Hernia note by S.

Wichien (SNG KKU)

Anatomy -inguinal canal 4-6 cm -spermatic cord : 3a,3v,2n Nerve of inguinal region 1.illioinguinal n--L1 2.illiohypogastric n--T12-L1 3.genitofemoral n--L1-2 4.lat.femoral cutaneous n--L2-3 1,2--in canal Cord structure 3 fascia 1.internal--IO-->cremasteric m 2.external--EO 3.superficial--fascia of Gallaudet (innominate fascia) Post perspective 1.umbilicus 2.median umbilical lig 3.medial umbilical lig--obliterate UV 4.lat umbilical lig--inf epigastric vv Bogros space -space btw peritoneum & post of TF Myoepithelial orifice of Fruchaud (Tripple triangle of groin) 1.lateral triangleIIH 2.medial triangleDIH 3.femoral trianglefemoral hernia Triangle of doom -medial=vas def -lateral=spermatic vv -apex=deep ring -content=ext illiac vv,genital of GF n Triangle of pain -medial=spermatic vv -sup=iliopubic tract -content=femoral n,femoral of GF n, lat.femoral cuta.n Iliopubic tract -transaversalis fascia -ASIS to pubis -below inguinal lig Hernia Epidermiology Inguinal hernia -75% of hernia -m 90% , f 10% -1/3 unilat = develop contralat -<1yr, >40yr Femoral hernia -m 30% , f 70% -most in female = inguinal hernia -below inguinal lig, lat pubic tubercle Littre hernia -meckel diverticulum in hernia sac Amyand hernia -appendix in hernia sac Post/lumbar hernia -sup lumbar triangleGrynfelt hernia -inf lumbar trianglePetit hernia Etiology Acquire--weakness in abdo.wall Congen--patent processus vaginalis Classification Gilbert classification T1 small indirect T2 medium indirect T3 large indirect (>2FB) T4 direct T5 diverticular direct T6 combine (pantaloon) T7 femoral Nyhus classification T1 indirect hernia (congen) normal internal ring T2 indirect hernia enlarge internal ring not extend scrotum T3a direct hernia T3b indirect hernia scrotal hernia T3c femoral hernia T4 recurrent hernia Ix -gold std=laparoscopic -least sens=PE -most sense=MRI

Hernia note by S.Wichien (SNG KKU)

Hernia Tx 1.groin mass A.asymp=discuss conservative B.symp=sx repair Incarcerate=open sx Unilat=open vs lap Bilat=lap Recur=approach through virgin plane 2.pain,discomfort A.palpable groin mass=sx repair B.no groin mass=Ix (us,CT,MRI) No hernia=conservative Hernia=sx repair Sx--definite Tx repair Non sx -asymp/minimal symp inguinal hernia -yearly risk of incar/strangu = 0.3% Open Sx c/p 1.post op pain -n entrapment/scar/mesh adhere -sharp localized pain--pin&needle -numbness over cuta.distribution -formication--sens of insect crawling Inj mech -during close EOA--II -entrap in mesh--II,IH,lat.femoral cu -fix in lap--lat.femoral.cuta,GF Postherniorrhaphy pain synd 1.somatic pain--lig,m inj :pain on exertion :Tx--rest,nsaid 2.visceral pain--symp n plexus inj :pain during ejaculation 3.neuropathic pain--n inj :localized sharp pain :Tx--nsaid,n.inject of steroid :failneurectomy 2.cord&testis inj excess handle--hematoma/ischemia scrotal hematoma -blue/black discoloration Tx--self limited/reassure Ischemic orchitis -1st wk s/p sx (<1% of sx) -low gr fever,enlarge/pain testis -inj to pampiniform plexus -u/s--reduce blood flow Tx--self limited/reassure (if necrosis=E.orchidectomy) Testis atrophy--inj to testicular a Ptosis -divide cremasteric m -in shuoldice T Infertile -vas def inj -crushing inj in lap sx -transection--Tx=reanastomosi -chronic scar--pain/burn ejaculate Tx--self limited 3.wound infection-1-2% 4.seroma -in large hernia -avoid aspiration unless persist -warm compress 5.hematoma -open sx--wound hematoma -lap sx--rectus sheath,retroperi -inj iliac vv--progressive expanding H 6.bladder inj -consider in lap sx -open xs may in :sliding hernia of bladder :previous sx 7.osteitis pubis -pain over medial groin,pubis -suture in periosteum -major in athletes--jump,kick,run -Ix--bone scan -CT/MRI--r/o recurrent hernia -Tx--rest,ice,nsaid,local steroid inject -fail--open remove suture/bone resect 8.urinary retention -common short term c/p -LA 0.2%, GA/RA--13% -p/o pain,narcotic,distend bladder -limit iv hydration Lap sx cp 1.visceral inj -small & large bowel, bladder -TEP<TAPP -risk=previous abdo sx -electrocautery inj 2.vascular inj -mesh fixation -trochar placement in TAPP :IEA inj :prevent--direct vision 3.bowel obstruction 1.common in TAPP :inadequate peritoneum closure :trochar site hernia 2.adhere implant mesh

