hernia

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. TREATMENT OF INGUINAL HERNIA
BY
DR IBRAHIM GALAL
PROFESSOR OF GENERAL SURGERY
CAIRO UNIVERSITY

3. EUROPEAN HERNIA SOCIETY GUIDELINES
SEPTEMBER,2009
THE WORLD JOURNAL OF HERNIA AND ABDOMINAL WALL SURGERY

4. GUIDELINES
• INDICATIONS.
• INVESTIGATIONS.
• RISK FACTORS.
• TYPE OF REPAIR.
• APPROACH.
• MESH TYPE, TECHNIQUE, SIZE.
• ANAESTHESIA.
• ANTIBIOTICS.

5. INDICATIONS
• ASYMPTOMATIC INGUINAL HERNIA:
WATCHFUL WAITING. (Grade A)

6. INDICATIONS
• ASYMPTOMATIC INGUINAL HERNIA:
WATCHFUL WAITING.( Grade A)
• SYMPTOMATIC INGUINAL HERNIA:
ELECTIVE SURGERY. (Grade D)

7. INDICATIONS
• ASYMPTOMATIC INGUINAL HERNIA:
WATCHFUL WAITING. (Grade A)
• SYMPTOMATIC INGUINAL HERNIA:
ELECTIVE SURGERY. (Grade D)
• STRANGULATED HERNIA:
URGENT SURGERY. (Grade D)

8. INVESTIGATIONS
• CLINICALLY EVIDENT CASE:
NOT NEEDED. (Grade C)

9. INVESTIGATIONS
• CLINICALLY EVIDENT CASE:
NOT NEEDED. (Grade C)
• OBSCURE CASE (GROIN PAIN/LUMP):
-US.(30%)
-HERNIOGRAPHY. (80%)
-MRI & CT.(90%) (Grade C)

10. INVESTIGATIONS
• CLINICALLY EVIDENT CASE:
NOT NEEDED. (Grade C)
• OBSCURE CASE (GROIN PAIN/LUMP):
-US.(30%)
-HERNIOGRAPHY. (80%)
-MRI & CT.(90%)(Grade C)
• DIFFERENTIATION BETWEEN DIRECT& OBLIQUE:
-NOT USEFUL. (Grade C)

11. RISK FACTORS
• SMOKING, POSITIVE FAMILY HISTORY, PATENT PROCESSES
VAGINALIS, COLLAGEN DISEASE, AFTER LONG-TERM HEAVY
WORK ,ABDOMINAL AORTIC ANEURYSM , APPENDICECTOMY ,
ASCITES, PERITONEAL DIALYSIS, COPD, CONSTIPATION AND
PROSTATISM.
• SMOKING CESSATION IS THE ONLY SENSIBLE ADVICE THAT CAN
BE GIVEN WITH RESPECT TO PREVENTING THE DEVELOPMENT
OF AN INGUINAL HERNIA. (GRADE C)

12. TYPE OF REPAIR
• MESH REPAIR (TENSION FREE):
SHOULD BE USED IN ALL CASES EXCEPT IN
THE PRESENCE OF INFECTION.(Grade A)

13. TYPE OF REPAIR
• MESH REPAIR (TENSION FREE):
SHOULD BE USED IN ALL CASES EXCEPT IN
THE PRESENCE OF INFECTION.(Grade A)
• NON MESH REPAIR (SHOULDICE TECHNIQUE):
SHOULD BE USED ONLY IF THERE IS RISK OF
INFECTION. (Grade A)

14. APPROACH
• OPEN AS WELL AS LAPAROSCOPIC APPROACH ARE EQUALLY
EFFECTIVE IN UNILATERAL PRIMARY HERNIA. (Grade A)
• LAPAROSCOPIC APPROACH IS SUPERIOR IN MULTIPLE
HERNIAS ,IN FEMALES & IN ACTIVE PERSONS. (Grade A)
• OPEN APPROACH (LICHTENSTEIN TECHNIQUE) IS SUPERIOR
IN LARGE HERNIA , IRREDUCIBLE HERNIA & IS MORE COST
EFFECTIVE. (Grade A)

15. APPROACH TO RECURRENT HERNIA
• RECURRENCE AFTER ANTERIOR APPROACH(OPEN REPAIR) :
POSTERIOR APPROACH (LAPAROSCOPIC OR OPEN
PREPERITONEAL REPAIR). (Grade A)
• RECURRENCE AFTER POSTERIOR APPROACH:
ANTERIOR APPROACH.(Grade A)

16. LAPAROSCOPIC APPROACH
• TEP IS SUPERIOR TO TAPP REGARDING VISCERAL INJURY
PORT SITE HERNIA & POSTOPERATIVE PAIN ,BUT THE
LEARNING CURVE IS LONGER. (Grade B)

17. MESH TYPE
• THE USE OF LIGHTWEIGHT/LARGE-PORE (>1000
MICRON) MESHES CAN DECREASE LONG TERM
DISCOMFORT BUT POSSIBLY AT THE COST OF
INCREASED RECURRENCE RATE.(GRADE A)

18. MESH TECHNIQUE
• EXCEPT FOR THE LICHTENSTEIN AND LAPAROSCOPIC
TECHNIQUES (GRADE B), NONE OF THE ALTERNATIVE MESH
TECHNIQUES (EHS,PLUG,PATCH,) HAVE RECEIVED
SUFFICIENT SCIENTIFIC EVALUATION TO BE GIVEN A PLACE
IN THESE GUIDELINES.

19. MESH SIZE
• IN LAPAROSCOPIC UNILATERAL HERNIA REPAIR,THE IDEAL
MESH SIZE SHOULD BE 10 × 15 cm. (GRADE D)

20. ANAESTHESIA
• IN OPEN REPAIR, LOCAL ANAESTHESIA IS CONSIDERED
FOR ALL ADULT PATIENTS WITH A PRIMARY REDUCIBLE
UNILATERAL INGUINAL HERNIA. (GRADE A)
• GENERAL ANAESTHESIA WITH SHORT-ACTING AGENTS
COMBINED WITH LOCAL INFILTRATION ANAESTHESIA
MAY BE A VALID ALTERNATIVE TO LOCAL ANAESTHESIA.
(GRADE B)

21. ANTIBIOTICS
• THERE IS NO INDICATION FOR THE ROUTINE USE OF
ANTIBIOTIC PROPHYLAXIS IN ELECTIVE OPEN GROIN
HERNIA REPAIR IN LOW RISK PATIENTS.( GRADE A)
• IN LAPAROSCOPIC HERNIA REPAIR, ANTIBIOTIC
PROPHYLAXIS IS PROBABLY NOT INDICATED.(GRADE B)