Inguinal hernia

SIR GANGA RAM HOSPITAL,FJMC, Lahore

Dr. Sadia

case History

Name : Rafique Age : 65 yrs Sex : male Occupation: vendor Address: shalamar town old eid

gah lahore D.O.A: 25th april 2012 M.O.A: OUTDOOR T.O.A: 11:0am

TREATMENT

Surgical Treatment is the best option.

1. Open surgical treatment2. Laparoscopic surgical treatment3. Non-surgical treatment(Truss)

Treatment

Open surgical T/M

Inguinal Herniotom

y

Herniorrhaphy

Hernioplasty

Laparoscopic surgical T/M

Transabdominal

approach(TAPP)

Preperitoneal approach(TE

P)

Open surgical treatment

Inguinal Herniotomy:1. Anaesthesia Local, Epidural, Spinal Generaal anaesthesia

2. Incision Incision is made in skin and subcutaneous tissue

1.25 cm above and parallel to the medial 2/3rd of inguinal ligament.

External oblique aponeurosis is incised in the line of fibers.

External oblique aponeurosis is separated from the internal oblique by the blunt dissection.

Cremasteric fibers are divided longitudinallyto display spermatic cord.

Inguinal Herniotomy cont’d3. Dissection and opening of hernial sac If the sac is small, it is totally freed and then opened. If long, Fundus need not to be sought out, the sac is

freed and divided in inguinal canal.

4. Reduction of contents Contents i.e. intestine and omentum are returned to

the peritoneal cavity. If omentum is adherent to the neck, it is freed and if it

is adherent to the fundus; it is isolated, ligated and cut across at a suitable sight.

5. Isolation and ligation of the neck of the sac

Neck is freed and fingur is passed thru the mouth of sac to make sure the absence of adherence.

Neck is transfixed, ligated at high level and the sac is excised 1.25cm below the ligature.

Wound is closed in layers.

Herniotomy cont’d

Herniotomy video

Herniorrhaphy

1. Inguinal Herniotomy2. Repair of the transversalis fascia and

internal ring Lytle method: Repairing and narrowing of the superficial

inguinal ring with lateral displacement of spermatic cord. Shouldice method: Ring and fascia are incised and carefully

separated from inferior epigastric vessels and extraperitoneal fat before an overlapping repair(double breasting) of lower flap behind the upper flap is effected.

Herniorrhaphy cont’d

3. Reinforcement of posterior inguinal wall Bassini repair Modified Bassini repair Daring repair: Approximation of the posterior inguinal wall

without tension the tendinous and aponeurotic part of conjoined muscle to the pubic tubercle and inguinal ligament, but there are repair consists of two layers of continupus sutures without any tension (forming figure of 8 with each suture).

4. Completion of operation External oblique is directly sutured leaving a new

external ring. Skin incision is closed.

Hrniorrhaphy cont’d

Hernioplasty

Placement of a mesh e.g. polypropylene mesh, as an extra lamina, anterior to the posterior wall and overlapping it generously in all directions, including medially over the pubic tubercle.

Laparoscopic surgical treatment

In bilateral and recurrent inguinal hernias1. Transabdominal approach(TAPP) Pneumoperitoneum is established. Synthetic mesh is placed peritoneally by dissecting

the peritoneal off the hernial orfices. Position the mesh beneath the peritonium Close the peritonium over the mesh.

2. Preperitoneal approach(TEP) Completely preperitoneal. Paraumbilical incision, balloon or direct incision. Hernial orfices identified and hernial sac is reduced. Alarge mesh is placed over the hernial orfices in

preperitoneal plane.

Laparoscopic inguinal surgery

Non-surgical treatment(Truss) When surgery is

contraindicaed or refused.

Controls small or moderate sized inguinal hernia.

Should be applied before patient gets up and while hernia is reduced.

Should be worn continuously during work.

Should be renewed timely.