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HERNIA
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Tension FreeTension Free Hernia RepairHernia Repair
Basrul HanafiBasrul HanafiDigestive Surg, Dept. of Surgery Padjadjaran Digestive Surg, Dept. of Surgery Padjadjaran
University, Hasan Sadikin HospitalUniversity, Hasan Sadikin Hospital
BandungBandung
1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Abrahamson et al. Maingot’s Abdominal Operations. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.
1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Abrahamson et al. Maingot’s Abdominal Operations. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.
HERNIAS:HERNIAS:
Prevalence,Causes, Prevalence,Causes, and Repairsand Repairs
Estimated incidence in the general population is 3%Estimated incidence in the general population is 3%11
Male-to-female ratio: 25:1Male-to-female ratio: 25:122
More than 700,000 hernia repairs performed annually More than 700,000 hernia repairs performed annually in the United Statesin the United States33
Indirect 2:1 DirectIndirect 2:1 Direct Type 4 direct is single most commonType 4 direct is single most common
Estimated incidence in the general population is 3%Estimated incidence in the general population is 3%11
Male-to-female ratio: 25:1Male-to-female ratio: 25:122
More than 700,000 hernia repairs performed annually More than 700,000 hernia repairs performed annually in the United Statesin the United States33
Indirect 2:1 DirectIndirect 2:1 Direct Type 4 direct is single most commonType 4 direct is single most common
HERNIAS:HERNIAS:
Recurrence RatesRecurrence Rates
10% to 30% recurrence rate with primary 10% to 30% recurrence rate with primary inguinal hernia repairinguinal hernia repair11
Estimated 35% or higher recurrence rate Estimated 35% or higher recurrence rate with recurrent hernia repairswith recurrent hernia repairs22
10% to 30% recurrence rate with primary 10% to 30% recurrence rate with primary inguinal hernia repairinguinal hernia repair11
Estimated 35% or higher recurrence rate Estimated 35% or higher recurrence rate with recurrent hernia repairswith recurrent hernia repairs22
1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.2. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.
1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.2. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986.
Abdominal wall layersAbdominal wall layers
1. Peritoneum2. Subperitoneal fat 3. Transversalis fascia4. Transversus abdominis muscle5. Internal oblique muscle6. External oblique muscle7. Subcutaneus fat8. Skin
Inguinal ligament
External oblique m. & apon.
Rectus m.
Spermatic cord
Linea alba
INGUINAL REGION
Cremaster
External oblique apon.
External oblique
Internal oblique m. & apon.
Inguinal ligament
Saphenous v.
Femoral vein
Conjoint Tendon
INGUINAL REGION
INGUINAL REGION
External inguinal ring
Cremaster (sperm. cord)
External oblique apon. External
oblique m.
Internal oblique m.
Transversus abdominus m.
Inferior epigastric vessels
Conjoint tendon
Cooper’s ligament
Transv. fascia
INGUINAL REGION
Preperitoneal View
Rectus m.
Inferior epigastric vessels
Lacunar ligament
Cooper’s lig
Spermatic cord
Iliac vessels
Internal inguinal ring
Inguinal ligament
Transversus m.
Pubis
Transversalis fascia
INGUINAL REGION
Testicular vessels
Vas Deferens
Iliac vessels
Inferior epigastric vessels
Spermatic cord
Inguinal lig.
Lacunar lig.
Pubis
Cooper’s lig.
Femoral vessels
Parietal peritoneum
Transversalis fascia
External oblique apon.
Abdom. muscles
Preperitoneal fat
INGUINAL REGION
Iliac vesselsAbdominal aorta
Cooper’s lig.
Pubis
Lacunar lig. Femoral vessels
Inguinal lig.
Iliac crest
INGUINAL REGION
Iliac vessels
Iliac crest
Abdom. m.
Ext. oblique apon.
Femoral vessels
Inguinal lig.
Sperm. cord
Ext. inguinal ring
Transv. fascia
Peritoneum
Rectus m.
Pyramidalis m.
HESSELBECH’S TRIANGLEHESSELBECH’S TRIANGLE
rectussheath
internal ring
inguinalligament
inferiorepigastricartery
pubis
Inguinal Hernias:Inguinal Hernias: ClassificationClassification
Type 1 Type 2 Type 3
Type 4 Type 5
From Gilbert. Perspectives in General Surgery. 1991;2(1):113-129. From Gilbert. Perspectives in General Surgery. 1991;2(1):113-129.
