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hernia m.pptx
1. 2018 WORLD GUIDELINES FOR GROIN
HERNIA MANAGEMENT:
The HerniaSurge Group
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital,
Lahore
2. 1. INTRODUCCION
TECNICAS DE REPARACION DE HERNIAS INGUINALES
CON TENSION Shouldice
Bassini
Desarda
SIN TENSION
Lichtenstein
Trans inguinal pre-peritoneal (TIPP)
Trans rectal pre-peritoneal (TREPP)
Plug and patch
PHS (bilayer)
Variations
TECNICAS
ENDOSCOPICAS
Totally extra-peritoneal (TEP)
Trans abdominal pre-peritoneal repair
(TAPP) Single incision laparoscopic
4. LA INCIDENCIA HI EN ADULTOS ES DEL 27-42,5% PARA LOS
HOMBRES Y DEL 3-5,8% PARA LAS MUJERES.
Familiares de primer grado diagnosticados con HI
elevan la incidencia de HI, especialmente en las
mujeres).
La reparaciĂłn de HI es aproximadamente de 8 a 10
veces mĂĄs comĂşn en los hombres).
5. ⢠Edad (prevalencia mĂĄxima a los 5 aĂąos ď indirecta
70-80 aĂąos ď directa).
⢠Metabolismo del colågeno (disminución de la relación colågeno tipo I/III).
⢠Obesidad /(nivel de evidencia: moderado)
6. ⢠Aumento de los niveles sistÊmicos de metaloproteinasa de la matriz.
⢠Trastornos raros del tejido conectivo (p. ej., sĂndrome de Ehlers-Danlos).
⢠Raza (los HI son significativamente menos frecuentes en adultos de raza negra).
⢠Estreùimiento crónico / Consumo de tabaco
7. Enfermedad pulmonar (EPOC y tos crĂłnica que
posiblemente aumentan el riesgo de formaciĂłn de IH).
La enfermedad hepĂĄtica, la enfermedad renal y el consumo
de alcohol no se han investigado adecuadamente para
determinar si son factores de riesgo para la formaciĂłn de HI.
8. 2.FACTORESDERIESGO
ÂżCuĂĄles son los factores de riesgo adquiridos,
demogrĂĄficos y perioperatorios de recurrencia
despuĂŠs del tratamiento de la HI en adultos?
9. ď§La tĂŠcnica quirĂşrgica incorrecta es probablemente la
razĂłn mĂĄs importante de recurrencia despuĂŠs de la
reparaciĂłn primaria de la IH.
La tĂŠcnica quirĂşrgica deficiente se incluye:
â˘
⢠Falta de superposición de malla,
⢠Elección incorrecta de la malla,
⢠Falta de fijación adecuada de la malla.
11. ÂżQuĂŠ modalidad diagnĂłstica es la mĂĄs adecuada para
diagnosticar las hernias inguinales?
Se recomienda el examen clĂnico solo para confirmar
el diagnĂłstico de una
hernia inguinal
13. NO EXISTE CONSENSO SOBRE LA MEJOR MODALIDAD DE IMAGEN.
LA EF POR SĂ SOLA PUEDE PASAR POR ALTO HERNIAS,
ESPECIALMENTE AQUELLAS QUE SON PEQUEĂAS.
EJEMPLOď HERNIAS FEMORALES EN MUJERES Y HOMBRES
OBESOS)
14. INDICACIONES para realizar estudios de imagen en
hernia inguinal:
HinchazĂłn vaga de la ingle e incertidumbre diagnĂłstica
HinchazĂłn difusa no localizaciĂłn evidente, (pequeĂąa
oculta en grasa espesa, mĂşltiple).
HinchazĂłn intermitente que no estĂĄ presente en el
momento del examen fĂsico.
15. ÂżQuĂŠ modalidad diagnĂłstica es la mĂĄs adecuada para diagnosticar a los pacientes con
dolor difuso / hinchazĂłn con duda diagnostica?
Se recomienda la combinaciĂłn del examen clĂnico y la ecografĂa.
Se puede considerar la resonancia magnĂŠtica o la tomografĂa computarizada dinĂĄmica (con
maniobra de Valsalva) para una evaluaciĂłn adicional si la ecografĂa es negativa o no
diagnĂłstica.
