Hernia

TISSUE REPAIRS FOR GROIN HERNIA

• INDICATED IN FOLLOWING SITUATIONS1. STRANGULATED INGUINAL HERNIA2. ALLERGY TO MESH MATERIAL3. PATIENT DOES NOT GIVE CONSENT FOR FOREIGN

MATERIAL4. There are reports that in young males in in the

reproductive age with bilateral groin hernia , mesh repair on both sides may produce oligospermiaor subfertility because of entrapment of vas in mesh. (ATLAS OF GENERAL SURGERY, page 40)

POPULAR TISSUE REPAIRS

1. BASSINI’S REPAIR2. MARCY REPAIR3. ILLIOPUBIC TRACT REPAIR4. Mc VAY REPAIR5. SHOULDICE REPAIR

ANAESTHESIA

• MAJORITY OF OPEN GROIN HERNIA REPAIRS CAN BE PERFORMED UNDER LOCAL ANAESTHESIA UNLESS THE HERNIA IS VERY BIG OR IF IT IS SLIDING HERNIA OR REACHING UPTO THE SCROTUM

COMMON STEPS IN OPEN NON PROSTHETIC TISSUE REPAIR

• 1. INCISION--- AN OBLIQUE OR HORIZONTAL INCISION IS PLACED 2 CM ABOVE AND PARALLEL TO THE INGUINAL LIGAMENT OVER ITS MEDIAL 2/3rd

• 2. THE INCISION IS DEEPENED THROUGH THE CAMPER’S AND SCARPA’S FASCIA TILL EXTERNAL OBLIQUE APONEUROSIS IS EXPOSED

INCISION

MOBILISATION OF CORD STRUCTURES

HERNIOTOMY

LIGATION OF SAC

DIFFERENT REPAIRS

• BASINI’S REPAIR • GOLD STANDAED• INCISION IN EXTERNAL

OBLIQUE SUPERIOR TO SKIN INCISION.

• FLAP OF FASCIA TRANSVERSALIS, TRANSVERSUS ABDOMINIS AND INTERNAL OBLIQUE

• FIRST STITCH CONSISTS OF FLAP OF TRIPPLE LAYER SUPERIORLY AND THE PERIOSTEUM INFERIOLY

MARCY’S REPAIR• THIS REPAIR IS INDICATED

FOR GILBERT’S TYPE 2 HERNIAS IN CHILDREN AND YOUNG ADULTS.

• THIS BASICALLY COMPRISES OF HIGH LIGATION OF SAC AND NARROWING OF THE INTERNAL RING BY TAKING INTERRUPTED SUTURES THROUGH FASCIA TRANSVERSALIS AND TRANSVERSE ABDOMINUS MUSCLE

ILIOPUBIC TRACT REPAIR

• IT WAS DESCRIBED BY CONDON IN 1989.THIS REPAIR APPROXIMATES TRANSEVERSE ABDOMINIS APONEUROTIC ARCHTO THE ILIOPUBIC TRACT BY INVERTED SUTURES

McVAY REPAIR

• This repair is known as COOPER’S ligament repair . Interrupted non absorbable sutures are used to approximate The transversus abdominis aponeurosis to cooper’s ligament

• RARELY PERFORMED THESE DAYS

SHOULDICE REPAIR

• DOUBLE BREASTING THE INGUINAL CANAL

• REINFORCING THE FLOOR OF THE INGUINAL CANAL BY A FOUR LAYERED REPAIR

• TRANSVERSALIS FASCIA IS SPLIT IN ITS MIDDLE FROM DEEP ING. RING TO PUBIS –TWO FLAPS ARE MADE—SUP AND INF

• FIRST LAYER—LOWER FLAP OF T. FASCIA –LATERAL BORDER OF RECTUS MEDIALLY AND UNDER SURFACE OF UPPER FLAP OF T. FASCIA

• A FREE EDGE OF UPPER FLAP IS LEFT

• AFTER REACHING THE DEEP RING LATERAL TO MEDIAL

• PICKING UP THE FREE EDGE OF THE UPPER FLAP OF T. FASCIA AND APPROPXIMATING IT TO THE INGUINAL LIGAMENT UP TO PUBIC TUBERCLE

• THIRD LAYER APPROXIMATING THE INTERNAL OBLIQUE AND TRANSEVERSE ABDOMINIS SUPERIORLY TO THE INNER ASPECT OF THE INGUINAL LIGAMENT

