Morbidity and MortalityMorbidity and MortalityHernia Repair Hernia Repair

Kings County Hospital Kings County Hospital August 18, 2006August 18, 2006

JoelleJoelle PierrePierre

Case PresentationCase Presentationxx xx y/oy/o male with male with h/oh/o ESRD presented to Kings ESRD presented to Kings County Hospital for repair of a right inguinal County Hospital for repair of a right inguinal herniaherniaLabs preLabs pre--op : op : HctHct 43.1, PT :11.8, PTT 31.643.1, PT :11.8, PTT 31.6HemodialysisHemodialysis: 1 day pre: 1 day pre--opopPt underwent an uneventful right inguinal hernia Pt underwent an uneventful right inguinal hernia repair with patch and plug system and was repair with patch and plug system and was discharged home.discharged home.

CourseCourse

POD#1 : Pt received POD#1 : Pt received hemodialysishemodialysis with 3,000U with 3,000U of heparinof heparinPOD# 4 : Pt returned to the ER complaining of POD# 4 : Pt returned to the ER complaining of swelling to the right inguinal region. swelling to the right inguinal region.

HctHct : 35: 35PT 11.4, PTT 22.0PT 11.4, PTT 22.0Pt had an AXR and CT Scan of the Abdomen Pt had an AXR and CT Scan of the Abdomen

Course continuedCourse continued

Pt was admitted for observation and IV Pt was admitted for observation and IV atbxatbxHematomaHematoma was stable and the swelling was stable and the swelling decreaseddecreasedHctHct stabilized at 30 stabilized at 30 Pt was discharged home on PO Pt was discharged home on PO atbxatbx

Complications of Complications of Inguinal Hernia RepairInguinal Hernia Repair

August 18, 2004August 18, 2004

Inguinal hernia repair: Inguinal hernia repair: herniarrophyherniarrophy

Most commonly performed general surgical Most commonly performed general surgical operationoperationMen > women 12:1Men > women 12:1Etiology: increased abdominal pressure : chronic Etiology: increased abdominal pressure : chronic constipation or cough, heavy lifting constipation or cough, heavy lifting Weakness of the abdominal wallWeakness of the abdominal wall

Goal of the inguinal hernia repairGoal of the inguinal hernia repairrestore the abdominal wallrestore the abdominal wallwithout recurrence without recurrence With the least amount of operativeWith the least amount of operative

and postoperative discomfortand postoperative discomfort

The inguinal hernia repair has evolved as new The inguinal hernia repair has evolved as new procedures were developed to improve the outcome. procedures were developed to improve the outcome.

Most notably inguinal hernia repairs have evolved from Most notably inguinal hernia repairs have evolved from tension to tension free repairstension to tension free repairs

Facilitated by an increased understanding of the anatomy of Facilitated by an increased understanding of the anatomy of the region. the region.

Anatomy Anatomy

““ The anatomy of the inguinal The anatomy of the inguinal region is misunderstood by region is misunderstood by

surgeons at all levels of senioritysurgeons at all levels of seniority””

AnatomyAnatomy

Anatomy of the Inguinal CanalAnatomy of the Inguinal Canal

•Anterior: external oblique fascia along the entire length with contribution from the internal oblique fascia at the lateral one third.

Posterior: fusion of the transversalis fascia and the transversus abdominis fascia.

•Inferior (floor): the inguinal ligament and its shelving edge and medially the lacunar ligament of Gimbernat.

Superior (roof): the arch formed by the internal oblique and transversusabdominis muscle (conjoint tendon).

Inguinal ligament (Inguinal ligament (PoupartPoupart’’ss ligament):ligament):This is the condensed lower portion This is the condensed lower portion of the external oblique fascia and of the external oblique fascia and extends from the anterior superior extends from the anterior superior iliac spine to the pubic tubercle. Its iliac spine to the pubic tubercle. Its medial third has a free edge, whereas medial third has a free edge, whereas the lateral two thirds are attached to the lateral two thirds are attached to the the iliopsoasiliopsoas fascia.fascia.

