10 a.new groin hernias dr.fidel

ABDOMINAL WALL & Groin ABDOMINAL WALL & Groin HERNIASHERNIAS

Celso M. Fidel, Celso M. Fidel, MD,FPSGS,FPCSMD,FPSGS,FPCS

Diplomate Philippine Board of Diplomate Philippine Board of SurgerySurgery

Descent of the TestisDescent of the Testis

GENERAL CONSIDERATIONSGENERAL CONSIDERATIONSHernia of the abdominal wallHernia of the abdominal wall Are the most common conditions requiring Are the most common conditions requiring major surgery major surgery Perfect results continue to elude surgeonsPerfect results continue to elude surgeons

Rate of surgical failure( recurrence) is humblingRate of surgical failure( recurrence) is humbling

Outcome of hernia repair is highly surgeon Outcome of hernia repair is highly surgeon dependentdependent

GENERAL CONSIDERATIONSGENERAL CONSIDERATIONSHernia of the abdominal wallHernia of the abdominal wall No disease of the human body, belonging to No disease of the human body, belonging to the province of Surgeons, require in its the province of Surgeons, require in its treatment a greater combination of treatment a greater combination of accurate anatomical knowledge w/ surgical accurate anatomical knowledge w/ surgical skills than hernia in all its varieties. skills than hernia in all its varieties.

FeaturesFeatures

Size of hernia is determined by:Size of hernia is determined by:

dimension of the neckdimension of the neck

volume of the distended sacvolume of the distended sac

Hernia Type III BHernia Type III B

FeaturesFeatures Anatomical featuresAnatomical features

External= sac protrudes completely through the External= sac protrudes completely through the abdominal wallabdominal wall

Inter-parietal= sac contained in the abdominal wallInter-parietal= sac contained in the abdominal wall

Internal= sac within the visceral cavityInternal= sac within the visceral cavity

Reducible Reducible Irreducible Irreducible Incarcerated Incarcerated Strangulated Strangulated Richter’s Hernia= contents is one side of wall ofRichter’s Hernia= contents is one side of wall of IntestineIntestine

Hernias of the GroinHernias of the Groin Anatomy Anatomy The only structurally important layer of the The only structurally important layer of the groin of concern to hernia surgeon is the groin of concern to hernia surgeon is the innermost aponeuroticofascial layer of the of the abdomenabdomen

transverse abdominal muscletransverse abdominal muscle

transverse aponeurosistransverse aponeurosis

transversalis fasciatransversalis fascia

Hernias of the GroinHernias of the Groin Anatomy Anatomy The The transverse aponeurotico fascia at the transverse aponeurotico fascia at the upper border of the fascial sheath upper border of the fascial sheath is known is known as:as: Iliopubic Tract>> North American SurgeonsIliopubic Tract>> North American Surgeons

Bandolette of Thomson>>French SurgeonsBandolette of Thomson>>French Surgeons

Deep Crural Arch>>>English SurgeonsDeep Crural Arch>>>English Surgeons

Hernias of the GroinHernias of the Groin

Anatomy Anatomy

This This innermost aponeuroticofascial layer innermost aponeuroticofascial layer of of

transverse aponeurotic fascia becomes the transverse aponeurotic fascia becomes the inferior inferior

cruscrus of the deep ring of the deep ring

The The superior crus superior crus of the deep ring is formed of the deep ring is formed

by the by the transverse aponeurotic arch transverse aponeurotic arch that insert that insert

on the pectineal line of the pubis (pectin pubison the pectineal line of the pubis (pectin pubis))


Anatomy Anatomy

The portion of the tendon of the rectus The portion of the tendon of the rectus

abdominis that curves laterally to pectin pubis abdominis that curves laterally to pectin pubis

is known as is known as HENLE’S ligamentHENLE’S ligament

The angle of entrance of the deep ring is The angle of entrance of the deep ring is ACUTEACUTE

medially and medially and OBTUSEOBTUSE laterally laterally


AnatomyAnatomy

The The MEDIAL border MEDIAL border of Deep ring= the of Deep ring= the transverse aponeurosis & transversalis transverse aponeurosis & transversalis fascia; fibrous, definable, and palpable is fascia; fibrous, definable, and palpable is the margin the Surgeons repair during the margin the Surgeons repair during hernia operationhernia operation

