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Hernia Surgery - Science topic
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Hi all,
Here’s a simple but still very important (I think!) question regarding the philosophy of mesh overlap in open ventral hernia…
I’m keen to clarify the concept of transverse diameter mesh overlap, the key point in open hernia repair
In lap ventral hernia repair it’s easy as there is a defect effectively left open and just covered with an IPOM mesh. Hence e.g. an 8x8cm defect needs to be covered with 5cm overlap in all directions i.e. at least a 13x13cm mesh
In open hernia repair the fascia defect is in the linea alba to be precise (not posterior or anterior rectus sheath). We can easily get craniocaudal overlap by dissecting retroxiphoid and retropubic into the cave of Retzius… BUT…
If we bring together the posterior elements (PRS) to ensure giant prosthetic reinforcement of the visceral sac (GPRVS) - the whole point of hernia surgery - then what about the 5cm overlap?
If the defect was e.g. 10cm but the PRS comes together, we only put mesh to the linea semilunaris on both side i.e. the natural limit of a Rives-Stoppa.
We do not go retromuscular into the TAR plane just for overlap if the PRS comes together (or at least I don’t!).
Thus when we bring the posterior layer together (and hence just do a Rives-Stoppa) the original defect may have originally been eg 8-10cm but is now closed in the posterior midline and our mesh in transverse diameter is eg 15cm, that is not 5cm overlap on all sides…
What do you all think?! Something I’ve long thought about! Do we overlap the original fascial defect, in which case we’d have to do more TARs even when the PRS comes together and a Rives-Stoppa will suffice; or just do we just cover from linea semilunaris to linea semilunaris and get craniocaudal overlap accepting that we have covered the viscera, got a nice retrorectus sublay plane for visceral protection and vascular graft and close the ARS on top…?!
Interesting to think about the basic principles!
Tell me if I’m way off!
Look forward to hearing peoples’ thoughts!
Many thanks,
John.
42 years old men having with all good medical reports and no pain in the past, just safety and future purpose, he is seeking help for hernia repair.
Which is best preferred Laparoscopic Vs Open surgery -epigastric hernia 1.5 cm ?
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It is very important to eliminate them in laparoscopic ventral hernia repair (LVHR) in order to prevent their many intra- and postoperative complications (organs iatrogenic lesions, intraoperative bleeding, hematomas, postoperative abdominal-wall chronic pain (1.4-30%), mesh breakdown, suture site infections, thin skin scars, etc.), and to reduce operation time.
In open surgery, the size of the incision may be a concern, while in laparoscopic technique the cost of the mesh may be a concern - how does one balance this option?
The use of mesh reinforcement for giant hiatal hernia repair is stilled among surgeons debates.
Do you use mesh reinforcement of the cruroplasty when performing antireflux and hiatal hernia surgery?
general surgeon had debate regarding immediate or delayed traumatic abdominal wall hernia , so which is better and according to what size or condition do we need to decide to do immediate or delayed repair
Can we check wound hyperalgesia after hernia surgery between Tap block with clonidine and spinal clonidine?
I have a patient in worsening pain and requiring removal of polypropylene mesh used 3 years ago for repair of a femoral hernia. It has been difficult finding an experienced surgeon. Any help appreciated.
mesh seem to be the modern innovation , but what is the impact for developing countries.
An orthopaedic expert stated in his report that as regards to an inguinal hernia, spinal belts are often used as part treatment of hernias. Would any surgeons care to comment on this?
This is the most important part of the Letter to the Editor that we sent (without references). If you have additional problems during experiments, new ideas for experiments or additional methodological problems, please state.
1. Man is unique in his bipedal stance and no animal model can precisely replicate the complex anatomic and structural forces placed on the human inguinal canal.
2. Ordinarily, spermatic vein testosterone levels are markedly higher than peripheral blood levels. One cannot completely exclude the possibility of sampling error despite samples being obtained as close to the gonad as possible to avoid any dilutional effects from the extensive collateral flow around the testes.
3. Subtle changes in number of Leydig cells might be difficult to quantify with light microscopy alone. Ordinarily, Leydig cell function is well preserved despite spermatogenic cell dysfunction or loss. Whether these findings represent an early or progressive defect remains unknown.
4. The vas sits between the external and internal spermatic fascia and involvement may depend on the amount of cremaster muscle or the presence of a cord lipoma, both of which can serve to buffer the vas from involvement by the mesh reaction. In addition, the vas is sometimes found in intimate association with the hernia sac and may require careful and complete dissection away from all surrounding structures leaving it with little adjacent tissue.
5. The same hernia classification system should be used for the comparison of the preoperative and postoperative results. Most studies have hernia-dependent exclusion criteria - bilateral, relapsed, femoral, incarcerated or strangulated hernias, and systemic disease exclusion criteria - cirrhosis, heart deficiency, diabetes mellitus hypertension, collagen vascular diseases.
