Management of groin hernias Flashcards
(33 cards)
How may IAP be managed to optimise outcome in management of groin hernias?
weight loss, management of ascites,management of constipation and prostatism
IAP refers to intra-abdominal pressure, which can affect various gastrointestinal and urological conditions.
What nonoperative measure/medical comorbidities are particularly important to manage to optimise the outcome in management of hernias??
- Smoking cessation
- Diabetes control
- Use of abdominal binder for symptomatic relief of large uncomplicated hernias
What should be done if strangulation is not suspected in a hernia?
A reduction of the hernia can be attempted with appropriate analgesia. The patient must be observed after successful reduction.
Strangulation refers to the loss of blood supply to the herniated tissue, which is a surgical emergency.
What should be done prior to urgent surgery for acute or complicated hernias?
- Adequate intravenous fluid resuscitation
- Antibiotics
- Analgesia
- +/- Nasogastric tube (NGT) placement
What is a crucial consideration when manipulating a hernia with contents at risk of infarction?
The hernia should not be manipulated to avoid sepsis or reduction of missed strangulated bowel.
Should mesh be used in acutely incarcerated or strangulated hernias?
Generally contra-indicated; preference is for open primary tissue repair.
What should be considered if there is bowel obstruction, ischemia, or perforation?
Deal with the acute pathology alone, relieve obstruction, resect dead bowel, and do a primary closure or leave the hernia to be fixed later or plug with omentum.
What classification can be considered in the management of hernia wounds?
CDC wound classification
The CDC wound classification system classes wounds from class 1 to class IV. What are each of these classes?
I Clean
II Clean- contaminated
III Contaminated
IV Dirty
Give an example of types of hernia presentation for each of the CDC classes, and how the hernia should be repaired in each scenario
Class I: Clean: Elective repair or incarcerated hernia with no concern for strangulated. Repair Open or lap, + Mesh
Class II: Clean-contaminated: strangulated hernia / comminated bowel resection required. No major spillage or loss of sterility. Open repair, consider mesh
Class III: Contaminated: Strangulated hernia with bowel perforation or major spillage . Open, NO Mesh!!
Class IV: Dirty: Old, traumatic wound. Existing infection or perforated viscous. Open, NO mesh or referred repair.
What anaesthetic options are available in the repair of groin hernias?
General,
Regional (spinal),
Local.
What is the role of watchful waiting in the management of groin hernias in older patients, and in younger patients?
What is the rate of acute complications in asymptomatic patients with non operatively managed inguinal hernias?
What percentage of patients with non-operatively managed inguinal hernias will have deveoped symptoms at ten years such that they now require an operation?
Males asymptomatic or minimally symptomatic hernias and pregnant patients with uncomplicated hernias can be observed
Rational
RCTs have shown in asymptomatic pts the rate of acute complications (strangulation/incarceration needing OT) is low ~1-2 per /1000 pt yrs
However when followed up for 3yr then 10yrs the rate of increasing symptoms increase an approx 1/3rd need OT, ⇢ consider operating on younger pts
In what hernia subtype is is herniotomy performed, in inguinal hernia surgery?
Herniotomy – Excise hernia sac ® only performed if an IIH.
In a DIH, sac is formed from layers of the posterior wall of the inguinal canal ® so no herniotomy performed.
What are the subtypes of open inguinal hernia repair?
Herniorrhaphy – Approximation of adjacent tissues to restore normal anatomy
- Shouldice
- Bassini
- Nylon darn and/ or
Hernioplasty – Insertion of additional material/ mesh
- Lichenstein = Without herniorrhaphy
What are the subtypes of laparoscopic inguinal and femoral hernia repair?
TEP - Totally extraperitoneal (TEP) groin hernia
TAPP - Transabdominal preperitoneal (TAPP) repair
There are three approaches for open femoral hernia repair. Please name and briefly describe them.
- Low/ sub-inguinal (Lockwood) approach –
Used for small, uncomplicated femoral hernias (i.e. elective repair) → incision made over the hernia.
NB// +/- plug mesh
- Intermediate (Lotheissen): Inguinal approach
- High/ supra-inguinal (McEvedy) approach –
Used for large or complicated femoral hernias (i.e. emergency repair) ® access preperitoneal space, open sac, inspect sac contents +/- bowel resection, reduce contents and herniotomy. Then repair femoral ring.
What are the advantages of open inguinal hernia repair (cf laparoscopic)
Quicker
Cost less
Can be done under local/regional anaesthesia
What are the disadvantages of open inguinal hernia repair (cf laparoscopic)
Higher wound complications
Post-op pain
What are the advantages of laparoscopic inguinal hernia repair (cf open)
Less pain
Earlier return to work
Reduce wound complications - infection/haematoma
Bilateral hernias
Identify and repair concurrent femoral hernia
What are the disadvantages of laparoscopic inguinal hernia repair/in what clinical scenarios is laparoscopic inguinal hernia repair inappropriate (cf open)
Requires GA
- Large inguinal scrotal hernias - difficult to reduce laparoscopically
- Laparoscopic plane is not accessible or difficult, e.g.
Open prostectomy, bladder surgery, lower midline laparotomy or severe intra-abdo adhesions - Ascites
- When mesh repair is needs to be avoided
ie. gross infection, bowel perforation, small but real risk of bowel or major vessel injury
What is the difference in recurrence rate and in operative morbidity/mortality for laparoscopic vs open inguinal hernia repair?
There is no difference in recuurence rate or complication rate.
What is the general rule of thumb for open vs lap approach to inguinal hernia in the context of recurrence?
What is the recommendation for repair access in the context of bilateral inguinal hernias?
If orginal OT was Laparoscopic, then do open
If orginal OT was open then do laparoscopic
Bilateral hernias = do lap
What are the borders of the triangle of pain? what does it contain?
medial - gonadal vessles
lateral iliopubic tract
Contains the lateral and anterior femoral cutaneous nerves
What are the borders of the triangle of doom? What does it contain?
Medial - vas deferens
Lateral - gonadal vessels
Base - peritoneum
Contains - the external iliac vessels and the genital branch of the GFN
