Hernia Basics

7/28/2019 Hernia Basics

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RATIONALE & PRINCIPLES

PREPERITONEAL REPAIR OF

GROIN HERNIA

K JAYARAMA SHENOY


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Hesselbach's triangle.

bounded by the rectus abdominis muscle medially, inguinal

ligament inferiorly and the inferior epigastric vessels laterally..


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Transversus abdominis muscle and its aponeurosis

and fascial covering are the most important layer in

the groin.

The objective of any hernia repair should be to

return the transversus abdominis layer to normal

Because of Nyhus's leadership and landmark work, the

procedure of the posterior preperitoneal approach for

repair using the iliopubic tract or mesh buttressing beknown as the Nyhus operation

Hernia. 2011 Feb;15(1):1-5. Epub 2010 Oct 26.
http://www.ncbi.nlm.nih.gov/pubmed/20976610http://www.ncbi.nlm.nih.gov/pubmed/20976610http://www.ncbi.nlm.nih.gov/pubmed/20976610


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Nyhus classificationdesigned for the posterior approach based on

the size of the internal ring and the integrity of the posterior wall.

Type 1 indirect hernia with a normal internal ring

Type 2 indirect hernia with an enlarged internal ring

Type 3a direct inguinal hernia

Type 3b indirect hernia with posterior wall weakness;

Type 3c femoral hernia;

Type 4 represents all recurrent hernias


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A Groin "Hernia" is really a Pathologic Hole orDefect within the Transversalis Fascia, that occurs

specifically within the area of a poorly reinforced and

therefore hernia prone anatomic hole,which is called the MYOPECTINEAL ORIFICE.


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FRUCHAUDS MYOPECTINEAL ORIFICE


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Hernia is like a Puddle /hole in -FROZEN LAKE


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The Puddle or "Hole", is surrounded byan area of "THIN ICE".

So too, a hernia,, - not as simple as a visible hole.

It is always surrounded by an area of weakened,

thinned-out, significant and hernia-prone fascia:

This is the entire Transversalis Fascia of the MPO.

".


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REPAIR NOT JUST the "HOLE" area

but the WHOLE AREA


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Abdominal pressure v/s mesh


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APPROACH TO PREPERITONEAL SPACE

Anterior trans inguinal approach- (Anandale)

Condon

Rives repair

Posterior Approach

supra inguinal (Nyhus)

Grid Iron(kugels )

Midline- Cheatle - Henrys Stoppas GPRVS

McEvedys oblique incision ( rectus sheath)

Laparoscopic TEP (Dulucq)

- TAPP (Arrigue/Dion & Morin)


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viewed from inside the pelvis toward the direct and indirect sites.

A broad portion of mesh is placed to span both hernia defects.


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Preperitoneal approach -

advantages

Mesh covers the Myo Pectineal Orifice hence

effectively repairs nyhus types- 3 & 4

Less risk of

Damage to nerves

Damage to spermatic cord

Testicular atrophy


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Disadvantages

Involves more extensive dissection of preperitoneal

space

Requires a larger mesh reinforcement

Future entry difficult (especially- for uro/vascular

surgeries)

Risk of damage to

major vessel (iliac veins)Bowel

Bladder

Extraperitoneal hematoma


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Selection & relative

contraindicationsIndicated in

All recurrences after Anterior /onlay repairs

All Nyhus type 3 & 4 hernias

Incarceration

TEPP- OPEN CONVERSION

Avoid in patients-

Unfit for regional anesthesiaBleeding tendency

Concurrently with TURP/bladder surgery

Known malignancy


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Technical Tips & requirements

Good visibility

Good retraction

Regional/general anesthesia

Full knowledge of preperitoneal anatomy

is a must for the assistant.

Larger mesh ( 15 x 7.5 /15x 10 cm)


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Technical Tips & requirements

Use a large size mesh - covering MPO

Overlap 2.5 cm of supra/retropubic space

Overlap 2.5 cms of Bogros space

Fix to Coopers ligament

Lateral fixation to inguinal ligament Overlap 3 cm of the superior lips of incision

Closure of incision - muscles in layers

To prevent lateral recurrences


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complications

Hematomaavoid aspirin/clopidogrel pt

Seroma- in inguinal/scrotal space aspirate

Recurrences inadequate mesh overlap Mesh migrationfixation to coopers ligament

Lateral recurrences due to wound failure after improper

closure


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.

Author

Type of

repair

Number

of patients

Follow-up

period

Complication

rate (%)

Hernia

recurrence

rate (%)

Results of Hernia Repairs at Specialty Centers

Rutledge McVay - 906 9 years 2.0

Welsh and

AlexanderShouldice 214919 1 month to 40 years 0.1

Shouldice 2748 35 years 1.5

Amid, et al Lichtenstein - 3250 Average of 4 years (range:1 to 8 years)

0.1

Rutkow and

Robbins

Rutkow - 2060 NR 0.1

Nyhus Posterior iliopubic tract

repair- 1200 cases

37 years 1-6

Felix, et al. TAPP - repair 733

TEP-382

Average of 24 months

(range: 1 to 44 )

Average of 9 months

0.3

0.3


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Type of

repair

Number

of patients

Follow-up

period

Complication

rate (%)

Results of Hernia Repairs at Nonspecialty Centers

no Follow upcomp

re

cur

McVay 136 Average of 3 years, a range of 1 to 5

years

NR 9

Shouldice 136 Average of 3 years, a range of 1 to 5

years

NR 7

Bassini 125 3.3 years 28 10

Shouldice 119 3.4 years 29 2

Bassini 63 2 years 18 14

Shouldice 65 2 years 18 11


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r

Complications of Open and Laparoscopic Hernia Repairs

MajorHemorrhage

Testicular atrophy

Vas deferens transection

Bowel injury

Bladder injury

MajorHemorrhage

Bowel injury

Bladder injury

Major vessel injury

MinorScrotal ecchymosis

Wound infection

Urinary retention

RecurrenceHydrocele

Nerve transection

Nerve entrapment

MinorUrinary retention

Trocar site hernia

Nerve injury

Wound infection

Small-bowel obstruction

.


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Inf epig vessels Cor lipoma and sac


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Ligation-Division of sac Dissection of entire

Myo Pectineal Orifice


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Mesh inlay

Mesh covers M P O


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CONCLUSIONS & recommendations

Effective approach to M P O

For repair of all hernias -Nyhus type 3 & 4

Open alternative to Lap-hernia repairs

Documents

Hernia Basics