TYPES OF MANAGEMENT IN HERNIA (CONSERVATIVE AND OPERATIVE)
TYPES OF SURGERY
(IN CHILDREN/ADULTS ,OPEN/LAPAROSCOPIC)
HERNIOTOMY ,TYPES OF HERNIORRAPHY ,HERNIOPLASTY (INCLUDING MESH)
"LAPAROSCOPIC ANATOMY"
LAPAROSCOPIC REPAIRS (TEP,TAPP)
EMERGENCY AND ELECTIVE TREATMENT IN INGUINAL FEMORAL AND OTHER TYPES OF HERNIAS
COMPLICATIONS
THYROIDECTOMY- Operative Surgery
Dear viewers,
Greetings from “Surgical Educator”
Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. I have already uploaded two videos on open and Laparoscopic Appendicectomy. In this video today, I have discussed Thyroidectomy Surgery. However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the videos.
NECROTISING FASCIITIS- the flesh eating infection
#surgicaleducator #necrotisingfasciitis #surgicaltutor #babysurgeon #usmle
· Dear Viewers
· Greetings from “Surgical Educator”
· Today in this episode I have discussed about Necrotising Fasciitis- the flesh eating infection
· It is common in immunocompromised patients even after trivial trauma.
· I have discussed about the overview,etiology,types,clinical features,complications and treatment of Necrotising Fasciitis
· I hope this video is interesting and also useful to all of you
· You can watch the video in the following links:
· surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
Thank you for watching the video
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
THYROIDECTOMY- Operative Surgery
Dear viewers,
Greetings from “Surgical Educator”
Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. I have already uploaded two videos on open and Laparoscopic Appendicectomy. In this video today, I have discussed Thyroidectomy Surgery. However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the videos.
NECROTISING FASCIITIS- the flesh eating infection
#surgicaleducator #necrotisingfasciitis #surgicaltutor #babysurgeon #usmle
· Dear Viewers
· Greetings from “Surgical Educator”
· Today in this episode I have discussed about Necrotising Fasciitis- the flesh eating infection
· It is common in immunocompromised patients even after trivial trauma.
· I have discussed about the overview,etiology,types,clinical features,complications and treatment of Necrotising Fasciitis
· I hope this video is interesting and also useful to all of you
· You can watch the video in the following links:
· surgicaleducator.blogspot.com youtube.com/c/surgicaleducator
Thank you for watching the video
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
OPEN INGUINAL HERNIA REPAIR- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #openinguinalherniarepair #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy, Modified Radical Mastectomy and open and
Laparoscopic Cholecystectomy
• In this video today, I have discussed Open Inguinal Hernia Repair.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Approximately 75% of abdominal wall hernias occur in the groin.
The lifetime risk of inguinal hernia is 27% in men and 3% in women.
And hence Of inguinal hernia repairs, 90% are performed in men, and 10% are performed in women.
The incidence of inguinal hernia in men has a distribution, with peaks before the first year of life and after age 40.
Indirect inguinal and femoral hernias occur more commonly on the right side.
This is attributed to a delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development.
The predominance of right-sided femoral hernias is thought to be caused by the tamponading effect of the sigmoid colon on the left femoral canal
The prevalence of hernias increases and the likelihood of strangulation and need for hospitalization increase with aging.
'Surgical Incisions on Abdominal Wall', a Surgical Anatomy Seminar by 1st yr MBBS students of Venkateswara Institute of Medical Science, Galraula, UP. India
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. TYPES OF MANAGEMENT FOR HERNIA
• CONSERVATIVE
• SURGICAL{Surgery is the treatment of choice}
3. CONSERVATIVE
• WATCHFUL WAITING: In elderly people, if the hernia
is asymptomatic, small in size, can be reduced easily
and is not causing anxiety, then observation alone
should be sufficient.
• Small paraumbilical hernias are common and they
cause few symptoms and usually contain fat or
omentum with a very low risk of complications.
• In obese and elderly patients, these risks may
outweigh the benefits of surgery so it is common to
adopt a conservative approach.
