MorbidityMorbidity andand MortalityMortality HerniaHernia RepairRepair

KingsKings CountyCounty HospitalHospital AugustAugust 18,18, 20062006 JoelleJoelle PierrePierre CaseCase PresentationPresentation „ xxxx y/oy/o malemale withwith h/oh/o ESRDESRD presentedpresented toto KingsKings CountyCounty HospitalHospital forfor repairrepair ofof aa rightright inguinalinguinal herniahernia „ LabsLabs prepre--opop :: HctHct 43.1,43.1, PTPT :11.8,:11.8, PTTPTT 31.631.6 „ HemodialysisHemodialysis:: 11 dayday prepre--opop „ PtPt underwentunderwent anan uneventfuluneventful rightright inguinalinguinal herniahernia repairrepair withwith patchpatch andand plugplug systemsystem andand waswas dischargeddischarged home.home. CourseCourse

„ POD#1POD#1 :: PtPt receivedreceived hemodialysishemodialysis withwith 3,000U3,000U ofof heparinheparin „ POD#POD# 44 :: PtPt returnedreturned toto thethe ERER complainingcomplaining ofof swellingswelling toto thethe rightright inguinalinguinal region.region. „ HctHct :: 3535 „ PTPT 11.4,11.4, PTTPTT 22.022.0 „ PtPt hadhad anan AXRAXR andand CTCT ScanScan ofof thethe AbdomenAbdomen

CourseCourse continuedcontinued

„ PtPt waswas admittedadmitted forfor observationobservation andand IVIV atbxatbx „ HematomaHematoma waswas stablestable andand thethe swellingswelling decreaseddecreased „ HctHct stabilizedstabilized atat 3030 „ PtPt waswas dischargeddischarged homehome onon POPO atbxatbx

ComplicationsComplications ofof InguinalInguinal HerniaHernia RepairRepair AugustAugust 18,18, 20042004 InguinalInguinal herniahernia repair:repair: herniarrophyherniarrophy

„ MostMost commonlycommonly performedperformed generalgeneral surgicalsurgical operationoperation „ MenMen >> womenwomen 12:112:1 „ Etiology:Etiology: increasedincreased abdominalabdominal pressurepressure :: chronicchronic constipationconstipation oror cough,cough, heavyheavy liftinglifting „ WeaknessWeakness ofof thethe abdominalabdominal wallwall „ GoalGoal ofof thethe inguinalinguinal herniahernia repairrepair „ restore the abdominal wall „ without recurrence „ With the least amount of operative and postoperative discomfort

„ TheThe inguinalinguinal herniahernia repairrepair hashas evolvedevolved asas newnew proceduresprocedures werewere developeddeveloped toto improveimprove thethe outcome.outcome.

„ MostMost notablynotably inguinalinguinal herniahernia repairsrepairs havehave evolvedevolved fromfrom tensiontension toto tensiontension freefree repairsrepairs „ Facilitated by an increased understanding of the anatomy of the region. AnatomyAnatomy

““ TheThe anatomyanatomy ofof thethe inguinalinguinal regionregion isis misunderstoodmisunderstood byby surgeonssurgeons atat allall levelslevels ofof seniorityseniority”” AnatomyAnatomy

AnatomyAnatomy ofof thethe InguinalInguinal CanalCanal

•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 transversus abdominis muscle (conjoint tendon). „ Inguinal ligament (Poupart’s ligament): This is the condensed lower portion of the external oblique fascia and extends from the anterior superior iliac spine to the pubic tubercle. Its medial third has a free edge, whereas the lateral two thirds are attached to the iliopsoas fascia.

„ Pectineal ligament (Cooper’s ligament): This is a strong ligament attached to the pubic ramus and formed jointly from the aponeurosis of the internal oblique, transversus abdominis, and pectineus muscles.