PectinealPectineal ligament (Cooperligament (Cooper’’s ligament):s ligament):This is a strong ligament attached to This is a strong ligament attached to the pubic the pubic ramusramus and formed jointly and formed jointly from the from the aponeurosisaponeurosis of the internal of the internal oblique, oblique, transversustransversus abdominisabdominis, and , and pectineuspectineus muscles.muscles.

IliopubicIliopubic tract (Thompsontract (Thompson’’s ligament):s ligament): This This is the condensed part of the is the condensed part of the transversalistransversalis fascia and extends from fascia and extends from the the pectinealpectineal ligament medially, forms ligament medially, forms the inferior border of the internal the inferior border of the internal ring and the anterior wall of the ring and the anterior wall of the femoral sheath, and attaches laterally femoral sheath, and attaches laterally to the to the iliopectinealiliopectineal arch (medial arch (medial thickening of thickening of iliopsoasiliopsoas fascia).fascia).

Contents of the Inguinal CanalContents of the Inguinal CanalMale Male

Spermatic cordSpermatic cordIlioinguinalIlioinguinal, genital branch of the , genital branch of the genitofemoralgenitofemoral nerve, sympathetic nerve, sympathetic nervesnervesthree arteriesthree arteries

are the spermatic artery from are the spermatic artery from the aorta, the aorta, the artery to the vas deferens the artery to the vas deferens from the superior vesicle, from the superior vesicle, cremastericcremasteric artery from the deep artery from the deep epigastricepigastric artery.artery.

the vas deferensthe vas deferensthe the pampiniformpampiniform venous plexusvenous plexusthe lymphatic channelsthe lymphatic channels

The cord has three coveringsThe cord has three coveringsthe outer external spermatic the outer external spermatic fascia,fascia,-- the external oblique fasciathe external oblique fasciathe middle the middle cremastericcremasteric muscle muscle layer,layer,--internal oblique muscleinternal oblique musclethe inner internal spermatic the inner internal spermatic fasciafascia——and and transversustransversus fascia,fascia,

Female Female Round ligament of the uterusRound ligament of the uterusIlioinguinalIlioinguinal nervenerveGenital branch of the Genital branch of the genitofemoralgenitofemoralnerve nerve

HistoryHistory1871 1871 –– Marcy closed the inguinal ring and Marcy closed the inguinal ring and

tranversalistranversalis fasciafasciaLucasLucas--ChampionniereChampionniere MethodMethod

A decade following Marcy,A decade following Marcy,the Lucasthe Lucas--ChampionnierChampionnier methodmethodinvolved slitting the externalinvolved slitting the externaloblique oblique aponeurosisaponeurosis to exposeto exposethe inguinal canal and, under direct vision, the inguinal canal and, under direct vision,

dissecting and dissecting and ligatingligating the hernia sac the hernia sac

BassiniBassini

Father of the modern Father of the modern herniorrhaphyherniorrhaphyA successful repair depended on the reconstruction A successful repair depended on the reconstruction of underlying abdominal wall. of underlying abdominal wall. Thus the first to dissect and reconstruct the Thus the first to dissect and reconstruct the inguinal canal to restore the functional anatomyinguinal canal to restore the functional anatomyHe repaired the He repaired the transversalistransversalis fascia using a 3 fascia using a 3 layered techniquelayered techniqueStressed the importance of opening the external Stressed the importance of opening the external ring and dissecting the ring and dissecting the creamstericcreamsteric fibersfibers

HalsteadHalstead

Added a fourth layer to the repair by Added a fourth layer to the repair by reapproximatingreapproximating the external oblique to the the external oblique to the shelving edge of the inguinal ligament.shelving edge of the inguinal ligament.

Mc Mc VayVay

Surgeon and anatomistSurgeon and anatomistObserved that the Observed that the transversustransversus abdominusabdominus muscles muscles and the and the transversalistransversalis fascia insert into the Cooper fascia insert into the Cooper ligament ligament Applied the stitches to the Cooper ligamentApplied the stitches to the Cooper ligamentRequired relaxing incisions into the ligamentRequired relaxing incisions into the ligamentPt had a slow recovery time Pt had a slow recovery time

ShouldiceShouldice1945 1945 –– multilayered repair multilayered repair imbricatingimbricating the full thickness the full thickness of the of the transversalistransversalis fascia to the inguinal ligamentfascia to the inguinal ligament

