Surgery for an Inguinal Hernia - Assignment Example

Topic: surgery for an inguinal hernia. Open and laparoscopic pros and cons for each one. Instructions: I have no essay criteria.I have to critically anaylise the work in this title. This is a presentation to a group. I dont have time to prepare for this. Let me know if you need more information and I will try to help. Many thanks Melanie Lister. Harvard Hernia is an abnormal protrusion of whole or a part of a viscus through an opening in the wall of the cavity in which it is contained. Treatment is divided into two parts conservative and operative. I am discussing about the operative part that is the surgical part. There types of operations are available 1. Herniotomy 2. Herniorrhaphy 3. Hernioplasty 1. Herniotomy It consists of excision of sac only. The sac is isolated, opened and the contents reduced. The neck of the sac is transfixed and ligated followed by excision of remaining portion of the sac. Indications: I. It is done in patients/children up to 14 - 16 years of age. II. In young adults with good musculature III. It should be applied or indirect inguinal hernia irrespective of age of the patient. It is important to note that herniotomy is not performed in direct inguinal hernia instead the sac is inverted here. 2. Herniorrhaphy It can be of two types: A. Bassini's and B. Shouldice A. Bassini's: Herniotomy+ with reconstruction of posterior wall of inguinal canal by approximating conjoint muscle and tendon to recurved edge of inguinal ligament with non-absorbable suture such as silk, nylon or prolene. This is known as bassini's repair. Silk is usually avoided as if it becomes infected it will cause sinuses. Aim of bassini's repair: Strengthen the posterior wall by pulling down the conjoint muscle and tendon behind the spermatic cord. Suture must be done with out tension as this will lead to cutting of the muscle or ligaments from their sutures. To avoid the tension one may add tanner's slide operation where a curved release incision is made in anterior rectus sheath above the conjoint tendon so that the lateral leaf of the incision at once retracts down and makes the tense conjoint tendon loose. Indications of bassini's Herniorrhaphy: I. Indirect hernia with good muscle tone II. Direct hernia with good muscle tone Criticism for bassini's Herniorrhaphy: I. It is a repair with tension II. Conjoint tendon and inguinal ligament approximation is not physiological. Modification added to bassini's repair have been advocated: I. Repair of stretched internal inguinal ring on its middle side if it is too wide - in indirect hernia. II. Plication of fascia transversalis - direct hernia. III. Halstead modification: Spermatic cord is exteriorised by suturing the external oblique aponeurosis behind it. Thus cord remains insubcutaneous. IV. Willy - Andrews modifications: Upper flap of external oblique aponeurosis is sutured down to inguinal ligament as an added posterior layer and lower flap is brought over the cord and sutured to upper flap, so that cord was sandwiched between two layers of external oblique. Indication: adults with week abdominal musculature. Note: Irrespective of type of hernia, Mesh repair (Lichpenstein) is recommended today as first line of repair. B. Shouldice: I. It is the most popular tensionless method where only local tissues are used. II. After opening the inguinal canal herniotomy is done. III. Transversalis fascia which forms the posterior wall is incised from internal ring till pubic tubercles. IV. Upper and lower flap of transversais facia are sutured in double bresting manner by using non-absorbable sutures like 34-gauge stainless steel wire, poyamide or polypropylene. This is the first layer of shouldice repair. V. The second layer is like bassini's where conjoint tendon is sutured to inguinal ligament by using non-absorbable sutures. VI. The third layer is completed by suturing upper flap of external oblique aponeurosis to the inguinal ligament. VII. The results have been good in shouldice hands and operation needs expertise. 3. Hernioplasty: Herniotomy+ reinforcement of posterior wall of inguinal canal by filling the defect of the posterior wall by some material, autogenous or heterogenous. Hernioplasty refers to strengthening the posterior wall of inguinal canal. Two types of hernioplasty are commonly practiced. I. Strenthening the posterior wall of inguinal canal by a prolene mesh or Marlex mesh. The fibroblasts and capillaries grow over the mesh and thus converting it into thick fibrous sheath (Lichtenstain repair). Mesh is to be sutured to transversalis fascia, lacunar ligament and inguinal ligament. Lacunar ligament is that portion of the inguinal ligament which extends backward and upwards to pectineal line and forms middle mergine of femoral ring. II. Prolene darning: Suturing the conjoint tendon to inguinal ligament with out tension in a crisscross manner by using prolene suture material (hand made mesh). This is preferred indirect and direct hernias. Indications of hernioplasty: I. Indirect or direct hernia with a good muscle tone as in such cases darning can be done. II. Indirect or direct hernia with week muscle tone - mesh plasty is preferred. III. Recurrent hernia Note: autogenous materials means patients own tissue like strip of fascia lata taken from lateral side of the thigh (Gallie) 2. Strip of external oblique aponeurosis taken from cut edge of upper flap of external oblique aponeurosis (MacArthur). 