Hernia Repair: Open or Laparoscopic?

DR. MOHAMAD AL-GAILANI FRCS .الكيالني محمد د

Consultant Surgeon استش*اري جراح

KSA الس*عودية العربية المملكةTEL: 00966 11 4250000

WWW.ALHAMMADIHOSPITAL.COM

Hernia Repair: Open or

Laparoscopic?

OUTLINE Hernia Repair Milestones Update on Hernia repair Guidelines Case photos & videos Take Home Message &

RecommendationsDR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد2 الكيالني

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد3 الكيالني

HERNIADEFINITION

• Hippocrates used the Greek “hernios” for bud or bulge to describe abdominal hernias.

• A hernia is protrusion of an organ or part of it through the wall of the cavity in which it is normally contained.

Epigastric

Umbilical Incisional

Direct inguinalIndirect inguinal

Femoral

HERNIA TYPES

Spigelian

Lumbar

Obturator

75% of all abdominal wall hernias occur in the Groin.

HERNIA PREVALENCE & COMPLICATIONS

The overall lifetime risk of developing a groin hernia is 15% in men and < 5% in women.

Age standardized hernia surgery rate is 100/100,000 population per annum.

Risk of strangulation and obstruction can be life threatening.

COMPLICATED HERNIA GANGRENE SMALL BOWEL

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد الكيالني

5. Internal Oblique Aponeurosis

6. Transversalis Fascia

7. Cremasteric Fascia 8. Pubic Tubercle

GROIN ANATOMY1. Inguinal ligament

2. Muscular part of Transversus Abdominis

3. Transversus Abdominis Aponeurosis

4. Muscular part of Internal Oblique

Inguinal ligament

Spermatic cord

Site for a femoral hernia

Site for an indirect inguinal hernia

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد الكيالني

Left Femoral herniaRight

Direct Inguinal /Femoral? hernia

Open or Laparoscopic?

RIGHT INGUINO- SCROTAL HERNIA

Open or Laparoscopic?

0PEN OR LAPAROSCOPIC?

VENTRAL-INCISIONAL HERNIA

HERNIA REPAIR MILESTONES

1. OPEN REPAIR:Eduardo Bassini

(1844-1924) Italy

Eduardo Bassini

2. TENSION FREE MESH REPAIR: Irving L. Lichtenstein

(1920-1980) USA

Irving L. Lichtenstein

3. LAPAROSCOPIC REPAIR (1989)Sergei Bogojavlensky

(1941-2013) USA

A (Gynaecologist) from Alaskareported the first case of Laparoscopic (Plug) mesh hernia repair in 1989.

Sergei Bogojavlens

THE “DAM” EFFECT PRINCIPLE

Laparoscopic

LAPAROSCOPIC HERNIA REPAIR TYPES:

• Inguinal: Trans Abdominal Pre Peritoneal (TAPP)

• Inguinal: Total Extra Peritoneal (TEP)• Intra Peritoneal Onlay Mesh (IPOM)

VENTRAL (INCISIONAL) OPEN HERNIA REPAIR

ANATOMY OF THE ANT. ABDOMINAL WALL AS SEEN IN LAPAROSCOPY

MEDIAL UMBILICAL LIGAMENT

LATERAL UMBILICAL LIGAMENT

DIRECT INGUINAL HERNIA

INDIRECT INGUINAL HERNIA

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA 21 د. محمد الكيالني

FEMORAL

DIRECT INGUINAL

INDIRECT INGUINAL

LAPAROSCOPIC INGUINAL HERNIA REPAIR ANATOMY

RIGHT INDIRECT INGUINAL HERNIA

Lateral Umbilical Ligament

Right Indirect inguinal hernia

MEDIAL UMBILICAL LIGAMENT

INGUINAL HERNIA RECURRENCE

FOLLOWING (TAPP) REPAIRELEVATED LOWER

BORDER OF MESH

RECURRENT HERNIA

Author’s Modification (Al-Gailani) “OVERLAP”

Right Spermatic Cord

OVERLAP Spermatic Cord

by mesh

VIDEO 1:LAPAROSCOPIC (TAPP) (R) INGUINAL HERNIA REPAIR

PARA UMBILICAL HERNIA(PUH)

