A JOURNEY WITH HERNIA SURGERY

Dr.Sreejoy Patnaik.Shanti Memorial Hospital.

A JOURNEY WITH HERNIA SURGERY

Dr.Sreejoy Patnaik.Shanti Memorial Hospital.

• •Hippocrates used the Greek hernios for bud or bulge to describe abdominal hernias

Hernia

•Huge Inguinal Hernias

Definition

• An abnormal protrusion of the contents of a closed cavity through a potential or an abnormal opening

•Epigastric•Femoral

•Incisional/Ventral

•Inguinal

•Umbilical

•Diaphragmatic•(Hiatal Hernia)

Describing a Hernia

THE HISTORY OF SURGERY

IS ALMOST AS OLD AS LIFE

ITSELF

Famous hernia patient

Galileo Galilei (1564-1642) was incapacitated by an irreducible hernia in his later life.

Medical causes for the formation ofHERNIAS

CAUSES OFHERNIAS

INCREASEDPRESSURE

INSIDE

WEAKNESSOF THE WALLS

Causes Of Increased Pressure

F o rce

S M O K IN G & A S T H M A

H E A V Y W E IG H TS

F a tP U T T IN G O N

W E IG H T

F a e ce s & F la tusS E V E R E

C O N S T IP A T IO N

F lu idD IF IC U L T Y INU R IN A T IO N &

F L U ID IN A B D O M E N

F o e tusP R E G N A N C Y

IN C R EASEDPR ESSU R E

Causes of Weakness in the Covering Layers

A G E O P E R A T IV ES C A R S

M U S C L EB U L K L O S S

S ta rva tio n e tc.

W E A K N E S S

So I Have a Hernia.Why Should I Have Surgery?Operation ?

• There is pressure at the neck of the sac which can cut off the blood supply causing strangulation.

Inguinal Hernia Repair Techniques

• Tension Repair– Bassini– Shouldice

• Tension-free Repair– Open

• Lichtenstein

• Devices

– Laparoscopic• TAPP

• TEP

Tissue Repair – Bassini

•Tension – Pain - Recurrence

•Defect repaired by stitches

• Established - the end of the nineteenth century

• The prototype of the purest tissue repair

• 3 Layers of suturing:

Superiorly:– internal oblique muscle– transversus abdominis muscle – transversalis fascia and Inferiorly: – the inguinal ligament and the iliopubic tractThe spermatic cord lies against the newly

reconstructed posterior inguinal wall, with the external oblique aponeurosis closed over it.

•Bassini Repair Bassini Repair

• Shouldice repair – the Canadian repair (Toronto)

• Established in 1952

• Similar to the Bassini Repair– The essential difference is in the reconstruction of the

posterior inguinal wall, which in the Bassini repair is carried out with interrupted sutures (three lines) while the Shouldice uses continuous sutures back and forth (four lines), creating an overlap.

Shouldice Repair

Advantages of Tension Repair

• Easy to perform

• Cost effective

• 4. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.

• 5. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.

Disadvantages of Tension Repairs

High recurrence rates

• 10% to 30% recurrence rate with primary inguinal hernia repair 4

• Estimated 35% or higher recurrence rate with recurrent hernia repairs 5

Patient discomfort

Other potential complications

Tension-Free Repairs

• Introduced in 1984•Improved results over prior methods of repair•Open anterior approach•Steps

– deal with the sac– mesh sutured to floor and

around spermatic cord (between transversalis fascia and external oblique)

– running or interrupted sutures

•Lichtenstein (Onlay) Lichtenstein (Onlay) RepairRepair

Tension Free – Lichtenstein

• Pioneered in 1984.

• Covering the defect of the hernia with a patch of mesh, instead of sewing the edges together

• PAIN FREE repair

• Return to full activities at the earliest

Lichtenstein Technique

• Advantages– Tension-Free

Anterior Mesh Repair

– Quick and Easy– Easily

Teachable

• Disadvantages– No Posterior

Repair– No “Plugging”

of the defect– Extensive

continuous or interrupted suturing

Hernia repaired by plug

•Defect repaired by Plug

•3 plugs in one patient with a recurrence.Image courtesy of Karl LeBlanc, MD.

• Results often compromised with incidences of recurrence

•Erosion of a shrunken soft Marlex™ plug into the bladder wall.Image courtesy of Parviz K. Amid, MD.

•Problem often of mesh migration

The PROLENE Hernia System

• Introduced in 1998

• A secure posterior repair from a simple anterior approach

• Lowest reported recurrence rates 8

• Low cost

• 3 points of protection•8. Combined Anterior and Posterior Inguinal Hernia Repair: Intermediate recurrence rates with three groups of surgeons•Gilbert, AI et al. Hernia, 2004:8: 203-207

Lichtenstein Tension Free Single Flat Mesh

• Ease of use.• Tension-free repair.• Dramatic reduction in the

incidence of recurrence.• However, the mesh was

situated above the defect.• Recurrence could occur

between the mesh and the defect.