„ Iliopubic tract (Thompson’s ligament): This is the condensed part of the transversalis fascia and extends from the pectineal ligament medially, forms the inferior border of the internal ring and the anterior wall of the femoral sheath, and attaches laterally to the iliopectineal arch (medial thickening of iliopsoas fascia). ContentsContents ofof thethe InguinalInguinal CanalCanal „ Male „ Spermatic cord „ Female „ Ilioinguinal, genital branch of the Ilioinguinal, genital branch of the „ Round ligament of the uterus genitofemoral nerve, sympathetic „ Ilioinguinal nerve nerves „ Genital branch of the genitofemoral „ three arteries nerve „ are the spermatic artery from the aorta, „ the artery to the vas deferens from the superior vesicle, „ cremasteric artery from the deep epigastric artery. „ the vas deferens „ the pampiniform venous plexus „ the lymphatic channels „ The cord has three coverings „ the outer external spermatic fascia,- the external oblique fascia „ the middle cremasteric muscle layer,-internal oblique muscle „ the inner internal spermatic fascia—and transversus fascia, HistoryHistory 18711871 –– MarcyMarcy closedclosed thethe inguinalinguinal ringring andand tranversalistranversalis fasciafascia „ LucasLucas--ChampionniereChampionniere MethodMethod AA decadedecade followingfollowing Marcy,Marcy, thethe LucasLucas--ChampionnierChampionnier methodmethod involvedinvolved slittingslitting thethe externalexternal obliqueoblique aponeurosisaponeurosis toto exposeexpose thethe inguinalinguinal canalcanal and,and, underunder directdirect vision,vision, dissectingdissecting andand ligatingligating thethe herniahernia sacsac BassiniBassini

„ FatherFather ofof thethe modernmodern herniorrhaphyherniorrhaphy „ AA successfulsuccessful repairrepair dependeddepended onon thethe reconstructionreconstruction ofof underlyingunderlying abdominalabdominal wall.wall. „ ThusThus thethe firstfirst toto dissectdissect andand reconstructreconstruct thethe inguinalinguinal canalcanal toto restorerestore thethe functionalfunctional anatomyanatomy „ HeHe repairedrepaired thethe transversalistransversalis fasciafascia usingusing aa 33 layeredlayered techniquetechnique „ StressedStressed thethe importanceimportance ofof openingopening thethe externalexternal ringring andand dissectingdissecting thethe creamstericcreamsteric fibersfibers HalsteadHalstead

„ AddedAdded aa fourthfourth layerlayer toto thethe repairrepair byby reapproximatingreapproximating thethe externalexternal obliqueoblique toto thethe shelvingshelving edgeedge ofof thethe inguinalinguinal ligament.ligament. McMc VayVay

„ SurgeonSurgeon andand anatomistanatomist „ ObservedObserved thatthat thethe transversustransversus abdominusabdominus musclesmuscles andand thethe transversalistransversalis fasciafascia insertinsert intointo thethe CooperCooper ligamentligament „ AppliedApplied thethe stitchesstitches toto thethe CooperCooper ligamentligament „ RequiredRequired relaxingrelaxing incisionsincisions intointo thethe ligamentligament „ PtPt hadhad aa slowslow recoveryrecovery timetime ShouldiceShouldice „ 19451945 –– multilayeredmultilayered repairrepair imbricatingimbricating thethe fullfull thicknessthickness ofof thethe transversalistransversalis fasciafascia toto thethe inguinalinguinal ligamentligament „ Imbricating the full thickness of the transversus arch – fascia, muscle and internal oblique- to the inguinal ligament „ Then adding an overlying double layer of transversus and internal oblique aponeurosis to the undersurface of the the external oblique aponeurosis „ “Vest over pants” „ An unusual feature of the procedure is the routine sacrifice of the lateral cremasteric bundle, a structure that contains the external spermatic vessels and the genital branch of the genitofermoral nerve. „ Shouldice surgeons have not reported any ill effects related to this step. The minor sensation loss that results from dividing that nerve has not proven to be a substantial or longstanding disability. „ Pt Discharge – 48 – 72 hours post operative Progress?Progress?