ImbricatingImbricating the full thickness of the the full thickness of the transversustransversus arch arch –– fascia, fascia, muscle and internal obliquemuscle and internal oblique-- to the inguinal ligament to the inguinal ligament Then adding an overlying double layer of Then adding an overlying double layer of transversustransversus and and internal oblique internal oblique aponeurosisaponeurosis to the undersurface of the to the undersurface of the thetheexternal oblique external oblique aponeurosisaponeurosis““Vest over pantsVest over pants””An unusual feature of the procedure is the routine sacrifice of An unusual feature of the procedure is the routine sacrifice of the lateral the lateral cremastericcremasteric bundle, a structure that contains the bundle, a structure that contains the external spermatic vessels and the genital branch of the external spermatic vessels and the genital branch of the genitofermoralgenitofermoral nerve.nerve.

ShouldiceShouldice surgeons have not reported any ill effects related to this surgeons have not reported any ill effects related to this step. The minor sensation loss that results from dividing that nstep. The minor sensation loss that results from dividing that nerve erve has not proven to be a substantial or longstanding disability.has not proven to be a substantial or longstanding disability.

Pt Discharge Pt Discharge –– 48 48 –– 72 hours post operative72 hours post operative

Progress?Progress?

Recurrence rates 10Recurrence rates 10--15% with 15% with BassiniBassini, Halstead , Halstead and and McVayMcVay to 1to 1--2% with 2% with ShouldiceShouldice repairsrepairs

HoweverHowever

These were all considered tension repairs and These were all considered tension repairs and resulted in postoperative pain and extensive resulted in postoperative pain and extensive patient disability.patient disability.

FruchardFruchard19501950’’s : introduced a better s : introduced a better understanding of the anatomy understanding of the anatomy of the abdominal wall in the of the abdominal wall in the groin.groin.Need to protect the anatomic Need to protect the anatomic defect defect -- femoral triangles femoral triangles –– in in order to have a successful order to have a successful repairrepairRives and Rives and StoppaStoppa developed developed the posterior the posterior preperitonealpreperitonealapproach to hernia repairsapproach to hernia repairs

Tension Free !Tension Free !In 1958 In 1958 –– Usher et. al. described a hernia repair using Usher et. al. described a hernia repair using MarlexMarlex mesh.mesh.

The mesh was sutured to theThe mesh was sutured to theundersurface of the undersurface of the thethe medial medial margin of the defect and to the margin of the defect and to the shelving edge of the inguinal ligamentshelving edge of the inguinal ligament

Tails created from the meshTails created from the meshencircled the spermatic cord and encircled the spermatic cord and were sutured to the inguinal were sutured to the inguinal ligament ligament

StoppaStoppa and later and later NyhusNyhus used a posterior approach used a posterior approach The mesh was placed between the The mesh was placed between the transversalistransversalis fascia and the fascia and the peritoneum.peritoneum.

Lichtenstein Lichtenstein

Popularized the use mesh coining the term Popularized the use mesh coining the term ““tension free repairtension free repair””

Uses non absorbable sutures and a prosthetic flat Uses non absorbable sutures and a prosthetic flat mesh to reinforce the canal floormesh to reinforce the canal floorDo not need general anesthesia and can be Do not need general anesthesia and can be performed on an outpatient basisperformed on an outpatient basisBut : no posterior support and no protection of the femoral But : no posterior support and no protection of the femoral canalcanal

Gilbert Gilbert

Wanted to reduce the chance of injuring the Wanted to reduce the chance of injuring the nerves and the spermatic cord. His goal was to nerves and the spermatic cord. His goal was to direct his repair to the hernia sac and the defect direct his repair to the hernia sac and the defect in the at the internal ring. in the at the internal ring. Described a Described a suturelesssutureless repair where he used a repair where he used a self made cone shaped piece of mesh to repair self made cone shaped piece of mesh to repair indirect hernias. indirect hernias.

