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MANAGEMENT OF RECURRENT INGUINAL HERNIAS

MANAGEMENT OF RECURRENT INGUINAL HERNIAS. Dr Sanjay De Bakshi MS; FRCS. CAUSE OF RECURRENCE. PATIENT FACTORS. Smoking Older age at initial hernia presentation Arteriosclerosis Diabetes mellitus Metabolic disorders including obesity and renal insufficiency

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MANAGEMENT OF RECURRENT INGUINAL HERNIAS

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  1. MANAGEMENT OF RECURRENT INGUINAL HERNIAS Dr Sanjay De Bakshi MS; FRCS.

  2. CAUSE OF RECURRENCE

  3. PATIENT FACTORS • Smoking • Older age at initial hernia presentation • Arteriosclerosis • Diabetes mellitus • Metabolic disorders including obesity and renal insufficiency • Deficiency of coagulation factor VIII or vitamin C • Steroids and chemotherapeutic agents • Increased intra-abdominal pressure caused by postoperative chronic cough, constipation, and bowel distention • Connective tissue disorder

  4. PATIENT FACTORSDifferent levels at which problems may occur • Inflammation. • Fibroblast migration and proliferation. • Collagen formation. • Growth factors. • Nutrition. • Tissue perfusion.

  5. COLLAGEN FAILURE Reason for considering collagen failure over technical is the gradual increase in incidence of recurrence.

  6. Collagen Failure • A constitutive and systemic increase in type III collagen synthesis may result in reduced collagen fibril assembly in the abdominal wall, eventually leading to the development of herniation. Increases in Type Ill Collagen Gene Expression and Protein Synthesis in Patients with Inguinal Hernias. David W et al. ANNALS OF SURGERY Vol. 218, No. 6, 754-760; 1993

  7. Collagen Failure • Whereas collagen type I is characteristic for mature scars or fascial tissue, the collagen type III represents the mechanically instable, less cross-linked collagen synthesized during the early days of wound healing.

  8. Matrix Metalloproteinase-2 • MMP-2 is important in tissue remodeling, embryogenesis, and angiogenesis. In addition it transforms mesenchymal cells and fibroblasts to actively proliferating and migratory phenotypes . Polymeric meshes induce zonal regulation of matrix metalloproteinase-2 gene expression by macrophages and fibroblasts. Petra Lynen Jansen et al. The FASEB Journal. April 2007,vol. 21 no. 4:1047-1057

  9. Matrix Metalloproteinase-2 • MMP-2 is important in tissue remodeling, embryogenesis, and angiogenesis. In addition it transforms mesenchymal cells and fibroblasts to actively proliferating and migratory phenotypes . MMP2s Made Easy; Assessment and diagnosis, Complex wounds, Diabetic foot ulcers | D Gibson D, B Cullen, R Legerstee, Harding KG and Schultz G.KG and Schultz G. Wounds International, Vol 1; Issue 1 (http://www.woundsinternational.com/made-easys/mmps-made-easy)

  10. Matrix Metalloproteinase-2 • Surprisingly, statistically, serum levels of MMP-2 were significantly increased in all the hernia patients as compared to controls. This increment was maximum in patients of direct hernia. Hernia = Less MMP2 in tissues; More MMP2 in Serum Study of Matrix Metalloproteinase-2 in Inguinal Hernia. Vinod Jain et al Volume 1, Number 5, December 2009, Page 285-289

  11. Collagen I/III ratio --14 Collagen I/III ratio – 3.6 MMP-2 staining Hernia recurrence as a problem of biology and collagen; Uwe Klinge et al. J Minim Access Surg. 2006 September; 2(3): 151–154.

  12. SURGEON FACTORS • Inadequate knowledge of Anatomy • Insufficient extent of dissection. • Missed hernia. • Lipoma of the cord or preperitoneal lipoma. • Suboptimal mesh placement. • Inappropiate fixation. • Mesh lifted by haematoma. • Inferior margin of mesh lifted at closure.

