Hernia pptx - مهند الشلاه

HERNIA

Lecture 2
Professor
Dr. Mohanned Alshalah

LEARNING OBJECTIVES

To know and understand:

• Applied anatomy of the most common groin hernia

• Pathophysiology, clinical features, Investigations and principles of management of groin Hernias

Femoral Hernia

Femoral Canal Anatomy

Subtypes of Femoral Hernia

Watchful Wait vs Repair

Cumulative risk of strangulation over 2 years 476 patients (439 Inguinal, 37 Femoral)
34 strangulations (22 Inguinal, 12 Femoral)
•
• Cumulative Probability of Strangulation

3 months

2 years
Inguinal
2.8%
4.5%
Femoral
22.0%
45.0%

Strangulation

Richters Hernia

Femoral Hernia Repair

Mortality risk (Inguinal and Femoral)
0.1% < 60 years
0.2% 60 – 69
1.6% 70 – 79
3.3% > 80 years

Emergency repair for strangulation x 10 mortality risk – overall 10%

Groin Hernia GuidelinesASGBI 2013

Laparoscopic Femoral Hernia Repair

Inguinal Hernia

Nyhus Classification of Groin Hernias

Type I--indirect inguinal hernia
Internal inguinal ring normal (i.e., paediatric hernia)

Type II--indirect inguinal hernia

Dilated internal inguinal ring with posterior inguinal wall intact

Type III--posterior wall defects

Direct inguinal hernia
Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e., massive scrotal, sliding hernia)
Femoral hernia

Type IV--recurrent hernia

Inguinal hernia
Epidemiology:

• Male : Female
• by 9 to 1 ratio
• Lifetime risk Male 27%, Female 3%
• young adults mostly have indirect inguinal hernia
• As age of patient increases, the incidence of direct hernias increases
• 10% emergency surgery

Inguinal Anatomy

Inguinal Hernia Surgery

Bassini
Shouldice
McVay
Lichtenstein
Preperitoneal
Laparoscopic

Bassini Repair (1884)

Conjoined tendon to the inguinal ligament.

Shouldice Repair (1930s)

Multilayer repair of the posterior wall of the inguinal canal
Double breasting of transversalis fascia
Transverse abdominis aponeurotic arch to the iliopubic tract and Conjoined tendon to the inguinal ligament

McVay Repair (1948)
Transverse abdominis aponeurosis to Cooper's ligament and iliopubic tract

Lichtenstein (1989)

First pure prosthetic, tension-free repair to achieve low recurrence rates

Prosthetic Repair

• Allows for a fibrotic reaction to occur between the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect

Laparoscopic Inguinal Hernia Repair

TAPP - transabdominal preperitoneal repair was reported in 1992, Arregui et al. (Surg Laparosc Endosc 2:53-58, 1992) and Dion and Morin (Can J Surg 35:209-212, 1992)

TEP – totally extraperitoneal approach reported by Dulucq (Cahiers Chir 79:15-16, 1991)

NICE guidelines on Laparoscopic Hernia – 2004
• 37 RCTs were examined – Lap v open
• Lap longer operating time (13.3 min)
• Quicker return to work/ activities (3 days)
• Reduced rate of numbness (TAPP & TEP)
• NICE TA083 guidance DOH 2004

Laparoscopic Inguinal Hernia Repair

Complications of Inguinal Hernia Repair

Seroma/haematoma
Testicular Ischaemia
Visceral injury
Nerve injury
• Numbness
• Chronic pain - up to 40%
• Foreign body feeling
Recurrence 1%
Mesh infection 0.2%
Mortality ‹ 1%

Comparison of open approachesRecurrence

Recurrence rateSurgical Trainees

Watchful Wait vs Repair

Cumulative risk of strangulation over 2 years
• 476 patients (439 Inguinal, 37 Femoral)
• 34 strangulations (22 Inguinal, 12 Femoral)
• Cumulative Probability of Strangulation

