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Now What Do I Do? Tough Situations in Inguinal Hernia Repair &
How to Avoid or Manage Them
Avoid tough situations in inguinal hernia surgery by tailoring the operation.
It’s clearly not one size fits all. There are now many technique and material options that should
be carefully selected to optimize outcomes.
Avoid and Manage Tough Situations
• Dr. Heniford: which operation ?
• Dr. Sarr: Sport’s Hernia
• Dr. Lee: Inguinodynia
Avoid and Manage Recurrence
• If anterior, go posterior • European studies show this
is happening only 10% of the time
• Lap or open
• Consider Stoppa (GPRVS)– Bilaterals too
• If posterior, go anterior• Wide-on-lays; biologicals
• Lower quadrant component separation
• Bone anchors
Mesh Complications
• Infections unusual– Low thresh-hold for infected mesh
explant
• Meshoma’s and Migrations– Parviz Amid
– Organ erosion (bowel and bladder)
– Iliac vessels
– Shrinkage
• Can be the cause of chronic pain
Meshoma
“Surgical treatment for these patients is
explantation of the meshoma.”
Synthetic prostheses
Plug
Colon
Mesh plug
Colon
Plug, inflammation and pain
Recurrence after anterior repair
Avoid and Manage Pain
• Open hurts more than people say it does
• Pre-Op pain predicts Post-Op pain
• Tack pain post lap– Wait, wait, wait
– Diagnose• Use imaging
– Inject
– Wait some more
– Enlist Pain Experts
– Remove screws from Cooper’s ligament or Pain triangle with nerve transection
Evaluation of Groin Painfollowing Herniorrhaphy
Notes:
Neuropathic pain may respond to nerve blocks and may improve over time.
Neuroma pain may remain ongoing, therefore, surgical intervention is performed if the pain is debilitating or lasts for 5 years, due to complications of the surgery.
• Biological disease– AAA
– Ehlers-Danlos• Family Hx
– Immunosuppressed
• TEPPA– Wide mesh coverage
» Hydrophilic
» LW, large pore
– No Wound
– Increase the fixation
Manage or Avoid Abnormal Wound Healing
Send him to Rosen…
Laparoscopic Hernia RepairAnatomy: Triangle of Doom
• Avoid it!
• Follow inferior epigastrics
• Identify Cooper’s ligament
• Don’t confuse vas for iliac artery
• Close branches to iliac vein will bleed too
• Not an intern case!
• Lap IH Clip 03.mpg
Inguinal HerniasLoss of Domain
Giant Inguinal Hernia
• Loss of domain
• Plan for ventilator support– Pre-op PFTs
• Consider laparotomy– Temporary open
abdomen VAC
– Component separation
Avoid tough situations in inguinal hernia surgery by tailoring the operation.
• Know all the technical options– Lap vs Open
– Caveat: The best operation for your patient is the one you do best…
– Short and long-term plans for pain management
• There is a role for neurectomy
• Know the advantages and disadvantages of all the mesh materials– Polymer type
– Mesh shape
– Mesh position