Greater Omentum herniated

PUHRELEASE OF HERNIA CONTAINTS

PUHMESH FIXATION

PUH Mesh In Situ

Repair Completed

VIDEO 2:LAPAROSCOPIC (PUH) REPAIR

INCISIONAL HERNIA REPAIR following

Kocher Incision (Open Cholecystectomy)

Omental Adhesions to

Incisional Hernia

INCISIONAL HERNIA RELEASE OF ADHESIONS

INCISIONAL HERNIA Adhesolysis Completed

Old nylon suture of previous Kocher incision closure

INCISIONAL HERNIA Mesh Fixation with “Protac”

Recommended Mesh Overlap (5 cm)

OVERLAP 5CM (ALL AROUND)DEFECTOVERLAP 5CM

(ALL AROUND)

VIDEO 3:LAPAROSCOPIC INCISIONAL HERNIA REPAIR

HERNIA REPAIR GUIDELINES

2001NATIONAL INSTITUTE CLINICAL EXCELLENCE (NICE)

HERNIA REPAIR GUIDELINES

• Only 4.1% of repairs done laparoscopically

• Only to be done by trained surgeons• Laparoscopic hernia repair for bilateral and recurrent hernias

2004NICE GUIDELINES

1. Reduced postoperative pain2. Earlier return to normal activities 3. Repair of bilateral hernias 4. Occult hernias

2004NICE GUIDELINES

Reduction in long term pain and numbness

Recurrence rates similar to open repair

Associated with fewer Surgical Site I & Haematoma

2008ETHICON: U.K Hernia Repairs • 15-20% of inguinal hernias repaired Laparoscopically (4.1% 2001)

• 20% of Incisional hernias repaired Laparoscopically

2013ASSOCIATION of SURGEONS GB &

IRELAND (ASGBI)INDICATIONS

LAPAROSCOPICPatients at risk of Chronic Pain

Groin hernias in Women (may be Femoral?)

OPEN (L.A)Older patientsSignificant Co-morbidity

2013ASGBI

Recurrent Inguinal Hernia:

• Recurrence after Open Repair Laparoscopic Repair

• Recurrence after Laparoscopic Repair Open Repair

2016SOCIETY AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)

VENTRAL HERNIALaparoscopic V Open Repair:

• Lower rate of wound infections.• Recurrence rates and post-operative pain are

similar • Contraindications: 1. The need to remove previously placed prosthetic

mesh2. Large abdominal wall defects

2016SAGES

(LAP) CLOSURE OF HERNIA DEFECT

• Theoretical advantage• Not proven by good quality comparative studies

• Undertaken at the surgeon’s discretion

2016SAGES

SEROMA POST OPERATIVE (LAP)• Common and should be anticipated!• Reduced by:1. Cauterization of the hernia sac2. Use of pressure dressings 3. Suture closure of the hernia defect

LAPAROSCOPIC HERNIA REPAIR COMPLICATIONS

• Visceral injury• Vascular injury• Injury to vas, spermatic vessels

• Port site hernia

• Bowel adhesions to mesh

• Intestinal obstruction

• Persistent groin pain

• Mesh infectionDR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد48 الكيالني

IMMEDIATE LATE

SUMMARYLAPAROSCOPIC

HERNIA REPAIR

Less postoperative painFewer wound

complicationsFaster return to work Improved cosmesis

LOWER INCIDENCE OF CHRONIC GROIN PAIN

BILATERAL THROUGH ONE SET OF INCISIONS

LONGER LEARNING CURVE

TAKE HOME MESSAGE

WHICH HERNIA REPAIR?

INGUINAL Hernia Repair

LAPAROSCOPIC Bilateral Unilateral (choice)Women Recurrent following Open repair

INGUINAL Hernia RepairOPEN MESH

Unfit for GA (Spinal or Local anaesthesia)

Recurrent following LaparoscopicLarge Inguino-ScrotalDR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA د. محمد52 الكيالني

VENTRAL Hernia Repair

Open Mesh: Large Ventral or Infected Mesh

Laparoscopic: Recurrent OpenSurgeon’s experience!

Customized Surgery…

according to Patient’s Needs!

Which Hernia Repair?

CONSULTANT BREAST & GENERAL SURGEON

WWW.ALHAMMADIHOSPITAL.COM

TEL: 00966 11 4250000

Hernia Repair: Open or Laparoscopic?

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