The The LATERAL border LATERAL border of the Deep ring of the Deep ring the transverse abdominal muscle is soft, the transverse abdominal muscle is soft, elastic, muscular, & indistinctelastic, muscular, & indistinct


Anatomy Anatomy The The cremasteric musclecremasteric muscle arising from the arising from the internal oblique muscleinternal oblique muscle embraces interior embraces interior aspect of spermatic cord in the inguinal aspect of spermatic cord in the inguinal canalcanal

The The cremasteric vesselscremasteric vessels arise from the arise from the inferior epigastric vesselsinferior epigastric vessels and pass through and pass through posterior wall of the inguinal canal; these posterior wall of the inguinal canal; these vessels are w/ the genital nerve that vessels are w/ the genital nerve that supplies the tunica of the testis and supplies the tunica of the testis and cremasteric musclecremasteric muscle

INGUINAL CANALINGUINAL CANAL

AnatomyAnatomy Boundaries of the inguinal canal Boundaries of the inguinal canal Anterior wall= external oblique muscleAnterior wall= external oblique muscle Posterior & Medial wall= transverse Posterior & Medial wall= transverse abdominal muscle and transversalis abdominal muscle and transversalis fasciafascia Lateral border=transversus abdominis Lateral border=transversus abdominis muscle muscle The internal oblique muscle covers the The internal oblique muscle covers the deep ring and forms the deep ring and forms the shutter shutter mechanism.mechanism.

Inguinal CanalInguinal Canal

Internal ObliqueInternal Oblique

Anatomy Anatomy Spermatic cord begins at deep ring & Spermatic cord begins at deep ring & contains:contains: Vas deferens Vas deferens Testicular ArteryTesticular Artery Testicular Veins Testicular Veins LymphaticsLymphatics Autonomic Nerves Autonomic Nerves Fatty TissueFatty Tissue

Spermatic CordSpermatic Cord

ScrotumScrotum

Superficial spermatic f.Superficial spermatic f.

External spermatic f.External spermatic f.

Cremaster muscleCremaster muscle

– Cremasteric arteryCremasteric arteryInternal spermatic f.Internal spermatic f.

Processus vaginalis Processus vaginalis Canal of NuckCanal of Nuck

DefinitionsDefinitions Hernia= protrusion of a viscus through an Hernia= protrusion of a viscus through an opening in the wall of the cavity in which it is opening in the wall of the cavity in which it is contained.contained. FeaturesFeatures

Clinically the important point in the definition Clinically the important point in the definition isis PROTRUSIONPROTRUSION, because without it , because without it diagnosis is essentially impossible.diagnosis is essentially impossible. Anatomically important features:Anatomically important features: Hernial orifice= defect in innermost Hernial orifice= defect in innermost aponeurotic layer of abdomenaponeurotic layer of abdomen Hernial Sac = out-pouching of peritoneumHernial Sac = out-pouching of peritoneum


AnatomyAnatomy FRUCHAUD’SFRUCHAUD’S Myopectineal Orifice Myopectineal Orifice He emphasized that groin hernia begins He emphasized that groin hernia begins within a single weak area bounded:within a single weak area bounded:

Superiorly- Internal oblique Muscle andSuperiorly- Internal oblique Muscle and Transverse Abdominal MuscleTransverse Abdominal Muscle

Laterally- Iliopsoas MuscleLaterally- Iliopsoas Muscle Medially- rectus muscle & sheathMedially- rectus muscle & sheath

Inferiorly- pectin pubisInferiorly- pectin pubis


Anatomy Anatomy This This bony muscular framework bony muscular framework is:is:

