1. Now What Do I Do? Tough Situations in Inguinal Hernia Repair & How to Avoid or Manage Them

2. Avoid tough situations in inguinal hernia surgery by tailoring the operation. It’s clearly not one size fits all. There are now many technique and material options that should be carefully selected to optimize outcomes.

3. Avoid and Manage Tough Situations Dr. Heniford: which operation ? Dr. Sarr: Sport’s Hernia Dr. Lee: Inguinodynia

4. Avoid and Manage Recurrence If anterior, go posterior European studies show this is happening only 10% of the time Lap or open Consider Stoppa (GPRVS) –Bilaterals too If posterior, go anterior Wide-on-lays; biologicals Lower quadrant component separation Bone anchors

5. Mesh Complications Infections unusual –Low thresh-hold for infected mesh explant Meshoma’s and Migrations –Parviz Amid –Organ erosion (bowel and bladder) –Iliac vessels –Shrinkage Can be the cause of chronic pain

6. Meshoma “Surgical treatment for these patients is explantation of the meshoma.”

7. Synthetic prostheses

8. Plug Colon

9. Mesh plug Colon

10. Plug, inflammation and pain

11. Recurrence after anterior repair

13. Avoid and Manage Pain Open hurts more than people say it does Pre-Op pain predicts Post-Op pain Tack pain post lap –Wait, wait, wait –Diagnose Use imaging –Inject –Wait some more –Enlist Pain Experts –Remove screws from Cooper’s ligament or Pain triangle with nerve transection

14. Evaluate for hernia recurrence --Physical Exam --Ultrasound Yes Surgical Repair No Neuropathic Pain (immediately post-op) Refer to Pain Clinic Neuroma Pain (occurs 3-4 weeks post-op) Surgical Intervention Nerve division/Mesh removal Evaluation of Groin Pain following Herniorrhaphy Notes: Neuropathic pain may respond to nerve blocks and may improve over time. Neuroma pain may remain ongoing, therefore, surgical intervention is performed if the pain is debilitating or lasts for 5 years, due to complications of the surgery.

15. Biological disease –AAA –Ehlers-Danlos Family Hx –Immunosuppressed TEPPA –Wide mesh coverage »Hydrophilic »LW, large pore –No Wound –Increase the fixation Manage or Avoid Abnormal Wound Healing

16. Send him to Rosen…

20. Laparoscopic Hernia Repair Anatomy: Triangle of Doom Avoid it! Follow inferior epigastrics Identify Cooper’s ligament Don’t confuse vas for iliac artery Close branches to iliac vein will bleed too Not an intern case! Lap IH Clip 03.mpg

21. Inguinal Hernias Loss of Domain

22. Giant Inguinal Hernia Loss of domain Plan for ventilator support –Pre-op PFTs Consider laparotomy –Temporary open abdomen VAC –Component separation

23. Avoid tough situations in inguinal hernia surgery by tailoring the operation. Know all the technical options –Lap vs Open –Caveat: The best operation for your patient is the one you do best… –Short and long-term plans for pain management There is a role for neurectomy Know the advantages and disadvantages of all the mesh materials –Polymer type –Mesh shape –Mesh position