Open Hernia Resident Conference 8.3.11_0

Resident ConferenceOpen Inguinal & Ventral Hernia RepairAndrew Gassman8/3/11

Inguinal Hernia

Inguinal Hernia EpidemiologyWorldwide: 20 million groin hernias are repaired each year.In the US 1,000,000 abdominal wall herniorrhaphies are performed each year750,000 - inguinal, 166,000 umbilical, 97,000 -incisional, 25,000 - femoral,75% of all abdominal wall hernias occur in the groin. R > LM > F (7-FOLD)In Men: Indirect >> Direct >>>>FemoralIn Women Indirect > Femoral > Direct

Femoral hernias account for fewer than 10% of all groin hernias40% present as emergencies (i.e., with incarceration or strangulation)Mortality is higher for emergency repair than for elective repair

Emergency operations are more frequently required for female patients.

Natural HistoryRJ Fitzgibbons, A Giobbie-Hurder, JO Gibbs, Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006 vol:295 page:285Randomized, controlled trial from 2006, Minimally symptomatic inguinal hernia was addressed in a in which 364 men were assigned to 'watchful waiting' (WW)356 men underwent routine operation.

Only two patients in the WW group required emergency operations for strangulation over the follow-up period of 2 to 4.5 years. This result is about 1/5 of 1% for each year that the hernia remains unrepaired. The two patients who required emergency operations recovered uneventfully.

At the conclusion of the study, functional status, as measured by quality-of-life instruments and pain scales, was identical in the two groups.

Postoperative complication rates were the same in patients who underwent immediate surgery as in those who were assigned to watchful waiting but had to cross over to surgical treatment.

Physiology / PathophysiologyInguinal HerniaEither indirect or directIndirect inguinal herniaPasses through internal inguinal ring, traverses inguinal canal to external ringMay extend into scrotum in males and labia majora in femalesPasses lateral to inferior epigastric vessels and has an oblique inferior courseConsidered a congenital defect and associated with a patent processus vaginalis5x more common than direct inguinal herniasDirect inguinal herniaProtrusion through Hesselbach triangleGenerally does not extend into scrotumPasses medial to inferior epigastric vesselsConsidered an acquired defectInguinal hernias 5-10x more common in men

AnatomyAnterior PelvisMuscles:External Oblique Most superficialCourse Inferiomedial

Internal Oblique Middle FlatCourse SuperiomedialTransversus Abdominus Inner Most Flat muscleCourse TransverselyRectus AbdominusVertical Strap MuscleInguinal Boundaries:Superior Aponeurosis of Tansversus Abdominus (Falx Inguinalis)Fuses with internal oblique aponeurosis to form conjoined tendon mediallyInferior Inguinal LigamentMedial portion attached on pectineal/ Coopers ligamentPosterior Tansversalis FasciaFuses anteriorly and inferior as the ileopubic tract Anterior External oblique AponeurosisForms shelving edge when traveling inferiorly and posteriorly cradling cord structuresInserts into inguinal ligament and travels posteriorly to ileopubic tract.

Canal Anatomy

Fascial AnatomyTransversalis fasciaattached to the iliac crest laterally inserts on the pubic tubercle mediallyForms anatomic landmarksiliopectineal arch,iliopubic tract,the thickened band of the transversalis fascia that courses parallel to the more superficially located inguinal ligamentcrura of the deep inguinal ring, Continues into insert into Cooper's ligament (i.e., the pectineal ligament) a condensation of the periosteum .

Fascial AnatomyBetween the transversalis fascia and the peritoneum is the preperitoneal space. In the midline behind the pubis - The space of Retzius; Laterally - The space of Bogros. The preperitoneal many of the inguinal hernia repairs are performed in this area.Within the preperitoneal space:inferior epigastric vesselsdeep inferior epigastric vein iliopubic vein retropubic veininternal spermatic vesselsvas deferens

Inguinal AnatomyInguinal CanalPassage through anterior abdominal wallConveys spermatic cord in males and round ligament in femalesFormed embryologically by evagination of processus vaginalis through anterior abdominal wallInternal or deep ringOpening through transversalis fasciaLocated above mid-portion of inguinal ligamentLateral to inferior epigastric arteryExternal or superficial ringTriangular opening of external oblique aponeurosisJust lateral to pubic tubercleHesselbach triangle Area of weakness in pelvic wallSite of direct inguinal herniasMedial border: Lateral edge of rectus sheathLateral border: Inferior epigastric arteryInferior border: Inguinal ligament

Inguinal Anatomy

Inguinal Nerves

Types of Repair

Marcy RepairChildren and young adults Concern about the long-term prosthetic material. High ligation of the sac and narrowing of the internal ring. Displacing the cord structures laterally allows the placement of sutures through the muscular and fascial layers