Bridged and Bisected by the inguinal ligamentBridged and Bisected by the inguinal ligament

Traversed by the Spermatic Cord & Femoral Traversed by the Spermatic Cord & Femoral VesselsVessels

Sealed like Sealed like a drum on its inner surface by thea drum on its inner surface by the Transversalis FasciaTransversalis Fascia


CLASSIFICATIONCLASSIFICATION Type I Type I Indirect Inguinal HerniaIndirect Inguinal Hernia Internal inguinal ring is normalInternal inguinal ring is normal Pediatric herniaPediatric hernia

Type II Type II Indirect Inguinal HerniaIndirect Inguinal Hernia Internal inguinal ring dilatedInternal inguinal ring dilated Posterior inguinal wall intactPosterior inguinal wall intact Inferior deep epigastric vessels not Inferior deep epigastric vessels not displaceddisplaced


CLASSIFICATIONCLASSIFICATION Type IIIType III Posterior Wall Defects Posterior Wall Defects

A. Direct Inguinal HerniaA. Direct Inguinal Hernia

Protrusion does not herniate thru internalProtrusion does not herniate thru internal (inguinal) abdominal ring(inguinal) abdominal ring

The weakened transversalis fascia (post inguinal The weakened transversalis fascia (post inguinal wall medial to inferior epigastric vessels) bulgewall medial to inferior epigastric vessels) bulge outward in front of the mass.outward in front of the mass.


CLASSIFICATION Type III Posterior Wall DefectsCLASSIFICATION Type III Posterior Wall Defects A. Direct Inguinal HerniaA. Direct Inguinal Hernia All direct hernias, small or large, are type III AAll direct hernias, small or large, are type III A Three Varieties:Three Varieties: Type 1 small defect in the medial aspect of Hesselbach’s triangle Type 1 small defect in the medial aspect of Hesselbach’s triangle near pubic tubercle.near pubic tubercle.

Type 11 is a Diverticular Hernia that protrudes thru an otherwiseType 11 is a Diverticular Hernia that protrudes thru an otherwise intact inguinal floor.intact inguinal floor.

Type 111 is a large Direct inguinal Hernia that protrudes thru theType 111 is a large Direct inguinal Hernia that protrudes thru the entire floor of the Hesselbach’s triangleentire floor of the Hesselbach’s triangle

Hesselbach’s TriangleHesselbach’s Triangle

Hesselbach’s Triangle Posterior ViewHesselbach’s Triangle Posterior View


CLASSIFICATION Type III Posterior Wall DefectsCLASSIFICATION Type III Posterior Wall Defects B. Indirect Inguinal Hernias B. Indirect Inguinal Hernias

With large dilated ring that has expanded medially and With large dilated ring that has expanded medially and encroaches on the posterior inguinal wall (floor) to a greater encroaches on the posterior inguinal wall (floor) to a greater or lesser degree. or lesser degree.

Frequently with scrotal position Frequently with scrotal position

Occasionally cecum on the right & the sigmoid in the left Occasionally cecum on the right & the sigmoid in the left makes up a portion of the sac wall. This sliding hernia makes up a portion of the sac wall. This sliding hernia destroys a portion of the inguinal floor.destroys a portion of the inguinal floor.

celso m. fidel


CLASSIFICATION Type III Posterior Wall DefectsCLASSIFICATION Type III Posterior Wall Defects B. Indirect Inguinal Hernias B. Indirect Inguinal Hernias Deep ring may be dilated w/o displacement of inferiorDeep ring may be dilated w/o displacement of inferior epigastric vessels.epigastric vessels.

