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