4. SURGICAL TREATMENT OF HERNIA
• For any hernia the surgical option comprises 2
components :
– Herniotomy
– Herniorrhaphy or hernioplasty
• It is either :
– Open repair
– Laparoscopic repair
5. INDICATIONS FOR SURGERY
• All cases of femoral hernia should be repaired
surgically as they have higher possibility of
strangulation.
• Any case of irreducible hernia with pain and
tenderness, unless coexisting medical factors place
the patient at very high risk from surgery or
anaesthesia.
• Increasing difficulty in reduction and increasing size.
• In younger adult patients as symptoms and
complications are likely over time.
• acute pain in a hernia and if it is irreducible, should
be offered surgery.
6. SURGICAL APPROACHES TO HERNIA
All surgical repairs follow the same basic principles:
1. Reduction of the hernia content into the
abdominal cavity with removal of any non-viable
tissue and bowel repair if necessary.
2. Excision and closure of a peritoneal sac if present
or replacing it deep to the muscles.
3. Reapproximation of the walls of the neck of the
hernia if possible.
4. Permanent reinforcement of the abdominal wall
defect with sutures or mesh
7. HERNIAL SURGERY IN INFANTS
• Only herniotomy is preferred in infants in both
hernia and hydrocele.
• This surgery is called as “Michaelis plank
operation”
8. HERNIAL SURGERY IN ADULTS
1. HERNIOTOMY – excision of hernial sac
2. HERNIORRHAPHY – herniotomy + posterior
wall strengthening
3. HERNIOPLASTY – herniorraphy with mesh
usage
10. HERNIOTOMY
• Anaesthesia: spinal or G/A or local anaesthesia
• Cleaning and draping ; skin is incised—1.25 cm above & parallel to
the medial two/third of inguinal ligament.
• Superficial fascia & external oblique aponeurosis is incised &
inguinal ligament is exposed.
• Ilioinguinal nerve is safeguarded.
• Cremasteric muscle is opened.
• Cord structures dissected. Sac is identified as pearly white in
colour.
• Sac is opened at the fundus. Finger is passed to release any
adhesions. Sac is twisted so as to prevent the content from
coming back.
• It is transfixed using absorbable suture material (chromic catgut 2-0
or vicryl) and is excised distally.
11. Skin incision—1.25 cm above &
parallel to the medial two/third of
inguinal ligament
Twisting of the sac to prevent the
contents to get in.
13. BASSINI’S HERNIORRHAPHY
1. The conjoined tendon is retracted upward
2. the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract that
lies adjacent to the inguinal ligament with several
interrupted sutures.
3. The second layer of the repair involves suturing
the conjoined tendon to the inguinal ligament
with interrupted sutures.
4. This suture line extends from the pubic tubercle to
the medial border of the internal ring.
14. • Opening the fascia transversalis from pubic tubercle to
deep ring.
• Approximation with interrupted stitches
• Approximation of conjoint tendon & upper leaf of
fascia transversalis with inguinal ligament & lower leaf
of fascia transversalis
15.
16. MODIFIED BASSINI’S HERNIORRHAPHY
Approximation with continuous interlocking stitch with
prolene.
• Sutures are placed between the conjoint tendon above and
the inguinal ligament below, extending from the pubic
tubercle to the deep inguinal ring.
17. LYTLE’S REPAIR
• INTERNAL ring is NARROWED by placing
interrupted sutures over the MEDIAL SIDE of the
ring to the transversalis fascia using either thread
or silk (To narrow the ring and push the cord
laterally)
18. SHOULDICE REPAIR
• an incision is made in the transversalis fascia.
This incision is extended from the internal ring
to the pubic tubercle.
• The repair involves placing four lines of
sutures.
19. • The first suture line is started at the pubic tubercle
using continuous polypropylene, and the white line
is approximated to the free edge of the inferior
transversalis fascial flap.
20. • The second suture line At the internal ring the suture is
tied and then continued medially by approximating the free
edge of the superior flap to the shelving edge of the
inguinal ligament. When the pubic tubercle is reached, the
suture is tied and divided.
21. • The third suture line is started at the level of the
internal ring where the conjoined tendon is
approximated to the inguinal ligament and tied
when the pubic tubercle is reached.