Direct or Indirect components of the hernial sac mayDirect or Indirect components of the hernial sac may straddle those vessels to form a pantaloon herniastraddle those vessels to form a pantaloon hernia

C. Femoral Hernias C. Femoral Hernias Type IV Recurrent HerniaType IV Recurrent Hernia

celso m. fidel

Hernia Type III BHernia Type III B


Men has 25 X risk to develop hernia than womenMen has 25 X risk to develop hernia than women Inguinal Hernia arises above the abdominoInguinal Hernia arises above the abdomino Crural CreaseCrural Crease

Femoral Hernia arises below the Abdomino Femoral Hernia arises below the Abdomino Crural CreaseCrural Crease

Sac of DIRECT HERNIA protrudes directlySac of DIRECT HERNIA protrudes directly OUTWARDOUTWARD and FORWARD and FORWARD

Hernias of the GroinHernias of the Groin Sac of INDIRECT HERNIA passes Sac of INDIRECT HERNIA passes obliquely obliquely or indirectly or indirectly towards and ultimately into towards and ultimately into the scrotumthe scrotum

In men indirect hernia outnumber direct In men indirect hernia outnumber direct hernia at a ratio of 2:1hernia at a ratio of 2:1

Both indirect inguinal and femoral hernia are Both indirect inguinal and femoral hernia are twice as common on the right than on the twice as common on the right than on the left left

Route of Groin HerniasRoute of Groin Hernias


EpidemiologyEpidemiology Strangulation occurs in 1.3% to 3% of groin Strangulation occurs in 1.3% to 3% of groin herniashernias

Femoral has a higher rate of strangulation; 2- 20% of Femoral has a higher rate of strangulation; 2- 20% of all herniasall hernias Aging:Aging: Increases the incidence of groin HerniasIncreases the incidence of groin Hernias Likelihood of StrangulationLikelihood of Strangulation Need for Hospitalization Need for Hospitalization

Hernias of the GroinHernias of the Groin EpidemiologyEpidemiology 10% of women and 50% men with femoral 10% of women and 50% men with femoral hernia will develop an inguinal herniahernia will develop an inguinal hernia Probability of groin hernia’s strangulation Probability of groin hernia’s strangulation varies with Location & Durationvaries with Location & Duration

INGUINAL HERNIASINGUINAL HERNIAS After 3 months strangulation 2.8%After 3 months strangulation 2.8% After 2 years strangulation is 4.5%After 2 years strangulation is 4.5%

FEMORAL HERNIASFEMORAL HERNIAS After 3 months strangulation is 32%After 3 months strangulation is 32% After 21 months strangulation 45%After 21 months strangulation 45%

celso m. fidel


EE ETIOLOGY ETIOLOGY

Congenital due to patent processus vaginalis found in:Congenital due to patent processus vaginalis found in: 80% of newborns80% of newborns 50% of 1 year old50% of 1 year old Position of humans beings (standing) Position of humans beings (standing) Loss of Loss of tissue strength and elasticity tissue strength and elasticity due due to destruction of connective tissueto destruction of connective tissue::


EE ETIOLOGY ETIOLOGY Destruction of connective tissueDestruction of connective tissue:: Increased intra abdominal pressureIncreased intra abdominal pressure 1. Lifting heavy objects 1. Lifting heavy objects 2. coughing; asthma COPD2. coughing; asthma COPD 3. benign prostatic hypertrophy 3. benign prostatic hypertrophy 4. pregnancy4. pregnancy 5. carcinoma of colon and rectum 5. carcinoma of colon and rectum 6. Ascites; intra abdominal tumors 6. Ascites; intra abdominal tumors 7.obesity 7.obesity


EE ETIOLOGY ETIOLOGY Destruction of connective tissueDestruction of connective tissue:: Smoking Smoking AgingAging

Connective tissue diseaseConnective tissue disease Systemic IllnessSystemic Illness

Etiology cont’dEtiology cont’d These reduces the strength of the fascia andThese reduces the strength of the fascia and aponeurosisaponeurosis

Fractures of the elastic fibers & alteration ofFractures of the elastic fibers & alteration of the structure, quantity and metabolism of the structure, quantity and metabolism of collagen have been demonstrated in thecollagen have been demonstrated in the connective tissue structures in groin connective tissue structures in groin hernia patients.hernia patients.