16. ÂżQuĂŠ modalidad diagnĂłstica es la mĂĄs adecuada para diagnosticar el dolor crĂłnico tras
la cirugĂa de hernia inguinal?
Se sugiere el uso de bloqueos nerviosos guiados por ecografĂa (bloqueo TAP > bloqueo ciego
del nervio ilio-hipogĂĄstrico) como el mĂĄs adecuado para diagnosticar la causa del dolor
crĂłnico despuĂŠs de la cirugĂa de hernia inguinal
.
La ecografĂa, la TC / RM son Ăştiles para identificar causas no neuropĂĄticas del dolor inguinal
crĂłnico (patologĂas relacionadas con la malla, hernias recurrentes).
17. 4 CLASSIFICATION
Is a groin hernia classification system necessary, and if
so, which classification system is most appropriate?
18. 4 CLASSIFICATION
Is a groin hernia classification system necessary, and if so,
which classification system is most appropriate?
Use of the EHS(European Hernia Society) 2009 classification system for inguinal
hernias is suggested for the purposes of
a. performing research,
b. tailoring treatments and
c. performing quality audits.
19. 4 CLASSIFICATION
Previously available classification
systems in literature
1. Nyhus and Gilbert,
2. Rutkow,
3. Schumpelick,
4. Harkins,
5. Casten ,
6. Halverson and McVay,
7. Lichtenstein,
8. Bendavid,
9.Stoppa,
10.Ponka,
11.Alexandre and
12.Zollinger
20. 4 CLASSIFICATION
0 = no hernia
detectable
1 = < 1.5 cm (one
finger)
2 = < 3 cm ( two
fingers)
3 = > 3 cm ( more than
two fingers)
x = not investigated
EXAMPLE: A primary, indirect, inguinal hernia with a 3-cm defect size
would be PL2
LIMITATION: The EHS-system was not developed to classify hernia types
preoperatively.
22. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
What is the risk of a hernia complication (strangulation or bowel obstruction)
in this population?
There is a low complication risk (incarceration or strangulation) in asymptomatic or
minimally symptomatic men with inguinal hernias.
24. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
Is a management strategy of watchful waiting safe for men with
asymptomatic inguinal hernias?
Although most patients will develop symptoms and need surgery, watchful waiting
for minimal or asymptomatic inguinal hernias is safe since the risk of hernia
complications is low and can be recommended.
(very low risk of complication versus high incidence of chronic post-herniorrhaphy
pain i.e. to prevent complication in 1 patient we have to treat large number of
patients ending in chronic post-herniorrhaphy pain )
26. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
What is the crossover rate from watchful waiting to surgery?
Most men with minimally symptomatic or asymptomatic inguinal hernias will develop
symptoms and require surgery.
The crossover rate to surgery in men with minimal symptomatic inguinal hernias is
high due to the development to symptoms, mostly pain.
28. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
What is the risk of a hernia complication (strangulation or bowel obstruction)
in men with symptomatic inguinal hernias?
No data exist on the risk of incarceration or strangulation in men with symptomatic
inguinal hernias.
30. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
Is a management strategy of watchful waiting safe for men with symptomatic
inguinal hernias?
There is no evidence to support watchful waiting as a management strategy in men
with symptomatic inguinal hernias.
32. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
Are emergent inguinal herniorrhaphies associated with higher morbidity and
mortality?
Emergent repair of incarcerated or strangulated inguinal hernias in men is associated
with higher morbidity and mortality compared with elective repair in men with
symptomatic inguinal hernias.
33. 5TREATMENTOPTIONS
FOR SYMPTOMATICAND
ASYMPTOMATICPATIENTS
Are emergent inguinal herniorrhaphies associated with higher morbidity and
mortality?
Discussions with patients about timing of hernia repair are recommended to involve
attention to social environment, occupation and overall health. The lower morbidity
of elective surgery has to be weighed against the higher morbidity of emergency
surgery.
35. 6 SURGICALTREATMENT
Which non mesh technique is the preferred repair method for inguinal
hernias?
The Shouldice technique has lower recurrence rates than other suture repairs and is
recommended in non-mesh inguinal hernia repair.
37. 6 SURGICALTREATMENT
Which is the preferred repair method for inguinal hernias: Mesh or non-
mesh?
A mesh-based repair technique is recommended for patients with symptomatic
inguinal hernias.
38. 6 SURGICALTREATMENT
Which is the preferred repair method for inguinal hernias: Mesh or non-
mesh?
