بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم قَالُواْ سُبْحَانَكَ لاَ عِلْمَ لَنَا إِلاَّ مَا عَلَّمْتَنَا إِنَّكَ أَنتَ الْعَلِيمُ الْحَكِيمُ صدق الله العظيم

2. The Role Of Narrowing Of The Internal Ring In The Outcome Of Laparoscopic Treatment Of Indirect Inguinal Hernia. By Mohammed Saleh Al-dawbali MD (Egy.), MRCS (Eng.) Ass. Prof Of Surgery (Sana'a University)

3. Introduction -- Hernia is a frequent disease in the community so that it produce a sizable part of many general surgeons practice. -- The success of laparoscopic cholecystectomy has resulted in the enthusiasm to modify other abdominal procedures so that they can be performed laparoscopically. -- laparoscopic Inguinal hernioplasty is one of such procedure.

4. Introduction (cont.) • Over the past 20 years, several hernia repair techniques have been introduced .The main cause for the development of these new techniques was to reduce the recurrence rate. • The introduction of the Lichtenstein tension-free hernioplasty, which uses a mesh to reinforce the abdominal wall, has decreased recurrence rates greatly. • However, certain types such as recurrent,bilateral hernias are particularly suited for a laparoscopic approach . • Laparoscopic inguinal hernioplasty is associated with shorter recovery periods, earlier return to daily activities and work, and decreased postoperative pain.

5. Indications • Certain types of hernia such as - Recurrent, - Bilateral, are particularly suited for a laparoscopic approach . BUT also it can be done for primary unilateral hernias as first patient preference

6. Approach • Laparoscopic hernia repair can be done either through: • 1. Transabdominal Preperitoneal Approach (TAPP )or • 2. Total Extra-peritoneal Approach (TEP).

7. Aim Of The Work • Our study aim to assess whether the addition of the closure of internal ring to the classical TAPP has a better short outcome on regard to post operative pain, bulging, seroma or haematoma formation and on the long term outcome in regard to recurrence .

8. Patients And Methods • - A total of 40 patients were selected from those presented to the Outpatient Clinic with indirect inguinal hernia from the period May 2009 to April 2011

9. Patients And Methods Exclusion criteria for patient selection were as follows:- • - younger than 12 years of age • - severe obesity (BMI >35). • - associated medical problems that contraindicate safe induction of general anesthesia or elective surgery

10. Patients And Methods • The forty Patients were randomly divided into two groups, group Acontain 20 patients and were treated by closure of the ring and classical TAPP ,while group B contain 20 patients and was treated by Classical TAPP Only.

11. Operation • In the theater, neither nasogastric tube nor urinary catheter were needed (patient were instructed to evacuate their bladder before coming to the theater).

12. Op. Technique (cont.) • Insertion Of The Trocar (open tech.) • Induction Of Pneumoperitoneum (14mmHg) • abdominal cavity and viscera are inspected in a systematic order

15. Two working ports were further introduced at a level just caudal to the umbilicus and lateral to the rectus muscle of both right and left lower quadrants. • N.B This array of trocars was used in either unilateral or bilateral cases.

16. EXPLORATION

17. Peritoneal incision (Right)

18. Left peritoneal incision

19. Right side dissection

20. Left side dissection

21. Ring closure

22. Mesh fixation

23. Peritoneal closure

24. Results Patients characteristics: • The patient’s ages ranged from 25→55 years old • The mean age was 33 years in Group A and 30 years in Group B • All of our pt were male (no female)

25. Distribution of Hernia site • 24 cases (60%) were right side , 6 cases ( 15%) were left side and 10 cases (25 %) were bilateral .