3. A strip of skin taken from margin of incised wound and made into ribbon(Mair) 4. Other acts like dermoplasty, and Bloodgood. Note: Heterognous materials: any non-absorbabale suture like silk, nylon, prolene, stainless steel wire can be used for darning. Other surgeries for inguinal hernia are: I. kuntz operation II. Andrews imbrication III. Mcvay IV. Nyhus repair I. Kuntz operation: Spermatic cord is divided at deep ring and is removed along with testis so that the deep ring can be permanently closed and hernia never recurs. It is indicated in elderly patients with recurrent hernia and poor abdominal muscle tone. II. Andrews imbrication: In this operation overlapping of external oblique aponuriosis III. Mcvay: It refers to suturing of conjoint tendon to Cooper's ligament. IV. Nyhus repair: Ideally indicated in by lateral direct hernia where a broad mesh is kept in preperitoneal space. SURGICAL TECHNIQUES: Open and laparoscopic (Keyhole) surgery Hernia repair is carried out as a day case with no overnight stay in hospital. Open hernia repair is most common among the two but if the hernia is on both sides of groin or is a recurrence then laparoscopic (Keyhole) surgery is recommended. Before anesthesia you must not eat, smoke or drink for about six hours. Some anaesthetists allow occasional sips of water until two hours earlier. Nurse will take care of the patients and will test your urine along with checking your heartbeat, blood pressure. You may be asked to shave your groin or wear compression stockings to help prevent blood clots forming in the veins of your legs. The operation takes 30 to 50 minutes depending on the technique used. Figure1. Inguinal hernia and use of anaesthetic before operation. Complication of operations Intraoperative I. Injury to inferior epigastric vessels II. Injury to external iliac vein III. Injury to vas deferens IV. Injury to urinary bladder V. Injury to contents of the sac Early postoperative I. Retention of urine II. Haematoma of cord and scrotum III. Wound infection Late postoperative I. Neuralgic pain due to ilioinguinal nerve involvement II. Recurrence III. Sinuses IV. Atrophy of the testis due to damage to spermatic cord V. Painful scar VI. Epidermoid cysts Recommended measures for patients I. When the patient is hospitalized the foot end of the bed is raised so that that irreducible hernia may reduce by gravity. This step cannot be recommended if there is a suspicion of gangrene. II. Ryle's tube is introduced to decompress the stomach thus preventing vomiting and reducing the abdominal distension. III. Intravenous fluids are given to correct dehydration and to prevent renal failure. IV. Analgesics are given to reduce the pain V. Attempts should be made to reduce the swelling when there is no gangrene by following measures: a. Good sedation b. Patients thigh is flexed, adducted and medially rotated. c. With right hand sac is gently squeezed by applying the pressure over the scrotum. At the same time the left hand is used to the proximal potion of the sac, which is guided into the inguinal canal. This process is called taxis and is contra indicated if there is gangrene. e/ complications of force reduction: This include 1. Contusion of intestinal wall 2. Rupture of sac at neck and reduction-en-mass. It means the entire sac with a contents are reduced into the abdominal cavity. VI. Now the preparation is prepared for the surgery and the blood is arranged for it. VII. If the patient is suffering from any complication like diabetes the following precautionary measures should be taken in case of diabetes mellitus type 2 the measures like diet intake should be measured. Low calorie intake like low fat, low sugar, low caffeine, no drugs, cigarette and alcohol should be reduced. Low intake of salt content is very important. Consumption of food should be high in high protein and low fat calorie intake. VIII. Drugs containing the blood glucose level should be regularly taken to control the blood sugar level. Examples like glicazide, glimpizide, sulfonylureas, diathiazones, alpha-glucose inhibitors etc. What to expect afterwards If patient have general anaesthesia, he will be taken from the operating theatre to a recovery room, where he will come round from the anaesthesia under close supervision. After this (or immediately after an operation under local anaesthesia) he will be taken back to his room. Patient will need to rest until the effects of the anaesthesia have passed. Nurse will check the operation site and monitor his heart rate and blood pressure. Patients' groin area may feel sore and he may need painkillers. When a patient feel ready, he can begin to drink and eat, starting with clear fluids. Patient will usually be able to go home once he has made a full recovery from the anaesthesia. However, he will need to arrange for someone to drive him home and then stay with him for the first 24 hours. Before the patient goes home, his doctor may give him antibiotics to take home. He will be given instructions on how to use these and advice about caring for his healing wound(s), hygiene and bathing. After you return home If a patient needs painkiller, he can continue taking them as advised by the hospital. General anaesthesia can temporarily affect patients' co-ordination and reasoning skills, so patient should not drink alcohol, operate machinery or sign legal documents for 48 hours afterwards. Surgeon will give specific advice about when he can resume his normal lifestyle. In general, patient will need to take it easy for the first two to three days. He should not lift heavy items or do strenuous exercise for at least a fortnight. He may experience some discomfort in the groin area for a few weeks after the operation, but this will gradually settle and can be helped by wearing close-fitting underwear. Vegetables, fruit and high fiber foods such as brown rice and whole meal bread and pasta is recommended to eat. This helps to avoid constipation, which can cause straining of the wound and discomfort. Dissolvable stitches will disappear in about seven to 10 days. Work cited "Advice for Adult Patients Having Inguinal Hernia Repair." Royal College of Surgeons of England. 4 Nov. 2007 . Bhattacharya, S K. Short Cases in Surgery. Fifth ed. Delhi: CBS, 2005. 1-285. Brygel, Maurice, and Lesley Pocock. "Pre-Operative Evaluation of the Elderly." Middle East Journal of Age and Ageing 3 (2006). 5 Nov. 2007 . Chhikara, Sumit, Anupam K. Singh, Sandeep K. Thakur, and Pradeep Gupta. Manual of Surgery. First ed. Noida: Jaypee, 2005. 1-279. Hess, Christopher. "Laparoscopic Inguinal Hernia Repair." 25 May 2005. 6 Nov. 2007 . "Inguinal hernia." Wikipedia. 31 Oct. 2007. 6 Nov. 2007 . "Inguinal hernia." Wikipedia. 2 Nov. 2007. 6 Nov. 2007 . "Laparoscopic surgery for inguinal hernia repair TA83." NICE. 4 Nov. 2007 . Rishi, Manyu. "Open and Laparoscopic (Keyhole) Surgery Images." Email to the author. 8 Nov. 2007. Shenoy, Rajgopal K. Manipal Manual of Surgery. Second ed. Delhi: CBS, 2006. 1-827. Read More