  13. The anatomy of the inguinal region is HERNIA ANATOMY Misunderstood by surgeons of ALL levels of seniority!!!! Robert E Condon; MD. Chairman of Surgery; Medical College of Wisconsin, Milwaukee Author; Books and Treatises on Hernias

  14. INCIDENCE OF DIFFERENT TYPES OF HERNIAS

  15. Nyhus Classification • Type I: Indirect inguinal herniaInternal inguinal ring normal (simple pediatric hernia) • Type II: Indirect inguinal hernia Internal inguinal ring dilated but posterior inguinal wall intact (inferior deep epigastric vessels not displaced)

  16. Nyhus Classification • Type III: Posterior wall defect • A. Direct inguinal hernia • B. Indirect inguinal hernia- internal inguinal ring dilated (massive scrotal or sliding hernia) • C. Femoral hernia • Type IV: Recurrent hernia • A. Direct • B. Indirect • C. Femoral • D. Combined

  17. VARIANTS OF A HERNIAPANTALOON HERNIA

  18. VARIANTS OF A HERNIASLIDING HERNIA COLON BLADDER AMYAND’S HERNIA –contains an inflamed appendix

  19. RARER HERNIAS Velpeau hernia Cooper's hernia

  20. Richter’s hernia

  21. Rare Hernias Richter’s hernia: Noncircumferential incarceration of the nonmesenteric bowel wall Littre’s Hernia: Incarcerated Meckel’s Amyand's Hernia: Acute appendicitis inside an incarcerated inguinal hernia

  22. Athletic pubalgia • Athletic pubalgia, also called the sportman's hernia or sports hernia, Gilmore's groin or groin disruption, is a medical condition of the groin affecting athletes. Jerry Gilmore recognized the syndrome in 1980 and developed a surgical repair technique. It is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal. • A hernia cannot be found on physical examination or medical imaging, and is not revealed during surgery. The term hernia thus is a misnomer, but has persisted, as surgical reconstructions similar to those performed for inguinal hernias are often effective for "sports hernias" as well.

  23. Rare Hernias Petit’s Hernia AKA: Inferior Lumbar Hernia Boundaries: Ext abdominal oblique Latissimus Dorsi Iliac Crest

  24. Rare Hernias Grynfelt’s Hernia AKA: Superior Lumbar Hernia Boundaries: Internal abdominal oblique Lumbodorsal aponeurosis 12th rib

  25. Rare Hernias Sciatic Hernia: (Post. Pelvis) Herniation through the greater sciatic foramen, high rate of strangulation Obturator Hernia: (Ant. Pelvis) Diagnosis by bowel gas below the superior pubic ramus. Howship-Romberg Sign seen w/Obturator Hernias Inner thigh pain with internal rotation

  26. WHY INGUINAL?

  27. PROBLEM OF EVOLUTION

  28. PROBLEM OF EVOLUTIONBorn from a need to “Run” food down on the plains of Africa AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL RIDGE”OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY WHILE RUNNING.

  29. PROBLEM OF EVOLUTIONBorn from a need to “Run” food down on the plains of Africa BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

  30. PROBLEM OF EVOLUTIONBorn from a need to “Run” food down on the plains of Africa -THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED- “THE MYOPECTINEAL ORIFICE”

  31. THE MYOPECTINEAL ORIFICE The MPO is bordered: • Above by the arching fibers of the internal oblique and transversus abdominus Muscles, • Medially (towards the center or to the right) by the Rectus Abdominus Muscle and its Fascial Rectus Sheath, • Inferiorly by Coopers Ligament, and • Laterally by the Ileopsoas Muscle. FRUCHAUD

  32. Henri Fruchaud 1894-1960 • French anatomist and surgeon • Described the Myopectineal Orifice • Mentor to Stoppa and Rives

  33. INSTRUMENT FAILUREAlso a Surgical Misadventure!! • Mesh size too small • Heavyweight mesh/ excessive shrinkage. • Inadequate fixation of mesh – mesh migration. • Use of absorbable material. • Too wide a slit for the cord.

