Hernia Abdominal Wall Defect Potential for bowel obstruction Congenital or acquired Potential for bowel obstruction Incarceration Strangulation May suggest underlying pathology Hepatic disease, BPH, COPD, obstructing colon mass

Pertinent History Duration/onset Symptoms Prior Incarceration Local Obstructive Nausea, emesis, pain, distension, obstipation Prior Incarceration Related comorbidity Pulmonary, Constipation, Ascites Operative risk

Pertinent Exam Location Reducible? Tender? Skin changes? Palpable edges, Size? Genitalia Rectal

Common Hernias Umbilical Ventral Incisional Inguinal Direct, indirect, femoral, obtuator

Bassini repair

Lichtenstein(Amid) hernia repair Nerves and vessels identified Lichtenstein(Amid) hernia repair Dome

Posterior view of the groin “myopectineal orifice” H. Fruchaud (1956)

Nomenclature in inguinal hernia repairs in adults Shouldice= 3 layer tissue repair Bassini repair- term often incorrectly used, specify details! McVay-Lotheissen= use of suprapubic ligament “Open mesh repair”- specify! Lichtenstein= anterior open repair with mesh onlay Mesh plug- with or without onlay (Rutkow) Special designs- (Gilbert, Kugel) TEP = lap. preperitoneal hernioplasty TAPP= lap. Transabd. preperitoneal hernioplasty Stoppa repair= Open wrapping of peritoneal sac with mesh, midline approach

onlay – inlay - underlay

Laparoscopic Ventral Hernia

Tension free? More than a fad! Reduces pain Reduces recurrences Reduces overall costs

Umbilical Hernia Congenital Most close by age 3 May remain small and asymptomatic Can increase with obesity, pregnancy, ascites, peritoneal dialysis Typical umbilicus

Hernia outcome assessment Past: recurrence, complications, procedure cost Future: acute pain, chronic pain, convalescence time ..chronic herniorraphy pain represents a scientific challenge because the pathogenesis, diagnostic criteria, and therapeutic interventions all have been incompletely evaluated.. H. Kehlet, Hernia, 2002