ABSITE Review - Department of Surgery

Transcription

www.downstatesurgery.org
ABSITE Review:
Inguinal and Femoral
Hernias
Sybile Val M.D.
SUNY Downstate Medical Center
Department of Surgery
June 27, 2008
Obj ti
Objectives
Correctly identify anatomical landmarks
intra-operatively
Differentiate
Diff
ti t between
b t
femoral
f
l and
d inguinal
i
i l
hernias
Understand different approaches at
surgical repair
Compare operative approaches

Q
Questions
ti
1.
From which muscle layer
y is the inguinal
g
ligament
g
derived?
a.
b.
c.
d.
2.
Transversus abdominus
External oblique
Internal oblique
None of the above
What are the borders of the femoral canal?
a.
b.
c.
d
d.
External oblique, femoral vein, empty space
external oblique, femoral vein, empty space iliopubic tract and
f
femoral
l vein
i
iliopubic, cooper’s, femoral vein and junction of iliopubic and
cooper’s ligament
None of the above
Q
Questions
ti
3
3.
A McVay repair
a.
b.
c.
d.
4
4.
May be used to repair femoral hernias
Entails suturing Poupart’s to the conjoined tendon
Is no longer performed
Does not require a relaxing incision
TAPP
a.
b.
c.
d.
Is contraindicated in the elderly
Requires traversing the peritoneal cavity
Is totally extraperitoneal
Has a low learning curve
Q
Questions
ti
5
5.
The base of Hasselbach’s triangle is
a.
b.
c.
d.
Derived from the external oblique
Cooper’s ligament
There is no base
The inferior epigastric
I t d ti
Introduction

In the US ~1 million abdominal wall hernia
p
y
repairs/year
750,000
– inguinal
25,000 - femoral
I t d ti
Introduction
From latin word meaning rupture
Definition: Abnormal protrusion

Occur
at sites where the aponeurosis and
fascia are not covered by striated muscle
Male preponderance (7:1)
Presentation:

Groin
bulge/pain
Right
g more common than left
I t d ti
Introduction

Risk Factors:
Age
Obesity
Ob it
COPD
Chronic
constipation
Straining
Pregnancy
Ascites
Peritoneal dialysis
I
Inguinal
i lH
Hernia
i

Indirect
Most
common type
Weakness in the
internal inguinal ring
Associated with patent
processus vaginalis
i li

Direct
Weakness
in the
transversalis fascia
Due to “wear and tear”
Abd i l W
Abdominal
Wallll A
Anatomy
t

Muscles

Nerves

External oblique
Internal oblique
Transversalis abdominus
Ilioinguinal
Genitofemoral
Blood supply

Superior epigastric
Inferior epigastric
Deep circumflex
Posterior intercostal
L b
Lumbar
G i Anatomy
Groin
A t
I
Inguinal
i lC
Canall

Allows passage b/w
abdomen and testes
Transmits ilioinguinal
nerve
Parallel to inguinal
ligament
Walls:

Anterior- external oblique
Posterior – transversalis
fascia
Inferior – inguinal ligament
Superior – int oblique &
trans abd
G i Anatomy
Groin
A t

Femoral Canal

Medial compartment
Blind pouch
Borders:

superiorly: iliopubic tract
inferiorly – cooper’s
ligament
laterally – femoral vein
medially
di ll – junction
j
ti off
iliopubic tract and cooper’s
ligament
O
Operative
ti R
Repair
i

Indicated for all symptomatic hernias
Based on surgeon’s experience
May be:
Via
anterior or posterior approach
Primary:
Pi

Preferred in presence of contamination
Best choice in female patients
p
Accomplished using: Bassini, McVay or Shouldice technique
O
Operative
ti R
Repair
i
Prosthetic
Mesh Repair technique:
Onlay versus preperitoneal
Mesh bridges inguinal defect
Foreign body reaction incited
Common strategy entails:

Minimal tissue dissection
Anchoring
g of mesh with interrupted
p
sutures

O
Operative
ti R
Repair
i
Laparoscopic
technique:
Based on reconstruction of weakened posterior
abdominal wall
Steep learning curve
Two approaches:

