my journey with hernia surgery
DESCRIPTION
A hernia is the protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it.There are different kinds of hernia, each requiring a specific management or treatment. SIGNS AND SYMPTOMS By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica. A hiatal hernia occurs when the stomach protrudes into the mediastinum through the esophageal opening in the diaphragm. Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ. Hernias are not tears in the tissue but are openings in the adipose tissue. It is possible for a hernia to come and go, but in most cases a pain will persist. Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area. Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation. Strangulated hernias are always painful and pain is followed by tenderness. Nausea, vomiting, or fever may occur in these cases due to bowel obstruction. Also, the hernia bulge in this case may turn red, purple or dark and pink. In the diagnosis of abdominal hernias, imaging is the principal means of detecting internal diaphragmatic and other nonpalpable or unsuspected hernias. Multidetector CT (MDCT) can show with precision the anatomic site of the hernia sac, the contents of the sac, and any complications. MDCT also offers clear detail of the abdominal wall allowing wall hernias to be identified accurately. CAUSES OF HERNIA Causes of hiatal hernia vary depending on each individual. Among the multiple causes, however, are the mechanical causes which include: improper heavy weight lifting, hard coughing bouts, sharp blows to the abdomen, and incorrect posture. Furthermore, conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate).TRANSCRIPT
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A JOURNEY WITH HERNIA SURGERY
Dr.Sreejoy Patnaik.Shanti Memorial Hospital.
A JOURNEY WITH HERNIA SURGERY
Dr.Sreejoy Patnaik.Shanti Memorial Hospital.
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• •Hippocrates used the Greek hernios for bud or bulge to describe abdominal hernias
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Hernia
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•Huge Inguinal Hernias
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Definition
• An abnormal protrusion of the contents of a closed cavity through a potential or an abnormal opening
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•Epigastric•Femoral
•Incisional/Ventral
•Inguinal
•Umbilical
•Diaphragmatic•(Hiatal Hernia)
Describing a Hernia
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THE HISTORY OF SURGERY
IS ALMOST AS OLD AS LIFE
ITSELF
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Famous hernia patient
Galileo Galilei (1564-1642) was incapacitated by an irreducible hernia in his later life.
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Medical causes for the formation ofHERNIAS
CAUSES OFHERNIAS
INCREASEDPRESSURE
INSIDE
WEAKNESSOF THE WALLS
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Causes Of Increased Pressure
F o rce
S M O K IN G & A S T H M A
H E A V Y W E IG H TS
F a tP U T T IN G O N
W E IG H T
F a e ce s & F la tusS E V E R E
C O N S T IP A T IO N
F lu idD IF IC U L T Y INU R IN A T IO N &
F L U ID IN A B D O M E N
F o e tusP R E G N A N C Y
IN C R EASEDPR ESSU R E
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Causes of Weakness in the Covering Layers
A G E O P E R A T IV ES C A R S
M U S C L EB U L K L O S S
S ta rva tio n e tc.
W E A K N E S S
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So I Have a Hernia.Why Should I Have Surgery?Operation ?
• There is pressure at the neck of the sac which can cut off the blood supply causing strangulation.
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Inguinal Hernia Repair Techniques
• Tension Repair– Bassini– Shouldice
• Tension-free Repair– Open
• Lichtenstein
• Devices
– Laparoscopic• TAPP
• TEP
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Tissue Repair – Bassini
•Tension – Pain - Recurrence
•Defect repaired by stitches
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• Established - the end of the nineteenth century
• The prototype of the purest tissue repair
• 3 Layers of suturing:
Superiorly:– internal oblique muscle– transversus abdominis muscle – transversalis fascia and Inferiorly: – the inguinal ligament and the iliopubic tractThe spermatic cord lies against the newly
reconstructed posterior inguinal wall, with the external oblique aponeurosis closed over it.