Bassini RepairReconstruction of the inguinal floor by opening the transversalis fascia from the internal inguinal ring to the pubic tubercle, thereby exposing the preperitoneal fat, Bluntly dissected undersurface of the superior flap of the transversalis fascia 'triple layer' approximation The layer of transversalis fascia and the transversus abdominis is sutured, with the internal oblique muscle, to the reflected inguinal ligament

Shouldice Repair2 layersA continuous running suture re-approximates the inguinal floorA second layer is started near the internal ring, approximating the internal oblique muscle and the transversus abdominis to a band of external oblique aponeurosis superficial and parallel to Poupart's ligamentThis suture line ends at the pubic crest.A fourth suture line may be added

Shouldice Repair

McVay RepairSimilar to the Bassini repair, Except that it uses Cooper's ligament instead of the inguinal ligamentInterrupted sutures are placed from the pubic tubercle laterally along Cooper's ligament, progressively narrowing the femoral ringTreatment of Femoral HerniaThe last stitch in Cooper's ligament is known as a transition stitch and includes the inguinal ligament.Relaxing Incision

McVay Repair

Lichtenstein Repair

Femoral AnatomyFemoral HerniaBegins posterior to medial portion of inguinal ligamentTraverses femoral canal to fossa ovalisHerniated contents are below inguinal ligament, lateral to pubic tubercle and medial to femoral vesselsMore common in older women

Femoral AnatomyBelow the iliopubic tract Iliopectineal arch separates the vascular compartment (femoral vessels) from the neuromuscular compartment (iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous nerve)Vascular compartment 3 subcompartments: (1) the lateral, containing the femoral artery and the femoral branch of the genitofemoral nerve; (2) the middle, containing the femoral vein;(3) the medial, which is the cone-shaped cul-de-sac known as the femoral canal. The femoral canal is normally a 1 to 2 cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis.normally contains preperitoneal fat, connective tissue, and lymph nodes (including Cloquet's node at the femoral ring) The femoral ring is bordered by the superior pubic ramus inferiorly, the femoral vein laterally, and the iliopubic tract (with its curved insertion onto the pubic ramus) anteriorly and medially. A femoral hernia exists when the blind end of the femoral canal becomes an opening (the femoral orifice) through which a peritoneal sac can protrude.

Femoral Anatomy

Ventral Hernia

Fascial AnatomyLinea albaRaphe of the flat abdominal musclesRectus sheathInvests Rectus abdominis muscles Epigastric vesselsAponeuroses of external oblique, internal oblique and transversus abdominis musclesInternal oblique aponeurosis splits:Upper abdominal wall:Anterior portion and joins external oblique aponeurosis to form anterior rectus sheathPosterior portion joins transversus abdominis aponeurosis to form posterior rectus sheathLower third of abdominal wall (below anterior superior iliac spine) all aponeurosis join and course anterior to rectus abdominis musclesCreates arcuate line on posterior surface of abdominal wallBelow arcuate line covered only by transversalis fascia, which is separated from parietal peritoneum by extraperitoneal fat

Fascial Anatomy

Ventral Hernia EpidemiologyIncidence of incisional hernia after laparotomy varies in reports 3-20% Doubles with presence of infectionUpper midline incisions are associated with the highest incidence of ventral hernia formationTransverse or oblique incisions with the lowest. Most incisional hernias are detected within 1 year of surgeryMale-to-female incidence ratio is 1:1, Early evisceration is more common in males.

Incisional herniaRisk factors for (Re/O)ccurrence:Male sex, age, obesity, jaundice, underlying disease process, wound infection, abdominal distension, pulmonary diseases

TimelinePrior to 1960sPrimary repair wit natural materialsTransposition of tissue1959 - Advent of synthetic material Polyproplene suture and meshMaterials and positions for mesh closure1983 PTFE used for mesh closure1980s Rives and Stoppa separately described Subfascial/ pre-peritoneal placement of mesh1990 Ramirez, described a method to close incisional hernia defects by separating the muscle planes of the abdominal wall termed, component separation.

Primary vs. Mesh-based repairs:

Sahlin and Roberts - primary repair.No difference in recurrence rate for primary repairs performed with either monofilament or braided suture. No difference for repairs performed in a running or interrupted fashionLuijendijk et al. at 3-years, regardless of hernia size, mesh repair was statistically superior to suture repair (43% vs. 24%) in the recurrence of midline abdominal incisional hernias.(21) Burger et al.Follow-up work by documented a 10-year cumulative recurrence rate of 63% for suture repair and 32% for underlay mesh repairs of first time midline incisional hernia defects

Mesh placement in relation to fasciaHawn et al.,The effectiveness of mesh repair varied by its position. Compared to suture repair: open underlay mesh repair (hazard ratio = 0.72) and laparoscopic intraperitoneal repair (hazard ratio = 0.49) significantly reduced the risk of recurrence. Mesh onlay or inlay had no improvement over primary suture repair.