22. • the fourth suture line (Using the same suture)
attaches these same structures to one another and
is tied at the level of the internal ring.
23. • The cord is replaced within the inguinal canal,
and the external inguinal aponeurosis is
reapproximated with continuous absorbable
sutures
24. Desarda’s repair
• An operation where a 1- to 2-cm strip of external
oblique aponeurosis lying over the inguinal canal
is isolated from the main muscle,
• The continuity with muscle and insertion is kept
intact both medially and laterally.
• It is then sutured to the conjoint tendon and
inguinal ligament, reinforcing the posterior wall
of the inguinal canal.
• As the abdominal muscles contract, this strip of
aponeurosis tightens to add further physiological
support to the posterior wall.
25.
26. Tanner Slide Operation
• To reduce the tension in the repair area, relaxing
incision is placed over the lower rectus sheath after
modified bassini’s surgery so that conjoined tendon
is allowed to slide downward.
27. Darning (Abrahamson Nylon Darning)
• Continuous non absorbable sutures are placed
between : conjoint tendon and inguinal ligament to
give good support to posterior wall of inguinal
hernia.
28. McVay Operation
• It is repair by placing interrupted suture is
applied between transversalis fascia to
copper’s ligament starting from pubic tubercle
medially towards femoral sheath and later
continued as suture repair between
transversalis fascia and iliopubic tract laterally
upto entrance of cord
• Covers all three groin defects- indirect, direct,
and femoral.
29. 1. Andrew’s Operation - It involves overlapping
of the external oblique aponeurosis.
2. Nyhus Iliopubic Repair - Transaponeurotic
arch (transverse abdominis muscle and
transversalis fascia) is sutured below to
Copper’s ligament and iliopubic tract.
3. Wilkinson Method - Transversus abdominis
and internal oblique are sutured to inguinal
ligament with continuous monofi lament
sutures
31. Tension – free repair
• There are several options for placement of
mesh during anterior inguinal herniorrhaphy,
including
– The Lichtenstein approach
– The plug-and-patch technique
– The sandwich technique with both an anterior and
preperitoneal piece of mesh.
32. LICHTENSTEIN’S REPAIR.
• Lichtenstein described a tension-free, simple, flat,
polypropylene mesh repair for inguinal hernia.
• The initial part of the operation is identical to Bassini’s. Once
the hernia sac has been removed and any medial defect
closed, a piece of mesh, measuring 8 × 15 cm, is placed over
the posterior wall, behind the spermatic cord, and is split to
wrap around the spermatic cord at the deep inguinal ring.
• Loose sutures hold the mesh to the inguinal ligament and
conjoint tendon.
• Two major advantages are claimed:
– lowered hernia recurrence rates and
– accelerated postoperative recovery.
34. MESH IN HERNIA REPAIR
• The term ‘mesh’ refers to prosthetic material, either
a net or a flat sheet, which is used to strengthen a
hernia repair. Mesh can be used:
• To bridge a defect: the mesh is simply fixed over the
defect as a tension-free patch;
• To plug a defect: a plug of mesh is pushed into the
defect;
• To augment a repair: the defect is closed with
sutures and the mesh added for reinforcement.
• A well-placed mesh should have good overlap
around all margins of the defect up to 5 cm if
possible.
35. Mesh characteristics
• Woven, knitted or sheet
• Synthetic or biological – mainly synthetic
• Light, medium or heavyweight – lightweight
becoming more popular
• Large pore, small pore – large pore causes less
fibrosis andpain
• Intraperitoneal use or not – non-adhesive mesh
on one side
• Non-absorbable or absorbable – mainly non-
absorbable
36. Synthetic
mesh
• Avoided in infection and
strangulation.
• Eg.
– Prolene
– Polyester
– Vypro (vicryl+prolene)
– PTFE(polytetrafluoroethylene)
Biological
mesh
• Can be used where there is
infection.