26. Average Operative Time

27. Intra-Operative Complications • Intra-operative complication occur in a single case (2.5 %) in the form of urinary bladder injury during reduction of the structure from a left hernia defect in a patient with bilateral hernia. The injury was recognized at the time of operation and dealing with it was done in the form of repair in two layer after putting of urinary catheter. The hernia repair was completed then as usual .The patient recover post operatively without further complication

28. Post Operative Care. • The patients were shifted from the operating theater to the surgical ward and were discharged in the next day (except when complications were suspected). In the surgical ward recording of the postoperative pain using the Visual analogue scale (VAS) was used . • Patients were seen after 1 week , then after 1 month and then after 6th months postoperatively and they were told to contact us if they face any problem regarding their hernia. During the follow up of these patients they were examined clinically to assess the post operative pain and to look for the presence of odema, seroma , hematoma , wound infection ,post operative bulge, recurrence or any other complications.

29. Hospital Stay -All patient of both group were ambulated in the same day of operation and discharged in the next day of the operation. -Only 1 case (2.5 %) who discharged in the 3rd POD.

30. Follow up • Postoperative pain. there was no significant difference between patients of both groups (P value < 0.01) and the pain score was ranged from VAS 1 to VAS 3 (mild ) and in more than 90% of cases pain was overcomed with simple analgesics . The causes of pain seems to be multifactorial (dissection , fixation of the mesh, foreign body reaction……etc)

31. Visual analogue scale (VAS)

32. - Seromaoccur in two cases (10 %) of the second group and was treated conservatively . No seroma occur in pts of the first group

33. Post operative bulging was noted in 16 case (80 %) of the second group and it last for a period of around two months postoperatively , while in the first group there were No bulging neither in the early nor in the late postoperative period. This make the patients of the first group more satisfy .

34. The follow-up period ranged from 1 to 1.5 year postoperatively ( average 1 year) • The results of follow up show: On clinical basis all patients of both groups were relived of the symptoms of hernia • No recurrence have been reported in all cases of both group.

36. Conclusion • Laparoscopic surgery is becoming widely accepted as an alternative to conventional procedures. With-miniaturization of instrument it isbecoming more and more evident that laparoscopic techniques can be applied safely and successfully to hernia patients. The selection criteria for patients who are eligible for laparoscopic procedures is dynamic and as skills and technologies improve fewer patients are found to have absolute exclusion criteria

37. Result show that Laparoscopic narrowing of the internal inguinal ring was found to be safe , effective and low cost procedure for treatment of oblique inguinal hernia with better outcome regarding post operative serohematoma and postoperative bulging which are annoying problem to hernia patients .

38. However, the important Question isWhether the closure of the internal ring will be an auxiliary step in the classical TAPP procedures in the light of these substantial benefits as regard to less postoperative complications. More studies needed to answer this question but in our study narrowing of the internal ring with hernioplasty was simple, sufficient and effective .

39. Thank you !

40. Numerical rating scale (NRS)

41. Faces rating scale (FRS)

43. Pain rating scales instructions Subjective pain score • All patients are to have a functional activity score recorded in addition to the chosen subjective score. Visual analogue scale (VAS) • Instruct the patient to point to the position on the line between the faces to indicate how much pain they are currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst pain ever’. Numerical rating scale (NRS) • Instruct the patient to choose a number from 0 to 10 that best describes their current pain. 0 would mean ‘No pain’ and 10 would mean ‘Worst possible pain’. Faces rating scale (FRS) • Adults who have difficulty using the numbers on the visual/numerical rating scales can be assisted with the use of the six facial expressions suggesting various pain intensities. Ask the patient to choose the face that best describes how they feel. The far left face indicates ‘No hurt’ and the far right face indicates ‘Hurts worst’. Document number below the face chosen. Behavioural rating scale • The behavioural pain assessment scale is designed for use with non-verbal patients unable to provide self-reports of pain. • Rate each of the five measurement categories (0,1 or 2). • Add these together. • Document the total pain score out of 10. Functional activity score • This is an activity-related score. Ask your patient to perform an activity related to their painful area (for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain). • Observe your patient during the chosen activity and score A, B or C. • A – No limitation meaning the patient’s activity is unrestricted by pain • B – Mild limitation means the patient’s activity is mild to moderately restricted by pain • C - Severe limitation means the patient ability to perform the activity is severely limited by pain • *Relative to baseline refers to any restriction above any pre–existing condition the patient may already have.