HerniaHernia

Abdominal Wall DefectAbdominal Wall Defect Congenital or acquiredCongenital or acquired

Potential for bowel obstructionPotential for bowel obstruction IncarcerationIncarceration StrangulationStrangulation

May suggest underlying pathologyMay suggest underlying pathology Hepatic disease, BPH, COPD, obstructing Hepatic disease, BPH, COPD, obstructing

colon masscolon mass

Pertinent HistoryPertinent History

Duration/onsetDuration/onset SymptomsSymptoms

LocalLocal ObstructiveObstructive

• Nausea, emesis, pain, distension, obstipationNausea, emesis, pain, distension, obstipation

Prior IncarcerationPrior Incarceration Related comorbidityRelated comorbidity

Pulmonary, Constipation, AscitesPulmonary, Constipation, Ascites Operative riskOperative risk

Pertinent ExamPertinent Exam

LocationLocation Reducible?Reducible? Tender?Tender? Skin changes?Skin changes? Palpable edges, Size?Palpable edges, Size? GenitaliaGenitalia RectalRectal

Common HerniasCommon Hernias

UmbilicalUmbilical VentralVentral IncisionalIncisional InguinalInguinal

Direct, indirect, femoral, obtuatorDirect, indirect, femoral, obtuator

Bassini Bassini repairrepair

LichtensteinLichtenstein(Amid)(Amid)

hernia hernia repairrepair

Nerves and vessels identified

Dome

Posterior view Posterior view of the groinof the groin

“myopectineal “myopectineal orifice”orifice”

HH. . Fruchaud (1956)Fruchaud (1956)

Laparoscopic Inguinal Hernia Technique

Nomenclature in inguinal Nomenclature in inguinal hernia repairs in adultshernia repairs in adults

ShouldiceShouldice= 3 layer tissue repair= 3 layer tissue repair BassiniBassini repair- term often incorrectly used, specify repair- term often incorrectly used, specify

details!details! McVay-LotheissenMcVay-Lotheissen= use of suprapubic ligament= use of suprapubic ligament ““Open mesh repair”- specify!Open mesh repair”- specify! LichtensteinLichtenstein= anterior open repair with mesh onlay= anterior open repair with mesh onlay Mesh plug- with or without onlay (Mesh plug- with or without onlay (RutkowRutkow)) Special designs- (Special designs- (GilbertGilbert, , KugelKugel)) TEP = lap. preperitoneal hernioplastyTEP = lap. preperitoneal hernioplasty TAPP= lap. Transabd. preperitoneal hernioplastyTAPP= lap. Transabd. preperitoneal hernioplasty StoppaStoppa repair= Open wrapping of peritoneal sac with repair= Open wrapping of peritoneal sac with

mesh, midline approachmesh, midline approach

onlay – inlay - underlayonlay – inlay - underlay

Ventral Hernia

Laparoscopic Ventral HerniaLaparoscopic Ventral Hernia

Laparoscopic Ventral HerniaTechnique

Tension free?Tension free?

More than a fad!More than a fad!

Reduces painReduces pain Reduces recurrencesReduces recurrences Reduces overall costsReduces overall costs

Umbilical HerniaUmbilical Hernia

CongenitalCongenital Most close by age 3Most close by age 3 May remain small and May remain small and

asymptomaticasymptomatic Can increase with Can increase with

obesity, pregnancy, obesity, pregnancy, ascites, peritoneal ascites, peritoneal dialysisdialysis

Typical umbilicusTypical umbilicus

Hernia outcome assessmentHernia outcome assessment

Past: Past:

recurrence, complications, procedure costrecurrence, complications, procedure cost

Future: Future: acute pain, chronic pain, convalescence timeacute pain, chronic pain, convalescence time

..chronic herniorraphy pain represents a scientific ..chronic herniorraphy pain represents a scientific challenge because the pathogenesis, diagnostic challenge because the pathogenesis, diagnostic criteria, and therapeutic interventions all have been criteria, and therapeutic interventions all have been incompletely evaluated.. incompletely evaluated.. H. Kehlet, Hernia, 2002H. Kehlet, Hernia, 2002