Laparoscopic Herniorrhaphy

TAPP

• TAPP = TransAbdominal PrePeritoneal

• Laparoscopic Approach

• Posterior Repair •Transversalis Fascia

•Mesh

•Incision

•Preperitoneal Space •Trocar

TEP

• TEP = Totally ExtraPeritoneal

• Laparoscopic Approach

• Posterior Repair

• Steps of Repair•Transversalis Fascia

•Mesh

•Preperitoneal• Space

•Trocar

•Peritoneum

Ventral / Incisional Hernia

Ventral / Incisional Hernias

• Develop as the result of a thinning, separation or tear in the muscle or tendon closure from prior surgery

• Often due to too much tension placed on the closure itself

• Hernias may be small but can enlarge and become problematic

• Surgical repair is best performed early when first diagnosed

Ventral/Incisional Hernias

• The problem:– 3-13% of laparotomy incisions develop hernias– 90,000 ventral/incisional hernia repairs per year– Recurrence rates of 25-50%– Prostethic mesh reduces recurrences, but..

• Increases wound complications

• Has been associated with chronic pain from poor compliance

Ventral / Incisional Hernias

• Facts:– Most hernias occur in the midline– Transverse incision tends to herniate where they

cross the midline– Initial closure is very important– Faulty technique universally leads to development

of herniation

•YOU NEED TO KNOW THE ANATOMY !!!

Ventral / Incisional Hernia Anatomy

Abdominal Wall

Defect

Adhesions

Bowel

Ventral Hernia Anatomy

•Incisional/Ventral •Umbilical

•Epigastric

Ventral Hernia Anatomy

Ventral/Incisional Hernia Repair

Procedural Options

Ventral/Incisional HerniaRepair Techniques

• Tissue to tissue

• Onlay

• Inlay

• Retromuscular/Preperitoneal

• Open Intra-abdominal

• Laparoscopic

Tissue to Tissue Technique

• Approximation of fascia under tension

Tissue to Tissue Technique

• Approximation of fascia with suture (under tension)– Strengths

• Inexpensive

• Easy to perform

• No foreign body

– Weaknesses• Tension on suture line

• High recurrence rates (43%-58%)

• Not suitable for large defects

• Difficult to identify multiple defects

•* Data on file

Onlay Technique

• Approximation of fascia with suture (under tension). Polypropylene mesh placed on top of fascia and fixated circumferentially

Onlay Technique

Onlay Technique

• Approximation of fascia with suture (under tension). Polypropylene mesh placed on top of fascia and fixated circumferentially.

– Strengths

• Inexpensive

• Easy to perform

– Weaknesses

• May not be able to use on large hernias

• High recurrence rates (20%-24%)2

• Intra-abdominal pressure working against repair

• Chance for strangulation and incarceration

• High incidence of seromas (subcutaneous dissection)

• Need for drains

• Chance of infection

• Difficult to identify multiple defects

•* Data on file

Inlay Technique

Retromuscular Technique

Retromuscular/Preperitoneal Technique

• Development of a preperitoneal pocket. Mesh placed into this pocket and fixated to the rectus sheath– Strengths

• Lower recurrence rates <10%• Intra-abdominal pressure working for the repair

– Weaknesses• Extensive lateral dissection• Creating the pocket may be difficult; ripping the peritoneum• High incidence of seromas• High incidence of infections 18.5%• Need for drains• May loop a bowel when fixating patch• Difficult to identify multiple defects

•* Data on file

Open Intra-Abdominal Technique

• Open Intra-abdominal – Hernia sac removed, intra-abdominal cavity entered, mesh fixated to the abdominal wall

– Strengths

• Lower recurrence rates <5%

• Intra-abdominal pressure working for the repair

• Less likely chance of seroma formation

• Less likely chance of infection

• Can easily identify multiple defects

– Weaknesses

• Adhesions and fistula formation to prosthetic materials

• Chance of enterotomy

• Usually large incisions

– Must Use TSM

•* Data on file

Laparoscopic Technique

Laparoscopic Technique

• Insufflation of the intra-abdominal cavity. Use of 5mm & 10mm ports and instruments to reduce hernia contents. Mesh placed in the intra-abdominal cavity, adjacent to viscera.

– Strengths• Low recurrence rates <3%• Low infection rate <1%• Intra-abdominal pressure working for the repair• Minimally invasive (small scars)• Can easily identify multiple defects

– Weaknesses• Expensive (tacker, Disposable instruments)• Difficult to perform• High learning curve• Chance of enterotomy

– Must Use TSM

•* Data on file

Pascal’s Principle

What mesh should be used?

CONSIDER:• Infection• Where is it going to be placed?• Adhesions• Shrinkage• Integration• Pain• Loss of domain

Many Meshes

• Marlex knitted polypropylene

• Prolene woven polypropylene

• Mersilene woven polyester

• Gore-Tex ePTFE

• Vicryl knitted polyglactin

• Dexon knitted polyglactin

• Composix Kugel

• Composix

• Sepramesh

• Surgisis

• Alloderm

• Permacol

• ULTRAPRO

• Parietex

• PROCEED

Advantage of Lap Hernia Rep.

• It offers minimal access approach to preperitoneal hernia repair.

• Lap Preperitoneal Repair provides much better views of what one is doing than open repair and avoid large incision & large mesh to cover the incision in order to prevent incisional hernia.

• Cost effectiveness of Lap Hernia com to Open .

• Patients can back to normal life as soon as possible as compared to Open Hernia.