SURGERY CASE

SURGERY CASEJIs Guzman, Montefalcon, SulitClinical DiagnosisDiagnosisCertaintyTreatmentIndirect Inguinal Hernia90%SurgicalDirect Inguinal Hernia10%SurgicalClinical DiagnosisDo I need a paraclinical diagnostic procedure?Generally, patient who present with typical symptoms and signs of groin hernia do not require further imaging for confirmation. The diagnosis is clinical. Chiow, et al. Inguinal Hernias: a current review of an old problem. Proceedings of Singapore Healthcare. 2010. 19(3):202-211The sensitivity of clinical diagnosis of inguinal hernia is 75-95% and the specificity of clinical diagnosis of inguinal hernias is 64-96% (Toms, et al., 2011)

Clinical DiagnosisDo I need a paraclinical diagnostic procedure?No.Clinical DiagnosisDiagnosisCertaintyTreatmentIndirect Inguinal Hernia90%SurgicalDirect Inguinal Hernia10%SurgicalTreatment GoalHigh ligation of sacPrevention of recurrencePrevention of complicationsTreatment OptionsTreatmentBenefitRiskCostAvailabilityOpen hernioplasty (Lichtenstein)Easy to performLow rate of complications0.2-0.5% recurrence rateGraft rejection+P5,000 to P8,000AvailableOpen Herniorrhapy (Shouldice)Low rate of complicationsAnatomic repair of the floor6% recurrence rate+P5,000AvailableLaparoscopic Hernia RepairBetter cosmetic resultLess superficial infectionEasy return to activities2.4% recurrence rateIncrease in perioperative complication++P15,000 to P20,000AvailablePreoperative PreparationInformed consent securedPsychosocial preparationScreening for medical problemOptimizing physical conditionPreparing OR needsAdmissionOn the 1st hospital dayDAT then NPO post midnightIVF: D5LRS 1L to run at 125 cc/hrTherapeutics:Ranitidine 50 mg TIV q8h while on NPOIs antibiotic prophylaxis recommended in elective groin hernia surgery?Antibiotic prophylaxis is NOT recommended in elective groin hernia surgery (Grade D recommendation). For hernia repair using mesh, antibiotic therapy is also NOT recommended (Grade C recommendation). (Cabaluna & Bongala, 2010)

Operative TechniquePatient supine under SABAsepsis- AntisepsisSterile drapes placedTransverse incision done on the skin between the anterior superior iliac spine and pubic tubercle andcarrieddown to the subcutaneous tissueOperative TechniqueLocation ofthe external inguinal ring palpatedExternal Oblique aponeuroses identified, cut & opened up to the external inguinal ringPlaced a clamp on both leaves of the external oblique aponeurosis and identify the ilioinguinal nerveOperative TechniqueIntra op findings notedSpermatic cord separated from the underside of the external oblique aponeurosis bysharp and blunt dissectionPicked up the cremasteric muscle and incised it longitudinallyGently shell the cord from its surrounding cremasteric muscleOperative TechniqueIdentify the vas deferensHernial sac identified and isolatedReduced any content of the hernial sacHernial sac ligated using purse string suture ligation using silk-0Prolene mesh, placed under spermatic cord, 3-4 cm larger than the defectOperative TechniqueProlene mesh sutured with silk 2-0 with the use of interrupted mattress around the perimeter of the defect, penetrating the anterior rectus sheath, rectus muscle, and transversalis fascia along medial aspect. Along the lateral margin of the defect, it was sutured to the Pouparts ligament going from the pubic tubercle laterally to the region of femoral canal

Operative TechniqueLayer by Layer closureFascia closed by simple interrupted sutures using Vicryl-0Subcutaneousclosed by Inverted T sutures using Chromic 2-0Skin closed by simple interrupted sutures using silk 4-0Dry sterile dressingappliedPatient tolerated the procedure wellPost-op condition- stableIntraoperative FindingsHernial sac located anteromediallyInternal ring measures 4cm with no incarcerated contents.3rd Hospital Day/ 1st post-operative dayPostoperative CareAdequate analgesiaProper wound careAvoid strenuous activities for at least a monthDIDACTICSManagementUncomplicated hernias require either:No treatmentSupport with a trussOperative treatmentComplicated hernias:Always require surgery, often urgently

Management

A number of effective operative therapies exist in the treatment of inguinal hernias. To attain and maintain consistent, successfuloutcomes, the general surgeon must have a proficient understanding of groin anatomy and be mindful of surgical principles. Theapplication of prosthetics to effect a tension-free repair created an operation that was simple, effective, and reproducible across a rangeof operative experience, and reduced recurrence rates to a much lower level. Further advances in hernia treatment were part of thelaparoscopic revolution, which has improved postoperative pain and shortened recovery time. Although laparoscopic repairs require moreextensive training and equipment than open repairs, significant benefits can be imparted to the patient. Despite the controversiesassociated with laparoscopic inguinal hernia repair for primary unilateral inguinal hernias, the general surgeon must not only becognizant, but also able to perform a variety of inguinal hernia repairs. By having more than one approach in one's armamentarium, thesurgeon has the ability to choose the appropriate procedure for the problem at hand22Conservative ManagementAimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contentsFor hernias that are not strangulated or incarcerated can be mechanically reducedAssuming a recumbent positionTruss, an elastic belt or brief

The definitive treatment of all hernias is surgical repair.A hernia defect will not decrease in size, but likely increase and possibly progress to incarceration or strangulation of the sac's contents.

Surgery can be delayed or avoided in situations where the patient's medical status prohibits operative treatment.

Conservative management is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents.

Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia. 4

A truss, an elastic belt or brief that aims to keep the hernia reduced, may also be worn; however, its use does not prevent hernia progression or incarceration. A truss may provide relief in up to 65% of patients; however, many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration23TRUSS

Emergent repairIncarcerated herniasStrangulated herniasINCARCERATED HERNIAReasons for incarceration large amount of intestinal contents within the hernia sacdense and chronic adhesions of hernia contents to the sacsmall neck of the hernia defect in relation to the sac contentsINCARCERATED HERNIAAn incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergencyHowever, once the patient demonstrates bowel obstruction secondary to incarceration or a sliding inguinal hernia, operative intervention becomes expedited. Patients will often present with vomiting, constipation, obstipation, a distended abdomen, or combination thereof27INCARCERATED HERNIAReduction should be attempted before definitive surgical intervention. INCARCERATED HERNIAHernias that are not strangulated and do not reduce with gentle pressure should undergo taxis. STRANGULATED HERNIAFemoral > Indirect > DirectFever, leukocytosis, and hemodynamic instability. The hernia bulge usually is very tender, warm, and may exhibit red discoloration.

Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressedIf the blood supply to incarcerated contents becomes compromised, an incarcerated hernia becomes a strangulated hernia. These pose a significant risk to life because the strangulated contents are ischemic and may quickly lose viability.Clinical signs that indicate strangulation include Fever, leukocytosis, and hemodynamic instability.

30OPERATIVE TECHNIQUESSurgery aims to Reduce the hernia contentsExcise the sac (herniotomy) in most casesRepair and close the defect either by herniorrhapy or hernioplastyAnterior repairnon prostheticOPEN APPROACH

An oblique or horizontal incision is performed over the groin.A point two fingerbreadths inferior and medial to the anterior superior iliac spine is chosen as the most lateral point of the incisionIt is then progressed medially for approximately 6 to 8 cm34OPEN Approach

The iliohypogastric and ilioinguinal nerves are identified and retracted from the operative field by placing a hemostat beneath their course and then grasping one of the edges of the aponeurosis

Some surgeons obtain preoperative consent to cut the ilioinguinal nerve to avoid possible entrapment and post operative pain however, the patient may experience numbness of inner thigh or lateral scrotum which usually goes away in 6 months

With the contents of the inguinal canal completely encircled, identification of cord contents and the hernia sac can be effected

Direct hernias will become evident as the floor of the inguinal canal is dissected.

An indirect hernia sac will generally be found on the anterolateral surface of the spermatic cord. In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identified to allow dissection of the sac from the cord

Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic position

small enough to contain the contents of the inguinal canal and prevent a future false-positive diagnosis of recurrent herniaThe new external ring should be small enough to contain the contents of the inguinal canal and prevent a future false-positivenot be tight and should allow entrance of a finger

35Bassini RepairIs frequently used for indirect inguinal hernias and small direct herniasThe conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

inferior arch of transversalis fascia (TF) or conjoint tendon is approximated to shelving portion of inguinal ligament.

36Mcvay repairinguinal and femoral canal defectsThe conjoined tendon is sutured to Coopers ligament from the pubic cubicle laterally

TF is sutured to cooper ligament

The advantage of the McVay (Cooper's ligament) repair is the ability to address both inguinal and femoral canal defects37Shouldice Repair

TF is incised and reapproximated

The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia and the internal oblique and transverse abdominis muscles.

This is the second of the four suture lines. After the stump of the cremaster muscle is picked up, the suture is reversed back toward the pubic tubercle approximating the internal oblique and transversus muscles to the inguinal ligament. Two more suture lines will eventually be created suturing the internal oblique and transversus muscles medially to an artificially created "pseudo" inguinal ligament developed from superficial fibers of the inferior flap of the external oblique aponeurosis parallel to the true ligament.38Anterior repairprostheticLichtenstein Tension-Free RepairThe most commonly performed inguinal hernia repair today is the Lichtenstein repair. A flat mesh is placed on top of the defect

It is a "tension-free" repair that does not put tension on muscles

It involves the placement of a mesh to strengthen the inguinal region.

Patients typically go home within a few hours of surgery, often requiring no medication beyond Paracetamol.

Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation.

Lichtenstein Tension-Free Repair

41Initial exposure and mobilization of cord structures is identical to other open approachesA lateral view demonstrates that the prosthesis is situated between the cord and the hernia defect (HD). The hernia defect has been imbricated to allow for facile prosthesis placement only (this does not affect the strength of the repair). MESHPERMANENT MESHCommercial meshes are typically made of prolene (polypropylene) or polyester.

Mosquito-net mesh-Meshes made of mosquito net clothes, in co-polymer of polyethylene and polypropylene have been used for low-income.

ABSORBABLE MESHBiomeshes are increasingly popular since their first use in 1999. They are absorbable and they can be used for repair in infected environment, like for an incarcerated hernia. Moreover, they seem to improve comfort.

Transabdominal Preperitoneal Procedure (TAPP) Totally Extraperitoneal (TEP) Repair

Indications include bilateral inguinal hernia, recurring hernia, need for early recoveryLAPAROSCOPIC HERNIA REPAIR When performed by a surgeon experienced in hernia repair, laparoscopic repair causes less complications than Lichtenstein, and especially half less chronic pain.

43LAPAROSCOPIC HERNIA REPAIR

RECURRENCEAround 1% for Shouldice repairMost recurrences are of the same type as the original hernia

Recurrence FactorsPatientTechnicalTissueCommon causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair. 45RECURRENCEPatient factors malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors wound infection, tissue ischemia, and increased tension within the surgical repairCommon causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair. 46complicationsThe overall risk of complications of inguinal hernia repair is low.

Common ComplicationsPain, injury to the spermatic cord and testes, wound infection, seroma, hematoma, bladder injury, osteitis pubis, and urinary retention