10 a.new groin hernias dr.fidel

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  • please will you kindly help me to share in this nice teaching program for medical students ,realy i find difficulties in downloading of some topics
    happy time
    Professor Dr. Abdulqadir zangana -Erbil ,KURDISTAN IRAQ
    prof.abdulqadir@gmail.com
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  • How much does the surgery for inguinal hernia cost? Please give estimate. Thank you
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  • Includes high ligation of the hernia sac plus narrowing the internal ring by approximating the surrounding muscular and aponeurotic layers on the medial side
  • The Shouldice repair emphasizes a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique. The Shouldice repair is associated with a very low recurrence rate and a high degree of patient satisfaction.
  • The Bassini repair is performed by suturing the transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament. was the most popular type of repair done before the advent of tension-free repairs.
  • In the Lichtenstein repair, a piece of prosthetic nonabsorbable mesh is fashioned to fit the canal. A slit is cut into the distal, lateral edge of the mesh to accommodate the spermatic cord. The mesh is held in place with the use of a continuous monofilament nonabsorbable suture.
  • The “tension-free” mesh repair has been modified from the original Lichtenstein repair. Gilbert reported using a cone-shaped “plug” of polypropylene mesh that when inserted into the internal inguinal ring would deploy like an upside-down umbrella and occlude the hernia. This plug is sewn to the surrounding tissues and held in place by an additional overlying mesh patch. This so-called plug and patch repair, an extension of Lichtenstein’s original mesh repair, has become the most commonly performed primary anterior inguinal hernia repair.
  • 10 a.new groin hernias dr.fidel

    1. 1. ABDOMINAL WALL & Groin HERNIAS Celso M. Fidel, MD,FPSGS,FPCS Diplomate Philippine Board of Surgery
    2. 3. Descent of the Testis
    3. 4. Descent of the Testis
    4. 5. GENERAL CONSIDERATIONS Hernia of the abdominal wall  Are the most common conditions requiring major surgery  Perfect results continue to elude surgeons  Rate of surgical failure( recurrence) is humbling  Outcome of hernia repair is highly surgeon dependent
    5. 6. GENERAL CONSIDERATIONS Hernia of the abdominal wall No disease of the human body, belonging to the province of Surgeons, require in its treatment a greater combination of accurate anatomical knowledge w/ surgical skills than hernia in all its varieties.
    6. 7. Features <ul><li>Size of hernia is determined by: </li></ul><ul><ul><li>dimension of the neck </li></ul></ul><ul><ul><li> volume of the distended sac </li></ul></ul>
    7. 9. Hernia Type III B
    8. 10. Features <ul><li> Anatomical features </li></ul><ul><ul><li> External= sac protrudes completely through the </li></ul></ul><ul><ul><li>abdominal wall </li></ul></ul><ul><ul><li>Inter-parietal= sac contained in the abdominal wall </li></ul></ul><ul><ul><li>Internal= sac within the visceral cavity </li></ul></ul><ul><ul><li> Reducible  Irreducible </li></ul></ul><ul><ul><li> Incarcerated  Strangulated </li></ul></ul><ul><ul><li> Richter’s Hernia= contents is one side of wall of </li></ul></ul><ul><ul><li>Intestine </li></ul></ul>
    9. 11. Hernias of the Groin  Anatomy  The only structurally important layer of the groin of concern to hernia surgeon is the innermost aponeuroticofascial layer of the abdomen  transverse abdominal muscle  transverse aponeurosis  transversalis fascia