3 months

2 years
Inguinal
2.8%
4.5%
Femoral
22.0%
45.0%

Watchful Wait vs Repair
Two independent systematic reviews both concluded that watchful waiting is safe, but most patients will develop symptoms (mainly pain) over time and will require an operation

Inguinal Hernia RepairMortality

ELECTIVE
• All series < 1%
• Swedish Registry – not raised above that of background population
• Danish study - 26,304 patients
0.02% <60 years, 0.48% >60 years
EMERGENCY
• 7% in Danish Study
• Swedish Registry – x7 emergency surgery
x20 bowel resection

Mortality and Groin Hernias

Women have a higher mortality risk than men, due to a greater risk for emergency procedure irrespective of hernia anatomy and a greater proportion of femoral hernias
After a femoral hernia operation, the mortality risk was increased seven-fold for both men and women

Groin Hernia GuidelinesASGBI 2013Speed of Referral

Men, reducible, symptomatic – ROUTINE
Men, irreducible – URGENT
Women – URGENT
Strangulated/obstructed - EMERGENCY

Groin Hernia GuidelinesASGBI 2013Imaging
Diagnostic uncertainty
To exclude other pathology

USS – first line

MRI – if USS neg, and groin pain persists

Groin Hernia GuidelinesASGBI 2013Indications for Surgery

Symptomatic Inguinal
All Femoral hernias

Asymptomatic Inguinal – can be managed conservatively – but likely to require surgery in the future

Inguinal Hernia RepairPerioperative Antibiotics

Controversial
Surgical Site Infection (SSI) rates 0 -14%
antibiotics may reduce wound infection rate
Mesh infection – 0.3 – 2%
Meta analysis/ Cochrane Reviews –
antibiotics vs controls – no significant difference in SSI or mesh infections
Routine use of prophylactic antibiotics – not recommended, except in high risk patients - >75yrs, Obesity, urinary catheter, Diabetes

Groin Hernia GuidelinesASGBI 2013Laparoscopic or Open Repair
Laparoscopic

• Younger patients

• Females
• Groin pain with small hernias
• Bilateral hernias
• Recurrent (index op – Open)
• Femoral - elective
Open

• Elderly (LA)

• Comorbidity (LA)
• Anticoagulants
• Large inguino-scrotal
• Hostile Abdomen
• Recurrent (index op – Lap)

Groin Hernia GuidelinesASGBI 2013Post Op Activity

“Do what you feel you can” – heavy weight lifting 2-3 weeks.
Return to work – median 7 days (open and lap)
Driving – 7 days

Obturator Hernia
9 : 1 female to male ratio
Typical patient is > 70 yrs of age
Multiparous women
Up to 20% bilateral
Concurrent Femoral hernias common

CLINICAL PRESENTATION

• Intestinal obstruction
• most common presentation (80%)
• Up to 70% mortality with strangulation
• Overall mortality 25%
• Correct preoperative diagnosis in 20% to 38% of patients

ANATOMY

Formed by rami of the ischium and pubis
Bilaterally in anterolateral pelvic wall
Medial to the acetabulum

Obturator Foramen

• Covered by obturator membrane
• Internal orifice closed by preperitoneal fat
• Contains obturator nerve and vessels

MRI

Obturator HerniaOperative Approach

• REPAIR
• Simple closure of the hernial defect with one or more interrupted sutures
• Plugging the canal with cartilage, free omentum ,obturator fascia, polypropylene mesh, teflonpatch, or bladder wall.
• Recurrence – 10% for simple closure

Intraoperative image showing left sided obturator hernia within white outline and incidental femoral hernia at 11’o clock position.

Noel P. Lynch et al. J. surg. case rep. 2013;2013:rjt050

Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2013.

• Write a report to Identify, discuss and defend the medico-legal, socio-cultural and ethical issues when pertaining informed consent to patient presented with elective inguinal hernia.

https://youtu.be/YzMT7y545Zk

In the link below you find lecture in YouTube application