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Inguinal Hernia

Oct 22 | 1:30 PM

Due to a lack of awareness, inguinal hernias are one of the most common problems treated by general surgeons in India, with significant morbidity and mortality. Inguinal hernias are relatively common; research estimates that approximately 27% of men and 3% of women will develop one at some point in their lives. Let us examine the current surgical approaches for treating inguinal hernias with Dr Monty Khajanchi.

[Music] um good evening everyone and uh i'm dr niveda from netflix and on behalf of team netflix i welcome you all to today's session on inguinal hornia uh we have with us today uh dr monty kajanji who's the assistant professor of general surgery at uh safety is medical college in km hospital mumbai uh sir has been a part of many global health projects and grants and along with that he's also had also presented at uh various uh national and international conferences hello good evening everyone and thank you at the outset i would like to thank matrix for giving me the opportunity to connect with so many students at one go thank you matrix so i don't believe in lectures anything more than 40 to 45 minutes so we have enough time after that probably i may finish before that also being vinyl hernia it's a very broad topic and before i even start with this topic i would like to understand uh what the audience is like so if i may ask nivedita to just share the poll i discussed with you to understand my audience so that i can go into the discussions or go into the lecture uh you know the depth i need to get into yes so i'm running the poll now uh there are five options so you all can scroll in case you're not able to see all the options it says mbbs student pg students senior resident general practitioner and others so you if you are a consultant then you can just select others so we have a lot of mbbs uh students there's about uh 36 of the audience is uh mbbs students and 26 are general practitioners uh others so i'm uh so a lot of consulting physicians as well and pg students and very few senior residents right so there's a quite a mix of students and consultants and senior residents who knowing wendell hernia pretty well um so so feel free to at the end of the lecture to ask but the majority is general practitioners or mbbs so my la my whole talk may be directed towards them because that's the majority of the audience i am going to move on from here and as a pg student or as an mbbs student i think this is something which we come across uh in uh in most of our clinics in most of our opd or in hospital patients or uh even the operation theaters what we come across and though uh it's it's you know so common there but uh the whole fact that you would have heard so many repairs when you are going through ingrained hernias chapter that a long time ago a professor in surgery told me that if there are many ways to do a particular thing no way is perfect and so people have been still adopting adapting to different techniques and innovating their own techniques and that's uh that what makes inguinal hernia very interesting navita has given me a very very broad topic i would say and to cover all aspects in this lecture it's going to be boring first of all and it's not possible also so whatever i would try to touch upon the important stuff in the inguinal hernia and feel free then uh to discuss your clinical queries or anything else you feel uh would be relevant for you oh so this is what i have kind of broadly uh made my lecture into the definition ideology anatomy again idiology or pathogenesis sorry for that classification diagnosis treatment options old and new complications and guidelines on environment so these whole lecture have been based on certain guidelines the european hernia society even the japanese hernia society and the international hernia societies and most many of the stuff is from your textbooks also so if you quickly look why this inguinal hernia not all the hernias but inguinal hernia per se is very important is because of the whole burden of disease which is there and at times you know the whole numbers run into 20 million groin hernias which are performed worldwide each year and being into some amount into public health or some amount into global health i would say that uh more than uh in 20 million around uh around only a million is done by the u.s alone uh the hernia surgeries each year uh in particularly england hernia and this would uh uh leave the other whole world to a 19 million and we still have a huge burden in our opd's in our uh setups which is the low middle income setup and uh with the uh i think we need to gear up or shift up our all general surgeons need to move up and educate also and uh kind of get into the whole even if you're a gi surgeon and any surgeon you can contribute by repair by doing a good uh inguinal hernia surgery and so there are guidelines about being symptomatic or asymptomatic uh and 30 have they found about uh symptomatic hernias which nowadays if it's uh asymptomatic they would ask them to wait uh for now uh a smaller symptomatic hernia not the large ones but the small ones five to ten percent of them complicate not the uh symptomatic but overall five to ten percent complicate the complications uh you would very well know and are obstructions triangulation uh they would come those are the complications in inguinal hernia 17 are recurrent surgeries out of all the surgeries done in inguinal hernia 17 are because of recurrence smokers have increased incidence of hernias and this last statement i thought was very novel or i even i found it very different because i was the opinion before this lecture that obesity is a cause of inguinal hernia but actually speaking obesity is protective as studies ensured i would get into depth of that not now but so definition a hernia is the bulging of the part of the contents of the abdominal cavity through a weakness in the abdominal wall so i would explain my patients if asked because that's what we all do is clinical practice is what you your patients need to understand one first you have understood and digested and then you explain so i generally give the example of a bag which is there so hernia is like a bag your abdomen is like a bag and if there is a defect in the bag things from inside the back start coming out or leaking out and the