• Eg:
• Alloderm
• Acellular porcine
dermis
• Acellular human dermis
38. PROPERTIES OF IDEAL MESH
• Possess good handling characteristics in the OR
• Invoke a favorable host response
• Be strong enough to prevent recurrence
• Place no restrictions on post implantation function
• Perform well in the presence of infection
• Resist shrinkage or degradation over time
• Make no restrictions on future access
• Block transmission of infectious disease
• Be inexpensive
• Be easy to manufacture
42. SUBLAY
BETWEEN FASCIAL LAYERS IN THE ABDOMINAL WALL
(INTRAPARIETAL OR SUBLAY);IMMEDIATELY EXTRAPERITONEALLY,
AGAINST MUSCLE OR FASCIA(ALSO SUBLAY);
44. COMPLICATIONS OF MESHPLASTY
• Mesh plug can form a dense ‘meshoma’ of plug and
collagen.
• Seroma’s develop with any mesh type but those with larger
pores may be less likely to do so.
• Migration, erosion into adjacent organs.
• Fistula formation
• Chronic pain
• Materials such as PTFE have a good profile for adhesion risk
but a high risk of infection.
• In contrast, polypropylene meshes are durable and have a
low infection risk but they have little flexibility and a high
adhesion risk.
48. • ‘Deep’ repair of inguinal hernia deals with the
issue from the ‘point of origin’ rather than the
‘point of presentation’.
• This exercise has two important final results.
– Firstly, the ‘inlay/ posterior’ mesh placement
provides a mechanical edge on the ‘onlay/ anterior’
mesh placement.
– Secondly covering the entire ‘Myopectineal orifice
(of Fruchaud’) the ‘deep’ repair handles all the
potential sites in danger
49. MYOPECTINEAL ORIFICE OF FRUCHAUD
• In 1956, Henry Fruchaud espoused the theory that all
groin (inguinofemoral) hernia and obturator originate
in a single weak area called the Myopectineal orifice.
This oval, funnel like, ‘potential’ orifice formed by the
following structures, forms the ‘Myopectineal orifice of
Fruchaud’.
1. Superiorly Internal oblique and transverses
abdominis muscles.
2. Inferiorly Superior pubic ramus.
3. Medially Rectus muscle sheath.
4. Laterally Iliopsoas muscle.
50.
51. THE PERITONEAL LANDMARKS
• Since the growth and development of the
laparoscopic method for treating groin hernia an
increased attention is being paid to ‘pure anatomy’
issues such as the infraumbilical fossae. These types
of fossae have two important roles-
– The fossae delineate the websites of groin herniation.
– They are an essential landmark for orientation during
hernia repairs.
• The fossae are created by the presence of
peritoneal folds, which radiate from the umbilicus
or umbilical area.
52. Median Umbilical Ligament
This ligament ascends within the
median plane in the apex of the
bladder towards the umbilicus. It
represents the obliterated allantoic
duct and its lower part may be the site
from the unusual urachal cyst.
Medial Umbilical Ligament
This ligament symbolizes the
obliterated umbilical artery on both
sides and can be traced down to the
internal iliac artery.
Lateral Umbilical Ligament
It's the ridge of peritoneum, which is
raised by the Inferior Epigastric artery
and its companion two veins because
they course around the medial border
from the internal inguinal ring after
which pass upwards into the posterior
rectus sheath.
53. • Supravesical fossae: The infra-umbilical area between
the median and medial umbilical structures. This is
actually the site for that source of the supravesical
hernia.
• Medial Umbilical fossae: The infra-umbilical area
between the medial and lateral umbilical ligaments. This
is the site for the ori- gin of the femoral and direct
inguinal hernia.
• Lateral Umbilical fossae: The infra-umbilical area
horizontal towards the lateral umbilical ligament. This is
actually the site for the origins of the indirect inguinal
hernia.
62. Operations for inguinal hernia
Herniotomy
TENSION REPAIR
Open suture repair
• Bassini
• Shouldice
• Desarda
Tension-free Repair
1. Open flat mesh repair
• Lichtenstein
2. Open complex mesh repair
• Plugs
• Hernia systems
3. Open preperitoneal repair
• Stoppa
4. Laparoscopic repair
• TEP
• TAPP
63.