„ RecurrenceRecurrence ratesrates 1010--15%15% withwith BassiniBassini,, HalsteadHalstead andand McVayMcVay toto 11--2%2% withwith ShouldiceShouldice repairsrepairs

HoweverHowever

„ TheseThese werewere allall consideredconsidered tensiontension repairsrepairs andand resultedresulted inin postoperativepostoperative painpain andand extensiveextensive patientpatient disability.disability. FruchardFruchard „ 1950’s : introduced a better understanding of the anatomy of the abdominal wall in the groin. „ Need to protect the anatomic defect - femoral triangles – in order to have a successful repair „ Rives and Stoppa developed the posterior preperitoneal approach to hernia repairs TensionTension FreeFree !! „ InIn 19581958 –– UsherUsher et.et. al.al. describeddescribed aa herniahernia repairrepair usingusing MarlexMarlex mesh.mesh. „ The mesh was sutured to the undersurface of the the medial margin of the defect and to the shelving edge of the inguinal ligament „ Tails created from the mesh encircled the spermatic cord and were sutured to the inguinal ligament „ StoppaStoppa andand laterlater NyhusNyhus usedused aa posteriorposterior approachapproach „ The mesh was placed between the transversalis fascia and the peritoneum. LichtensteinLichtenstein

„ PopularizedPopularized thethe useuse meshmesh coiningcoining thethe termterm ““tensiontension freefree repairrepair”” „ UsesUses nonnon absorbableabsorbable suturessutures andand aa prostheticprosthetic flatflat meshmesh toto reinforcereinforce thethe canalcanal floorfloor „ DoDo notnot needneed generalgeneral anesthesiaanesthesia andand cancan bebe performedperformed onon anan outpatientoutpatient basisbasis „ ButBut :: nono posteriorposterior supportsupport andand nono protectionprotection ofof thethe femoralfemoral canalcanal GilbertGilbert

„ WantedWanted toto reducereduce thethe chancechance ofof injuringinjuring thethe nervesnerves andand thethe spermaticspermatic cord.cord. HisHis goalgoal waswas toto directdirect hishis repairrepair toto thethe herniahernia sacsac andand thethe defectdefect inin thethe atat thethe internalinternal ring.ring. „ DescribedDescribed aa suturelesssutureless repairrepair wherewhere hehe usedused aa selfself mademade conecone shapedshaped piecepiece ofof meshmesh toto repairrepair indirectindirect hernias.hernias. „ Rutkow and Robbins „ Used it to repair both direct and indirect hernias „ Started as an umbrella plug held together by a suture „ Led to the development of the PerFix plug (C.R.Bard) „ Patch and Plug system: an onlay patch, which can be used with or without sutures, is placed over the posterior wall and around the spermatic cord lateral to the internal ring. „ The patch is there to strengthen the direct space „ GilbertGilbert –– 19901990’’ss „ Then used the inguinal ring to access the preperitoneal space through an open anterior approach „ Led to the development of the Prolene Hernia System (PHS – Ethicon) „ 3 in 1 system consisting of an underlay patch, an overlay patch and an interconnecting ring „ TheThe underlayunderlay meshmesh isis placedplaced viavia thethe inguinalinguinal ringring inin thethe preperitonealpreperitoneal spacespace andand isis notnot sutured.sutured. „ TheThe overlayoverlay meshmesh isis suturedsutured „ TheThe interconnectorinterconnector reducesreduces thethe likelihoodlikelihood ofof meshmesh migrationmigration „ ReducedReduced ratesrates ofof recurrencerecurrence !! „ because of coverage of the lateral triangle of the groin where recurrence can occur at the point between the mesh and the weaker adjacent tissue Complications?Complications? Complications of inguinal hernia repair

Operative Early Later Incision Bruising, hematoma Infection Chronic sepsis & sinus formation Scrotum Genital edema orchitis/atrophy Technique

open: Nerve injuries and Hydrocele recurrence and injury to vas pain Laparo- As above and Vascular Hydrocele seroma port site scopic: injuries, Visceral hernias injuries recurrence pain Systemic General/local Chest infection anesthesia Urinary retention Venous thrombosis BM Stephenson, Surg Clin N Am 83 (2003) 1255-1278 ComplicationsComplications „ RecurrenceRecurrence „ 1010--15%15% toto 1.51.5 %% atat thethe ShouldiceShouldice clinicclinic „ 1%1% withwith meshmesh reparisreparis „ InfectionInfection „ MeshMesh removalremoval

CR Voyles Surg Clin N am 83 (2003) 1279 - 1287 WoundWound infection?infection?