Whether a non-mesh technique is an alternative for mesh-based techniques in
individual cases (e.g. young males with lateral hernia L1) is unknown and requires
further study.
The use open non-mesh repair in specific patients or types (e.g. young males with
lateral hernia L1) of inguinal hernia to replace the Lichtenstein technique should only
be performed in research settings.
39. 6 SURGICALTREATMENT
Which is the preferred open mesh technique for
inguinal hernias: Lichtenstein or other open flat mesh
and gadgets via an anterior approach?
40. 6 SURGICALTREATMENT
Open anterior approach mesh IH repair
1. Lichtenstein technique (criterion standard)
2. plug-and-patch (or mesh-plug) technique
3. Trabucco technique (plug + flat mesh ), and
4. ProleneÂŽ Hernia System (PHS)
41. 6 SURGICALTREATMENT
Which is the preferred open mesh technique for inguinal hernias:
Lichtenstein or other open flat mesh and gadgets via an anterior approach?
The recurrence rate and postoperative chronic pain are comparable between plug-
and-patch/ PHS and the Lichtenstein technique.
Self-gripping meshes do not provide any benefit in the short- and medium-term
versus the Lichtenstein technique except a somewhat decreased operative time.
42. 6 SURGICALTREATMENT
Which is the preferred open mesh technique for inguinal hernias:
Lichtenstein or other open flat mesh and gadgets via an anterior approach?
Despite comparable results, the plug-and-patch and PHS are not recommended
because of the
⢠excessive use of foreign material,
⢠the need to enter both the posterior and anterior plane (no virgin approach if
recurrence occurs) and
⢠the additional cost.
The use of other meshes or gadgets to replace the standard flat mesh in the
Lichtenstein technique is currently not recommended.
44. 6 SURGICALTREATMENT
OPEN PRE-PERITONEAL TECHNIQUES
Open anterior approach to the pre-
peritoneal space via opening the inguinal
canal
Open posterior approach to the pre-
peritoneal space without entering the
inguinal canal
Transinguinal pre-peritoneal (TIPP) repair Transrectus pre-peritoneal (TREPP)
approach
Onstep approach Kugel technique
Rivesâ technique Ugahary technique
Wantz techniqque
45. 6 SURGICALTREATMENT
Which is preferred open mesh technique: Lichtenstein versus open pre-
peritoneal?
MERITS:
Open pre-peritoneal mesh repairs may, in the short term (one year), result in less
postoperative and chronic pain and faster recovery.
DEMERITS:
It must however be considered that some of these approaches use both anterior and
posterior anatomical planes.
Use of mesh devices results in increased costs and there are possible issues with the
memory ring in some.
46. 6 SURGICALTREATMENT
Which is preferred open mesh technique: Lichtenstein versus open pre-
peritoneal?
In open surgery there is insufficient evidence to recommend a pre-peritoneal mesh
repair over Lichtenstein repair.
The use of open pre-peritoneal mesh techniques to replace the standard flat mesh in
the Lichtenstein technique is suggested to only be performed in research settings.
48. 6 SURGICALTREATMENT
Is TEP or TAPP the preferred laparo-endoscopic technique for inguinal
hernias?
TAPP and TEP have similar
1. operative times,
2. overall complication risks,
3. postoperative acute and chronic pain incidence and
4. recurrence rates.
49. 6 SURGICALTREATMENT
Is TEP or TAPP the preferred laparo-endoscopic technique for inguinal
hernias?
DEMERITS OF TAPP
⢠Although very rare, there is a trend in TAPP for more visceral injuries.
⢠Although very low, in TAPP the frequency of port-site hernias is higher.
DEMERITS OF TEP
⢠Although very rare, there is a trend in TEP for more vascular injuries.
⢠Although very low, in TEP the conversion rate is higher.
⢠TEP has a longer learning curve than TAPP.
50. 6 SURGICALTREATMENT
Is TEP or TAPP the preferred laparo-endoscopic technique for inguinal
hernias?
Similar costs may be incurred in TAPP and TEP.
In laparo-endoscopic inguinal hernia repair, TAPP and TEP have comparable
outcomes; hence it is recommended that the choice of the technique should be based
on the surgeonâs skills, education and experience.