Etiology cont’dEtiology cont’d Muscle deficiency contributes to herniationMuscle deficiency contributes to herniation insufficiencies of internal oblique muscle insufficiencies of internal oblique muscle Fracture deformities of the pelvis; denervationFracture deformities of the pelvis; denervation of the shutter mechanism following a lowof the shutter mechanism following a low cosmetic appendectomy incision.cosmetic appendectomy incision.


Hernia of the GROINHernia of the GROIN

SymptomsSymptoms

Natural history is slow enlargement to the Natural history is slow enlargement to the point of irreducibility and disfigurement with point of irreducibility and disfigurement with risk of strangulation even presentrisk of strangulation even present

Wide variety of non specific discomfort Wide variety of non specific discomfort related to the related to the contentscontents of the sac and the of the sac and the pressurepressure by the sac on the adjacent by the sac on the adjacent structures.structures.

Hernia of the GROINHernia of the GROIN

DiagnosisDiagnosis

Simple Simple physical examination will show an physical examination will show an enlarge mass which transmit a palpable enlarge mass which transmit a palpable impulse when patient strains or coughsimpulse when patient strains or coughs

Those not detectable by physical exams. can Those not detectable by physical exams. can be demonstrated by:be demonstrated by: UltrasonographyUltrasonography Computerized tomographyComputerized tomography Magnetic resonance imagingMagnetic resonance imaging HerniographyHerniography

Hernia of the GROINHernia of the GROIN.. Diagnosis cont’dDiagnosis cont’d

Strangulation producesStrangulation produces Intense pain in the hernia Intense pain in the hernia Tenderness Tenderness Intestinal obstruction Intestinal obstruction Signs& symptoms of sepsisSigns& symptoms of sepsis

Does not enlarge or transmit an impulse Does not enlarge or transmit an impulse when patient coughswhen patient coughs

Incisional HerniaIncisional Hernia

Strangulated HerniaStrangulated Hernia

Strangulated bowelsStrangulated bowels

STRANGULATED HERNIASTRANGULATED HERNIA

Management of Management of Groin HerniASGroin HerniAS

Hernias of the GROINHernias of the GROIN

Taxis=Taxis= manual manipulation required manual manipulation required to reduce viscera entrapped in a to reduce viscera entrapped in a hernial sac. Should not be done for hernial sac. Should not be done for strangulated herniastrangulated hernia

Trusses are contraindicated for Trusses are contraindicated for femoral herniafemoral hernia

Hernias of the GROINHernias of the GROIN Indications for SurgeryIndications for Surgery

All hernias should be repaired unless All hernias should be repaired unless local or systemic conditions in the local or systemic conditions in the patients preclude a safe outcome . patients preclude a safe outcome . Exceptions, hernias with wide neck Exceptions, hernias with wide neck and shallow sacand shallow sac

Surgery Surgery for GROIN Herniasfor GROIN Hernias

1. Aim is to prevent peritoneal protrusion 1. Aim is to prevent peritoneal protrusion through myopectineal orificethrough myopectineal orifice

2. Restoration of the integrity of the 2. Restoration of the integrity of the myopectineal orifice based on myopectineal orifice based on 3. Fruchaud’s concept of Groin 3. Fruchaud’s concept of Groin hernias: hernias:

Surgery Surgery for GROIN Herniasfor GROIN Hernias

Fruchaud’s concept of Groin Fruchaud’s concept of Groin hernias: hernias: a. Aponeurotic closure of the a. Aponeurotic closure of the myopectineal orifice to the extent myopectineal orifice to the extent necessarynecessary

b. Replacement of the defective b. Replacement of the defective transversalis fascia w/ synthetic transversalis fascia w/ synthetic prosthesisprosthesis

Surgery for Groin HerniasSurgery for Groin Hernias REPAIR OF MYOPECTINEAL orificeREPAIR OF MYOPECTINEAL orifice