• FOURTH LAYER IS AGAIN APPROXIMATING THE INTERNAL OBLIQUE AND TRANSVERSUS ABDOMINIS SUPERIORLY TO THE INNER ASPECT OF EXTERNAL OBLIQUE APONEUROSIS IN A MORE SUPERFICIAL

THIS IS FOUR LAYER REPAIR

AFTER THAT EXTERNAL OBLIQUE FLAPS ARE CLOSED TO CLOSE INGUINAL CANAL

FEMORAL HERNIA REPAIR • In human anatomy of the leg, the femoral sheath

has three compartments. The lateral compartment contains the femoral artery, the intermediate compartment contains thefemoral vein, and the medial and smallest compartment is called the femoral canal. The femoral canal contains efferent lymphatic vessels and a lymph node embedded in a small amount of areolar tissue. It is conical in shape and is about 2 cm long.

• FOR A FEMORAL HERNIA SURGERY IS ADVISED FOR TWO REASONS:THE INCIDENCE OF STRANGULATION IN THESE HERNIAS IS HIGH. IN ELDERLY CONSIDERABLE MORBIDITY

• FEMORAL SHEATH• ANTERIORLY ---INGUINAL LIGAMENT• POSTERIORLY---PECTINEAL LIGAMENT • MEDIALLY ---- SHARP LATERAL MARGIN OF

LACUNAR LIGAMENT• LATERAALY----ILIOPSOAS MUSCLE

TYPES OF OPERATION

• THREE APPROACHES ARE DESCRIBED • NO SINGLE OPERATION IS IDEAL1. THE ABDOMINAL, SUPRAPUBIC OR

EXTRAPERITONEAL OPERATION DEVELOPED BY HENRY( Mc Evedy APPROACH)

2. THE INGUINAL OR HIGH OPERATION3. THE CRURAL OR LOW OPERATION

THE LOW OPERATION

• PT SHOULD BE CATHETERISED PREOPERATIVELY

• RYLES TUBE IF OBSTRUCTION• GENERAL ANAESTHESIA IS PREFERED• SUPINE POSITION• GROIN AND LOWER ABDOMEN ARE PREPARED

INCISION

• A 6.0 cm long and and oblique incision is made directly over the hernia and 2.0 cm below and parallel to the inguinal ligament

• Secure haemostasis should be attained before the sac is mobilised

MOBILISATION OF THE SAC

• THE SAC HAVING EMERGED FROM THE FEMORAL CANAL , CARIES BEFORE IT THE TRANSVERSALIS FASCIA AND FAT IN FRONT OF WHICH IS THE ATTENUATED CRIBRIFORM FASCIA AND FEMORAL VESSEL FASCIAL LAYER

• BECAUSE OF THESE FASCIAL LAYERS THE SAC USUALLY MAKES A FORWARD AND UPWARD TURN IN THE PATH AND ITS FUNDUS CAN BE FOUND LYING OVER THE INGUINAL LIGAMENT

• IT IS IMPORTANT TO APPRECIATE THIS BEFORE MOBILISATION IS ATTEMPTED . ONCE THE SAC IS IDENTIFIED THE FASCIAL LAYERS ARE ARE SEPARATED FROM IT BY BLUNT DISSECTION .

INSPECTION OF CONTENTS OF SAC• THE LATERAL SIDE OF THE

FUNDUS SHOULD BE OPENED . THE MEDIAL SIDE SHOULD BE AVOIDED AS IT MAY BE PARIALLY FORMED BY BLADDER. ADHERENT EXTRAPERITONEAL FAT ON THE FUNDUS CONTAINS MANY DISTENDED VEINS. HAEMOSTASIS IS REQUIRED. SAC IS FREED AND CONTENTS REDUCED TO PEROTONEAL CAVITY

• IF STRANGULATION THEN AN ALTERNATIVE APPROACH MAY BE REQUIRED

• CLOSURE AND EXCISION OF SAC IS DONE

• IT MAY RECEDE THROUGH FEMORAL CANAL

REPAIR OF THE CANAL

RAISING FLAP OF PECTINEAL FASCIA

TENSION FREE MESH HERNIOPLASTY FOR GROIN HERNIA—LICHTENSTEIN ,1989

• THIS OPERATION BASICALLY COMPRISES OF HERNIOTOMY AND STRENGTHENING OF POSTERIOR WALL OF INGUINAL CANAL BY THE MESH( HERNIOPLASTY)

EXTERNAL OBLIQUE