Now What Do I Do? Tough Situations in Inguinal Hernia Repair &

How to Avoid or Manage Them

Avoid tough situations in inguinal hernia surgery by tailoring the operation.

It’s clearly not one size fits all. There are now many technique and material options that should

be carefully selected to optimize outcomes.

Avoid and Manage Tough Situations

• Dr. Heniford: which operation ?

• Dr. Sarr: Sport’s Hernia

• Dr. Lee: Inguinodynia

Avoid and Manage Recurrence

• If anterior, go posterior • European studies show this

is happening only 10% of the time

• Lap or open

• Consider Stoppa (GPRVS)– Bilaterals too

• If posterior, go anterior• Wide-on-lays; biologicals

• Lower quadrant component separation

• Bone anchors

Mesh Complications

• Infections unusual– Low thresh-hold for infected mesh

explant

• Meshoma’s and Migrations– Parviz Amid

– Organ erosion (bowel and bladder)

– Iliac vessels

– Shrinkage

• Can be the cause of chronic pain

Meshoma

“Surgical treatment for these patients is

explantation of the meshoma.”

Synthetic prostheses

Plug

Colon

Mesh plug

Colon

Plug, inflammation and pain

Recurrence after anterior repair

Avoid and Manage Pain

• Open hurts more than people say it does

• Pre-Op pain predicts Post-Op pain

• Tack pain post lap– Wait, wait, wait

– Diagnose• Use imaging

– Inject

– Wait some more

– Enlist Pain Experts

– Remove screws from Cooper’s ligament or Pain triangle with nerve transection

Evaluation of Groin Painfollowing Herniorrhaphy

Notes:

Neuropathic pain may respond to nerve blocks and may improve over time.

Neuroma pain may remain ongoing, therefore, surgical intervention is performed if the pain is debilitating or lasts for 5 years, due to complications of the surgery.

• Biological disease– AAA

– Ehlers-Danlos• Family Hx

– Immunosuppressed

• TEPPA– Wide mesh coverage

» Hydrophilic

» LW, large pore

– No Wound

– Increase the fixation

Manage or Avoid Abnormal Wound Healing

Send him to Rosen…

Laparoscopic Hernia RepairAnatomy: Triangle of Doom

• Avoid it!

• Follow inferior epigastrics

• Identify Cooper’s ligament

• Don’t confuse vas for iliac artery

• Close branches to iliac vein will bleed too

• Not an intern case!

• Lap IH Clip 03.mpg

Inguinal HerniasLoss of Domain

Giant Inguinal Hernia

• Loss of domain

• Plan for ventilator support– Pre-op PFTs

• Consider laparotomy– Temporary open

abdomen VAC

– Component separation

Avoid tough situations in inguinal hernia surgery by tailoring the operation.

• Know all the technical options– Lap vs Open

– Caveat: The best operation for your patient is the one you do best…

– Short and long-term plans for pain management

• There is a role for neurectomy

• Know the advantages and disadvantages of all the mesh materials– Polymer type

– Mesh shape

– Mesh position