    10. 12. Hernias of the Groin  Anatomy  The transverse aponeurotico fascia at the upper border of the fascial sheath is known as:  Iliopubic Tract>> North American Surgeons  Bandolette of Thomson>>French Surgeons  Deep Crural Arch>>>English Surgeons
    11. 13. Hernias of the Groin Anatomy  This innermost aponeuroticofascial layer of transverse aponeurotic fascia becomes the inferior crus of the deep ring  The superior crus of the deep ring is formed by the transverse aponeurotic arch that insert on the pectineal line of the pubis (pectin pubis )
    12. 14. Hernias of the Groin  Anatomy  The portion of the tendon of the rectus abdominis that curves laterally to pectin pubis is known as HENLE’S ligament  The angle of entrance of the deep ring is ACUTE medially and OBTUSE laterally
    13. 15. Hernias of the Groin  Anatomy  The MEDIAL border of Deep ring= the transverse aponeurosis & transversalis fascia; fibrous, definable, and palpable is the margin the Surgeons repair during hernia operation  The LATERAL border of the Deep ring the transverse abdominal muscle is soft, elastic, muscular, & indistinct
    14. 16. Hernias of the Groin  Anatomy The cremasteric muscle arising from the internal oblique muscle embraces interior aspect of spermatic cord in the inguinal canal The cremasteric vessels arise from the inferior epigastric vessels and pass through posterior wall of the inguinal canal; these vessels are w/ the genital nerve that supplies the tunica of the testis and cremasteric muscle
    15. 17. INGUINAL CANAL
    16. 18. Anatomy  Boundaries of the inguinal canal  Anterior wall= external oblique muscle  Posterior & Medial wall= transverse abdominal muscle and transversalis fascia  Lateral border=transversus abdominis muscle  The internal oblique muscle covers the deep ring and forms the shutter mechanism.
    17. 19. Inguinal Canal
    18. 20. Internal Oblique
    19. 21. Anatomy  Spermatic cord begins at deep ring & contains:  Vas deferens  Testicular Artery  Testicular Veins  Lymphatics  Autonomic Nerves  Fatty Tissue
    20. 22. Spermatic Cord <ul><li>Scrotum </li></ul><ul><li>Superficial spermatic f. </li></ul><ul><li>External spermatic f. </li></ul><ul><li>Cremaster muscle </li></ul><ul><ul><li>Cremasteric artery </li></ul></ul><ul><li>Internal spermatic f. </li></ul><ul><li>Processus vaginalis Canal of Nuck </li></ul>sac IIN GFN P vas ISA
    21. 24. Definitions  Hernia= protrusion of a viscus through an opening in the wall of the cavity in which it is contained.  Features  Clinically the important point in the definition is PROTRUSION , because without it diagnosis is essentially impossible.  Anatomically important features:  Hernial orifice= defect in innermost aponeurotic layer of abdomen  Hernial Sac = out-pouching of peritoneum
    22. 26. Hernias of the Groin Anatomy  FRUCHAUD’S Myopectineal Orifice  He emphasized that groin hernia begins within a single weak area bounded:  Superiorly- Internal oblique Muscle and Transverse Abdominal Muscle  Laterally- Iliopsoas Muscle  Medially- rectus muscle & sheath  Inferiorly- pectin pubis
    23. 28. Hernias of the Groin Anatomy  This bony muscular framework is:  Bridged and Bisected by the inguinal ligament  Traversed by the Spermatic Cord & Femoral Vessels  Sealed like a drum on its inner surface by the Transversalis Fascia
    24. 29. Hernias of the Groin  CLASSIFICATION Type I Indirect Inguinal Hernia  Internal inguinal ring is normal  Pediatric hernia Type II Indirect Inguinal Hernia  Internal inguinal ring dilated  Posterior inguinal wall intact  Inferior deep epigastric vessels not displaced
    25. 30. Hernias of the Groin  CLASSIFICATION Type III Posterior Wall Defects A. Direct Inguinal Hernia  Protrusion does not herniate thru internal (inguinal) abdominal ring The weakened transversalis fascia (post inguinal wall medial to inferior epigastric vessels) bulge outward in front of the mass.