Milestones in Hernia RepairMilestones in Hernia Repair
Marcy (1870s) Marcy (1870s) Recognized importance of transversalis fascia Recognized importance of transversalis fascia
and internal ring closureand internal ring closure Used carbolized catgut to suture the ring Used carbolized catgut to suture the ring
Lucas-Championniere (1880s)Lucas-Championniere (1880s) Slit external oblique aponeurosis to expose the canalSlit external oblique aponeurosis to expose the canal Dissected and ligated sac at internal ring under Dissected and ligated sac at internal ring under
direct visiondirect vision
Marcy (1870s) Marcy (1870s) Recognized importance of transversalis fascia Recognized importance of transversalis fascia
and internal ring closureand internal ring closure Used carbolized catgut to suture the ring Used carbolized catgut to suture the ring
Lucas-Championniere (1880s)Lucas-Championniere (1880s) Slit external oblique aponeurosis to expose the canalSlit external oblique aponeurosis to expose the canal Dissected and ligated sac at internal ring under Dissected and ligated sac at internal ring under
direct visiondirect vision
From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.
Milestones in Hernia RepairMilestones in Hernia Repair (Cont’d)(Cont’d)
Bassini (1880s) “Father of Modern Herniorrhaphy”Bassini (1880s) “Father of Modern Herniorrhaphy” Dissected and reconstructed inguinal canal Dissected and reconstructed inguinal canal
to preserve functional anatomyto preserve functional anatomy Repaired transversalis fascia and reinforced Repaired transversalis fascia and reinforced
the canal’s posterior wall the canal’s posterior wall
Shouldice (1945)Shouldice (1945) Multi-layered repair, suturing only local tissues Multi-layered repair, suturing only local tissues
without prosthetic material; local anesthesiawithout prosthetic material; local anesthesia
Bassini (1880s) “Father of Modern Herniorrhaphy”Bassini (1880s) “Father of Modern Herniorrhaphy” Dissected and reconstructed inguinal canal Dissected and reconstructed inguinal canal
to preserve functional anatomyto preserve functional anatomy Repaired transversalis fascia and reinforced Repaired transversalis fascia and reinforced
the canal’s posterior wall the canal’s posterior wall
Shouldice (1945)Shouldice (1945) Multi-layered repair, suturing only local tissues Multi-layered repair, suturing only local tissues
without prosthetic material; local anesthesiawithout prosthetic material; local anesthesia
From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.From Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.
Milestones in Hernia RepairMilestones in Hernia Repair(Cont’d)(Cont’d)
Martin and Shureih (1983) Martin and Shureih (1983) Used MarlexUsed MarlexTM TM mesh deep to the transversalis fascia mesh deep to the transversalis fascia
in primary inguinal hernia repairin primary inguinal hernia repair
Stoppa (1984, 1987)Stoppa (1984, 1987) Extensive prosthetic reinforcement of the peritoneumExtensive prosthetic reinforcement of the peritoneum
using Mersileneusing MersileneTM TM (Dacron) mesh between the (Dacron) mesh between the peritoneum peritoneum and transversalis fasciaand transversalis fascia11
Martin and Shureih (1983) Martin and Shureih (1983) Used MarlexUsed MarlexTM TM mesh deep to the transversalis fascia mesh deep to the transversalis fascia
in primary inguinal hernia repairin primary inguinal hernia repair
Stoppa (1984, 1987)Stoppa (1984, 1987) Extensive prosthetic reinforcement of the peritoneumExtensive prosthetic reinforcement of the peritoneum
using Mersileneusing MersileneTM TM (Dacron) mesh between the (Dacron) mesh between the peritoneum peritoneum and transversalis fasciaand transversalis fascia11
1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.1. Abrahamson. Maingot’s Abdominal Operations. Vol 1. 9th ed. Appleton & Lange: East Norwalk, Conn; 1990:chap 11.
