HERNIOPLASTY

HERNIOPLASTY
Procedure of strengthening of weakened
abdominal wall.
Weakening of abdominal wall tissue is one of
the causes of inguinal hernias
But early generations of prosthesis resulted in
disastrous complications that where due to
rejections and infections
It was not until the introduction of
polypropylene mesh by USHER in 1959
HERNIOPLASTY was realized
 Techniques of Hernioplasty

 Open anterior approach

 Open preperitoneal approach

 Combination of anterior &

preperitoneal
 Laparoscopic repair
 Open anterior approach
 Lichtenstein tension free hernioplasty
 Mesh plug &patch

Open preperitoneal approach

 Anterior approach –Read Rives
 Posterior approach

• Wantz/ Stoppa

• Kugel & ugahary

 Contd…

Combination of anterior& preperitoneal

approach
 Prolene polypropylene hernia system

Laparoscopic methods
 Transabdominal preperitoneal

 Totally extraperitoneal

 Intraperitoneal onlay of mesh

 OPEN ANTERIOR APPROACH
Lichtenstein tension free hernioplasty
 With the necessity of prosthesis for repair
of inguinal hernia in mind & focusssing on
principle of “ no tension” Lichtenstein
popularized routine use of mesh in 1984 &
coined the term “TENSION-FREE
HERNIOPLASTY”
 Contd…
 The prosthesis placed in between
The prosthesis placed in between
transeversalis fascia & external oblique
aponeurosis extends well beyond
Hesselbach’s triangle to provide
sufficient mesh /tissue interface.
.
 In tension –free hernioplasty ,instead
of suturing anatomic structures that
are not in apposition the entire
inguinal floor is reinforced by a sheet
of mesh
 Contd…
 On increased intraabdominal pressure
external oblique aponeurosis applies
counter pressure on mesh thus using
intraabdominal pressure in favor of
repair
 OPEN ANTERIOR APPROACH
Lichtenstein tension free hernioplasty
Procedure
Can be done under local
anaesthesia.
A 5 cm skin incision
starting from pubic tubercle
and extends within langer’s
line.
External oblique
aponeurosis is opened
 Contd…

The cord with its

cremaster covering is
separated from floor of
inguinal canal & pubic bone
for a distance of 2 cm
beyond pubic tubercle.
Cremasteric sheath is
incised / longitudinally at
the level of deep ring.
Indirect hernial sac is
freed from cord & inverted
back to abdomen without
ligation.
 Contd…
 Direct sacs are inverted
with an absorbable suture.
 Rounded corner of 8 x16
cm of monofilament
polypropylene mesh is
sutured to aponeurotic
tissue overlapping pubic
bone by 1 to 1.5 cm
 Contd…
Lower end of patch is attached
to inguinal ligament just lateral
to internal ring.
In femoral hernia mesh is
sutured to cooper’s ligament also
to close internal ring.
A slit is made at the lateral end
of mesh creating 2 tails
The wider upper tail is crossed
over narrower one .
 contd
 Upper edge of patch is sutured in place with 2
absorbable sutures ,one to rectus sheath &the
other to internal oblique aponeurosis.
 Using a single non absorbable monofilament
suture the lower edges of tails are fixed to
inguinal ligament just lateral to completion
knot.
 The excess patch on lateral side is
trimmed ,leaving 5 cm of mesh beyond
internal ring.
 External oblique aponeurosis is closed over
cord with an absorbable

suture
 Outcome measures
 Postoperative pain is minimal
 Can return to work with in 2 to
14 days.
 Recurrence rate is less than 1
%
Complications
 Infection , hematoma,seroma
(1%of cases)
 Chronic neuralgia,testicular
atrophy(fraction of 1% of
cases.)
 Meshplug &patch

Developed by Gilbert
Technique
Hernia sac is dissected back
to preperitoneal space.
A flat sheet of polypropylene
mesh is rolled up in the form
of a cylinder.
This plug is inserted in defect.
 Contd

For a direct hernia plug is secured to neck

of defect.
For an indirect hernia to internal ring
Some of petals are removed to avoid
unnecessary bulk.
MILLIKAN modified it by sewing inside
petals to ring of defect.
I e,to Cooper’s ligament for direct and to
internal ring for indirect hernias.
 PRINCIPLES OF MESH
 REINFORCEMENT

 LESS RECURRENCE

 PATIENT COMFORT

 GREATER DAY CASE SURGERY

 About prosthesis
Cumberland’s ideal prosthetic
material
 Not modified physically by
tissue fluid
 Chemically inert
 Does not cause
inflammatory/foreign body
reaction
 Not carcinogenic
 Resistant to mechanical
strain
 Pliable & moldable
 Easily sterilized
 Contd…
 Initially metal
prosthesis were
used
 Then plastic
prosthesis came &
 Now polypropylene
meshes are used
 CLASSIFICATION

