بسم الله الرحمن الرحيم

TREATMENT OF INGUINAL HERNIA BY DR IBRAHIM GALAL PROFESSOR OF GENERAL SURGERY CAIRO UNIVERSITY

EUROPEAN HERNIA SOCIETY GUIDELINES SEPTEMBER,2009 THE WORLD JOURNAL OF HERNIA AND ABDOMINAL WALL SURGERY

GUIDELINES INDICATIONS. INVESTIGATIONS. RISK FACTORS. TYPE OF REPAIR. APPROACH. MESH TYPE, TECHNIQUE, SIZE. ANAESTHESIA. ANTIBIOTICS.

INDICATIONS ASYMPTOMATIC INGUINAL HERNIA: WATCHFUL WAITING. (Grade A)

INDICATIONS ASYMPTOMATIC INGUINAL HERNIA: WATCHFUL WAITING.( Grade A) ELECTIVE SURGERY. (Grade D)

INDICATIONS ASYMPTOMATIC INGUINAL HERNIA: WATCHFUL WAITING. (Grade A) ELECTIVE SURGERY. (Grade D) STRANGULATED HERNIA: URGENT SURGERY. (Grade D)

INVESTIGATIONS CLINICALLY EVIDENT CASE: NOT NEEDED. (Grade C)

INVESTIGATIONS CLINICALLY EVIDENT CASE: NOT NEEDED. (Grade C) OBSCURE CASE (GROIN PAIN/LUMP): -US.(30%) -HERNIOGRAPHY. (80%) -MRI & CT.(90%) (Grade C)

INVESTIGATIONS CLINICALLY EVIDENT CASE: NOT NEEDED. (Grade C) OBSCURE CASE (GROIN PAIN/LUMP): -US.(30%) -HERNIOGRAPHY. (80%) -MRI & CT.(90%)(Grade C) DIFFERENTIATION BETWEEN DIRECT& OBLIQUE: -NOT USEFUL. (Grade C)

RISK FACTORS SMOKING, POSITIVE FAMILY HISTORY, PATENT PROCESSES VAGINALIS, COLLAGEN DISEASE, AFTER LONG-TERM HEAVY WORK ,ABDOMINAL AORTIC ANEURYSM , APPENDICECTOMY , ASCITES, PERITONEAL DIALYSIS, COPD, CONSTIPATION AND PROSTATISM. SMOKING CESSATION IS THE ONLY SENSIBLE ADVICE THAT CAN BE GIVEN WITH RESPECT TO PREVENTING THE DEVELOPMENT OF AN INGUINAL HERNIA. (GRADE C)

TYPE OF REPAIR MESH REPAIR (TENSION FREE): SHOULD BE USED IN ALL CASES EXCEPT IN THE PRESENCE OF INFECTION.(Grade A)

TYPE OF REPAIR MESH REPAIR (TENSION FREE): SHOULD BE USED IN ALL CASES EXCEPT IN THE PRESENCE OF INFECTION.(Grade A) NON MESH REPAIR (SHOULDICE TECHNIQUE): SHOULD BE USED ONLY IF THERE IS RISK OF INFECTION. (Grade A)

APPROACH OPEN AS WELL AS LAPAROSCOPIC APPROACH ARE EQUALLY EFFECTIVE IN UNILATERAL PRIMARY HERNIA. (Grade A) LAPAROSCOPIC APPROACH IS SUPERIOR IN MULTIPLE HERNIAS ,IN FEMALES & IN ACTIVE PERSONS. (Grade A) OPEN APPROACH (LICHTENSTEIN TECHNIQUE) IS SUPERIOR IN LARGE HERNIA , IRREDUCIBLE HERNIA & IS MORE COST EFFECTIVE. (Grade A)

APPROACH TO RECURRENT HERNIA RECURRENCE AFTER ANTERIOR APPROACH(OPEN REPAIR) : POSTERIOR APPROACH (LAPAROSCOPIC OR OPEN PREPERITONEAL REPAIR). (Grade A) RECURRENCE AFTER POSTERIOR APPROACH: ANTERIOR APPROACH.(Grade A)

LAPAROSCOPIC APPROACH TEP IS SUPERIOR TO TAPP REGARDING VISCERAL INJURY PORT SITE HERNIA & POSTOPERATIVE PAIN ,BUT THE LEARNING CURVE IS LONGER. (Grade B)

MESH TYPE THE USE OF LIGHTWEIGHT/LARGE-PORE (>1000 MICRON) MESHES CAN DECREASE LONG TERM DISCOMFORT BUT POSSIBLY AT THE COST OF INCREASED RECURRENCE RATE.(GRADE A)

MESH TECHNIQUE EXCEPT FOR THE LICHTENSTEIN AND LAPAROSCOPIC TECHNIQUES (GRADE B), NONE OF THE ALTERNATIVE MESH TECHNIQUES (EHS,PLUG,PATCH,) HAVE RECEIVED SUFFICIENT SCIENTIFIC EVALUATION TO BE GIVEN A PLACE IN THESE GUIDELINES.

MESH SIZE IN LAPAROSCOPIC UNILATERAL HERNIA REPAIR,THE IDEAL MESH SIZE SHOULD BE 10 × 15 cm. (GRADE D)

ANAESTHESIA IN OPEN REPAIR, LOCAL ANAESTHESIA IS CONSIDERED FOR ALL ADULT PATIENTS WITH A PRIMARY REDUCIBLE UNILATERAL INGUINAL HERNIA. (GRADE A) GENERAL ANAESTHESIA WITH SHORT-ACTING AGENTS COMBINED WITH LOCAL INFILTRATION ANAESTHESIA MAY BE A VALID ALTERNATIVE TO LOCAL ANAESTHESIA. (GRADE B)

ANTIBIOTICS THERE IS NO INDICATION FOR THE ROUTINE USE OF ANTIBIOTIC PROPHYLAXIS IN ELECTIVE OPEN GROIN HERNIA REPAIR IN LOW RISK PATIENTS.( GRADE A) IN LAPAROSCOPIC HERNIA REPAIR, ANTIBIOTIC PROPHYLAXIS IS PROBABLY NOT INDICATED.(GRADE B)

Thank You