SURGERY CASE

JIs Guzman, Montefalcon, Sulit

Clinical Diagnosis
Diagnosis
Indirect
Inguinal
Hernia
Direct
Inguinal
Hernia

Certainty
90%

Treatment
Surgical

10%

Surgical

Clinical Diagnosis
Do I need a paraclinical diagnostic
procedure?
Generally, patient who present with
typical symptoms and signs of groin
hernia do not require further imaging for
confirmation. The diagnosis is clinical.
Chiow, et al. Inguinal Hernias: a current review of an old problem. Proceedings of
Singapore Healthcare. 2010. 19(3):202-211

The sensitivity of clinical diagnosis of

inguinal hernia is 75-95% and the
specificity of clinical diagnosis of
inguinal hernias is 64-96% (Toms, et al., 2011)

Clinical Diagnosis
Do I need a paraclinical diagnostic
procedure?
No.

Clinical Diagnosis
Diagnosis
Indirect
Inguinal
Hernia
Direct
Inguinal
Hernia

Certainty
90%

Treatment
Surgical

10%

Surgical

Treatment Goal
High ligation of sac
Prevention of recurrence
Prevention of complications

Treatment Options
Treatment

Benefit

Risk

Cost

Availability

Open
hernioplasty
(Lichtenstei
n)

Easy to
perform
Low rate of
complicatio
ns

0.2-0.5%
recurrence
rate
Graft
rejection

+
P5,000 to
P8,000

Available

Open
Herniorrhap
y
(Shouldice)

Low rate of
complicatio
ns
Anatomic
repair of the
floor

6%
recurrence
rate

+
P5,000

Available

Laparoscopi
c Hernia
Repair

Better
cosmetic
result
Less
superficial
infection

2.4%
recurrence
rate
Increase in
perioperativ
e

++
P15,000 to
P20,000

Available

Preoperative Preparation

Informed consent secured

Psychosocial preparation
Screening for medical problem
Optimizing physical condition
Preparing OR needs

Admission
On the 1st hospital day
DAT then NPO post midnight
IVF: D5LRS 1L to run at 125 cc/hr
Therapeutics:
Ranitidine 50 mg TIV q8h while on NPO

 Is antibiotic prophylaxis
recommended in elective groin
hernia surgery?
Antibiotic prophylaxis is NOT
recommended in elective groin hernia
surgery (Grade D recommendation). For
hernia repair using mesh, antibiotic
therapy is also NOT recommended
(Grade C recommendation). (Cabaluna & Bongala,
2010)

Operative Technique

Patient supine under SAB

Asepsis- Antisepsis
Sterile drapes placed
Transverse incision done on the skin
between the anterior superior iliac
spine and pubic tubercle
and carried down to the
subcutaneous tissue

Operative Technique
Location of the external inguinal ring
palpated
External Oblique aponeuroses
identified, cut & opened up to the
external inguinal ring
Placed a clamp on both leaves of the
external oblique aponeurosis and
identify the ilioinguinal nerve

Operative Technique
Intra op findings noted
Spermatic cord separated from the
underside of the external oblique
aponeurosis by sharp and blunt
dissection
Picked up the cremasteric muscle
and incised it longitudinally
Gently shell the cord from its
surrounding cremasteric muscle

Operative Technique
Identify the vas deferens
Hernial sac identified and isolated
Reduced any content of the hernial
sac
Hernial sac ligated using purse string
suture ligation using silk-0
Prolene mesh, placed under
spermatic cord, 3-4 cm larger than
the defect

Operative Technique
Prolene mesh sutured with silk 2-0
with the use of interrupted mattress
around the perimeter of the defect,
penetrating the anterior rectus sheath,
rectus muscle, and transversalis fascia
along medial aspect. Along the lateral
margin of the defect, it was sutured to
the Pouparts ligament going from the
pubic tubercle laterally to the region of
femoral canal

Operative Technique
Layer by Layer closure
Fascia closed by simple interrupted
sutures using Vicryl-0
Subcutaneous closed by Inverted T
sutures using Chromic 2-0
Skin closed by simple interrupted
sutures using silk 4-0

Dry sterile dressing applied

Patient tolerated the procedure well
Post-op condition- stable

Intraoperative Findings
Hernial sac located anteromedially
Internal ring measures 4cm with no
incarcerated contents.