    26. 31. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects A. Direct Inguinal Hernia  All direct hernias, small or large, are type III A  Three Varieties:  Type 1 small defect in the medial aspect of Hesselbach’s triangle near pubic tubercle.  Type 11 is a Diverticular Hernia that protrudes thru an otherwise intact inguinal floor.  Type 111 is a large Direct inguinal Hernia that protrudes thru the entire floor of the Hesselbach’s triangle
    27. 32. Hesselbach’s Triangle
    28. 33. Hesselbach’s Triangle Posterior View
    29. 34. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects B. Indirect Inguinal Hernias  With large dilated ring that has expanded medially and encroaches on the posterior inguinal wall (floor) to a greater or lesser degree.  Frequently with scrotal position  Occasionally cecum on the right & the sigmoid in the left makes up a portion of the sac wall. This sliding hernia destroys a portion of the inguinal floor.
    30. 35. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects B. Indirect Inguinal Hernias  Deep ring may be dilated w/o displacement of inferior epigastric vessels.  Direct or Indirect components of the hernial sac may straddle those vessels to form a pantaloon hernia C. Femoral Hernias Type IV Recurrent Hernia
    31. 36. Hernia Type III B
    32. 38. Hernias of the Groin  Men has 25 X risk to develop hernia than women  Inguinal Hernia arises above the abdomino Crural Crease  Femoral Hernia arises below the Abdomino Crural Crease  Sac of DIRECT HERNIA protrudes directly OUTWARD and FORWARD
    33. 39. Hernias of the Groin  Sac of INDIRECT HERNIA passes obliquely or indirectly towards and ultimately into the scrotum  In men indirect hernia outnumber direct hernia at a ratio of 2:1  Both indirect inguinal and femoral hernia are twice as common on the right than on the left
    34. 40. Route of Groin Hernias
    35. 41. Hernias of the Groin  Epidemiology  Strangulation occurs in 1.3% to 3% of groin hernias  Femoral has a higher rate of strangulation; 2- 20% of all hernias  Aging:  Increases the incidence of groin Hernias  Likelihood of Strangulation  Need for Hospitalization
    36. 42. Hernias of the Groin  Epidemiology  10% of women and 50% men with femoral hernia will develop an inguinal hernia  Probability of groin hernia’s strangulation varies with Location & Duration  INGUINAL HERNIAS  After 3 months strangulation 2.8%  After 2 years strangulation is 4.5%  FEMORAL HERNIAS  After 3 months strangulation is 32%  After 21 months strangulation 45%
    37. 43. Hernias of the Groin <ul><li>E  ETIOLOGY </li></ul><ul><li> Congenital due to patent processus vaginalis found in: </li></ul><ul><li> 80% of newborns </li></ul><ul><li> 50% of 1 year old </li></ul><ul><li> Position of humans beings (standing) </li></ul><ul><li> Loss of tissue strength and elasticity due </li></ul><ul><li>to destruction of connective tissue : </li></ul>
    38. 44. Hernias of the Groin <ul><li>E  ETIOLOGY </li></ul><ul><li> Destruction of connective tissue : </li></ul><ul><li> Increased intra abdominal pressure </li></ul><ul><li>1. Lifting heavy objects </li></ul><ul><li>2. coughing; asthma COPD </li></ul><ul><li>3. benign prostatic hypertrophy </li></ul><ul><li>4. pregnancy </li></ul><ul><li>5. carcinoma of colon and rectum </li></ul><ul><li>6. Ascites; intra abdominal tumors </li></ul><ul><li>7.obesity </li></ul>
    39. 45. Hernias of the Groin <ul><li>E  ETIOLOGY </li></ul><ul><li> Destruction of connective tissue : </li></ul><ul><li> Smoking </li></ul><ul><li> Aging </li></ul><ul><li> Connective tissue disease </li></ul><ul><li> Systemic Illness </li></ul>
    40. 46.  Etiology cont’d  These reduces the strength of the fascia and aponeurosis  Fractures of the elastic fibers & alteration of the structure, quantity and metabolism of collagen have been demonstrated in the connective tissue structures in groin hernia patients. Hernias of the Groin
    41. 47.  Etiology cont’d  Muscle deficiency contributes to herniation insufficiencies of internal oblique muscle  Fracture deformities of the pelvis; denervation of the shutter mechanism following a low cosmetic appendectomy incision. Hernias of the Groin
    42. 48. Hernia of the GROIN  Symptoms  Natural history is slow enlargement to the point of irreducibility and disfigurement with risk of strangulation even present  Wide variety of non specific discomfort related to the contents of the sac and the pressure by the sac on the adjacent structures.