Totally extraperitoneal
Transabdominal preperitoneal
(Intraperitoneal Onlay Mesh)

Hi t i l R
Historical
Review
i

Edoardo Bassini (1844-1924)
Father

of modern hernia repair
Performed and published a novel anatomical
dissection (1884)
Repair
empasized:
High ligation
Reconstruction of the inguinal
g
floor
Opening the transversalis fascia

Preparation for deep repair in three layer repair
B
Bassini
i iR
Repair
i

Opening of inguinal
floor
Suture Poupart’s
ligament:

lateral border of
internal oblique or
conjoint tendon
Sh ldi R
Shouldice
Repair
i

Complete dissection
& reconstruction of
inguinal floor
Imbricated layered
repair
i
Four layers
M V R
McVay
Repair
i

Suturing transversus
abdominus to
Cooper’s ligament
Transition stitch in
f
femoral
l sheath
h th
Relaxing incision in
external
t
l oblique
bli
Li ht
Lichtenstein
t i Repair
R
i

Gold standard by ACS
Transversalis fascia is not
opened
Fi key
Five
k elements:
l
t

Large sheet of mesh
Cross tails
Secure to rectus, int
oblique and inguinal
ligament
Keep mesh relaxed
Protect nerves
PK Amid Groin hernia repair – open technique. World J Surg 29;10461051 2005
Gilb t “plug
Gilbert
“ l and
d mesh”
h” Repair
R
i

Originally described
by Lichtenstein
Modified to include
indirect hernias
Rutkow and Robbins
included direct
h i
hernias
PK Amid Groin hernia repair – open technique. World J Surg 29;10461051 2005
O
Open
Preperitoneal
P
it
lM
Mesh
hR
Repair
i

Approaches
Trans-inguinal
Paramedian
Lower
midline
Pfannensteil
O
Open
Preperitoneal
P
it
lM
Mesh
hR
Repair
i

Associated with
injuries to:
Bladder
Bowel
Vascular
V
l

Recurrence rate
compared to in front
of TF are the same
PHS S
System
t
Repair
R
i

Combines
Lichtenstein and
preperitoneal repair
2 layers:
Deep
Superficial
L
Laparoscopic
i H
Hernia
i R
Repair
i

Transabdominal
preperitoneal (TAPP)

Mesh along anterior
abdominal
bd i l wallll
Identify

Median & medial umbilical
ligament
g
Lateral umbilical fold
Parietal peritoneum incised
and reflected
Mesh placed b/
b/w
peritoneum and
tranversalis fascia
L
Laparoscopic
i H
Hernia
i R
Repair
i

Totally extraperitoneal
Repair
via posterior approach
Entirely w/in preperitoneal space
Mesh positioned deep to hernia defect
F
Femoral
l Hernia
H i R
Repair
i

Low Groin Approach
Lichtenstein

Inguinal Approach
McVay

technique
repair
Preperitoneal
Approach
C
Complications
li ti

Recurrence
Postherniorrhaphy
p y
pain
Ischemic orchitis
Testicular atrophy

Hemorrhage
Osteitis p
pubis
Infection
Prosthesis-related
complication
Q
Questions
ti
off th
the h
hour…
1.
2.
3.
Is there a superior open repair
q
technique?
Is laparoscopic repair superior to open
repair?
Chronic pain, is it avoidable?
Open vs. Open
SS Awad et al. Improved
p
outcomes with the p
prolene hernia system
y
mesh
compared to the time-honored Lichtenstein onlay mesh repair for inguinal
hernia repair. Am J of Surgery 2007;193:697-701
Li ht
Lichtenstein
t i vs. PHS

Lichtenstein
Gold
standard
Low learning curve

PHS system
Combines
benefits of
anterior and posterior
repair
Only open repair to
cover myopectineal
ti
l
orifice
SS Awad et al. Improved outcomes with the prolene hernia system mesh
Li ht
Lichtenstein
t i vs. PHS

Retrospective study with 622 pts
321
– PHS repair
302 – LMR
Follow up was 20 months
Assessed:

Difference
in operating time
Complications
Recurrence
SS Awad et al. Improved outcomes with the prolene hernia system mesh
Li ht
Lichtenstein
t i vs. PHS
Li ht
Lichtenstein
t i vs. PHS