Reconstruction of the Deep RingReconstruction of the Deep Ring

Contrary to the belief of some Contrary to the belief of some surgeons the ANATOMY of the deep surgeons the ANATOMY of the deep ring is such that strangulation of the ring is such that strangulation of the spermatic cord by reconstruction of spermatic cord by reconstruction of the posterior wall of inguinal canal is the posterior wall of inguinal canal is virtually impossiblevirtually impossible

Treatment of Groin HerniasTreatment of Groin Hernias Repair of the groin hernia could be:Repair of the groin hernia could be:

Anterior ApproachAnterior Approach= thru a groin = thru a groin incision where structures in & around incision where structures in & around the inguinal canal must be divided to the inguinal canal must be divided to reach the aponeuroticofascial layerreach the aponeuroticofascial layer

Treatment of Groin HerniasTreatment of Groin Hernias Repair of the groin hernia could be:Repair of the groin hernia could be: Posterior Approach Posterior Approach Tension is avoided by using a mesh Tension is avoided by using a mesh prosthesis to patch or plug the prosthesis to patch or plug the myopectineal orifice replacing myopectineal orifice replacing transversalis fascia layer transversalis fascia layer

Repair of Groin herniasRepair of Groin hernias

Anterior ApproachAnterior Approach

MarcyMarcy

ShouldiceShouldice

BassiniBassini

LichtensteinLichtenstein

Lotheissen Cooper’s ligament , McvayLotheissen Cooper’s ligament , Mcvay

Ferguson AndrewsFerguson Andrews

Treatment of Groin HerniasTreatment of Groin Hernias

In the In the anterior classical Hernioplasty anterior classical Hernioplasty only three has withstood time:only three has withstood time: 1. Marcy’s simple ring closure1. Marcy’s simple ring closure 2. Bassini’s operation original as done 2. Bassini’s operation original as done in Shouldice Hospital in Torontoin Shouldice Hospital in Toronto 3. Mc Vay Lotheissen Cooper Ligament 3. Mc Vay Lotheissen Cooper Ligament Repair Repair

Treatment of Groin HerniasTreatment of Groin Hernias

Classical Hernioplasty has three parts:Classical Hernioplasty has three parts: 1. Dissection of the inguinal canal1. Dissection of the inguinal canal

2. Repair of the myopectineal orifice2. Repair of the myopectineal orifice 3. Closure of the inguinal canal3. Closure of the inguinal canal

MARCY REPAIRMARCY REPAIR

Consists of tightening an enlarged Consists of tightening an enlarged deep ring onlydeep ring only

Commonly called simple ring closureCommonly called simple ring closure

Indicated in men and women who have Indicated in men and women who have indirect hernias with only minimal indirect hernias with only minimal damage to the deep ringdamage to the deep ring

Marcy RepairMarcy Repair

SHOULDICE REPAIRSHOULDICE REPAIR

Uses the transversalis fascia, which is Uses the transversalis fascia, which is divided longitudinally and imbricated upon divided longitudinally and imbricated upon itself in two layersitself in two layers

The internal oblique muscle and conjoint The internal oblique muscle and conjoint tendon are then sutured to the reflection of tendon are then sutured to the reflection of the inguinal ligament in two layersthe inguinal ligament in two layers

Shouldice RepairShouldice Repair

BASSINI REPAIRBASSINI REPAIR

The transversalis fascia and conjoint The transversalis fascia and conjoint tendon above are sutured to the reflection tendon above are sutured to the reflection of the inguinal ligamentof the inguinal ligamentIn men,the spermatic cord is returned to its In men,the spermatic cord is returned to its normal anatomic location between the normal anatomic location between the reinforced inguinal canal floor and the reinforced inguinal canal floor and the external oblique aponeurosisexternal oblique aponeurosisIn women, the round ligament may be In women, the round ligament may be ligated and the internal ring closedligated and the internal ring closed

Bassini RepairBassini Repair

ANTERIOR PROSTHETIC GROIN ANTERIOR PROSTHETIC GROIN HERNIOPLASTIESHERNIOPLASTIES

TENSION FREE HERNIOPLASTIESTENSION FREE HERNIOPLASTIES

( Lichtenstein hernioplasty)( Lichtenstein hernioplasty)

Without formal repair mesh is sutured to the Without formal repair mesh is sutured to the internal oblique abdominal muscle, the internal oblique abdominal muscle, the rectus sheath and the shelving edge of the rectus sheath and the shelving edge of the inguinal ligament.inguinal ligament.

