1. بسم الله الرحمن الرحيم

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

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

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

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

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

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

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

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

10. 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)

11. 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)

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

13. 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)

14. 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)

15. 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)

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

17. 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)

18. 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.

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

20. 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)

21. 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)

22. Thank You