 NON-ABSORBABLE
Polypropylene Mesh
Polyester Mesh
 PARTIALLY ABSORBABLE

Composite Mesh
 ABSORBABLE

Polyglactin Mesh
POLYPROPYLENE MESH

Use of porous polypropylene

mesh allows large area for
ingrowths of connective
tissue leading to
permanent fixation of
prosthesis within
abdominal wall
 COMPOSITE MESH -
MULTIFILAMENT
FEATURES & ADVANTAGES
 Partially-Absorbable
 made of c. 50% polyglactin and 50%
polypropylene in mass
 Macroporous
 5 mm pore size (5000µm)
 Multifilament
 filaments of polyglactin and
polypropylene twisted together to
form composite yarns; yarns then
knitted to form composite mesh
structure
 Lightweight
 70% less permanently implanted
residual mass than polypropylene
 Behaves like abdominal wall
after absorption of
polygalactin
 reduces patient discomfort

 Optimal handling, pliability &

cutting characteristics due to
exclusive fabric construction
 appropriate stiffness initially
after implantation

 Less foreign mass over time

due to partly absorbable
construction

 Optimal tissue ingrowth due

to macroscopic pore size
 Composite mesh monofilament
 Knitted light weight
mesh for abdominal
wall reinforcement
 Composed of equal
parts of absorbable
monofilament
poliglecaperone &
nonabsorbable
polypropylene

 Pliable multilayer tissue separating
mesh
 Used for open &
laparoscopic hernia
repair
 Composed of
monofilament
polypropylene
encapsulated with
absorbable
polydioxanone &
oxidised regenerated
cellulose
 Open preperitoneal
Anterior approach-Read Rives
Technique
 Starts like classic Bassini.
 Inferior epigastric vessels are
identified &preperitoneal space is
opened.
 Spermatic cord is parietalised
 12x10cm piece of mesh is positioned
in preperitoneal space
 3 sutures are put each to pubic
tubercle, cooper’s ligament & psoas
muscle.
Transeversalis fascia is closed over prosthesis
 Posterior Approach
GPRVS by Stoppa
Giant Prosthesis for Reinforcement of Visceral sac
Indications
 Recurrent Hernias
 Multiple herniations
 Patient with obesity, advanced age or cirrhotic
ascites
Principle
 All groin hernias cross through musculopectineal
orifice. Within this the drum like transeversalis
fascia resist intra abdominal pressure & a mesh
prosthesis can reinforce this layer.
 Technique

 Can be done under local, spinal

or epidural anaesthesia
 Abdominal wall is incised in midline.
 Umbilicoprevesical fascia is cut along its entire length
 The preperitoneal & prevesical cleavage begun inferiorly
and medially in space of retzius.
 Dissection proceeds laterally under rectus abdominis &
posteriorly to inferior epigastric vessels
 Cleavage continues in space of bogros.
 In direct inguinal& femoral hernia pedicle of hernia
isolated from spermatic cord


 Contd…

 In indirect inguinal hernia pedicle

of hernia is connected to spermatic
cord
 External iliac vessels are exposed
within there sheath
 Hernia sacs are treated according
to there degree of adhesion
 Spermatic cord is retracted
 Funicular elements are separated
from peritoneal envelope.
Placement of giant prosthesis
The prosthesis is measured
directly on patient
The prosthesis is then cut into a
chevron shape
The giant prosthesis is then
simply
Spread out in place by grasping its corners
&middle of each side with 8 long kelly forceps
Placement is achieved by pushing the prosthesis
 Contd

 When necessary, drains

are installed anterior to
prosthesis
 Closure of midline incision
wound is by slowly
absorbing synthetic
material
 Subcutaneous fat is
approximated with fine
absorbable sutures
 Skin is closed with fine
monofilament nylon
 Post operative care
 Slow acting heparin
is used for first few
days after operation
 Antibiotics given
routinely
 Suction drain &
dressings are
removed on second
postoperative day
 The patient can be
discharged between
2 to 5 days
 Contraindications
Absolute
 Risk of sepsis in region of surgery
Relative
 Midline scar of previous surgery
 Impossibility of using anesthesia
 History of iliocaval thrombosis
WANTS OPERATION
Unilateral half cut GPRVS performed under
local anaesthesia
 Kugel
(A small 2 to 3 cm skin incision needed)
 This point is located by making an
oblique incision 1/3 lateral& 2/3 medial
to a point halfway between anterior
superior iliac spine and pubic tubercle
 The transeversalis fascia is opened
vertically
 Preperitoneal space is entered
 Inferior epigastric vessels retracted
medially and anteriorly
 Most hernia sacs are simply reduced

 Contd

 Specially designed 8x12cm prosthesis to fit through

small incision sprigs open to regain its normal shape
providing wide overlap over myopectineal orifice
UGAHARY’s operation
 No need of special prosthesis
 Instead a 10x15 cm piece of polypropylene mesh is
rolled onto a long forceps
 The rolled up mesh is introduced into preperitoneal
space
 Mesh is unrolled using clamps
 Combination of anterior &
preperitoneal approaches
PROLENE POLYPROPYLENE HERNIA SYSTEM
 Done for most primary& recurrent direct and indirect
inguinal hernias
Procedure
 Can be done under local, spinal or epidural anaesthesia
 A 5cm transverse incision extending lateral from pubic
tubercle is made
 Skin incised & subcutaneous layer is opened
 Superficial epigastric vessels are divided and ligated
 Contd
 External oblique aponeurosis is
opened through external ring
 Its medial flap is separated
from internal oblique creating
an anterior space
 The spermatic cord is retracted
 The mesentery of cord is
opened to accommodate on
lay patch
 The transparent internal
spermatic fascia is opened
 Contd