Hernia note by S.Wichien (SNG KKU)

Open sx Not mesh in -contaminate field -concern 2 azoospermia Incision -lateral--2FB inf/medial ASIS -medial--6-8cm Procedure -camper fascia-->scapa fascia -divide EO, aware ilioinguinal n -mobilize cord structure -divide blunt cremasteric fiber -identity sac--anterolat of cord -identify vas def,vv of cord -reduction sac = hi ligation -may open sac--ensure no incarcerate 1.Anterior repair (non prosthesis) 1.Bassini repair -suture TF,TA,IO (triple layer) fix to inguinal lig/periosteum 2.shouldice repair -continuous suture -multilayer recons Advantage -distribute tension over several layer -prevent herniation btw suture 1st layer -suture IP tract w medial flap (TF,TA,IO) 2nd layer -suture reverse back to pubic T -suture IO,TA w inguinal lig 3.McVay repair (cooper lig repair) -relaxing incision--incision at TF Advantage -tension reducing maneuver -can both inguinal & femoral defect Occlude femoral canal -suture cooper lig w TF Transitional stitch -suture TF w inguinal lig 2.Anterior repair (prosthesis) 1.Lichenstein tension free henia -expose inguinal lig,pubic tubercle Area for mesh -medial--2cm medial to pubic T -lat--continuous fix to inguinal lig -tail of mesh--interrupt suture -sup--fixed to IO,rectus Femoral hernia -medial--fix to cooper lig, lat--inguinal lig 2.plug & patch technic -prosthesis through internal ring 3.Preperitoneum repair -divide transversalis fascia -pfannelsteil/lowr midline incision Advantage -prosthesis place btw hernia & defect -inc intra abdo P--push mesh to floor -not touch n,cord 1.Read Rives repair -ant approach -groin incision -incised TF -blunt dissect preperitoneal space -identify int ring & dissect from perito -mesh 16*12 cm placed preperito :medial--cooper lig, lat--ASIS :3suture--cooper lig,pT,psoas 2.giant prosthesis reinforcement visceral sac (Rives,Stoppa,Wantz repair) -pfannelsteil,lower transverse incision -divide rectus & oblique m 10 cm -exposed TF,dissect spsce -placed large mesh :umbilicus to ASIS -1 cm :height 14 cm -3 suture 1.ASIS 2.linea semiluna 3.linea alba 3.iliopubic tract repair -combine tissue base repair &mesh -preperitoneum approach Reconstruction -suture TF w cooper lig/IP tract -mesh placed over post of TF 4.Kugel repair -2-3 cm incision above internal ring -muscle splits as appendectomy -blunt dissect in preperito space -hernia sac dissection and division -mesh 8*12 cm 5.prolene hernia system -mesh=2 flap :onlay--foor inguinal canal :underlay--preperitoneal space :have intervening connector -prevent mesh migration

