1. JIs Guzman, Montefalcon, Sulit
SURGERY CASE
JIs Guzman, Montefalcon, Sulit

2. Clinical Diagnosis Diagnosis Certainty Treatment
Indirect Inguinal Hernia
90%
Surgical
Direct Inguinal Hernia
10%

3. Clinical Diagnosis Do I need a paraclinical diagnostic procedure?
Generally, patient who present with typical symptoms and signs of groin hernia do not require further imaging for confirmation. The diagnosis is clinical. Chiow, et al. Inguinal Hernias: a current review of an old problem. Proceedings of Singapore Healthcare (3):
The sensitivity of clinical diagnosis of inguinal hernia is 75-95% and the specificity of clinical diagnosis of inguinal hernias is 64-96% (Toms, et al., 2011)

4. Clinical Diagnosis
Do I need a paraclinical diagnostic procedure?
No.

5. Clinical Diagnosis Diagnosis Certainty Treatment
Indirect Inguinal Hernia
90%
Surgical
Direct Inguinal Hernia
10%

6. Treatment Goal High ligation of sac Prevention of recurrence
Prevention of complications

7. Treatment Options Treatment Benefit Risk Cost Availability
Open hernioplasty (Lichtenstein)
Easy to perform
Low rate of complications
% recurrence rate
Graft rejection +
P5,000 to P8,000
Available
Open Herniorrhapy (Shouldice)
Anatomic repair of the floor
6% recurrence rate
P5,000
Laparoscopic Hernia Repair
Better cosmetic result
Less superficial infection
Easy return to activities
2.4% recurrence rate
Increase in perioperative complication ++
P15,000 to P20,000

8. Preoperative Preparation
Informed consent secured
Psychosocial preparation
Screening for medical problem
Optimizing physical condition
Preparing OR needs

9. Admission On the 1st hospital day DAT then NPO post midnight
IVF: D5LRS 1L to run at 125 cc/hr
Therapeutics:
Ranitidine 50 mg TIV q8h while on NPO

10. Is antibiotic prophylaxis recommended in elective groin hernia surgery?
Antibiotic prophylaxis is NOT recommended in elective groin hernia surgery (Grade D recommendation). For hernia repair using mesh, antibiotic therapy is also NOT recommended (Grade C recommendation). (Cabaluna & Bongala, 2010)

11. Operative Technique Patient supine under SAB Asepsis- Antisepsis
Sterile drapes placed
Transverse incision done on the skin between the anterior superior iliac spine and pubic tubercle and  carried  down to the subcutaneous tissue

12. Operative Technique Location of the external inguinal ring palpated
External Oblique aponeuroses identified, cut & opened up to the external inguinal ring
Placed a clamp on both leaves of the external oblique aponeurosis and identify the ilioinguinal nerve

13. Operative Technique Intra op findings noted
Spermatic cord separated from the underside of the external oblique aponeurosis by sharp and blunt dissection
Picked up the cremasteric muscle and incised it longitudinally
Gently shell the cord from its surrounding cremasteric muscle

14. Operative Technique Identify the vas deferens
Hernial sac identified and isolated
Reduced any content of the hernial sac
Hernial sac ligated using purse string suture ligation using silk-0
Prolene mesh, placed under spermatic cord, 3-4 cm larger than the defect

15. Operative Technique
Prolene mesh sutured with silk 2-0 with the use of interrupted mattress around the perimeter of the defect, penetrating the anterior rectus sheath, rectus muscle, and transversalis fascia along medial aspect. Along the lateral margin of the defect, it was sutured to the Poupart’s ligament going from the pubic tubercle laterally to the region of femoral canal

16. Operative Technique Layer by Layer closure
Fascia closed by simple interrupted sutures using Vicryl-0
Subcutaneous  closed by Inverted T sutures using Chromic 2-0
Skin closed by simple interrupted sutures using silk 4-0
Dry sterile dressing applied
Patient tolerated the procedure well
Post-op condition- stable

