Groin hernia prof.f.villeke

Department of General-, Visceral- and Vascular Surgery

Minimal invasivegroin hernia repair (not only)

Frank WillekeSt.Marien-Hospital Siegen

Teaching Hospital of the Philips-University Marburg

with Thomas Neufang and Stefan Post

Klinik für Allgemein- Viszeral und Gefäßchirurgie

Topics

• Overview

• Hernia type and classification

• Approach and surgical technique

• Mesh: Design, Position, Fixation

• Hernia recurrence

• avoiding complications

• managing hernias – a suggestion


Hernia location

TransversusarkadeHesselbach Triangle indirect

direct

femoral


Posterior aspect

CONDON

Hesselbach ∆epigastr.vessels

iliopubic tract

NYHUS


Clinical examination!!!


• Overview








indirect

direct




Anatomie - Operationstechnische

Aspekte

• Overview







anterior

Cutis

Subcutis

inguinal canal

posterior wall

preperit. space

peritoneum

posterior

anterioranterior

extra-peritonalextra-peritonal

Nyhus

Stoppa

Nyhus

Stoppa

BassiniMc VayShouldiceLichtenstein

BassiniMc VayShouldiceLichtenstein

TAPPTAPP

transabdominaltransabdominalEEHPEEHP posteriorposterior



Shouldice


Lichtenstein


TransperitonealTAPP


Rectus sheath

Rectus muscle

Arcuate line

Peritoneum


TransperitonealTAPP


SHOULDICE: resection of cremaster muscleLICHTENSTEIN: no resectionTEP / TAPP: no resection

R. genitalisn. genitofemoralis

u.a. nach Schumpelick


MESH…

• Overview








intraabd.

pressure

sublay

onlay


Lichtenstein TAPP, EEHP


SHOULDICE reconstruction:small diameter, lateralisation


LICHTENSTEIN:less tight, "sling" - principle

na ch SHULMAN


preperitoneal meshincison

TAPP


Mesh incison ...

Incison = weak area


TEP (EEHP) Neufang style: weak area = incison = covered by “wing”


technical details I

• Scrub the lower abdomen with wide lateral margins• Antibiotics prophylaxis, Foley catheter

• Small median subumbilical incison

• Transverse opening of the anterior rectus sheath

• Lifting the rectus muscle with a retractor• Opening the preperitoneal space with a pean clamp with

a wet small sponge on the tip• Introduce ballon trocar or similar device, ideally under

camera control, inflate and visualize the inflation of the preperitoneal space


●● ☼

☺☺

●

Trocar position

screen

● = 5 mm


15 cm

12 cm

5 - 6 cm 6 cm

mesh configuration


technical details II

• Place a special trocar or a Hassan trocar and start to inflate CO2 with 12 mm Hg

• Place a 5mm trocar under vision in the midline

• Open the dissection plane, slowly preparing laterally, leaving the epigastric vessels cranially at the abdominal wall

• Place a 5 mm trocar on the side of the hernia under vision through the abdominal wall 3 cm cranial to the anterior iliac crest

• Carefully dissect (usually blunt) the peritoneum cranially with reposition of the hernia sac


technical details III

• pull the lipoma out of the funiculus

• check meticulously for indirect hernia

• check the femoral region without dissection of the fatty tissue on the iliac vessels

• reduce large medial hernias (Roeder sling, suture)

• make sure the funiculus is free for mesh placement underneath

• prepare the mesh and introduce it into the preperitoneal space through the 10 mm trocar (blind)

• Unfold the mesh, place it medial to the later position and first make the pull through under the spermatic cord


technical details IV

• Relieve the stay suture at the lateral mesh and place it correctly

• Open the stay suture at the wing and place the wing properly over the spermatic cord structures

• Relieve some CO2 and check for bleeding

• In case of some oozing, place a redon over the lateral trocar

• Hold the mesh in position while deflating the preperitoneal space

• Closure of facia at the subumbilical trocar, skin closure with resorbable suture




Recurrence…

• Overview








Typical for hernia recurrence…

• Defect frequently in the medial corner of Hesselbach

• Cranial position of iliopubic tract = opening of femoral hernia

• Lateralization of funiculus / inner groin ring

• Cave! Funiculus in a subcutaneous position


do we have complications?

• Overview








testis

• Be careful with the vessels• Have an urologist in your team or

as a friendly consultant


many nerves in the groin region


Genital branchgenitofemoral nerve

Ilioinguinal nerve

Iliohypogastric nerve

Nerves coming anteriorlynach AMID


Cave: ∆ of pain

?


• Overview








Shouldice Lichtenstein EEHP TAPP

bilateral - - + -recurrence Ø - + +< 18 years + Ø Ø ØSportive Ø - + +femoral Ø Ø + +female + - + +equivocal Ø Ø - +incarceration -/+ - Ø -/+

+ good - less good Ø not suitable

which mode for…


Shouldice Lichtenstein EEHP

Antibiotics* - + +

Redon - - -

Skin closure intracutan. intracutan. intracutan.

Arguments for antibiostics:- adipositas?- Recurrence?

Arguments for drainage:- adipositas?- recurrence- bilateral? (EEHP!)

* 2nd generation cephalosporins* 2nd generation cephalosporins

some details…


Shouldice* Lichtenstein* EEHP

demission ∼ 3. day ∼ 3. day ∼ 2. day

work 14 days 14 days 10 days

normalphysics 10 days 10 days 10 days

heavyphysics 6 - 8 weeks 14 days 10 days

* Outpatient procedure possible

management…

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Groin hernia prof.f.villeke