Surgical Management of the Inguinal Hernia

1. Surgical Management of the Inguinal Hernia Jerry G Gaston DO FACOS Mid-Year Meeting ACOS April 2014

2. Surgeon Disclaimer • The following presentation is made on behalf of Davol Inc., and contains the opinions of, and personal surgical techniques practiced by Dr. Gaston. Any discussion regarding Davol products during the presentation is limited to information that is consistent with the FDA approvals or clearances for those products. The opinions and techniques presented herein are for informational purposes only and the decision of which techniques to use in a particular surgical application should be made by the surgeon based on the individual facts and circumstances of the patient and previous surgical experience. • Consult product labels and insert for any indications, contraindications, hazards, warnings, precautions, and instructions for use. • Dr. Gsston is a paid consultant for Davol, Takeda, and Myraid.

3. General • 770,000 performed in US each year • Indirect inguinal hernia most common • Tension free • Mesh • Reoccurrence • Chronic pain

4. Anatomy

7. Classification • Direct • Enters canal through posterior wall • Weakening of the abdominal musculature • Medial to the inferior epigastric vessels • Indirect • Enters canal through the deep inguinal ring • Congenital – failure of the processusvaginalis to regress and fuse • Femoral • Inferior to Inguinal ligament • Multiple presentations

8. Nerves • Iliohypogastric • L1-L2 nerve roots • Just medially and superior to ASIS • Lies beneath the aponeurosis of the external oblique • Supplies sensation to the skin of the suprapubic area • Ilioinguinal • L1 nerve root • 2cm medial to the ASIS • Lies beneath the aponeurosis of the external oblique • Supplies sensation to the skin of the pubic region and the upper part of the scrotum or labia majoria

9. Nerves • Genitofemoral • Genital branch and femoral branch • L2-L3nerves • Enters at the deep ring • Genital branch-scrotum and medial aspect of the thigh • Femoral branch-skin of the proximal anterior thigh

12. Repairs • Bassini • Marcy • Shouldice • McVay (Cooper Ligament) • Laparoscopic • Lichtenstein • Mesh • Kugel • Plug and patch • PHS

13. Repairs • To fix or not to fix • Mesh • Approach

14. Fix or not to fix • Data confirms that a strategy of watchful waiting is a safe and acceptable option for men with minimally symptomatic or asymptomatic hernias. • Fitzgibbons group trial • Glasgow group in UK

15. Mesh • Cochrane data 2001 – 50-75% reduction in the risk of recurrence with the use of mesh • PTFE • Mesh plug and patch • Prolene hernia system • Kugel • 3D max

16. Approach • Anterior • Posterior

17. AnteriorPlug and Patch

18. PosteriorKugel Posterior approach No fixation Ring Nerve avoidance Previous repair preperitoneal

19. Laparoscopic3D Max Laparoscopic TAPP vs TEP Nerve injury Lateral femoral cutaneous Closure of peritoneum Bilateral

20. Complications • Reoccurrence • Chronic pain • Mesh erosion • Hemorrhage • Nerve injury • Vas Deferens injury

21. ComplicationsReoccurrence • Mesh vs no mesh • Cochrane data 2001 – 50-75% reduction in the risk of recurrence with the use of mesh • Less than 5%

22. ComplicationsChronic Pain • Nerve injury vs non nerve injury • Long term • Short term • Work compensation

23. ComplicationsMesh Erosion • Bowel • Bladder • omentum

25. ComplicationsHemorrhage • Testicular vessels • Inferior epigastric • Cremestaric vessels • Femoral

27. ComplicationsNerve Injury • Transection • Manipulation • Triple neurectomy • Meshoma

28. ComplicationsVas Deferens • Difficult dissection • Previous mesh • Informed consent • Scrotal hernia

29. Conclusion • Multiple different approaches • Need a variety of tricks in the bag • Do what you feel comfortable and can reproduce • Know the surgical history • Don’t be afraid to pull the NO CARD