51. 6 SURGICALTREATMENT
When considering recurrence, pain, learning curve,
postoperative recovery and costs which is preferred
technique for inguinal hernias:
Best open mesh (Lichtenstein) or a laparo-endoscopic
(TEP and TAPP) technique?
52. 6 SURGICALTREATMENT
When considering recurrence, pain, learning curve, postoperative recovery
and costs which is preferred technique for inguinal hernias: Best open mesh
(Lichtenstein) or a laparo-endoscopic (TEP and TAPP) technique?
When the surgeon has sufficient experience in the laparo-endoscopic techniques,
comparable recurrence rates to Lichtenstein repair can be achieved.
When the surgeon has sufficient experience in the technique, laparo-endoscopic
techniques show advantages in terms of less early postoperative pain at rest and on
exertion and less chronic pain when compared with Lichtenstein technique.
53. 6 SURGICALTREATMENT
When considering recurrence, pain, learning curve, postoperative recovery
and costs which is preferred technique for inguinal hernias: Best open mesh
(Lichtenstein) or a laparo-endoscopic (TEP and TAPP) technique?
When the surgeon has sufficient experience in the technique, laparo-endoscopic
techniques do not take longer than Lichtenstein operations.
With sufficient experience, no significant differences are observed in the
perioperative complications needing reoperation between the laparo-endoscopic and
Lichtenstein techniques.
54. 6 SURGICALTREATMENT
When considering recurrence, pain, learning curve, postoperative recovery
and costs which is preferred technique for inguinal hernias: Best open mesh
(Lichtenstein) or a laparo-endoscopic (TEP and TAPP) technique?
The direct operative costs for laparo-endoscopic inguinal hernia repair are higher.
That difference decreases when the total community costs are taken into account and
the surgeon has sufficient experience.
55. 6 SURGICALTREATMENT
When considering recurrence, pain, learning curve, postoperative recovery
and costs which is preferred technique for inguinal hernias: Best open mesh
(Lichtenstein) or a laparo-endoscopic (TEP and TAPP) technique?
The learning curve for laparo-endoscopic techniques (especially TEP) is longer than
for Lichtenstein. There are rare but severe complications mainly described early in
the learning curve. Therefore, it is imperative that laparo-endoscopic techniques be
learned in a properly supervised manner.
56. 6 SURGICALTREATMENT
When considering recurrence, pain, learning curve, postoperative recovery
and costs which is preferred technique for inguinal hernias: Best open mesh
(Lichtenstein) or a laparo-endoscopic (TEP and TAPP) technique?
For male patients with primary unilateral inguinal hernia, a laparo-endoscopic
technique is recommended because of a
⢠lower postoperative pain incidence and
⢠reduction in chronic pain incidence,
provided that a surgeon with specific and sufficient resources is available.
However, there are patient and hernia characteristics that warrant a Lichtenstein as
first choice.
57. 6 SURGICALTREATMENT
In males with unilateral primary inguinal hernias which
is the preferred repair technique, laparo-endoscopic
(TEP/TAPP) or open pre-peritoneal?
58. 6 SURGICALTREATMENT
In males with unilateral primary inguinal hernias which is the preferred
repair technique, laparo-endoscopic (TEP/TAPP) or open pre-peritoneal?
The outcome measures of morbidity, mortality, and recurrence rates do not seem not
significantly different between laparoscopic and open pre-peritoneal repair.
With regards to visualization, laparoscopic pre-peritoneal repair is a safe and
standardized operation with possible technical advantages over open.
59. 6 SURGICALTREATMENT
In males with unilateral primary inguinal hernias which is the preferred
repair technique, laparo-endoscopic (TEP/TAPP) or open pre-peritoneal?
Especially in lower resource settings, techniques utilizing open pre-peritoneal mesh
placement may be become an acceptable alternative to laparoscopic pre-peritoneal
mesh repair.
No recommendation to advocate laparoscopic pre-peritoneal mesh placement over
open pre-peritoneal repairs can be made due to insufficient and heterogeneous data
61. 6 SURGICALTREATMENT
Which is the preferred technique in Bilateral hernia?
From a socio-economic perspective, a laparo-endoscopic repair is recommended in
bilateral hernia repair, provided expertise is available
62. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
Can IH treatment be standardized, or should it be
individualized?
If individualized, which determinants should influence
surgeonâs choices?
i.e.
âwhich technique should be used in which case?â
63. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
âwhich technique should be used in which case?â
In patients with primary bilateral hernias a laparo-endoscopic approach is
recommended provided expertise is available.
