GROIN HERNIA REPAIRWarko KarnadihardjaDepartment of Surgery, Hasan Sadikin HospitalUniversity of PadjadjaranBandung

EVOLUTION OF GROIN HERNIA SURGERY

The McVay Coopers ligament repair

Moloneys nylon darn repair

The Shouldice repair

MESH REPAIR

MESH REPAIR

ETIOLOGY OF GROIN HERNIAPatent processus vaginalisShutter mechanismRaised intra adominal pressureThe integrity of the fascia transversalsCollagenCigarette smokingGeneral factors

RECURRENT GROIN HERNIAThe incidence after primary repair variesfrom 1% in specialized centersto 30% in general surveyMost recurrences appear within 2-3 years of the primary repair

EARLY RECURRENCEEtiologic factorsExperience of he surgeonTensionInfectionThe suture materialSuturing techniqueGeneral factorsLocal factors

LATE RECURRENCEThe incidence of recurrence of groin hernias tappers off after the first 5 yearsSometimes some recurrences appear as many as 30 years laterHow about recurrent inguinal hernia in middle age men who as children underwent repair of an indirect hernia by herniotomy on the same side ?

PROSTHETIC MESHOriginally used for the repair of incisional herniaGreat success to the repair of recurrent groin herniasPossible to cure every hernia, regardless of its size or shape

SYNTHETIC MESH FOR PRIMARY REPAIRTension free repair: introduced by Lichtenstein (1986)Tensionless and sutureless : by Gilbert (1995)Open-mesh plug hernioplasty by Rutkow (1995)

WHAT IS THE DIFFERENCE BETWEEN CLASSIC VS PROSTHETIC REPAIR ? No need SkeletonizingNo need Extensive dissectionLess is now beatiful

To avoid recurrence of hernia !

TYPE OF MESH MATERIALSNon absorbableKnitted polypropyleneProlene, marlexKnitted polyesterMersileneExpanded polytetrafluoroethyleneCPTFE, Gore-texAbsorbableNo place in hernia repair

APPROACHOpen methodLaparoscopicTransabdominal / transperitonealExtraperitoneal

BASIC PRINCIPLES OF MESH HERNIA REPAIRThe sheet must be sufficiently large to overlap the hernia defect with an apron of at least a few centimeters, allow a wide area for fixationThe wider the area, the stronger the force holding the meshThe edges of the mesh must be fixed firmly in place in good & strong tissues as far from the weakened tissue

THESE BASIC PRINCIPLES IS USED INStoppa is giant prosthetic reinforcement of the visceral sac (GPRVS)Gilberts sutureless repairRutkows open-mesh plug hernioplastyThe deeper the level of the mesh, the less likely a recurrence

MIGHT BE A FAILURE AND LEADING TO RECURRENT HERNIA IF Superficially place mesh, more prone to be involved in any graft infection from superficial wound infectionThe inlay mesh position, is at a mechanical disadvantage in that the full force of the intra abdominal pressure is applied behind the unsupported mesh sutured to the scarred tissue along the edges of hernia openingThe onlay mesh placed on the outher surface of the external oblique muscle, tends to be lifted off the abdominal wall by intra abdominal pressure

Laparoscopic Inguinal Hernia RepairTAPP = Transabdominal Preperitonial Repair

Laparoscopic Inguinal Hernia RepairTEP = Totally Extraperitonial Repair

MESH PLUG

ONLAY PATCH

THE LICHTENSTEIN REPAIR

THE LICHTENSTEIN REPAIR

THE STOPPA GROIN HERNIA REPAIR(GIANT PROSTHETIC REINFORCEMENT OF THE VISCERAL SAC = GPRVS)Mainly used to manage complex hernias at high risk for recurrence and recurrent groin herniasThe essential features is the replacement of the transversals fascia in the groin by a large prothesis that extends far beyond the myopectineal orifice (MPO)GPRVS is sutureless and tension free

BILATERAL STOPPA

UNILATERAL STOPPA VIA ANTERIO ABDOMINAL INCISION

UNILATERAL STOPPA VIA ANTERIO ABDOMINAL INCISION

THE MYODECTINEAL ORIFICE (MPO)

THE CHEVRON-SHAPED MESH IN THE STOPPA OPERATION

CONCLUSIONThe causes of primary groin hernia are multi factorial and largely unaffected by human behaviorThe factors that bring about the recurrence of groin hernias after failed attempts at repair are almost controllable by relative simple meansPatients undergoing herniorraphy have the right to assume that the repair will last for the rest of their life. It is the surgeons responsibility to rise to these expectations