    43. 49. Hernia of the GROIN Diagnosis  Simple physical examination will show an enlarge mass which transmit a palpable impulse when patient strains or coughs  Those not detectable by physical exams. can be demonstrated by:  Ultrasonography  Computerized tomography  Magnetic resonance imaging  Herniography
    44. 50. Hernia of the GROIN .  Diagnosis cont’d  Strangulation produces  Intense pain in the hernia  Tenderness  Intestinal obstruction  Signs& symptoms of sepsis  Does not enlarge or transmit an impulse when patient coughs
    45. 51. Incisional Hernia
    46. 52. Strangulated Hernia
    47. 54. Strangulated bowels
    48. 55. STRANGULATED HERNIA
    49. 56. Management of Groin HerniAS
    50. 57. Hernias of the GROIN Taxis= manual manipulation required to reduce viscera entrapped in a hernial sac. Should not be done for strangulated hernia Trusses are contraindicated for femoral hernia
    51. 58. Hernias of the GROIN  Indications for Surgery  All hernias should be repaired unless local or systemic conditions in the patients preclude a safe outcome .  Exceptions, hernias with wide neck and shallow sac
    52. 59. Surgery for GROIN Hernias 1. Aim is to prevent peritoneal protrusion through myopectineal orifice 2. Restoration of the integrity of the myopectineal orifice based on 3. Fruchaud’s concept of Groin hernias:
    53. 60. Surgery for GROIN Hernias  Fruchaud’s concept of Groin hernias: a. Aponeurotic closure of the myopectineal orifice to the extent necessary b. Replacement of the defective transversalis fascia w/ synthetic prosthesis
    54. 61. Surgery for Groin Hernias  REPAIR OF MYOPECTINEAL orifice  Reconstruction of the Deep Ring  Contrary to the belief of some surgeons the ANATOMY of the deep ring is such that strangulation of the spermatic cord by reconstruction of the posterior wall of inguinal canal is virtually impossible
    55. 62. Treatment of Groin Hernias  Repair of the groin hernia could be:  Anterior Approach = thru a groin incision where structures in & around the inguinal canal must be divided to reach the aponeuroticofascial layer
    56. 63. Treatment of Groin Hernias  Repair of the groin hernia could be:  Posterior Approach Tension is avoided by using a mesh prosthesis to patch or plug the myopectineal orifice replacing transversalis fascia layer
    57. 64. Repair of Groin hernias <ul><li>Anterior Approach </li></ul><ul><li>Marcy </li></ul><ul><li>Shouldice </li></ul><ul><li>Bassini </li></ul><ul><li>Lichtenstein </li></ul><ul><li>Lotheissen Cooper’s ligament , Mcvay </li></ul><ul><li>Ferguson Andrews </li></ul>
    58. 65. Treatment of Groin Hernias  In the anterior classical Hernioplasty only three has withstood time: 1. Marcy’s simple ring closure 2. Bassini’s operation original as done in Shouldice Hospital in Toronto 3. Mc Vay Lotheissen Cooper Ligament Repair
    59. 66. Treatment of Groin Hernias  Classical Hernioplasty has three parts: 1. Dissection of the inguinal canal 2. Repair of the myopectineal orifice 3. Closure of the inguinal canal