In patients with pelvic pathology or scarring due to radiation or pelvic surgery, or for
those on peritoneal dialysis, consider an anterior approach.
64. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
âwhich technique should be used in which case?â
For recurrent IHs, use the opposite approach (e.g. for recurrence after anterior repair
use a posterior technique, and vice versa).
In high-risk IH patients with extensive comorbidities consider an open mesh repair
under local anesthesia.
65. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
âwhich technique should be used in which case?â
For IH patients with high preoperative pain, consider laparo-endoscopic repair.
Consider a laparo-endoscopic approach in active young patients with IHs.
66. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
âwhich technique should be used in which case?â
In femoral hernia patients a pre-peritoneal mesh repair is recommended.
In female patients with IHs a laparo-endoscopic repair is recommended.
67. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
âwhich technique should be used in which case?â
It is recommended that surgeons tailor treatments based on
⢠expertise,
⢠local/national resources,
⢠patient-related factors, and
⢠hernia-related factors.
68. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
DETERMINANTS OF SURGEONSâ PREFERENCES
PATIENT CHARACTERISTICS HERNIA
CHARACTERISTICS
EMERGENCY SITUATION
High preoperative pain Size Incarcerated hernia
Gender Type Strangulated hernia
Comorbidity (smoking, collagen disease,
obesity, ascites)
Primary or recurrent
Previous medical history (pelvic surgery, pelvic
radiation, lower abdominal surgery)
Reducibility
Previous hernia surgery Unilateral or bilateral
Occupation
Physical activity
Age
69. 7 INDIVIDUALIZATION
OF TREATMENT
OPTIONS
âwhich technique should be used in which case?â
Since a generally accepted technique, suitable for all inguinal hernias, does not exist,
it is recommended that surgeons/surgical services provide both an anterior and a
posterior approach option.
72. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In those with unilateral overt primary IHs, what is the likelihood they will also
have a contralateral occult IH?
In patients with unilateral overt primary inguinal hernias, an occult contralateral
inguinal hernia is seen at time of laparoscopic inguinal hernia surgery in up to 58% of
cases.
73. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In those with unilateral overt primary IHs, what is the
likelihood they will develop contralateral overt hernias
over time?
74. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In those with unilateral overt primary IHs, what is the likelihood they will
develop contralateral overt hernias over time?
In patients who have undergone a unilateral inguinal hernia repair, the chance of
developing a contralateral inguinal hernia increases with time; however, the true
incidence is unknown.
75. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In patients who have undergone a unilateral TEP and
negative contralateral exploration, what is the risk of
developing an overt hernia on the disease-free side?
76. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In patients who have undergone a unilateral TEP and negative contralateral
exploration, what is the risk of developing an overt hernia on the disease-
free side?
There is a low risk for the development of a contralateral overt inguinal hernia
following a previously negative TEP exploration.
78. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In cases where an occult contralateral IH is seen during TAPP will it become
symptomatic if not repaired?
The percentage of occult hernias noted at TAPP that become symptomatic will
increase over time; however, the true incidence is unknown.
79. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In those with overt unilateral primary IHs without
contraindications to bilateral TEP or TAPP repair,
should bilateral repair be performed?
80. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In those with overt unilateral primary IHs without contraindications to
bilateral TEP or TAPP repair, should bilateral repair be performed?
It is recommended that the contralateral groin be inspected at time of TAPP repair. If
a contralateral inguinal hernia is found and prior informed consent was obtained,
repair is recommended.
In those with overt unilateral primary inguinal hernias without contralateral hernias,
routine bilateral TAPP repair is not suggested.
81. 8 OCCULTHERNIASAND
BILATERAL REPAIR
In those with overt unilateral primary IHs without contraindications to
bilateral TEP or TAPP repair, should bilateral repair be performed?
Routine exploration by TEP of the contralateral groin in an asymptomatic patient with
no clinical hernia is not suggested.
83. 9 DAYSURGERY
Which inguinal hernias can be safely repaired in day surgery?
Day surgery is recommended for the majority of groin hernia patients provided
adequate aftercare is organized.
85. 9 DAYSURGERY
Can endoscopic and open herniorrhaphies be performed safely in day
surgery?
Day surgery is suggested for all endoscopic repairs of simple inguinal hernias
provided adequate aftercare is organized.
