Symposium

Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias

Pradeep K Chowbey, Rajesh Khullar, Magan Mehrotra, Anil Sharma, Vandana Soni, Manish Baijal Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi - 110 060, India

Address for correspondence: Pradeep K. Chowbey, Minimal Access and Bariatric Surgery Centre, Room No. 200 (2nd floor), Sir Ganga Ram Hospital, New Delhi - 110 060, India. E-mail: [email protected]

Abstract of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and Background: Numerous classifications for groin is a final classification that predicts the expected level and ventral hernias have been proposed over the of difficulty for an endoscopic hernia repair. past five to six decades. The old, simple classification of groin hernia in to direct, inguinal Key words: Total extraperitoneal repair, SGRH classification, and femoral components is no longer adequate to laparoscopic ventral hernia repair understand the complex pathophysiology and management of these hernias.The most commonly followed classification for ventral hernias divide CLASSIFICATION SYSTEMS FOR GROIN HERNIA them into congenital, acquired, incisional and traumatic, which also does not convey any Numerous classifications for groin hernia have been information regarding the predicted level of difficulty. proposed over the past five to six decades. The old Aim: All the previous classification systems were based on open hernia repairs and have their own simple classification of groin hernia into indirect and fallacies particularly for uncommon hernias that direct, inguinal and femoral components is no longer cannot be classified in these systems. With the adequate to understand the complex advent of laparoscopic/ endoscopic approach, pathophysiology and management of these hernias.[1] surgical access to the hernia as well as the In the 1950s and 1960s, many surgical classifications functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional for groin hernias were conceived, such as those by anatomy opened the doors for newer classifications. Casten,[2] Fruchaud,[3] Harkins[4] and Halverson et al.[5] The authors have thus proposed a classification However, they have little applicability in the current system based on the expected level of surgical practice for hernia. In 1988, Gilbert[6] described intraoperative difficulty for endoscopic hernia repair. a detailed classification based on anatomical and Classification: In the proposed classification higher grades signify increasing levels of expected functional defects established intraoperatively and intraoperative difficulty. This functional created a registry named ‘Cooperative Hernia Analysis classification grades groin hernias according to the: of Types and Surgeries’ (CHATS). In 1991, Nyhus et al[7] a) Pre -operative predictive level of difficulty of introduced a classification system based on anatomical endoscopic surgery, and b) Intraoperative factors criteria with emphasis on the state of the deep ring and that lead to a difficult repair. Pre operative factors [8] include multiple or pantaloon hernias, recurrent posterior wall of the inguinal canal. In 1993, Bendavid hernias, irreducible and incarcerated hernias. proposed the type, staging and dimension system for Intraoperative factors include reducibility at classification of hernias. All these classification systems operation, degree of descent of the hernial sac and based on open hernia repair techniques have their own previous hernia repairs. Hernial defects greater than shortcomings, particularly noninclusion of uncommon 7 cm in diameter are categorized one grade higher. hernias that cannot be classified. Conclusion: Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification Though there have been several classification systems

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106 CMYK Chowbey et al.: Classification of groin and ventral abdominal wall hernias for groin or inguinal hernias, none have been floor (Hesselbach’s triangle) described for total classification of all ventral hernias � Endoscopically - minimal dissection of sac from of the abdomen.[9] The most commonly followed fascia transversalis is required classification system for ventral hernias divides them into (i) congenital hernias - present at birth, which Grade II include omphalocele, gastroschisis and umbilical � Small, indirect, incomplete, reducible hernia hernia; (ii) acquired - including hernias in the midline, � Hernial swelling limited to inguinal canal median and paramedian areas, such as Spigelian, � Endoscopically - the sac can be reduced epigastric and paraumbilical hernias; (iii) incisional completely and may not require transection or hernias; and (iv) traumatic hernias - following ligation penetrating and blunt trauma. � Moderate-size direct hernia

� Swelling is present in standing and reduces in SGRH CLASSIFICATION the supine position

� Thumb-sized defect in the direct floor

With the advent of laparoscopic / endoscopic surgery, � Endoscopically, the sac needs to be dissected off surgical access to the hernia as well as the functional from the fascia transversalis anatomy viewed by the surgeon changed. The change � Reducible femoral hernia in the surgical approach and functional anatomy opened the doors for newer classifications. The Grade III authors have proposed a classification system based � Moderate-size indirect, reducible inguinal hernia on the expected level of intraoperative difficulty for � Hernial swelling (sac) extends beyond superficial endoscopic hernia repair. In the proposed ring, up to the neck of scrotum but does not classification, higher grades signify increasing levels descend to the testis of expected intraoperative difficulty. A hernial defect � Endoscopically - this type of hernia will require >7 cm in diameter is categorized one grade higher. transection of sac and ligation of the proximal CLASSIFICATION OF INGUINAL HERNIA FOR TEP part of sac REPAIR � Large reducible direct hernia � Involvement of the entire direct floor This functional classification grades groin hernias � Big bulge on clinical examination over the triangle according to the preoperative predictive level of of Hesselbach difficulty of endoscopic surgery. For multiple or � Endoscopically, creation of space in the midline pantaloon (direct and indirect components) hernias, is difficult. There is anatomical distortion ­ grading is according to the dominant hernia. Bowel stretching and lateral displacement of inferior obstruction and strangulation are unsuitable for the epigastric vessel total extraperitoneal (TEP) approach. Intraoperatively, � Recurrent groin hernia the factors considered as predictors of the grade of � Endoscopically - difficult dissection in region of difficulty include: spermatic cord and the space lateral to it