Tension Free RepairTension Free Repair

Open Mesh RepairOpen Mesh Repair

Lichtenstein RepairLichtenstein Repair

surgery for Groin Hernias surgery for Groin Hernias

Cooper ligament repair (McVay)Cooper ligament repair (McVay) Repair the 3 most valuable areas for Repair the 3 most valuable areas for herniation in myopectineal orificeherniation in myopectineal orifice Deep ringDeep ring Hesselbach’s triangleHesselbach’s triangle Femoral canalFemoral canal

Involves the suturing of the transverse Involves the suturing of the transverse aponeurotic arch to cooper’s ligament aponeurotic arch to cooper’s ligament medially; femoral sheath laterallymedially; femoral sheath laterally

Mc Vay RepairMc Vay Repair

Surgery for Groin HerniaSurgery for Groin Hernia

POSTERIOR HERNIOPLASTYPOSTERIOR HERNIOPLASTY

This was popularized by NYHUSThis was popularized by NYHUS

A short transverse incision in the lower A short transverse incision in the lower

quadrant up to pre-peritoneal fatty layerquadrant up to pre-peritoneal fatty layer

Suturing the iliopubic tract to the transverse Suturing the iliopubic tract to the transverse

aponeurotic arch aponeurotic arch

Narrows the deep ring w/ a few sutures Narrows the deep ring w/ a few sutures

placed placed lateral to the spermatic cordlateral to the spermatic cord

Posterior ApproachPosterior Approach

The use of Mesh PosteriorlyThe use of Mesh Posteriorly

Surgery for groin herniasSurgery for groin hernias

REPAIR OF MYOPECTINEAL OrificeREPAIR OF MYOPECTINEAL Orifice

In indirect hernias in infants, children In indirect hernias in infants, children

and some young men, merely eliminating and some young men, merely eliminating

sac & its high ligation cures the hernia. sac & its high ligation cures the hernia.

(HERNIOTOMY)(HERNIOTOMY)

PROSTHETIC MATERIALSPROSTHETIC MATERIALS

Non-degradable and biologic-tolerantNon-degradable and biologic-tolerant synthetic mesh readily availablesynthetic mesh readily available

1. MARLEX1. MARLEX

2. PROLENE2. PROLENE

3. TRELEX3. TRELEX

Resemble one another are composed of limited monofilament fibers of polypropylene. All are porous slightly elastic, semi rigid and relatively heavy and they contain plastic memory and buckle when bent in two directions at once.


44. SURGIPRO MESH- is composed of knitted, . SURGIPRO MESH- is composed of knitted, braided strands of polypropylene.braided strands of polypropylene.

5. MERSILENE-an open knitted mesh composed 5. MERSILENE-an open knitted mesh composed of pure and uncoated braided fibers of the of pure and uncoated braided fibers of the polyester DACRON.polyester DACRON.

PROSTHETIC MATERIALSPROSTHETIC MATERIALS It is porous, soft, lacelike, supple, It is porous, soft, lacelike, supple,

elastic, and without plastic elastic, and without plastic

memory.memory.

It has a grainy texture that prevent It has a grainy texture that prevent

slippage. slippage.

Has only a minimal tendency to Has only a minimal tendency to

buckle when bent in two direction buckle when bent in two direction

at once.at once.