86. 9 DAYSURGERY
Can patients with severe comorbidities (ASA III or
higher) be safely treated in day surgery?
87. 9 DAYSURGERY
Can patients with severe comorbidities (ASA III or higher) be safely treated in
day surgery?
Day surgery is suggested for selected older and ASA IIIa patients (open repair under
local anesthesia) provided adequate aftercare is organized.
88. 9 DAYSURGERY
Can patients with complex inguinal hernias (e.g.
scrotal hernias) be safely treated in day surgery?
89. 9 DAYSURGERY
Can patients with complex inguinal hernias (e.g. scrotal hernias) be safely
treated in day surgery?
Day surgery for patients with complex inguinal hernias is suggested only in selected
cases.
90. 9 DAYSURGERY
COMPLEX INGUINAL HERNIA
(DAY SURGERY NOT RECOMMENDED)
1. Groin hernias with signs of incarceration, strangulation, infection, relevant
preoperative chronic pain, difficult local findings in the groin such as large
(irreducible) scrotal hernias, (multiple) recurrence(s), recurrence with previous
mesh repair, a relevant history of lower abdominal surgery, radiation, and
comparable problems, nonagenarians (10 x mortality rate compared with younger
patients)
2. Groin hernias in patients with relevant comorbidities, (cardiovascular / pulmonary
/ endocrine / immune deficiency / hepatic / renal / gastro intestinal / mental
disorders / anxiety, immune deficiencies, post-transplantation status,
coagulopathies, antithrombotic medications)
91. 9 DAYSURGERY
COMPLEX INGUINAL HERNIA
(DAY SURGERY NOT RECOMMENDED)
3. Difficult intraoperative findings (severe adhesions, abnormal anatomy, excessive
bleeding) and intraoperative complications such as damage to viscera, blood vessels,
nerves and genitals
4. Symptoms and signs of postoperative local complications (bleeding, hematoma,
thromboembolism, urinary retention, bowel obstruction, peritonitis, sepsis, infection,
orchitis) and/or general complications (cardiovascular, respiratory, renal, hepatic,
gastrointestinal, cerebral organ failure, anxiety, psychic, mental distress)
92. 10ANTIBIOTICPROPHYLAXIS
Low-risk environment High-risk
environment
(Any type of
patient)
Average-risk
patient
High-risk patient
Open mesh repair Not recommended Suggested Recommended
Laparoscopic repair Not recommended
HIGH-RISK ENVIRONMENT: defined as >5% incidence of wound infection
AVERAGE-RISK PATIENT: defined as having
⢠primary hernias and
⢠minimal individual (e.g. immunosuppression, diabetes, heart failure) or operative
(e.g. wound infection incidence, hair shaving, drain use, seroma puncture) risk
factors.
93. 10ANTIBIOTICPROPHYLAXIS
ď§High wound infection rates were noted in studies from Pakistan,
Turkey, Japan and parts of India and Spain
ď§Reflecting the local differences in perioperative and operative practice
for hygiene protocols.
94. 11ANESTHESIA
Does local anesthesia influence outcomes after open
repair of reducible inguinal hernia when compared
with general or regional anesthesia?
95. 11ANESTHESIA
Does local anesthesia influence outcomes after open repair of reducible
inguinal hernia when compared with general or regional anesthesia?
When compared with general anesthesia, local anesthesia is associated with
⢠faster mobilization,
⢠earlier hospital discharge,
⢠lower hospital and total healthcare costs, and
⢠fewer complications such as urinary retention and early postoperative pain.
However, when surgeons inexperienced in its use administer local anesthesia, more
hernia recurrences might result.
96. 11ANESTHESIA
Does local anesthesia influence outcomes after open repair of reducible
inguinal hernia when compared with general or regional anesthesia?
When compared with regional anesthesia, local anesthesia is associated with
⢠earlier hospital discharge,
⢠lower hospital and total healthcare costs, and
⢠a lower incidence of urinary retention.
However, when surgeons inexperienced in its use administer local anesthesia, more
hernia recurrences might result.
97. 11ANESTHESIA
Does local anesthesia influence outcomes after open repair of reducible
inguinal hernia when compared with general or regional anesthesia?
Local anesthesia is recommended for open repair of reducible inguinal hernias
provided surgeons experienced in local anesthesia use administer the local
anesthetic.