The INSERTION MANEUVER

 The sac is invaginated through
internal ring & surgeon’s
forefinger is inserted
 An open 4 x 4 sponge is passed
on medial side of forefinger to
develop properitoneal space
 Contd
 By sponge’s traction the sac
is separated from elements
of cord &from transeversalis
fascia superficial to it
 For direct hernia
Hesselbach’s triangle is
opened
 The device is slid down ,the
medial side of finger into
properitoneal space
 Contd
 For indirect hernias the direction of
insertion is medial & superior
 For direct hernia the direction of
insertion is at right angle to the
opening
 Using a long forceps the edge or
circular underlay patch is deployed
from connector
 The onlay component is gently
extracted
 Underlay patch flattens against
abdominal wall when the patient stands
 Contd
 The surgeon places a finger in
connector of device& fully
extracts onlay component
 Then the lateral flap is
inserted beneath external
oblique in anterior space
 The connector remains in
internal ring
 The end of medial leaf is
positioned over pubic tubercle
 A central slit is made on onlay
patch to accommodate
spermatic cord
 Contd
 The tails are crossed & fixed with a
single suture
 The spermatic cord & ilioinguinal
nerve are replaced on onlay patch
 The external oblique is closed with
continuous suture recreating external
ring
 The subcutaneous layer is closed
 Derma bond is applied to skin
 Patient can be discharged after being
able to urinate
Laparoscopic methods
Indications
Recurrent hernia
after an open repair
Bilateral hernia
Inguinal hernia in a
patient who requires
laparoscopy for any
other procedure
 The major LHR are

 Totally extra
peritoneal
 Trans abdominal
preperitoneal
 Intra peritoneal onlay
of mesh.
 Transabdominal
preperitoneal(TAPP)
Procedure
 Usually performed
under GA
 An angled
laparoscope & 3
cannulae are required
 Umbilical cannula is
inserted first to
introduce laparoscope
2& 3 cannulae are placed just lateral to rectus
muscle at the level of umbilicus
 contd

 Peritoneum is incised 2
cm above superior edge
of hernia defect
 Cooper’s ligament is
dissected to its junction
with femoral vein
 Iliopubic tract is identified
&dissection continued
inferiorly
For DIRECT hernia
 Sac & preperitoneal fat is
reduced from hernia orifice
by gentle traction
 Peritoneal sac is separated
from transeversalis fascia
For INDIRECT hernia
 A small sac is mobilized from
cord structures & reduced
back into peritoneal cavity
 A large piece of mesh 11 x
6cm is placed over
myopectineal orifice to cover
direct, indirect &femoral
spaces
 Contd
 Medial edge of
mesh is stapled to
contra lateral pubic
tubercle &
symphysis pubis
 Medial inferior
border is secured
to cooper’s
ligament
 Contd…
 Mesh is stapled along
superior border to
posterior rectus
sheath&
transeversalis fascia
at least 2 cm above
hernia defect
 A point lateral to
anterior superior iliac
spine is location for
lateral edge
 Contd
 After fixation redundant
portion on inferior border is
trimmed
 Peritoneal flap is pulled over
mesh &pneumoperitoneum is
released
 All trocar sites are closed
with absorbable intracuticular
sutures
Totally extraperitoneal approach
Procedure (TEP)
 An incision is made at the
umbilicus
 Rectus sheath is opened on
one side &rectus muscle
retracted laterally
 The space is enlarged by
operating laparoscope
 Then 2 additional cannulae
are placed in midline
 Contd
 The dissection of preperitoneal space is
completed under direct vision
 Then proceeds as TAPP procedure
Advantages of TEP
 Intraabdominal organ injury or postoperative
bowel obstruction secondary to adhesions
caused by entering peritoneal cavity are
avoided
Intraperitoneal onlay of mesh
(experimental procedure)
 No peritoneal dissection involved
 Hernia sac is undisturbed

 Prosthesis is placed one layer deep to

preperitoneal space directly onto peritoneum
Disadvantages
 The prosthesis comes in direct contact with
abdominal organs &cause visceral adhesion,
erosion, fistula formation & sepsis
 complications
Related to
laparoscopy
 Bleeding
 Visceral injury
 Bowel obstruction
 Diaphragmatic
dysfunction
 Wound infection
 Hypercapnia
 Related to patient
 Ileus
 Aspiration pneumonia

 Cardiovascular & respiratory insufficiency

 Nausea and vomiting

 Urinary complications
 Related to hernia repair

Neurological complications
Cord & testicular complications
Hydrocele
Wound & prosthetic infection
Retroperitoneal hematoma
Foreign body reaction to mesh
 Contraindications
Absolute
 Intraabdomnal
infections
 Coagulopathy
Relative
 Previous surgery
 Ascites
 Incarcerated sliding
scrotal hernia