6. GORE-TEX- is expanded 6. GORE-TEX- is expanded polytetrafluoroethylene (FTFE),non polytetrafluoroethylene (FTFE),non porous, smooth, supple, fabric porous, smooth, supple, fabric material containing through and material containing through and through microscopic pores into which through microscopic pores into which fibroblast grows. fibroblast grows.


STOPPA PROCEDURE= Giant Prosthetic STOPPA PROCEDURE= Giant Prosthetic reinforcement of the visceral sac. reinforcement of the visceral sac. (MERSILENE is used)(MERSILENE is used)

1. For all complex hernias of the groin such 1. For all complex hernias of the groin such as recurrent hernia and hernia associated as recurrent hernia and hernia associated with connective tissue disorder.with connective tissue disorder.


STOPPA PROCEDURE= Giant Prosthetic STOPPA PROCEDURE= Giant Prosthetic reinforcement of the visceral sac. reinforcement of the visceral sac. (MERSILENE is used)(MERSILENE is used)

2. A large prosthesis is inserted into the 2. A large prosthesis is inserted into the properitoneal space of a single groin. The properitoneal space of a single groin. The prosthesis is held in place by intra abdominal prosthesis is held in place by intra abdominal pressure. pressure.

MESH PLUGMESH PLUG

COMPLICATIONSCOMPLICATIONSTesticular OrchitisTesticular Orchitis Develops insidiously, not apparent Develops insidiously, not apparent for 2-5 days after hernioplastyfor 2-5 days after hernioplasty

Testicle and spermatic cord Testicle and spermatic cord becomes swollen, hard, tender, becomes swollen, hard, tender, painful and retracted. Process last painful and retracted. Process last 6-12 weeks6-12 weeks

COMPLICATIONSCOMPLICATIONSTesticular OrchitisTesticular Orchitis Etiology is ischemic thrombosis of Etiology is ischemic thrombosis of the spermatic cordthe spermatic cord

No known successful treatment to No known successful treatment to

prevent prevent atrophy.atrophy.

COMPLICATIONSCOMPLICATIONS

Testicular OrchitisTesticular Orchitis Incidence can be minimized by Incidence can be minimized by reducing surgical trauma to the cord by:reducing surgical trauma to the cord by: Never excising the distal part of an Never excising the distal part of an indirect sac except when unavoidableindirect sac except when unavoidable Never re-dissecting an inguinal canal & Never re-dissecting an inguinal canal & spermatic cord with a previous surgery of spermatic cord with a previous surgery of the groin or scrotumthe groin or scrotum Never dissecting beyond pubic TubercleNever dissecting beyond pubic Tubercle


NeuralgiaNeuralgia

Chronic residual neuralgia can result from Chronic residual neuralgia can result from

surgical handling of the sensory nerves in surgical handling of the sensory nerves in

the groin the groin

A well known cause of residual neuralgia is a A well known cause of residual neuralgia is a

neuroma. It results from a portion of nerve neuroma. It results from a portion of nerve

fibers outside the neurilemma of a partially fibers outside the neurilemma of a partially

or completely divided nerveor completely divided nerve

COMPLICATIONSCOMPLICATIONS NeuralgiaNeuralgia

TREATMENT: TREATMENT:

Neurolysis of the involved nerve Neurolysis of the involved nerve

Injection w/ steroids to areaInjection w/ steroids to area


RecurrenceRecurrence one (1) to 3% in a 10 year follow upone (1) to 3% in a 10 year follow up due to:due to: 1. Excessive tension on the repair1. Excessive tension on the repair

2. Deficient tissues2. Deficient tissues

3. Inadequate hernioplasty3. Inadequate hernioplasty

4. Overlooked hernias4. Overlooked hernias

celso m. fidel


RecurrenceRecurrence More common in direct herniasMore common in direct hernias

Bilateral direct herniasBilateral direct hernias

Direct hernias combined w/ Direct hernias combined w/ Indirect herniaIndirect hernia

celso m. fidel

10 a.new groin hernias dr.fidel

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