    60. 67. MARCY REPAIR <ul><li>Consists of tightening an enlarged deep ring only </li></ul><ul><li>Commonly called simple ring closure </li></ul><ul><li>Indicated in men and women who have indirect hernias with only minimal damage to the deep ring </li></ul>
    61. 68. Marcy Repair
    62. 69. SHOULDICE REPAIR <ul><li>Uses the transversalis fascia, which is divided longitudinally and imbricated upon itself in two layers </li></ul><ul><li>The internal oblique muscle and conjoint tendon are then sutured to the reflection of the inguinal ligament in two layers </li></ul>
    63. 70. Shouldice Repair
    64. 71. Shouldice Repair 1 2 3 4
    65. 72. BASSINI REPAIR <ul><li>The transversalis fascia and conjoint tendon above are sutured to the reflection of the inguinal ligament </li></ul><ul><li>In men,the spermatic cord is returned to its normal anatomic location between the reinforced inguinal canal floor and the external oblique aponeurosis </li></ul><ul><li>In women, the round ligament may be ligated and the internal ring closed </li></ul>
    66. 73. Bassini Repair
    67. 74. ANTERIOR PROSTHETIC GROIN HERNIOPLASTIES <ul><li>TENSION FREE HERNIOPLASTIES </li></ul><ul><li>( Lichtenstein hernioplasty) </li></ul><ul><li> Without formal repair mesh is sutured to the internal oblique abdominal muscle, the rectus sheath and the shelving edge of the inguinal ligament. </li></ul>
    68. 75. Tension Free Repair
    69. 76. Open Mesh Repair
    70. 77. Lichtenstein Repair
    71. 79. surgery for Groin Hernias  Cooper ligament repair (McVay)  Repair the 3 most valuable areas for herniation in myopectineal orifice  Deep ring  Hesselbach’s triangle  Femoral canal  Involves the suturing of the transverse aponeurotic arch to cooper’s ligament medially; femoral sheath laterally
    72. 80. Mc Vay Repair
    73. 83. Surgery for Groin Hernia <ul><li> POSTERIOR HERNIOPLASTY </li></ul><ul><li> This was popularized by NYHUS </li></ul><ul><li> A short transverse incision in the lower </li></ul><ul><li>quadrant up to pre-peritoneal fatty layer </li></ul><ul><li> Suturing the iliopubic tract to the transverse </li></ul><ul><li>aponeurotic arch </li></ul><ul><li> Narrows the deep ring w/ a few sutures </li></ul><ul><li>placed lateral to the spermatic cord </li></ul>
    74. 85. Posterior Approach
    75. 87. The use of Mesh Posteriorly
    76. 88. Surgery for groin hernias <ul><li> REPAIR OF MYOPECTINEAL Orifice </li></ul><ul><li> In indirect hernias in infants, children </li></ul><ul><li>and some young men, merely eliminating </li></ul><ul><li>sac & its high ligation cures the hernia. </li></ul><ul><li>(HERNIOTOMY) </li></ul>
    77. 89. PROSTHETIC MATERIALS Non-degradable and biologic-tolerant synthetic mesh readily available 1. MARLEX 2. PROLENE 3. TRELEX Resemble one another are composed of limited monofilament fibers of polypropylene. All are porous slightly elastic, semi rigid and relatively heavy and they contain plastic memory and buckle when bent in two directions at once.
    78. 90. PROSTHETIC MATERIALS 4 . SURGIPRO MESH- is composed of knitted, braided strands of polypropylene. 5. MERSILENE-an open knitted mesh composed of pure and uncoated braided fibers of the polyester DACRON.