Conclusion:
PHS
was superior to LMR due to:
Lower recurrence rates
Decreased complications
Less p
post operative
p
p
pain
Earlier return to normal activity

SS Awad et al. Improved
p
outcomes with the p
prolene hernia system
y
mesh
Open vs. Laparoscopic
Neumayer L, Giobbie-Hurder A, jonasson O, et al. Veterans Affairs Cooperative
Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair
of inguinal hernia. N Engl J Med 2004; 350:1819-27
The data shows
shows…

Laparoscopic approach gaining popularity

Prelim recurrence rates ranged from 3-10%
Benefits included

Subsided enthusiasm due to:

Less Pain
Quicker return to activity
High cost
Steep
p learning
g curve
Serious complications
Need for general anesthesia
TAPP versus TEP:

TEP preferred because:

Wide exposure
Avoids abdominal entry
Associated with decrease post-op pain
Faster post-operative recovery
Open versus Laparoscopic

Goal:
Examine
perioperative outcomes and complications in
both TEP and open mesh repair

345 patients
198
147

– open mesh repair
– TEP repair
Follow
F
ll
up: th
three months
th
Compared:
Operative time
Complications
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 2004;18:221-227

Results:
Surg Endosc 18;221-227, 2004
Surg Endosc 18;221-227, 2004
Surg Endosc 18;221-227, 2004

Results:
Surg Endosc 2004;1:221-227

Conclusion:
TEP
repairs can be performed efficiently and
without major complications
Operative times are shorter in the hands of
experienced surgeons
TEP associated with lower rate of postoperative
p
numbness and p
prolonged
g g
groin p
pain
Surg Endosc 2004;18:221-227
Prospective, randomized controlled trial
Prospective
Conducted b/w 1996-1997
Follow up: 7.3 years
168 patients:
p

81
– TEP
87 - Lichtenstein
Hallen et al
al. Laparoscopic extraperitoneal inguinal hernia repair versus open
mesh repair:long term follow-up of a randomized controlled trial. SURGERY
2008;143:313-317
O
Open
versus Laparoscopic
L
i
O
Open
versus Laparoscopic
L
i

Conclusion:
Long
term cure of hernia in patient with lap or
open hernia
ope
e a repair
epa is
se
excellent
ce e
Individualized hernia repair yields best results
and is most cost effective
TEP is an excellent method for individuals in a
working population who require short
convalescence
TEP advantageous in recurrent hernias
Hallen et al. Laparoscopic extraperitoneal inguinal hernia repair versus open
mesh repair:long term follow-up of a randomized controlled trial. SURGERY
2008143:313-317
Ch i G
Chronic
Groin
i P
Pain
i
Potentially incapacitating complication
Cause not clear: ? Nerve Entrapment

Ilioinguinal
Iliohypogastric
Genital

branch of genitofemoral
Routine
R
ti preservation
ti and
d division
di i i have
h
been advocated
Prophylactic Ilioinguinal
Neurectomy in Open Hernia Repair

Double blinded randomized controlled trial
100 patients b/w 18-80yoa
50: whole ilioinguinal nerve excised
50: nerve preserved
Pi
Primary
outcome:
t
iincidence
id
off chronic
h i pain
i att 6
months
Secondaryy outcome: incidence of g
groin numbness

Follow up: 6 months

WL Mui et al “Prohylactic ilioinguinal neurctomy in open inguinal hernia repair”
Annals of Surgery 244;1, 2006
Prophylactic Ilioinguinal
Neurectomy in Open Hernia Repair

Results:
No
significant difference in:
incidence of pain at 6 months
Incidence of groin numbness and sensation
change
Quality of life

WL Mui et al “Prohylactic ilioinguinal neurctomy in open inguinal hernia repair”
Annals of Surgery 244;1, 2006
C
Conclusion
l i
Lichtenstein
Li
ht
t i continues
ti
to
t be
b standard
t d d
although PHS and laparoscopic techniques
are gaining acceptance
Surgeon experience is key to providing
good hernia repair
Learning curve in laparoscopic hernia repair
is steep however in hands of experienced
surgeons outcome comparable to open
repair