RutkowRutkow and Robbins and Robbins Used it to repair both direct and Used it to repair both direct and indirect herniasindirect hernias

Started as an umbrella plug held Started as an umbrella plug held together by a suture together by a suture Led to the development of the Led to the development of the PerFixPerFix plug (plug (C.R.BardC.R.Bard))Patch and Plug system: an Patch and Plug system: an onlayonlaypatch, which can be used with or patch, which can be used with or without sutures, is placed over the without sutures, is placed over the posterior wall and around the posterior wall and around the spermatic cord lateral to the internal spermatic cord lateral to the internal ring.ring.The patch is there to strengthen the The patch is there to strengthen the direct space direct space

Gilbert Gilbert –– 19901990’’ssThen used the inguinal ring to accessThen used the inguinal ring to access

the the preperitonealpreperitoneal space through an space through an open anterior approach open anterior approach

Led to the development of the Led to the development of the Prolene Hernia System (PHS Prolene Hernia System (PHS –– Ethicon)Ethicon)

3 in 1 system consisting of an underlay patch, an overlay 3 in 1 system consisting of an underlay patch, an overlay patch and an interconnecting ring patch and an interconnecting ring

The underlay mesh is placedThe underlay mesh is placedvia the inguinal ring in the via the inguinal ring in the preperitonealpreperitoneal space and is not sutured. space and is not sutured.

The overlay mesh is sutured The overlay mesh is sutured The The interconnectorinterconnector reduces the likelihood of mesh reduces the likelihood of mesh migrationmigrationReduced rates of recurrence !Reduced rates of recurrence !

because of coverage of the lateral triangle of the groin where because of coverage of the lateral triangle of the groin where recurrence can occur at the point between the mesh and the recurrence can occur at the point between the mesh and the weaker adjacent tissueweaker adjacent tissue

Complications?Complications?

Complications of inguinal hernia repair

Chest infection Urinary retention Venous thrombosis

General/local anesthesia

Systemic

port site hernias recurrence pain

Hydrocele seromaAs above and Vascular injuries, Visceral injuries

Laparo-scopic:

recurrence and pain

HydroceleNerve injuries and injury to vas

open:

Technique

Genital edema orchitis/atrophy

Scrotum

Chronic sepsis & sinus formation

InfectionBruising, hematomaIncision

LaterEarlyOperative

BM Stephenson, Surg Clin N Am 83 (2003) 1255-1278

ComplicationsComplicationsRecurrence Recurrence

1010--15% to 1.5 % at the 15% to 1.5 % at the ShouldiceShouldice clinicclinic1% with mesh 1% with mesh reparisreparis

InfectionInfectionMesh removalMesh removal

CR CR VoylesVoyles SurgSurg ClinClin N am 83 (2003) 1279 N am 83 (2003) 1279 -- 12871287

Wound infection?Wound infection?The possibility of wound infections was a The possibility of wound infections was a concern because the introduction of a foreign concern because the introduction of a foreign body into a clean case. body into a clean case. ShouldiceShouldice clinic clinic –– 11--2%2%33--9% reported by Bailey et al9% reported by Bailey et al-- hospital hospital vsvscommunity surveillance community surveillance Usual culprits Usual culprits –– Staphylococcus Staphylococcus aureusaureus and and epidermidisepidermidis. . Prophylactic antibioticsProphylactic antibiotics

Prophylactic AntibioticsProphylactic Antibiotics

Table 3.Table 3. Studies addressing the problem of wound infection and the routinStudies addressing the problem of wound infection and the routine use e use of antibiotics in open hernia repair with meshof antibiotics in open hernia repair with mesh

nn Infection (%)Infection (%) ConclusionsConclusionsHernia specialistsHernia specialists::Lichtenstein Lichtenstein 10000 10000 00 No commentNo commentKurzerKurzer et al et al 29062906 1.31.3 Not necessaryNot necessaryShulmanShulman et al et al 30193019 0.50.5 Not necessaryNot necessaryRobbins & Robbins & RutkowRutkow 15631563 0.40.4 Not necessaryNot necessaryGilbert Gilbert 10441044 0.90.9 Not necessaryNot necessaryNonspecialistsNonspecialists::Gilbert & Felton Gilbert & Felton 18341834 0.80.8 Not necessaryNot necessaryShulmanShulman et al et al 16,06816,068 0.60.6 Not necessaryNot necessaryProspective randomized studies:Prospective randomized studies:LazorthesLazorthes et al et al 153 153 vsvs 155155 4.6 4.6 vsvs 0.00.0 MandatoryMandatoryTaylor et al Taylor et al 280 280 vsvs 283283 8.9 8.9 vsvs 8.88.8 Not necessaryNot necessaryYerdelYerdel et al et al 133 133 vsvs 136136 9.0 9.0 vsvs 0.70.7 MandatoryMandatory