17. Intraoperative Findings
Hernial sac located anteromedially
Internal ring measures 4cm with no incarcerated contents.

18. 3rd Hospital Day/ 1st post-operative day

19. Postoperative Care Adequate analgesia Proper wound care
Avoid strenuous activities for at least a month

20. DIDACTICS

21. Management Uncomplicated hernias require either: Complicated hernias:
No treatment
Support with a truss
Operative treatment
Complicated hernias:
Always require surgery, often urgently

22. Management
A number of effective operative therapies exist in the treatment of inguinal hernias. To attain and maintain consistent, successful
outcomes, the general surgeon must have a proficient understanding of groin anatomy and be mindful of surgical principles. The
application of prosthetics to effect a tension-free repair created an operation that was simple, effective, and reproducible across a range
of operative experience, and reduced recurrence rates to a much lower level. Further advances in hernia treatment were part of the
laparoscopic revolution, which has improved postoperative pain and shortened recovery time. Although laparoscopic repairs require more
extensive training and equipment than open repairs, significant benefits can be imparted to the patient. Despite the controversies
associated with laparoscopic inguinal hernia repair for primary unilateral inguinal hernias, the general surgeon must not only be
cognizant, but also able to perform a variety of inguinal hernia repairs. By having more than one approach in one's armamentarium, the
surgeon has the ability to choose the appropriate procedure for the problem at hand

23. Conservative Management
Aimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contents
For hernias that are not strangulated or incarcerated can be mechanically reduced
Assuming a recumbent position
Truss, an elastic belt or brief
The definitive treatment of all hernias is surgical repair.
A hernia defect will not decrease in size, but likely increase and possibly progress to incarceration or strangulation of the sac's contents.
Surgery can be delayed or avoided in situations where the patient's medical status prohibits operative treatment.
Conservative management is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents.
Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia. 4
A truss, an elastic belt or brief that aims to keep the hernia reduced, may also be worn; however, its use does not prevent hernia progression or incarceration. A truss may provide relief in up to 65% of patients; however, many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration

24. TRUSS

25. Emergent repair
Incarcerated hernias
Strangulated hernias

26. INCARCERATED HERNIA Reasons for incarceration
large amount of intestinal contents within the hernia sac
dense and chronic adhesions of hernia contents to the sac
small neck of the hernia defect in relation to the sac contents

27. INCARCERATED HERNIA
An incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency
However, once the patient demonstrates bowel obstruction secondary to incarceration or a sliding inguinal hernia, operative intervention becomes expedited. Patients will often present with vomiting, constipation, obstipation, a distended abdomen, or combination thereof

28. INCARCERATED HERNIA
Reduction should be attempted before definitive surgical intervention.

29. INCARCERATED HERNIA
Hernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.

30. STRANGULATED HERNIA Femoral > Indirect > Direct
Fever, leukocytosis, and hemodynamic instability.
The hernia bulge usually is very tender, warm, and may exhibit red discoloration.
Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressed
If the blood supply to incarcerated contents becomes compromised, an incarcerated hernia becomes a strangulated hernia.
These pose a significant risk to life because the strangulated contents are ischemic and may quickly lose viability.
Clinical signs that indicate strangulation include Fever, leukocytosis, and hemodynamic instability.

31. OPERATIVE TECHNIQUES

32. Surgery aims to Reduce the hernia contents
Excise the sac (herniotomy) in most cases
Repair and close the defect either by herniorrhapy or hernioplasty

33. Anterior repair non prosthetic

34. OPEN APPROACH
An oblique or horizontal incision is performed over the groin.
A point two fingerbreadths inferior and medial to the anterior superior iliac spine is chosen as the most lateral point of the incision
It is then progressed medially for approximately 6 to 8 cm