Milestones in Hernia RepairMilestones in Hernia Repair(Cont’d)(Cont’d)
Lichtenstein (1986) e.g. Prolene MeshLichtenstein (1986) e.g. Prolene Mesh Used nonabsorbable sutures and prosthetic mesh screen Used nonabsorbable sutures and prosthetic mesh screen
to reinforce new canal floorto reinforce new canal floor22
Lichtenstein (1986) e.g. Prolene MeshLichtenstein (1986) e.g. Prolene Mesh Used nonabsorbable sutures and prosthetic mesh screen Used nonabsorbable sutures and prosthetic mesh screen
to reinforce new canal floorto reinforce new canal floor22
2. Lichtenstein. Am J Surg. 1989;157:188-193.2. Lichtenstein. Am J Surg. 1989;157:188-193.
Milestones in Hernia RepairMilestones in Hernia Repair(Cont’d)(Cont’d)
Gilbert (1987)Gilbert (1987)11 Used internal ring as direct access to the peritoneal spaceUsed internal ring as direct access to the peritoneal space Used polypropylene plug (later changed to the patch)Used polypropylene plug (later changed to the patch)
to repair indirect herniasto repair indirect hernias
Gilbert (1991)Gilbert (1991)22
Used sutureless “hand-fashioned umbrella” polypropylene Used sutureless “hand-fashioned umbrella” polypropylene plug to open as an underlay patchplug to open as an underlay patch
Gilbert (1987)Gilbert (1987)11 Used internal ring as direct access to the peritoneal spaceUsed internal ring as direct access to the peritoneal space Used polypropylene plug (later changed to the patch)Used polypropylene plug (later changed to the patch)
to repair indirect herniasto repair indirect hernias
Gilbert (1991)Gilbert (1991)22
Used sutureless “hand-fashioned umbrella” polypropylene Used sutureless “hand-fashioned umbrella” polypropylene plug to open as an underlay patchplug to open as an underlay patch
1. Gilbert. South Med J. 1987;80:191-195.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.1. Gilbert. South Med J. 1987;80:191-195.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.
Milestones in Hernia RepairMilestones in Hernia Repair(Cont’d)(Cont’d)
Robbins and Rutkow (1993)Robbins and Rutkow (1993)33
Fabricated, cone-shaped plug, with sutures and onlay Fabricated, cone-shaped plug, with sutures and onlay graftgraftwithout sutures for indirect and direct herniaswithout sutures for indirect and direct hernias
Robbins and Rutkow (1993)Robbins and Rutkow (1993)33
Fabricated, cone-shaped plug, with sutures and onlay Fabricated, cone-shaped plug, with sutures and onlay graftgraftwithout sutures for indirect and direct herniaswithout sutures for indirect and direct hernias
3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.3. Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.
TENSION-FREE REPAIR:TENSION-FREE REPAIR:
PrinciplesPrinciples High dissection of inguinal sacHigh dissection of inguinal sac
Head, neck and shoulders of the sacHead, neck and shoulders of the sac Prevent recurrence at the internal ringPrevent recurrence at the internal ring Reinforce the canal floor without tensionReinforce the canal floor without tension
High dissection of inguinal sacHigh dissection of inguinal sacHead, neck and shoulders of the sacHead, neck and shoulders of the sac
Prevent recurrence at the internal ringPrevent recurrence at the internal ring Reinforce the canal floor without tensionReinforce the canal floor without tension
SHOULDERS
NECK
HEAD
SPERMATICCORD
Image courtesy of Arthur Gilbert, MD. Image courtesy of Arthur Gilbert, MD.
TENSION-FREE REPAIR:TENSION-FREE REPAIR:
AdvantagesAdvantages
SimpleSimpleRapidRapidLess painfulLess painfulEffectiveEffectivePrompt resumption of unrestrictedPrompt resumption of unrestricted
physical therapyphysical therapyLow recurrence rateLow recurrence rate
SimpleSimpleRapidRapidLess painfulLess painfulEffectiveEffectivePrompt resumption of unrestrictedPrompt resumption of unrestricted
physical therapyphysical therapyLow recurrence rateLow recurrence rate
Common Common Tension-Free RepairsTension-Free Repairs
Lichtenstein – “repair patch”Lichtenstein – “repair patch”11
Plug and patchPlug and patch33
Kugel RepairKugel Repair Lap Hernia RepairLap Hernia Repair The Prolene Hernia SystemThe Prolene Hernia System
Lichtenstein – “repair patch”Lichtenstein – “repair patch”11
Plug and patchPlug and patch33
Kugel RepairKugel Repair Lap Hernia RepairLap Hernia Repair The Prolene Hernia SystemThe Prolene Hernia System
1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.3. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.