Rives and Stoppa independently described a method of repairing ventral hernias.When Rives and Stoppa described their pre-peritoneal reconstruction method only synthetic meshes with a high tendency to erode intra-abdominal organs were available.

Composite synthetic materials have been develop specifically to prevent visceral injury and adhesion formation. Wiliams et al., demonstrated that the Rives-Stoppa method, could be accomplished intra-peritoneally. Specifically, they performed open incisional hernia repairs using an intraperitoneal mesh underlay. In their study, the repairs were completed with a variety materials designed to limit visceral erosion including ePTFE, coated polyester, coated polypropylene, and biologic meshes.

Component Separation Repairs:

Ramirez et al.Separating the muscles of the abdominal wall and transposing their position to closure a hernia defect. Elevation of extensive lateral skin flapsExternal oblique muscle is detached from its medial insertion on the rectus sheath along the entire semi-lunar line. TThe external oblique muscle is subsequently elevated off of the internal oblique muscle. The horizontal translation of the musculature allows for greater approximation of the midline fascial elements. Additionally, separation of the posterior rectus sheath from the rectus muscle itself may be performed for additional intra-abdominal domain recovery.

De Vries Reilingh et al.Described the use of this technique for complex ventral hernia repair in both clean and contaminated surgical fields. Over a 1 to 4 year follow-up period, their work documented a recurrence rate that ranged from 4-30%. Additionally, wound complication (i.e. seroma, surgical site infection, etc.) rates varied from 1-84%. This variation was owed in part to variation in technique between the studies described. The higher wound complications were owed in part to the subsequent vascular compromise to the overlying skin flaps inherent the extensive surgical dissection.

Component Separation Repairs:

Questions

Question 1The Shelving portion of the inguinal ligament used for open inguinal hernia repair:A) is formed from the external oblique aponeurosisB) Arises from the transversalis fasciaC) Inserts directly on to creamasteric fasciaD) represents the superior border of the iliopubic tractE) is usually sutured to the transversus aponeurosis arch (flax inguinalis), which lies inferior to it , to complete a primary open repair

Question 2Which is true of the anatomy of the Abdominal Wall:A) The origin of the external oblique muscle is the 5 lowest ribsB) Embryologic origin of the Rectus Abdominus is the ectodermC) The Majority of the neurovascular structures that supply the abdominal wall lie between the external and internal oblique musclesD) An abdominal hernia requires a defect in transversus abdominusE) Lymphatic Drainage of the abdominal wall above the umbilicus goes to the ipselateral axillary lymph nodes.

Question 3Thirty years after having a right open inguinal hernia repair, a 67 year old man with hypertension presents with new onset bulge in his right groin. The bulge is apparent throughout the day and causes discomfort with valsalva. Five years ago, he had a radical retropubic prostatectomy and open cholecystectomy. On Exam, he has a moderately sized reducible right inguinal hernia. The most appropriate next step in management would be:

A) Open Primary HerniorrhapyB) Open Mesh HernioplastyC) Transabdominal Preperitoneal (TAPP) repairD) Total Extraperitoneal (TEP) repairE) Watchful Waiting

Question 3 Thirty years after having a right open inguinal hernia repair, a 67 year old man with hypertension presents with new onset bulge in his right groin. The bulge is apparent throughout the day and causes discomfort with valsalva. Five years ago, he had a radical retropubic prostatectomy and open cholecystectomy. On Exam, he has a moderately sized reducible right inguinal hernia. The most appropriate next step in management would be:

A) Open Primary HerniorrhapyB) Open Mesh HernioplastyC) Transabdominal Preperitoneal (TAPP) repairD) Total Extraperitoneal (TEP) repairE) Watchful Waiting

Question 3 - SESAP

Question 4A) systemic CorticosteroidsB) Local injection of CorticosteroidsC) Inguinal ExplorationD) LaparotomyE) Pubic Ramus Plating

Question 4 - SESAP

Question 5Which statement about watchful waiting of inguinal hernia is true?A) More Likely to limit physical activity due to painB) More likely to encounter complications if subsequent repair is requiredC) Have a 10% chance of incarceration in 2 years time.D) More cost effectiveE) 20% require operative repair in 2 years

Question 5

Question 6Which of the following is true regarding patients with liver cirrhosis, ascites, and umbilical hernia.A) They are best managed non-operativelyB) Ascites is a contraindication to operative repairC) They have a low recurrence riskD) They may be categorized by MELD score to predict rate of failureE) Elective operation is recommended

Question 6

Prior Absite ?s

Documents

Open Hernia Resident Conference 8.3.11_0