•Bassini Repair Bassini Repair
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• Shouldice repair – the Canadian repair (Toronto)
• Established in 1952
• Similar to the Bassini Repair– The essential difference is in the reconstruction of the
posterior inguinal wall, which in the Bassini repair is carried out with interrupted sutures (three lines) while the Shouldice uses continuous sutures back and forth (four lines), creating an overlap.
Shouldice Repair
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Advantages of Tension Repair
• Easy to perform
• Cost effective
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• 4. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.
• 5. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.
Disadvantages of Tension Repairs
High recurrence rates
• 10% to 30% recurrence rate with primary inguinal hernia repair 4
• Estimated 35% or higher recurrence rate with recurrent hernia repairs 5
Patient discomfort
Other potential complications
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Tension-Free Repairs
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• Introduced in 1984•Improved results over prior methods of repair•Open anterior approach•Steps
– deal with the sac– mesh sutured to floor and
around spermatic cord (between transversalis fascia and external oblique)
– running or interrupted sutures
•Lichtenstein (Onlay) Lichtenstein (Onlay) RepairRepair
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Tension Free – Lichtenstein
• Pioneered in 1984.
• Covering the defect of the hernia with a patch of mesh, instead of sewing the edges together
• PAIN FREE repair
• Return to full activities at the earliest
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Lichtenstein Technique
• Advantages– Tension-Free
Anterior Mesh Repair
– Quick and Easy– Easily
Teachable
• Disadvantages– No Posterior
Repair– No “Plugging”
of the defect– Extensive
continuous or interrupted suturing
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Hernia repaired by plug
•Defect repaired by Plug
•3 plugs in one patient with a recurrence.Image courtesy of Karl LeBlanc, MD.
• Results often compromised with incidences of recurrence
•Erosion of a shrunken soft Marlex™ plug into the bladder wall.Image courtesy of Parviz K. Amid, MD.
•Problem often of mesh migration
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The PROLENE Hernia System
• Introduced in 1998
• A secure posterior repair from a simple anterior approach
• Lowest reported recurrence rates 8
• Low cost
• 3 points of protection•8. Combined Anterior and Posterior Inguinal Hernia Repair: Intermediate recurrence rates with three groups of surgeons•Gilbert, AI et al. Hernia, 2004:8: 203-207
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Lichtenstein Tension Free Single Flat Mesh
• Ease of use.• Tension-free repair.• Dramatic reduction in the
incidence of recurrence.• However, the mesh was
situated above the defect.• Recurrence could occur
between the mesh and the defect.
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Laparoscopic Herniorrhaphy
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TAPP
• TAPP = TransAbdominal PrePeritoneal
• Laparoscopic Approach
• Posterior Repair •Transversalis Fascia
•Mesh
•Incision
•Preperitoneal Space •Trocar
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TEP
• TEP = Totally ExtraPeritoneal
• Laparoscopic Approach
• Posterior Repair
• Steps of Repair•Transversalis Fascia
•Mesh
•Preperitoneal• Space
•Trocar
•Peritoneum
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Ventral / Incisional Hernia
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Ventral / Incisional Hernias
• Develop as the result of a thinning, separation or tear in the muscle or tendon closure from prior surgery
• Often due to too much tension placed on the closure itself
• Hernias may be small but can enlarge and become problematic
• Surgical repair is best performed early when first diagnosed
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Ventral/Incisional Hernias
• The problem:– 3-13% of laparotomy incisions develop hernias– 90,000 ventral/incisional hernia repairs per year– Recurrence rates of 25-50%– Prostethic mesh reduces recurrences, but..
• Increases wound complications
• Has been associated with chronic pain from poor compliance
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Ventral / Incisional Hernias
• Facts:– Most hernias occur in the midline– Transverse incision tends to herniate where they
cross the midline– Initial closure is very important– Faulty technique universally leads to development
of herniation
•YOU NEED TO KNOW THE ANATOMY !!!
