1st Gen Mesh • Synthetic • Made by prolene or polypropyle ne •2nd Gen Mesh •Made by more than • one synthetic • materials •PP,PL,PTFE,TITENI UM •,OMEGA 3 •Given into INTRA PERITONEAL SPACE •Minimal adhesion •They are 2 types- •Absorbable and •3 Rd Gen Mesh •biological mesh •Collagen scaffold in donor area •E.g.- dermis from human •Porcine •Fetal bovine sources • FUTURE PERSPECTIVE •Coated mesh •They are highly improved performance in peritoneal
- 15. DIFFERENT TYPES OF HERNIOPLASTY LICHTENSTEIN 15×10 CM size mesh First bite at pubic tubercle Fix beyond the pubic tubercle Fix with 1-0 or2-o prolene without tension Mesh is use for to bridge the gap, for plug action, and augment the repair GILBERT PATCH AND PLUG Principle of steps- Herniotomy Internal ring is plugged with piece of prolene mesh[plug] On lay / Inlay mesh repair[patch] of post wall NYHUS CODON Supra inguinal horizontal incision Opening of posterior rectus sheath through lateral border of rectus muscle Access in pre peritoneal space Mesh place in pre peritoneal space deep to cord , conjoint tendon, and FT. and below mesh is folded deep to cooper ligament
- 16. STOPPA REPAIR GPRVS[Giant prosthetic reinforcement of visceral sac] Unilateral - 8-10 cm low transverse incision above internal inguinal ring Rectus and oblique muscle divide along the incision line Tansversalis fascia incised Enter into preperitoneal space and dissected widely Dissect medially to expose cooper ligament and laterally over ilio pubic tract to ASIS For direct- FT is sutured with cooper ligament For indirect-cord separate and sac ligation Large mesh cover ASIS to umbilicus and symphysis pubis in preperitoneal space The medial portion of lower corner is placed along the inferior margin of pre peritoneal space And lateral portion of lower corner is placer in iliac fossa For bilateral- single large mesh is used
- 17. KUGEL PATCH REPAIR Incision- oblique incision at 1/3 lateral and 2/3 medial of mid inguinal point just above the deep ring Skin , subcut tissue,, external oblique, internal oblique and Transverse Abdominis split Inferior epigastric vessel retract medially Preperitoneal space created For indirect- sac is dissected and herniotomy done Kugel mesh placed without any tissue bend FT is sutured , TA and IO is not sutured, EO apo neurosis close KUGEL MESH Kugel MESH 2 overlapping layers of knitted prolene mesh which are attached ultrasonically Near the outer edge of mesh there is polyester spring which stiffen the mesh to unfold The mesh have 1 cm extend radial slit for easy maneuverability. Anterior layer of mesh have single transverse slit for easy insertion Small v shaped hole act as suture less anchored
- 18. Gilbert’s PHS Repair REED RIVES SUBLAY Trans inguinal incision Up to Sac dissection is similar to open approach For direct- sac is not open Opening of FT MESH Placed in pre peritoneal space Reinforcement of anterior and posterior aspect of abdominal wall Indirect- sac is dissected and separate and pre peritoneal space is bluntly dissected through internal ring For direct-FT is opened at defect Sub lay flap of mesh positioned in pre peritoneal space through the defect On lay flap reinforcement similar to tension free repair PHS MESH SUBLAY flap is wider and on lay flap is modified rectangular , and connected with stiff rounded part
- 19. LAPAROSCOPIC REPAIR Pneumoperitoneum with varess needle Port placement-camera port at umbilicus and working two trocar on lateral to rectus sheath on either side of umbilicus few cm below the camera port 5 mm port for suture of mesh [12 mm use if fix with stapler] Diagnostic lap to rule out adhesion and to identify important anatomical land mark Content reduce carefully Creation of pre peritoneal space by hydro dissection or sharp dissection by giving incision 2 cm above and horizontal extend from umbilical ligament to ASIS Medial and lateral dissection done Parietalisation[ peritoneum is separated from gonadal vessel] Mesh placement Fixation of mesh Reperitonealisation Port placement TAPP Incision tapp
- 20. TEP[Totally extra peritoneal] 3 Port placement- incision- on 12 mm in sub umbilical region extend up to linea alba Skin & subcutaneous tissue cut Transverse incision over anterior rectus sheath followed by dissection up to exposure of extra peritoneal space 10 mm trocar place and create space between muscle and rectus sheath Creation of preperitoneal space Medial and lateral dissection Parietalisation Mesh placement and fixation Port placement TEP Approach
- 21. LAPROSCOPIC HERNIA REPAIR CONTRAINDICATION OF LAPAROSCOPIC REPAIR Recurrent hernia[ previously done by lap approach] Obstructed hernia Ascites Pelvic radiation INDICATION 1. Recurrent hernia –avoid scar tissue and visualize occult hernia 2. Bilateral hernia- reduces pain and early mobilization 3. Obese and athletic patient- for diagnostic and therapeutic
- 22. Take home message Surgical treatment of inguinal hernia repair has made important steps forward during the last 125 years. Laparoscopic hernia have some important steps, but not ideal for each patient. Laparoscopic technique and traditional open technique are coexist peacefully The evolutionary fact explain that the road to a perfect operation is still ahead of us.
- 23. Thankyou