Correctly performed local anesthesia is suggested to be a good alternative to general
or regional anesthesia in patients with severe systemic disease.
99. 11ANESTHESIA
Are outcomes different when open inguinal hernia repairs are performed
with regional versus general anesthesia?
When compared with regional anesthesia, general anesthesia offers no clear
advantages regarding
⢠incidence of postoperative pain,
⢠postoperative nausea, cost, or
⢠patient satisfaction.
MERITS:
Its use allows for faster patient discharge, which is of uncertain clinical significance.
Some studies report a higher incidence of urinary retention with regional anesthesia.
100. 11ANESTHESIA
Are outcomes different when open inguinal hernia repairs are performed
with regional versus general anesthesia?
When compared with general anesthesia, regional anesthesia in patients aged 65 and
older might be associated with a higher incidence of medical complications like
myocardial infarction, pneumonia and venous thromboembolism.
General or local anesthesia is suggested over regional in patients aged 65 and older.
102. 11ANESTHESIA
Can surgical residents/registrars safely perform open inguinal hernia repair
using local anesthesia?
Open inguinal hernia repair under local anesthesia can be safely performed by
trainees under supervision of surgeons experienced in the administration of local
anesthesia.
(Beginners, defined as those who have repaired <6 hernias under local anesthesia,
had a significantly higher recurrence rate)
104. 12 EARLYPOSTOPERATIVEPAIN-
PREVENTIONANDMANAGEMENT
Do preoperative or perioperative local anesthetic methods affect patientsâ
pain experiences after open groin hernia repair?
When general or regional anesthesia is used,
the addition of local anesthetic field blocks of the ilioinguinal and iliohypogastric
nerves and/or subfascial and subcutaneous infiltration
reduces early postoperative pain scores and the need for other analgesics.
(OTHER OPTIONS: Paravertebral block (PVB) , TAP block, local anesthetic
administration via intra-wound catheters by repeat bolus or continuous infusion)
105. 12 EARLYPOSTOPERATIVEPAIN-
PREVENTIONANDMANAGEMENT
⢠2010 Cochrane Database Systematic Review found only limited
evidence to suggest that the use of perioperative TAP blocks is opioid
sparing or reduces pain scores after abdominal surgery
106. 12 EARLYPOSTOPERATIVEPAIN-
PREVENTIONANDMANAGEMENT
Do preoperative or perioperative local anesthetic methods affect patientsâ
pain experiences after open groin hernia repair?
Long-acting local anesthetics are preferable to short-acting local anesthetics
but the timing of field blocks and/or infiltrationâeither preoperatively or at wound
closureâhas no proven effect on the occurrence of postoperative pain.
107. 12 EARLYPOSTOPERATIVEPAIN-
PREVENTIONANDMANAGEMENT
Do preoperative or perioperative local anesthetic methods affect patientsâ
pain experiences after open groin hernia repair?
Preoperative or perioperative local anesthetic measures like field blocks of the
inguinal nerves and/or subfascial/subcutaneous infiltration are recommended in all
open groin hernia repairs.
109. 12 EARLYPOSTOPERATIVEPAIN-
PREVENTIONANDMANAGEMENT
Which is the most effective oral analgesic pain management regimen after
open or endoscopic groin hernia repair?
NSAID or selective COX-2 inhibitors reduce postoperative pain and when given with
paracetamol reduce postoperative pain further.
NOTE:
⢠Paracetamol (Acetaminophen) has insufficient effect as single-agent therapy for
moderate to severe pain.
⢠Avoid using opioids analgesics. Whenever possible
Use of a conventional NSAID or a selective COX-2 inhibitor PLUS paracetamol is
recommended in open groin hernia repairs provided that there are no
contraindications.
111. 13 CONVALESCENCE
What is the recommended duration of convalescence
following uncomplicated inguinal hernia repair?
112. 13 CONVALESCENCE
What is the recommended duration of convalescence following
uncomplicated inguinal hernia repair?
Physical activity restrictions are unnecessary after uncomplicated inguinal hernia
repair and do not effect recurrence rates.
Patients should be encouraged to resume normal activities as soon as possible.
An early return to normal activities can safely be recommended.
113. 13 CONVALESCENCE
Work and leisure activities can be resumed by most patients within 3
â 5 days following elective laparoscopic or open IH repair without
risk of hernia recurrence or other complications.