  34. Anatomy of the Recurrent Inguinal Hernia Inguinal hernia recurrence: classification and approach. G. Campanelli et al. Hernia (2006) 10: 159–161 • type R1—first recurrence of ‘‘high’’ oblique external reducible hernia with small (<2 cm) defect NEAR INTERNAL RING in non-obese patients after pure tissue or mesh repair; • type R2—first recurrence of ‘‘low’’ direct reducible hernia with small (<2 cm) defect in non-obese patients NEAR PUBIC TUBERCLE after pure tissue or mesh repair; and • type R3—all other recurrences, including femoral recurrences, recurrent groin hernia with large defect (inguinal eventration), multi-recurrent hernias, after pure tissue or mesh repair.

  35. Anatomy of the Recurrent Inguinal Hernia Recurrent inguinal hernia. R W Postlethwait. Ann Surg. 1985 December; 202(6): 777–779.

  36. Anatomy of the Recurrent Inguinal Hernia Glassow reported on 2910 recurrent inguinal hernias in 1964

  37. PRINCIPLES OF REPAIR OF RECURRENT INGUINAL HERNIAS PRIMARY REPAIR OPEN PRIMARY REPAIR LAPAROSCOPIC Repeat operation ideally Open to enable one to work through virgin tissues • Repeat operation ideally Laparoscopic to enable one to work through virgin tissues OTHER CONSIDERATIONS:- Size of the hernia. Reducibility. Strangulation. Condition of the patient- i.e. is whether a General anaesthesia going to be possible. Surgical expertise. AN ORCHDECTOMY MAY BE NECESSARY! THE CHANCES OF THIS HERNIA REPAIR BEING MORE PAINFUL!

  38. REPAIR BY LAPAROSCOPY TAPP

  39. REPAIR BY LAPAROSCOPY TEP

  40. OPEN Lichtenstein Tension Free Single Flat Mesh Flat Mesh in a Single Anterior Layer of Protection http://youtu.be/H0wVNhvuljo

  41. PROBLEM OF THE LARGE RE-RECURRENCES!!! • THINK PREDISPOSING FACTORS. • THINK OF COLLAGEN FAILURE. • THINK OF TYPE & ROUTE OF HERNIA REPAIR. • CORRECT CO-MORBID CONDITIONS. • CONSENT FOR ORCHIDECTOMY.

  42. OPEN PHS REPAIR FOR A MASSIVE RECURRENT INGUINAL HERNIA

  43. Repair of the posterior wall tightening of the external inguinal ring Bassini 1880 Shouldice 1945 Susruta B.C./A.D. Stromayr 1559. Czerny 1877. Lichtenstein 1984 Use of Mesh HERNIA TIMELINE & SHIFT

  44. How did the Mesh repair Compare?

  45. Repair of the posterior wall tightening of the external inguinal ring Bassini 1880 Shouldice 1945 Susruta B.C./A.D. Stromayr 1559 Czerny 1877, Lichtenstein 1984 Useof Mesh HERNIA TIMELINE & SHIFT Use of the Posterior mesh Stoppa 1987 Ger 1990 Combination Mesh Gilbert 1991

  46. Concept of Posterior Repair It is far more difficult to break open a door against the direction it is opened It is far easier to do this in the direction the door is opened

  47. KICKING IN A DOOR!!!

  48. POSTERIOR SUPPORT-Either Laparoscopy or by PHS Mesh1)ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW2) BASED ON SOUND APPLICATION OF PHYSICSFOR THE INGUINAL HERNIA

  49. POSTERIOR SUPPORT-Either Laparoscopy or by PHS Mesh1)ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW2) BASED ON SOUND APPLICATION OF PHYSICSFOR THE DIRECT INGUINAL HERNIA

  50. POSTERIOR SUPPORT-Either Laparoscopy or by PHS Mesh1)ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW2) BASED ON SOUND APPLICATION OF PHYSICSFOR THE INDIRECT INGUINAL HERNIA

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