1. Lichtenstein. Hernia Repair Without Disability. 2nd ed. St. Louis, Mo: Ishiyaku Euroamerica, Inc; 1986:chap 2.2. Gilbert. Perspectives in General Surgery. 1991;2:113-129.3. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-511.
Common Common Tension-Free Repairs - Tension-Free Repairs - LichtensteinLichtenstein
Solid repair with good reported resultsSolid repair with good reported results Anterior supportAnterior support Suture intensiveSuture intensive No posterior supportNo posterior support Take about 40 minutesTake about 40 minutes EffectiveEffective Low recurrence rateLow recurrence rate No migrationNo migration
Solid repair with good reported resultsSolid repair with good reported results Anterior supportAnterior support Suture intensiveSuture intensive No posterior supportNo posterior support Take about 40 minutesTake about 40 minutes EffectiveEffective Low recurrence rateLow recurrence rate No migrationNo migration
Pre-shaped mesh in the inguinal boxPre-shaped mesh in the inguinal box
Closure of the aponeurosisClosure of the aponeurosis
Common Common Tension-Free Repairs - Plug & Tension-Free Repairs - Plug & PatchPatch
Good idea and has some good results Good idea and has some good results reportedreported
Suture intensive (the plug and the overlay Suture intensive (the plug and the overlay mesh)mesh)
No posterior supportNo posterior support Can take as much as 40 - 60 minutesCan take as much as 40 - 60 minutes No protection of the femoral canal No protection of the femoral canal Reported cases of mesh migrationReported cases of mesh migration Reported cases of patient discomfort longer Reported cases of patient discomfort longer
termterm
Good idea and has some good results Good idea and has some good results reportedreported
Suture intensive (the plug and the overlay Suture intensive (the plug and the overlay mesh)mesh)
No posterior supportNo posterior support Can take as much as 40 - 60 minutesCan take as much as 40 - 60 minutes No protection of the femoral canal No protection of the femoral canal Reported cases of mesh migrationReported cases of mesh migration Reported cases of patient discomfort longer Reported cases of patient discomfort longer
termterm
•Erosion of a shrunken soft Marlex™ plug into the bladder wall.Image courtesy of Parviz K. Amid, MD.
•3 plugs in one patient with a recurrence.Image courtesy of Karl LeBlanc, MD.
Plug & PatchPlug & Patch(also known as “umbrella”)(also known as “umbrella”)
Common Common Tension-Free Repairs - Kugel Tension-Free Repairs - Kugel PatchPatch Good idea. The repair is in the preperitoneal spaceGood idea. The repair is in the preperitoneal space Difficult to visualize the anatomy (approach)Difficult to visualize the anatomy (approach) A few anecdotal reported cases of mesh migrationA few anecdotal reported cases of mesh migration Reported cases of recurrenceReported cases of recurrence High cost of the meshHigh cost of the mesh
Good idea. The repair is in the preperitoneal spaceGood idea. The repair is in the preperitoneal space Difficult to visualize the anatomy (approach)Difficult to visualize the anatomy (approach) A few anecdotal reported cases of mesh migrationA few anecdotal reported cases of mesh migration Reported cases of recurrenceReported cases of recurrence High cost of the meshHigh cost of the mesh
Common Common Tension-Free Repairs - Lap Tension-Free Repairs - Lap Hernia Hernia
Solid repair!Solid repair! More challenging than open approachMore challenging than open approach General anesthesiaGeneral anesthesia Cost!!!Cost!!!
Solid repair!Solid repair! More challenging than open approachMore challenging than open approach General anesthesiaGeneral anesthesia Cost!!!Cost!!!
Common Common Tension-Free Repairs - The Tension-Free Repairs - The PHSPHS
Combines the three most common repairs (overlay, Combines the three most common repairs (overlay, plug, underlay)plug, underlay)
Non-Suture intensiveNon-Suture intensive Posterior support. Protects Femoral Canal from Posterior support. Protects Femoral Canal from
anterior approachanterior approach Can be done in 20 minutesCan be done in 20 minutes Conforms to anatomy in posterior space. Conforms to anatomy in posterior space.