Hernia note by S.Wichien (SNG KKU)

Lap hernia sx -trendelenberg position -surgeon--contralat side to hernia 1.TransAbdominal PrePerito H repair Advantage -large working space -in lower abdo.sx -in large hernia -ambiguous dx -anatomy--more obvious 3 trochar -12 mm--umbilicus--camera -5 mm*2 (each lower quadrant) (aware inf epi a inj) Procedure -iden bladder,umbilical lig,EIA,IEA -iden inguinal hernia -incised perito at medial umbi.lig :3-4cm above hernia :lateral--to ASIS -dissect preperito space -expose cord structure -lat to pubic symphysis=cooper lig -iden vas def,spermatic vv :avoid grasping inj -dissect indirect H.sac from cord -dissect peritoneum inferiorly -mesh 10*15 cm over myopectineal :medial--cooper lig :lateral--ASIS, above IP tract if below IP tract :inj genital br of GF & lat.cuta.n thigh -mesh lay in preperitoneum -grasp&return peritoneal edge -avoid bowel direct contact w mesh 2.Totally ExtraPeritoneum H repair Advantage -dec inj to intra abdo.organ -preserve post rectus--dec trochar H. -if whole preperito approach :not bowel obst,mesh erosion 3 trocar -12 mm--umbilicus -5 mm*2 (lower midline) Procedure -dissecting balloon toward PS -slowly inflate -if tear perito--closed defect :prevent mesh erosion,gut obstr -deflated slowly under direct vision :ensure prope mesh positioning 3.Intraperitoneal Onlay Mesh (IPOM) -port as TAPP -without dissect preperitoneum :dec operative time :inc neuralgia--unidentify nerve -sac not reduce -mesh direct over hernia defect -fix w suture/spiral track Use in -not safe in preperito dissection :previous sx--LRP,lap hernia Mesh -polypropylene--bowel adhere,erosion -polyester coated w porcine collagen :dec p/o c/p Mesh 1.Polypropylene,polyester -synthetic, non absorb 2.Polytetrafluoroethylene -not ingrowth into viscera -use in TAPP,IPOM -in difficult close peritoneum 3.Biologic mesh -not role in routine herniorrhaphy -limit in contaminate field

Hernia note by S.Wichien (SNG KKU)

Emergency hernia I/C -incarcerate hernia -strangulate hernia -sliding hernia--one wall within sac 1.Incarcerate -can't reduce hernia Factor -large amount intes content -dense,chronic adhesion -small neck clinical -n/v, constipate,distend abdo Tx 1.reduction--taxis -before definite sx -sedate, trendelenberg position -apply presure to most distal of sac 2.sx--fail 1 2.Strangulation clinical -fever,leukocytosis -hemodynamic instable -bulge+tender,warm,discolor Tx -not taxis -resuscitation Std transverse inguinal incision -open sac--assess viability of bowel 1.viable -can reduce 2.question -expand defect--relief pressure -mobilize bowel to op field -wrap bowelnin warm wet towel -look color/temp/peristalsis/ wood fluorescin test -ischemic=resection -if during sx=no inguinal henia :should aware femoral H 3.femoral hernia -entrap bowl in femoral H -cut inguinal lig -cut round lig in female -Mcvay repair uncommon -if incar/strangulate reduce after GA -convese to laparotomy/lap -fully assess bowel Sport hernia -sportsman hernia or athletic pubalgia -weak or tearing of post inguinal wall -often not identify until sx :tear TF/conjoint tendon :tear IO, avulsion IO at PT :tear EOA :widened ext ring :def of floor inguinal canal=most com occult hernia Clinical -deep groin pain -gradually worsening -pain on exertion -fail iden bulge/cough test -tender pubic,inguinal canal Tx 1.conservative 2.groin exploration as open sx -tissue repair vs lap preperito mesh