6. Giant scrotal hernias or large hernias have predisposition for testicular atrophy but are not suitable for laparoscopic hernioplasty by many institutions. Therefore, in these most important groups comparison of methods is not possible.
7. Difficulty in comparing the results of different studies due to modifications of mesh composition, mesh placement technique and mesh size in open repair, slit mesh or non-slit mesh methods of TEP repair, performance by different surgeons.
8. Direct and indirect thermal injury and other types of direct damage to the vas deference and surrounding vascularization mostly not recorded in medical records. This significant underestimation can falsely indicate the mesh as the main cause of partial/complete vasal damage/obstruction.
9. Tremendous variability with adhesion formation and tissue fibroblastic responses to mesh (patient heterogeneity)
10. Tremendous time variability (3 days to 2 years) of postoperative investigations of testicular function/perfusion changes and vasal obstruction.
11. The vast majority of testicular nerves are sympathetic axons with vasomotor function and innervate the small vessels supplying cluster of Leydig cells and regulate testicular LH receptors and blood flow. Therefore, interruption or damage of innervation, not perfusion could cause changes in hormone production and blood flow.
12. Lichtenstein repair, contrary to the TAPP procedure, induced a higher (probably reactive) perfusion at the groin on a pig model, even 6 months after operation.
13. Ultrasonographic examination should be performed in the supine position, and the patients holding the penis suprapubically in a temperature controlled room after resting for at least 10 minutes.
14. There are no studies about the long-term potential effect of mesh placement on testicular function. RI may be a useful marker in research going forward in the male population subjected to mesh repairs at a young age.
15. Many animal studies have small number of animal groups for the power of statistical analysis.
History. Female 64 years old, BMI 21, physically fit very active lifestyle, high abdominal muscle tone. Flat abdomen with smooth abdominal muscles. Right inguinal hernia 2-3 cm easily reducible.
TEP laparoscopic repair. 24 hours post op excruciating pain BP 106/69 incontinent urine which was very dark brown, 2-3 mls bright red blood bulging from right incision dressing. 1cm black mark 1cm above right incision. 5cm umbilical incision. Abdomen extremely distended, agony, 2 cm painful epigastric lump with subcutaneous emphysema. 48 hours post op bruising developing lower right abdomen and right loin. Urine still brown and incontinent for 5 days. Took 3 weeks before able to walk properly.
Subcutaneous emphysema reabsorbed but left with 3 ventral hernias diagnosed by ultra sound. Also constant nausea, reflux, trapped gas, only eat small meals. 1 year on abdomen still potbellied despite core strengthening exercise.
Richter's hernia is a rare form of hernia when an antimesenteric part only of the circumference of the small bowel is strangulated in a hernial sac. This kind of hernia is reported for the narrowest openings in the abdominal wall: umbilical, femoral, and obturator.
Mechanisms of the Richter's to develop were suggested as early as in the 18th century.
The first hypothesis was coined by A. Littre, 1701, that that sort of herniation may occur if adhesions between an intestinal loop and hernial sac have developed before the hernia formation. There are no adhesions found in the majority of cases, though.
The second mechanism was suggested by A. Richter, 1778, that the hernia develops due to the so-called 'elastic constriction' by a narrow opening after coughing, etc.
However, all these openings (umbilical, femoral, and obturator) are not elastic absolutely, so that this mechanism seems to be almost improbable.
Is there any news on the matter since the 18th century?
laparoscopic inguinal and ventral hernia repair is slowly gaining popularity.Now a variety of meshes ,fixation devices and surgeons are adopting various modified steps in the standard procedures.Consequently various probable complications are expected.So the trainee should be aware of all these problems as hernia is a common problem.
A 55 year old obese female patient has undergone Open Mesh Repair for Ventral Hernia (Onlay Technique) about 45 days back. It was a large hernia with defect size of about 20 x 15 cm. Mesh was placed and vacuum suction placed over it. Even after 45 days drain output is about 100 ml per day. There is no evidence of infection and the suture line has healed well. Do i have to wait till output comes to less than 30 ml per day or remove it now and use compression dressing?
I would like to share the experience about groin hernia in children and the use of ultrasound to assess the presence of contralateral PPV.
“Groin disruption” in athletes is caused by a pattern of injuries known as “Gilmore's Groin”, “Chronic groin pain’”, “Sportsmans Hernia”, “Athletic pubalgia”, “Slap shot gut syndrome”, “Sports hernia” etc.
It’s description includes a lack of visible external signs in the affected groin, dilatation of the superficial inguinal ring (felt by inversion of the scrotum with the little finger tip), a cough impulse, and marked tenderness on the affected side. Groin disruption is a complex musculoskeletal disruption, not a true hernia.