 3rd Hospital Day/ 1st post-operative

day

Postoperative Care
Adequate analgesia
Proper wound care
Avoid strenuous activities for at least
a month

DIDACTICS

Management
Uncomplicated hernias require
either:
No treatment
Support with a truss
Operative treatment

Complicated hernias:
Always require surgery, often urgently

Management

Conservative
Management
Aimed at alleviating symptoms
such as pain, pressure, and
protrusion of abdominal contents
For hernias that are not
strangulated or incarcerated can
be mechanically reduced
Assuming a recumbent position
Truss, an elastic belt or brief

TRUSS

Emergent repair
Incarcerated hernias
Strangulated hernias

INCARCERATED HERNIA
Reasons for incarceration
large amount of intestinal contents
within the hernia sac
dense and chronic adhesions of hernia
contents to the sac
small neck of the hernia defect in
relation to the sac contents

INCARCERATED HERNIA
An incarcerated inguinal hernia
without the sequelae of a bowel
obstruction is not necessarily a
surgical emergency

INCARCERATED HERNIA
Reduction should be attempted
before definitive surgical
intervention.

INCARCERATED HERNIA
Hernias that are not strangulated
and do not reduce with gentle
pressure should undergo taxis.

STRANGULATED HERNIA
Femoral > Indirect > Direct
Fever, leukocytosis, and hemodynamic
instability.
The hernia bulge usually is very tender,
warm, and may exhibit red discoloration.

Taxis should not be applied to

strangulated hernias as a potentially
gangrenous portion of bowel may be
reduced into the abdomen without being

OPERATIVE TECHNIQUES

 Surgery aims to
Reduce the hernia contents
Excise the sac (herniotomy) in most
cases
Repair and close the defect either by
herniorrhapy or hernioplasty

Anterior repair
non prosthetic

OPEN APPROACH

OPEN Approach

Bassini Repair
Is frequently used
for indirect inguinal
hernias and small
direct hernias
The conjoined
tendon of the
transversus
abdominis and the
internal oblique
muscles is sutured
to the inguinal
ligament

Mcvay repair
inguinal and
femoral canal
defects
The conjoined
tendon is
sutured to
Coopers
ligament from
the pubic
cubicle laterally

Shouldice Repair

Anterior repair
prosthetic

Lichtenstein TensionFree Repair

The most commonly performed inguinal hernia repair today is the
Lichtenstein repair. A flat mesh is placed on top of the defect
It is a "tension-free" repair that does not put tension on muscles
It involves the placement of a mesh to strengthen the inguinal
region.
Patients typically go home within a few hours of surgery, often
requiring no medication beyond Paracetamol.
Patients are encouraged to walk as soon as possible
postoperatively, and they can usually resume most normal
activities within a week or two of the operation.

Lichtenstein
Tension-Free
Repair

MESH
PERMANENT MESH
Commercial meshes are typically made of prolene
(polypropylene) or polyester.
Mosquito-net mesh-Meshes made of mosquito net clothes, in copolymer of polyethylene and polypropylene have been used for
low-income.
ABSORBABLE MESH
Biomeshes are increasingly popular since their first use in 1999.
They are absorbable and they can be used for repair in infected
environment, like for an incarcerated hernia. Moreover, they
seem to improve comfort.

LAPAROSCOPIC HERNIA
REPAIR
Transabdominal Preperitoneal
Procedure (TAPP)
Totally Extraperitoneal (TEP) Repair

Indications include bilateral inguinal

hernia, recurring hernia, need for
early recovery

LAPAROSCOPIC HERNIA
REPAIR

RECURRENCE
Around 1% for Shouldice repair
Most recurrences are of the same
type as the original hernia
Recurrence Factors
Patient
Technical
Tissue

RECURRENCE
Patient factors
malnutrition, immunosuppression,
diabetes, steroid use, and smoking.

Technical factors
mesh size, prosthesis fixation, and
technical proficiency of the surgeon.

Tissue factors
wound infection, tissue ischemia, and
increased tension within the surgical repair

complications
The overall risk of complications of
inguinal hernia repair is low.
Common Complications
Pain, injury to the spermatic cord and
testes, wound infection, seroma,
hematoma, bladder injury, osteitis
pubis, and urinary retention