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Ventral / Incisional Hernia Anatomy
Abdominal Wall
Defect
Adhesions
Bowel
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Ventral Hernia Anatomy
•Incisional/Ventral •Umbilical
•Epigastric
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Ventral Hernia Anatomy
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Ventral/Incisional Hernia Repair
Procedural Options
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Ventral/Incisional HerniaRepair Techniques
• Tissue to tissue
• Onlay
• Inlay
• Retromuscular/Preperitoneal
• Open Intra-abdominal
• Laparoscopic
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Tissue to Tissue Technique
• Approximation of fascia under tension
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Tissue to Tissue Technique
• Approximation of fascia with suture (under tension)– Strengths
• Inexpensive
• Easy to perform
• No foreign body
– Weaknesses• Tension on suture line
• High recurrence rates (43%-58%)
• Not suitable for large defects
• Difficult to identify multiple defects
•* Data on file
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Onlay Technique
• Approximation of fascia with suture (under tension). Polypropylene mesh placed on top of fascia and fixated circumferentially
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Onlay Technique
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Onlay Technique
• Approximation of fascia with suture (under tension). Polypropylene mesh placed on top of fascia and fixated circumferentially.
– Strengths
• Inexpensive
• Easy to perform
– Weaknesses
• May not be able to use on large hernias
• High recurrence rates (20%-24%)2
• Intra-abdominal pressure working against repair
• Chance for strangulation and incarceration
• High incidence of seromas (subcutaneous dissection)
• Need for drains
• Chance of infection
• Difficult to identify multiple defects
•* Data on file
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Inlay Technique
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Retromuscular Technique
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Retromuscular/Preperitoneal Technique
• Development of a preperitoneal pocket. Mesh placed into this pocket and fixated to the rectus sheath– Strengths
• Lower recurrence rates <10%• Intra-abdominal pressure working for the repair
– Weaknesses• Extensive lateral dissection• Creating the pocket may be difficult; ripping the peritoneum• High incidence of seromas• High incidence of infections 18.5%• Need for drains• May loop a bowel when fixating patch• Difficult to identify multiple defects
•* Data on file
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Open Intra-Abdominal Technique
• Open Intra-abdominal – Hernia sac removed, intra-abdominal cavity entered, mesh fixated to the abdominal wall
– Strengths
• Lower recurrence rates <5%
• Intra-abdominal pressure working for the repair
• Less likely chance of seroma formation
• Less likely chance of infection
• Can easily identify multiple defects
– Weaknesses
• Adhesions and fistula formation to prosthetic materials
• Chance of enterotomy
• Usually large incisions
– Must Use TSM
•* Data on file
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Laparoscopic Technique
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Laparoscopic Technique
• Insufflation of the intra-abdominal cavity. Use of 5mm & 10mm ports and instruments to reduce hernia contents. Mesh placed in the intra-abdominal cavity, adjacent to viscera.
– Strengths• Low recurrence rates <3%• Low infection rate <1%• Intra-abdominal pressure working for the repair• Minimally invasive (small scars)• Can easily identify multiple defects
– Weaknesses• Expensive (tacker, Disposable instruments)• Difficult to perform• High learning curve• Chance of enterotomy
– Must Use TSM
•* Data on file
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Pascal’s Principle
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What mesh should be used?
CONSIDER:• Infection• Where is it going to be placed?• Adhesions• Shrinkage• Integration• Pain• Loss of domain
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Many Meshes
• Marlex knitted polypropylene
• Prolene woven polypropylene
• Mersilene woven polyester
• Gore-Tex ePTFE
• Vicryl knitted polyglactin
• Dexon knitted polyglactin
• Composix Kugel
• Composix
• Sepramesh
• Surgisis
• Alloderm
• Permacol
• ULTRAPRO
• Parietex
• PROCEED
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Advantage of Lap Hernia Rep.
• It offers minimal access approach to preperitoneal hernia repair.
• Lap Preperitoneal Repair provides much better views of what one is doing than open repair and avoid large incision & large mesh to cover the incision in order to prevent incisional hernia.
• Cost effectiveness of Lap Hernia com to Open .
• Patients can back to normal life as soon as possible as compared to Open Hernia.