    79. 91. PROSTHETIC MATERIALS <ul><li> It is porous, soft, lacelike, supple, </li></ul><ul><li>elastic, and without plastic </li></ul><ul><li>memory. </li></ul><ul><li> It has a grainy texture that prevent </li></ul><ul><li>slippage. </li></ul><ul><li> Has only a minimal tendency to </li></ul><ul><li>buckle when bent in two direction </li></ul><ul><li>at once. </li></ul>
    80. 92. PROSTHETIC MATERIALS <ul><li>6. GORE-TEX- is expanded polytetrafluoroethylene (FTFE),non porous, smooth, supple, fabric material containing through and through microscopic pores into which fibroblast grows. </li></ul>
    81. 93. ANTERIOR PROSTHETIC GROIN HERNIOPLASTIES <ul><li>STOPPA PROCEDURE= Giant Prosthetic reinforcement of the visceral sac. (MERSILENE is used) </li></ul><ul><li>1. For all complex hernias of the groin such as recurrent hernia and hernia associated with connective tissue disorder. </li></ul><ul><li> </li></ul>
    82. 94. ANTERIOR PROSTHETIC GROIN HERNIOPLASTIES <ul><li>STOPPA PROCEDURE= Giant Prosthetic reinforcement of the visceral sac. (MERSILENE is used) </li></ul><ul><li>2. A large prosthesis is inserted into the properitoneal space of a single groin. The prosthesis is held in place by intra abdominal pressure. </li></ul>
    83. 95. MESH PLUG
    84. 96. COMPLICATIONS <ul><li> Testicular Orchitis </li></ul><ul><li> Develops insidiously, not apparent </li></ul><ul><li>for 2-5 days after hernioplasty </li></ul><ul><li> Testicle and spermatic cord </li></ul><ul><li>becomes swollen, hard, tender, </li></ul><ul><li>painful and retracted. Process last </li></ul><ul><li>6-12 weeks </li></ul>
    85. 97. COMPLICATIONS <ul><li> Testicular Orchitis </li></ul><ul><li> </li></ul><ul><li>Etiology is ischemic thrombosis of </li></ul><ul><li>the spermatic cord </li></ul><ul><li>No known successful treatment to prevent </li></ul><ul><li>atrophy. </li></ul>
    86. 98. COMPLICATIONS <ul><li> Testicular Orchitis </li></ul><ul><li> Incidence can be minimized by </li></ul><ul><li>reducing surgical trauma to the cord by: </li></ul><ul><li> Never excising the distal part of an </li></ul><ul><li>indirect sac except when unavoidable </li></ul><ul><li> Never re-dissecting an inguinal canal & </li></ul><ul><li>spermatic cord with a previous surgery of </li></ul><ul><li>the groin or scrotum </li></ul><ul><li> Never dissecting beyond pubic Tubercle </li></ul>
    87. 99. COMPLICATIONS <ul><li> Neuralgia </li></ul><ul><li> Chronic residual neuralgia can result from </li></ul><ul><li>surgical handling of the sensory nerves in </li></ul><ul><li>the groin </li></ul><ul><li> A well known cause of residual neuralgia is a </li></ul><ul><li>neuroma. It results from a portion of nerve </li></ul><ul><li>fibers outside the neurilemma of a partially </li></ul><ul><li>or completely divided nerve </li></ul>
    88. 100. COMPLICATIONS <ul><li>Neuralgia </li></ul><ul><li> TREATMENT: </li></ul><ul><li>Neurolysis of the involved nerve </li></ul><ul><li>Injection w/ steroids to area </li></ul>
    89. 101. COMPLICATIONS <ul><li> Recurrence </li></ul><ul><li> one (1) to 3% in a 10 year follow up </li></ul><ul><li>due to: </li></ul><ul><li>1. Excessive tension on the repair </li></ul><ul><li>2. Deficient tissues </li></ul><ul><li>3. Inadequate hernioplasty </li></ul><ul><li>4. Overlooked hernias </li></ul>
    90. 102. COMPLICATIONS <ul><li> Recurrence </li></ul><ul><li> More common in direct hernias </li></ul><ul><li> Bilateral direct hernias </li></ul><ul><li> Direct hernias combined w/ </li></ul><ul><li>Indirect hernia </li></ul>
    91. 104. THANK YOU!!!

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