Management of wound infectionManagement of wound infectionWorse complication is infection of the meshWorse complication is infection of the meshCare has to be taken with superficial wound infections not to Care has to be taken with superficial wound infections not to expose the underlying mesh even if the wound needs to be expose the underlying mesh even if the wound needs to be opened for drainageopened for drainageWith a true mesh infection the mesh can be seen floating in a With a true mesh infection the mesh can be seen floating in a pool of pus and surrounded by a thick fibrous capsule. pool of pus and surrounded by a thick fibrous capsule. Presents at around 4 months post op with groin sepsisPresents at around 4 months post op with groin sepsisMann Mann et.alet.al of Scotland suggested that the incidence is probably of Scotland suggested that the incidence is probably 1 in 1000 and 1 in 1000 and YerdelYerdel reports an incidence of 1% of meshes reports an incidence of 1% of meshes requiring removal requiring removal But there is little literature describing this to be a huge probBut there is little literature describing this to be a huge problem lem and mesh is used in cases with increased chances for infection and mesh is used in cases with increased chances for infection such as strangulated bowel and the repair of such as strangulated bowel and the repair of parastomalparastomal hernias hernias

Chronic groin pain Chronic groin pain According to some population based studies 1/3 of According to some population based studies 1/3 of patients complain of pain 12 months or more after the patients complain of pain 12 months or more after the repair. repair. Neuralgic Neuralgic inguinodyniainguinodynia

Hyperesthesia along the dermatome Hyperesthesia along the dermatome Exquisite pain at the site of the a Exquisite pain at the site of the a neuromaneuroma or trapped nerve or trapped nerve --patients describe a pain like an electric shockpatients describe a pain like an electric shockCareful technique preserving the Careful technique preserving the ilioinguinalilioinguinal and and iliohypogastriciliohypogastric nerve nerve particularly when closing the particularly when closing the aponeurosisaponeurosis of the of the thethe external external oblique in the creation of the new external ring. oblique in the creation of the new external ring.

Treatment Treatment –– rexplorationrexploration with division of the three groin with division of the three groin nerves. nerves.

Laparoscopic repair Laparoscopic repair Described initially by Ger, Shultz et al, Described initially by Ger, Shultz et al, CorbittCorbittand and FilipiFilipi et alet al

Placing a piece a mesh in the Placing a piece a mesh in the preperitonealpreperitoneal spacespaceEither Either extraperitonealextraperitoneal or or transabdominaltransabdominal approach approach with or without tacking sutureswith or without tacking sutures

Complications Complications

Laparoscopic repair Laparoscopic repair ––Small bowel obstructionSmall bowel obstructionInjury to the Injury to the epigastricepigastric vessels or vessels or obturatorobturator artery,artery,Internal hernia, Internal hernia, Bladder or visceral perforation,Bladder or visceral perforation,InfarctedInfarcted omentumomentumPort site herniaPort site herniaHigher recurrence ratesHigher recurrence rates

Laparoscopic RepairLaparoscopic Repair

Advantages:Advantages:Less postLess post--op pain, op pain, Earlier return to work Earlier return to work

14 14 vsvs 21 days21 days

But :But :High costHigh costSteep learning curve Steep learning curve More serious possible complications More serious possible complications General anesthesiaGeneral anesthesia

LaparoscopicLaparoscopic

Led to an increased adoption of the open Led to an increased adoption of the open preperitonealpreperitoneal approachapproachPreperitonealPreperitoneal vsvs LHRLHR

Return to work Return to work 10.3 days 10.3 days vsvs 12.6 days 12.6 days –– not statistically significant not statistically significant Less complicationsLess complications

CR CR VoylesVoyles SurgSurg ClinClin N am 83 (2003) 1279 N am 83 (2003) 1279 -- 12871287