35. OPEN Approach
The iliohypogastric and ilioinguinal nerves are identified and retracted from the operative field by placing a hemostat beneath their course and then grasping one of the edges of the aponeurosis
Some surgeons obtain preoperative consent to cut the ilioinguinal nerve to avoid possible entrapment and post operative pain however, the patient may experience numbness of inner thigh or lateral scrotum which usually goes away in 6 months
With the contents of the inguinal canal completely encircled, identification of cord contents and the hernia sac can be effected
Direct hernias will become evident as the floor of the inguinal canal is dissected.
An indirect hernia sac will generally be found on the anterolateral surface of the spermatic cord.
In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identified to allow dissection of the sac from the cord
Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic position
small enough to contain the contents of the inguinal canal and prevent a future false-positive diagnosis of recurrent hernia
The new external ring should be small enough to contain the contents of the inguinal canal and prevent a future false-positivenot be tight and should allow entrance of a finger

36. Bassini Repair
Is frequently used for indirect inguinal hernias and small direct hernias
The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
inferior arch of transversalis fascia (TF) or conjoint tendon is approximated to shelving portion of inguinal ligament.

37. Mcvay repair inguinal and femoral canal defects
The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
 TF is sutured to cooper ligament
The advantage of the McVay (Cooper's ligament) repair is the ability to address both inguinal and femoral canal defects

38. Shouldice Repair  TF is incised and reapproximated
The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia and the internal oblique and transverse abdominis muscles.
This is the second of the four suture lines. After the stump of the cremaster muscle is picked up, the suture is reversed back toward the pubic tubercle approximating the internal oblique and transversus muscles to the inguinal ligament. Two more suture lines will eventually be created suturing the internal oblique and transversus muscles medially to an artificially created "pseudo" inguinal ligament developed from superficial fibers of the inferior flap of the external oblique aponeurosis parallel to the true ligament.

39. Anterior repair prosthetic

40. Lichtenstein Tension-Free Repair
The most commonly performed inguinal hernia repair today is the Lichtenstein repair. A flat mesh is placed on top of the defect
It is a "tension-free" repair that does not put tension on muscles
It involves the placement of a mesh to strengthen the inguinal region.
Patients typically go home within a few hours of surgery, often requiring no medication beyond Paracetamol.
Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation.

41. Lichtenstein Tension-Free Repair
Initial exposure and mobilization of cord structures is identical to other open approaches
A lateral view demonstrates that the prosthesis is situated between the cord and the hernia defect (HD). The hernia defect has been imbricated to allow for facile prosthesis placement only (this does not affect the strength of the repair).

42. MESH
PERMANENT MESH
Commercial meshes are typically made of prolene (polypropylene) or polyester.
Mosquito-net mesh-Meshes made of mosquito net clothes, in co-polymer of polyethylene and polypropylene have been used for low-income.
ABSORBABLE MESH
Biomeshes are increasingly popular since their first use in 1999.
They are absorbable and they can be used for repair in infected environment, like for an incarcerated hernia. Moreover, they seem to improve comfort.

43. LAPAROSCOPIC HERNIA REPAIR
Transabdominal Preperitoneal Procedure (TAPP)
Totally Extraperitoneal (TEP) Repair
Indications include bilateral inguinal hernia, recurring hernia, need for early recovery
When performed by a surgeon experienced in hernia repair, laparoscopic repair causes less complications than Lichtenstein, and especially half less chronic pain.

44. LAPAROSCOPIC HERNIA REPAIR

45. RECURRENCE Around 1% for Shouldice repair
Most recurrences are of the same type as the original hernia
Recurrence Factors
Patient
Technical
Tissue
Common causes of hernia recurrence postrepair include patient, technical, and tissue factors.
Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking.
Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon.
Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair.

46. RECURRENCE Patient factors Technical factors Tissue factors
malnutrition, immunosuppression, diabetes, steroid use, and smoking.
Technical factors
mesh size, prosthesis fixation, and technical proficiency of the surgeon.
Tissue factors
wound infection, tissue ischemia, and increased tension within the surgical repair
Common causes of hernia recurrence postrepair include patient, technical, and tissue factors.
Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking.
Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon.
Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair.

47. complications
The overall risk of complications of inguinal hernia repair is low.
Common Complications
Pain, injury to the spermatic cord and testes, wound infection, seroma, hematoma, bladder injury, osteitis pubis, and urinary retention