� Reducibility

� Degree of descent of the hernial sac Grade IV

� Previous hernia repair � Large reducible indirect inguino-scrotal hernia

� Large sac extending up to the testis. The testis Grade I cannot be palpated separately from hernia in erect � Small, direct, reducible hernia position

� Swelling appears on coughing / straining and � The sac may contain omentum or small bowel, disappears on lying down which require manual reduction in supine position

� Fingerbreadth size defect in the functional direct � Endoscopically - the internal ring is enlarged with

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CMYK107 Chowbey et al.: Classification of groin and ventral abdominal wall hernias

a wide-mouthed sac. There is difficulty in sites such as Pfannensteil, subcostal incision or dissecting sac from cord structures. Medial extended sternotomy incisions displacement and stretching of the inferior epigastric vessels may occur. Inadvertent opening Grade IV

of peritoneum may lead to pneumoperitoneum � Primary hernia containing bowel, which is and dissection of sac becomes difficult partially reducible or irreducible

� There is higher incidence of postoperative seroma � More planning in port placement and mesh / hematoma because of traction on sac fixation is required

� The chances of damage to the cord structures are � Lumbar hernia

increased � Colon needs to be reflected

Grade V Grade V

� Large, complete, indirect inguinal hernia, which � Incisional hernia containing bowel - partially is only partially reducible or irreducible reducible or irreducible

� Irreducible femoral hernia � All margins of defect cannot be clearly felt

� The sliding component includes the bowel or � Patients will have symptoms of colic or subacute bladder intestinal obstruction (SAIO) on history and on

� Endoscopically - the sac is bulky. There are clinical examination (palpation / auscultation) will adhesions between contents of the sac and sac reveal presence of bowel in hernial sac wall. The sac often needs to be opened and the contents reduced laparoscopically. Injury to the Grade VI

contents (bowel, bladder and omentum) while � Multiple scarred abdomen

reducing them is likely � Multiple previous incisions

� Previous hernia repair (recurrent incisional hernia)

Notes � Presenting as acute obstruction

� For multiple / pantaloon hernias, ‘difficulty’ grading is according to the dominant hernia. Note

� Bowel obstruction / strangulation are unsuitable Patient having colicky intestinal pain or symptoms for TEP approach. of SAIO are considered in Grade IV at least. Clinically, on examination bowel loop may give gurgling CLASSIFICATION OF VENTRAL HERNIA sensation and reduce partially on palpation. This can be distinguished from omentum on palpation and Grade I auscultation. � Primary, small, completely reducible ventral hernia REFERENCES � The location may be umbilical / paraumbilical / epigastric / supravesical / spigelian 1. Rutkow IM, Robbins AW. Classification systems and groin hernias. Surg Clin North Am 1998;78:1117-27. 2. Casten DF. Functional anatomy of the groin area as related to the Grade II classification and treatment of groin hernias. Am J Surg � Completely reducible incisional hernia 1967;114:894-9. 3. Fruchaud H. Anatomic chirurgicale des hernias de l’aine. G Doin: � The margins of defect should be clearly palpable Paris; 1956. 4. Nyhus LM, Stevenson JK, Listerud MB, Harkins HN. Preperitoneal Grade III herniorrhaphy: A preliminary report in fifty patients. West J Surg Obstet Gynecol 1959;67:48-54. � Primary hernia - partially reducible or irreducible 5. Halverson K, McVay CB. Inguinal and femoral hernioplasty. Arch � Contents - omentum only Surg 1970;101:127-35. � Reducible incisional hernia at special operative 6. Gilbert AI. An anatomic and functional classification for the

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diagnosis and treatment of inguinal hernia. Am J Surg hernia. 5th ed. Lippincott Williams and Wilkins: Philadelphia; 1989;157:331-3. 2002. p. 71-9. 7. Nyhus LM, Klein MS, Rogers FB. Inguinal hernia. Curr Prob Surg 1991;28:417-36. 8. Rutkow IM, Robbins AW. Classification of groin hernias. In: Cite this article as: Chowbey PK, Khullar R, Mehrotra M, Sharma A, Soni V, Bendavid R (editor). Prosthesis and abdominal wall hernias. RG Baijal M. Sir Ganga Ram Hospital classification of groin and ventral abdominal Landes: Austin; 1994. p. 106. wall hernias. J Min Access Surg 2006;3:106-9. 9. Zollinger RM. Classification of ventral and groin hernias. In: Source of Support: Nil, Conflict of Interest: None declared. Fitzgibbons RJ, Greenburg AG (editors). Nyhus and Condon’s

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