„ TheThe possibilitypossibility ofof woundwound infectionsinfections waswas aa concernconcern becausebecause thethe introductionintroduction ofof aa foreignforeign bodybody intointo aa cleanclean case.case. „ ShouldiceShouldice clinicclinic –– 11--2%2% „ 33--9%9% reportedreported byby BaileyBailey etet alal-- hospitalhospital vsvs communitycommunity surveillancesurveillance „ UsualUsual culpritsculprits –– StaphylococcusStaphylococcus aureusaureus andand epidermidisepidermidis.. „ ProphylacticProphylactic antibioticsantibiotics ProphylacticProphylactic AntibioticsAntibiotics

Table 3. Studies addressing the problem of wound infection and the routine use of antibiotics in open hernia repair with mesh n Infection (%) Conclusions Hernia specialists: Lichtenstein 10000 0 No comment Kurzer et al 2906 1.3 Not necessary Shulman et al 3019 0.5 Not necessary Robbins & Rutkow 1563 0.4 Not necessary Gilbert 1044 0.9 Not necessary Nonspecialists: Gilbert & Felton 1834 0.8 Not necessary Shulman et al 16,068 0.6 Not necessary Prospective randomized studies: Lazorthes et al 153 vs 155 4.6 vs 0.0 Mandatory Taylor et al 280 vs 283 8.9 vs 8.8 Not necessary Yerdel et al 133 vs 136 9.0 vs 0.7 Mandatory ManagementManagement ofof woundwound infectioninfection

„ Worse complication is infection of the mesh „ Care has to be taken with superficial wound infections not to expose the underlying mesh even if the wound needs to be opened for drainage „ With a true mesh infection the mesh can be seen floating in a pool of pus and surrounded by a thick fibrous capsule. „ Presents at around 4 months post op with groin sepsis „ Mann et.al of Scotland suggested that the incidence is probably 1 in 1000 and Yerdel reports an incidence of 1% of meshes requiring removal „ But there is little literature describing this to be a huge problem and mesh is used in cases with increased chances for infection such as strangulated bowel and the repair of parastomal hernias ChronicChronic groingroin painpain „ AccordingAccording toto somesome populationpopulation basedbased studiesstudies 1/31/3 ofof patientspatients complaincomplain ofof painpain 1212 monthsmonths oror moremore afterafter thethe repair.repair. „ NeuralgicNeuralgic inguinodyniainguinodynia „ Hyperesthesia along the dermatome „ Exquisite pain at the site of the a neuroma or trapped nerve - patients describe a pain like an electric shock „ Careful technique preserving the ilioinguinal and iliohypogastric nerve „ particularly when closing the aponeurosis of the the external oblique in the creation of the new external ring. Treatment – rexploration with division of the three groin nerves. LaparoscopicLaparoscopic repairrepair „ DescribedDescribed initiallyinitially byby Ger,Ger, ShultzShultz etet al,al, CorbittCorbitt andand FilipiFilipi etet alal „ PlacingPlacing aa piecepiece aa meshmesh inin thethe preperitonealpreperitoneal spacespace „ EitherEither extraperitonealextraperitoneal oror transabdominaltransabdominal approachapproach withwith oror withoutwithout tackingtacking suturessutures ComplicationsComplications

„ LaparoscopicLaparoscopic repairrepair –– „ SmallSmall bowelbowel obstructionobstruction „ InjuryInjury toto thethe epigastricepigastric vesselsvessels oror obturatorobturator artery,artery, „ InternalInternal hernia,hernia, „ BladderBladder oror visceralvisceral perforation,perforation, „ InfarctedInfarcted omentumomentum „ PortPort sitesite herniahernia „ HigherHigher recurrencerecurrence ratesrates LaparoscopicLaparoscopic RepairRepair

„ Advantages:Advantages: „ LessLess postpost--opop pain,pain, „ EarlierEarlier returnreturn toto workwork „ 14 vs 21 days „ ButBut :: „ HighHigh costcost „ SteepSteep learninglearning curvecurve „ MoreMore seriousserious possiblepossible complicationscomplications „ GeneralGeneral anesthesiaanesthesia LaparoscopicLaparoscopic

„ LedLed toto anan increasedincreased adoptionadoption ofof thethe openopen preperitonealpreperitoneal approachapproach „ PreperitonealPreperitoneal vsvs LHRLHR „ ReturnReturn toto workwork „ 10.310.3 daysdays vsvs 12.612.6 daysdays –– notnot statisticallystatistically significantsignificant „ LessLess complicationscomplications

CR Voyles Surg Clin N am 83 (2003) 1279 - 1287