Patient comfort longer term!Patient comfort longer term! To date, no reported cases of recurrence To date, no reported cases of recurrence
Combines the three most common repairs (overlay, Combines the three most common repairs (overlay, plug, underlay)plug, underlay)
Non-Suture intensiveNon-Suture intensive Posterior support. Protects Femoral Canal from Posterior support. Protects Femoral Canal from
anterior approachanterior approach Can be done in 20 minutesCan be done in 20 minutes Conforms to anatomy in posterior space. Conforms to anatomy in posterior space.
Patient comfort longer term!Patient comfort longer term! To date, no reported cases of recurrence To date, no reported cases of recurrence
Appeal of The PROLENE* Appeal of The PROLENE* Hernia Hernia SystemSystem
Surgeons who want a posterior repair from a simple Surgeons who want a posterior repair from a simple anterior approach.anterior approach.
Surgeons who want a procedure under local or Surgeons who want a procedure under local or regional anesthesia.regional anesthesia.
Surgeons who want to test the repair in OR.Surgeons who want to test the repair in OR.
Surgeons using alternative methods and have grown Surgeons using alternative methods and have grown concern with issues of mesh shrinkage, plug concern with issues of mesh shrinkage, plug migration, patient comfort, cost, and recurrence rates.migration, patient comfort, cost, and recurrence rates.
OverlayMesh
CylinderConnector
UnderlayMesh
The Onlay/Underlay The Onlay/Underlay Patch DevicePatch Device
From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.
The PHS Innovative Three-In-One The PHS Innovative Three-In-One Design:Design:combines the three most popular combines the three most popular tension free techniques utilized today tension free techniques utilized today in the repair of inguinal herniasin the repair of inguinal hernias
The Onlay Patch, like the Lichtenstein flat mesh repair, covers the entire floor of the canal; the system overlaps the pubic tubercle for added support, and provides the security of conventional patch techniques.
The Connector, provides the simplicity of a plug repair. Additionally, it secures the underlay patch to minimize incidence of migration. Its profile is a significant improvement over the bulk of conventional plugs
The Underlay patch, like a laparoscopic repiar, provides posterior support from a simple anterior approach. This underlay patch lays in the preperitoneal space and opens to cover the entire Myopectineal orifice.
Covers both the Femoral and Inguinal regions to minimize the possibility of recurrence.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.From All in One: The Only One Hernia Repair. [CD-ROM] Ethicon, Inc; 1997.
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Images courtesy of Arthur Gilbert, MD.Images courtesy of Arthur Gilbert, MD.
Repair of Indirect Hernia Using Repair of Indirect Hernia Using Onlay/Underlay Patch DeviceOnlay/Underlay Patch Device(Cont’d)(Cont’d)
Onlay/Underlay Patch Device Onlay/Underlay Patch Device Incorrectly Positioned During Hernia Incorrectly Positioned During Hernia RepairRepair
Image courtesy of Arthur Gilbert, MD.Image courtesy of Arthur Gilbert, MD.
Summary and Summary and Overview of Available Overview of Available ResourcesResources
Mesh ‘plug’ repair vs Lichtenstein ‘patch’ Mesh ‘plug’ repair vs Lichtenstein ‘patch’ repairrepair 26 male pts, unilateral, primary, inguinal hernia repair26 male pts, unilateral, primary, inguinal hernia repair Randomised to 2 groups : plug and patch repairRandomised to 2 groups : plug and patch repair
Operating Operating time (mins)time (mins)
Ease of Ease of operation*operation*
Return to Return to work (days)work (days)
Return to Return to normality normality (days)(days)
Pain score**Pain score** Analgesia Analgesia (no. of (no. of tablets)tablets)
Lichtenstein Lichtenstein mean (+/- SD)mean (+/- SD)
38 (7)38 (7) 4.6 (2.1)4.6 (2.1) 29 (18)29 (18) 35 (12)35 (12) 3.9 (1.8)3.9 (1.8) 19 (10)19 (10)
Mesh plug Mesh plug mean (+/- SD)mean (+/- SD)
29 (6)29 (6) 2.7 (0.9)2.7 (0.9) 22 (13)22 (13) 25 (11)25 (11) 2.1 (1.5)2.1 (1.5) 13 (9)13 (9)
P valueP value 0.010.01 0.020.02 0.40.4 0.040.04 0.010.01 0.150.15
* Score out of ten(zero being the easiest and ten the most difficult – by visual analogue scale).