64. OPERATIONS FOR FEMORAL HERNIA
OPEN LAPROSCOPIC
HIGH APPROACH
(Above inguinal ligament)
McEVEDY
LOW APPROACH
LOCKWOOD
TEP TAPP
Inguinal approach
LOTHEISSEN
65. LOW APPROACH (LOCKWOOD)
• This is the simplest operation for a femoral hernia but
suitable only when there is no risk of bowel resection.
• It can easily be performed under local anaesthesia.
• A transverse incision is made over the hernia. The sac of
the hernia is opened and its contents reduced.
• The sac is also reduced and non-absorbable sutures are
placed between the inguinal ligament above and the fascia
overlying the bone below.
• A small incision can be made in the medial lacunar ligament
to aid reduction but there may be an abnormal branch of
the obturator artery just deep to it, which can bleed. The
femoral vein, lateral to the hernia, needs to be protected.
66. THE INGUINAL APPROACH
(LOTHEISSEN)
• The initial incision is identical to that of Bassini’s or
Lichtenstein’s operation into the inguinal canal.
• The spermatic cord (or round ligament) is mobilised and
the transversalis fascia opened from deep inguinal ring to
the pubic tubercle.
• A femoral hernia lies immediately below this incision and
can be reduced by a combination of pulling from above and
pushing from below.
• Once reduced, the neck of the hernia is closed with sutures
or a mesh plug, protecting the iliac vein throughout.
• The layers are closed as for inguinal hernia and the surgeon
may place a mesh into the inguinal canal to protect against
development of an inguinal hernia.
67. HIGH APPROACH (McEVEDY)
• This more complex operation is ideal in the emergency situation where the
risk of bowel strangulation is high.
• It requires regional or general anaesthesia.
1. A horizontal incision (classically vertical) is made in the lower abdomen
centred at the lateral edge of the rectus muscle.
2. The anterior rectus sheath is incised and the rectus muscle displaced
medially. The surgeon proceeds deep to the muscle in the preperitoneal
space.
3. The femoral hernia is reduced and the sac opened to allow careful
inspection of the bowel, and a decision made regarding the need for
bowel resection if necessary.
4. In dubious cases, the bowel is replaced into the peritoneal cavity for 5
minutes and then re-examined. The femoral defect is then closed with
sutures, mesh or plug.
This approach allows a generous incision to be made in the
peritoneum,which aids inspection of the bowel and facilitates bowel
resection.
69. UMBLICAL HERNIA
Very small defect
(1-2cm)
Mayo’s repair
(herniorraphy)
Large defects
Meshplasty
OPEN LAPROSCOPIC
INTRAPERITONEAL ONLAY REPAIRDefects up to 2 cm in diameter may be
sutured primarily with minimal tension,
although, the larger the defect,the
more tension and the more likely it is
that mesh reinforcement will be
beneficial. The classic repair was
described by Mayo.
Approximation of the musculofascial layers
should be done with minimal tension and
prosthetic mesh should be used to reduce
the risk of recurrence.
70. UMBLICAL HERNIA
• CONSERVATIVE MANAGEMENT (2-3 YEARS)
• IF PERSIST PROCEED WITH SURGICAL REPAIR
PARAUMBLICAL HERNIA
• DEFECT USUALLY SUPERIOR AND RIGHT SIDE
• SEEN IN OBESE FEMALE PT’S.
• SURGERY AS SOON AS POSSIBLE
71. LUMBER HERNIA
• Management can be by open or laproscopic surgery
• The Dowd-Ponka technique involves making an incision
over the hernia site, reducing the sac, and placement of
a prosthetic mesh which is sutured to the external
oblique, latissimus dorsi, and the lumbar periosteum.
SPLEGIAN AND OBTURATOR HERNIA
• OPEN
• LAPROSCOPIC (USUALLY TAPP IN OBTURATOR
HERNIA)
72. COMPLICATIONS OF SURGERY
• Reduction of hernia content is essential for a
successful repair. extensive dissection can lead to
bowel injury.
• bowel resection with subsequent risks of infection
and bowel anastomotic complications.
• There is risk of fluid formation within the sac
(seroma).
• simple closure of a hernia defect by sutures alone
leads to a high recurrence rate.
• Absorbable mesh has shown higher recurrence
rates.