If a Groin disruption is diagnosed and other disorders are excluded, the condition can be surgically repaired. For groin disruption open (mesh repair, sutured repair, neurolysis or neurectomy, etc) or laparoscopic surgery techniques (TAPP or TEP, etc) can be used. What operation is the optimal and most physiological for surgery of “groin disruption” in professional athletes? Which operation do you prefer? Open or laparoscopic? Mesh or sutures? Neurolysis or neurectomy? Commerce or medicine?
In trans abdominal proproteinial hernioplasty, is it important to fix the mesh??
Have you any experience in , not fixing the mesh??
Although most surgeons may claim to master all current hernia surgery techniques, a recent analysis show that outcomes of hernia surgery in different hospitals show a large variability. Additionally to two major problems of groin hernia surgery (chronic pain and hernia recurrence) remain a continuous challenge. A few networks (e.g. Denmark, Germany) have come up with a hernia database to monitor surgical quality and set benchmarks.
Do you think we need more quality management in hernia surgery?
We have about 15 cases experience with TAPP but it requires advance experience longer operation time. But at the end you are opening a new hetmiş site at the umblicus when compare with conventional kap TAPP.
We found this to be very annoying probelm during TEP hernioplasty. Even no tear is seen in the peritoneum at the end of the procedure pneumoperitoneum is present. We've tried changing troacar positions, lowering the pressure of insuflator- no significant effect. Finally we found solition for this situation by placing a Veress needle lateral to the 10mm port for the camera. What is your experience with this problem?
Laparoscopic inguinal hernia is an excellent technique with a lower complication rate and incidence of postoperative pain compared to conventional open repair. A rare complication is accumulation of fluid collection in the dead space left after removing the hernia sack. Post-operatively it presents as a lump in the groin region sometimes accompanied with groin or testicle pain. This gives quite big concerns to the patient and surgeon. As far as I know, conservative treatment is recommended. But is there any indication for surgical intervention?
How far one can proceed with aspiration? Is there another way to deal with Seromas following TEP repair? Inversion of the false sac and fixing it is one of the methods to reduce the seroma but what if happens postoperatively despite the above?
What about seromas following large incisional hernia repair?
I want to measure the size of the hiatal hernia during laparoscopy. Does anyone have a published or designed method?
Many of you would have performed many incisional hernia repairs, some specialists even in the thousands. Ever wonder why the defects are always circular ?
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We recently repaired a giant lumbar hernia and had a rare postoperative complication of delayed presentation of the loss of domain and ultimately managed it uneventfully.
Minimal access technique should be the gold standard and should be offered to patients when possible.One of the important issues in hernia surgery is Recti Diverication.Majority of patient are having advice of conservative measures like exercise,weight reduction,etc.Surgery is rarely suggested .
In the era of modern surgery,an acceptable and realistic solution is expected to be offered to these patients.
Case series here and there ,but no solid opinion is reflected in current literatures.
Have a patient who has most probably eventration of diaphragm. She is 77 years old and dyspneic plus there is divarication of recti. What to do?
I had a patient with recurrent attacks of inguinal pain following open mesh repair
Do you prefer open or Laparoscopic repair for uncomplicated hernias. For open repair, do you go for the high or low approach. What should be the strategy for acute presentations of these hernias?
52 year old male presented with acute abdominal pain, vomiting. History of similar episodes 2 to 3 times earlier settled spontaneously. This episode was severe hence attended ER at their own place. Plain x-Ray abdomen showed 3 to 4 fluid levels. CECT
in their place suspected to have paraduodenal hernia. When he was transferred to our hospital, started passing flatus and was feeling better but clinically mass was felt in the left hypochondrium. Exploration confirmed the diagnosis and the sac was excised, small was released placed in order. Could not close the the sac as it was too small.
This relatively new device is designed to close the annulus fibrosus defect and prevent reherniation. In any case it makes the discectomy more expensive. According to short-term observations this is a revolutionary device in disc surgery ? Is it really so?
The vertical suture of the rectus abdominis sheaths was stronger than the horizontal suture because of the more transversal arrangement of its aponeurotic fibers. Thus, routine use of the vertical suture in plications of the aponeurosis of the rectus abdominis muscles is suggested.
And is mash insertion indicated to prevent this?
The WSES Consensus Conference (Bergamo, 2013) guidelined the Cruse visual criteria as cornerstone for a desicion making whether or not a mesh should be implanted in the emergency repair of complecated abdominal hernia.
There are concerns regarding mesh infection during emergency hernia repair especially if a segment of bowel has compromised blood supply requiring resection. On the other hand, anatomical repair of these hernias will lead to a high recurrence rate. In these circumstances, what is your preferred technique of repair?
Surgery failures in patient who has undergone primary hiatal hernia laparoscopic repair are most commonly associated with recurrent herniation and breakdown of the fundoplication. The surgical techniques used to treat this failure are different: alternatives consist of laparoscopic reoperation, or laparatomic/transthoracic repair. How do you decide this dilemma?
For repair of inguinal hernia in infants and children, what age is appropriate for opening the external oblique muscle before herniotomy?