** Score out of ten (zero being no pain and ten the worst experience ever).
Open and Laparoscopic Approaches:Open and Laparoscopic Approaches: A ComparisonA Comparison
Selection by patient age No Limits Not for very young or old
Anesthesia Usually local/regional General
Expenses Operating room time Less Greater
Procedure time Less GreaterEquipment Less Greater
ComplicationsMinor Equal EqualMajor Less Greater
Recurrence Rate Lower Higher
Selection by patient age No Limits Not for very young or old
Anesthesia Usually local/regional General
Expenses Operating room time Less Greater
Procedure time Less GreaterEquipment Less Greater
ComplicationsMinor Equal EqualMajor Less Greater
Recurrence Rate Lower Higher
Factor Open Laparoscopic
Factor Open Laparoscopic
From Gilbert. Int Surg. 1995;80:4-8 and Gilbert, personal communication. From Gilbert. Int Surg. 1995;80:4-8 and Gilbert, personal communication.
Open and Laparoscopic Approaches:Open and Laparoscopic Approaches: A Comparison (Cont’d)A Comparison (Cont’d)
Surgeon ExperienceTraining Less MoreAcceptance Greater Less
Difficulty of Procedure Less Greater
Patient Discomfort Initial 2 hr Less Greater
2–48 hr Equal or greater Less or equalAfter 48 hr Equal Equal
Activity ResumptionNormal Equal EqualStrenuous Equal Equal
Surgeon ExperienceTraining Less MoreAcceptance Greater Less
Difficulty of Procedure Less Greater
Patient Discomfort Initial 2 hr Less Greater
2–48 hr Equal or greater Less or equalAfter 48 hr Equal Equal
Activity ResumptionNormal Equal EqualStrenuous Equal Equal
Factor Open Laparoscopic
Factor Open Laparoscopic
From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-512 and Gilbert, personal communication. From Robbins and Rutkow. Surg Clin North Am. 1993;73:501-512 and Gilbert, personal communication.
PROLENEPROLENE Polypropylene Polypropylene Hernia System:Hernia System:Characteristics and BenefitsCharacteristics and Benefits
Designed to repair all abdominal wall herniasDesigned to repair all abdominal wall hernias Produces minimal tissue reactionProduces minimal tissue reaction Strong tensile and bursting strengthsStrong tensile and bursting strengths Maximum exposed flat mesh surfaceMaximum exposed flat mesh surface
for tissue ingrowthfor tissue ingrowth Large pore sizeLarge pore size
Designed to repair all abdominal wall herniasDesigned to repair all abdominal wall hernias Produces minimal tissue reactionProduces minimal tissue reaction Strong tensile and bursting strengthsStrong tensile and bursting strengths Maximum exposed flat mesh surfaceMaximum exposed flat mesh surface
for tissue ingrowthfor tissue ingrowth Large pore sizeLarge pore size
From King et al. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Boca Raton, Fla:CRC Press Inc;1994:chap 15.From King et al. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Boca Raton, Fla:CRC Press Inc;1994:chap 15.
PROLENEPROLENE Polypropylene Polypropylene Hernia System:Hernia System: SummarySummary
Tension-free techniques reduce the likelihoodTension-free techniques reduce the likelihoodof hernia recurrencesof hernia recurrences
Prosthetic mesh is ideal for bridging defectsProsthetic mesh is ideal for bridging defectsin the abdominal wallin the abdominal wall
Posterior-wall defect can be repaired with combined underlay Posterior-wall defect can be repaired with combined underlay and onlay patchesand onlay patches
Tension-free repair made possible with mesh prosthetics Tension-free repair made possible with mesh prosthetics allows repair without distortion of normal anatomy and suture-allows repair without distortion of normal anatomy and suture-line tensionline tension
Tension-free techniques reduce the likelihoodTension-free techniques reduce the likelihoodof hernia recurrencesof hernia recurrences
Prosthetic mesh is ideal for bridging defectsProsthetic mesh is ideal for bridging defectsin the abdominal wallin the abdominal wall
Posterior-wall defect can be repaired with combined underlay Posterior-wall defect can be repaired with combined underlay and onlay patchesand onlay patches
Tension-free repair made possible with mesh prosthetics Tension-free repair made possible with mesh prosthetics allows repair without distortion of normal anatomy and suture-allows repair without distortion of normal anatomy and suture-line tensionline tension
Sekian Sekian