inside of your abdomen or your bag is all the intestines which are there or the fat which is there and which starts coming out and when there is even more pressure this would gradually increase or the whole hole or the defect would increase in size so uh that's what i would give as a simple example to the patient rather than this whole textbook definition which is important for the mbbs student when he kind of is asked in the exam about definition of a hernia but the simple definition is it's a bag and which has a defect and that starts uh you know leaking the contents from inside the bag uh so why does this really happen is because uh of the natural weaknesses which develop during the whole you know the uh during the whole fetal development descent of the testis which happens in the inguinal regions through the deeping vinyl ring is uh the whole deep environment ring itself you know tries to accommodate other than the cause structures even the test is down into the scrotum and that actually causes a bit of a bit of a weakness uh there are other theories or there are other causes which are the patent processes analysis which happens and it lacks to fuse and that is one of the reason which uh the indirect inguinal hernia really occurs so again the femoral region in the femoral region there are are obturators sorry in the femoral region there is a femoral hernia and that's because of the femoral vessels which grow there's a mistake out there there are obturator vessels which come out or from the obturator for ramen and that's why the obturator hernia there is a inherent weakness and the esophageal like the esophageal hiatus also it's a defect in the diaphragm and from where there is a uh hyattsonia which can develop so the whole abdomen is like a bag and there are these you know natural weaknesses or defects which are there and to these defects is what the hernia the hernia occurs now moving on why do these hernia occur at these weaknesses is one is the basic design is weak weakness due to structures entering and leaving that we've seen uh there are developmental failures at time process is vagina this is one good example uh there is a weakness because of the collagen uh which there's a congenital uh formation of the collagen which is there is not properly being developed so there is weakness in the tissues and the ligaments there and that again gives rise to hernia uh trauma gives rise to sudden increase in pressure and trauma gives rise to a weakness of the muscles and then probably a defect in there weakness due to aging and pregnancy is uh noted other than in vinyl in these ages your pregnancy have a very common umbilical hernia which occurs and even in obesity we've seen and this we know that obesity is one of the causes for umbilical hernia which is again a site of natural weakness there can be primary neurological and muscle diseases again that amounts to a weakness in the posterior wall of the inguinal hernia which gives rise to a direct inguinal hernia now excessive intra-abdominal pressure like ascites obesity bladder outlet obstruction etc is one of the aggravating factors which leads to a hernia if you already have a weakness which is a natural weakness uh obesity ascites that outlet obstruction uh leads to more chances of inguinal hernia so here you can see uh that these are the natural weaknesses you know the chord or the schematic chord which is coming out uh also from the deeping vinyl ring the obturator uh nerve which is coming out from the obturator for ramen uh i can't show the femoral vessels but yeah right beneath the is there a pointer out here i can use the pointer is there's no way for a point no sir you can um okay okay yeah yeah that's fine so yeah so these are the natural orifices which from which the hernia can occur so yeah so prochardin project had discussed about the myopectenial orifice and that's was to do more with the femoral hernias or the femoral vessels how they travel and this whole orifice is com or the myopectin orifice is uh composed of the pelvic and the uh ilium the ligaments there the muscles there and all the vital structures which are coming in and out from there uh so he described for the femoral but that theory or the whole myopictaneous or if his theory has extended over to the vinyl region and now the whole anatomy is being you know when it comes to inguinal hernia anatomy it is already always remembered for it so it is an oblique canal in the groin area and which is covered by muscles aponeurosis bone ligaments you know all this comprises that uh that bit of a structure which comes which is situated in the groin obliquely and from right from the deeping vinyl ring to the superficial inguinal brain it is of made up of varied structures it's not only one but of varied structures and what it contains uh what is the main content of it is the schematic code which contains your west vessels to the testes your past deference your vessels to the vas the pamphlet form texas the genetic female now uh generating branch of the genito femoral nerve and yeah so these are the vital structures which are in the spermatic cord so we call it vital everybody knows all blood supply to the testis and the vas is its importance and going on this is the diagram for uh in vinyl region you can see particularly i would like other than the uh anatomy class which you have already done uh for the whole practical pg purpose i would always tell them see how close the relationship of the femoral vessels is to the inguinal ligament because when you take that bite or when you do a repair for this hernia that whole inguinal ligament bite which you take needs to be very very superficial because the vessels are lying right beneath the inguinal ligament i have seen in my own experience uh people taking deeper bites and you can see the blood you know going up to the ceiling because of a rent in the femoral artery so be very careful when you uh take these bites in the inguinal ligament and of course just to understand uh there is hasselbach's triangle which is divided by the inferior epigastric artery and will come up come across its medial it's the direct hernia if it's lateral it's the indirect hernia to the epigastric artery yeah so this is the superficial or the external oblique the first diagram about on the left shows uh the external oblique fascia which completely covers it and there's a small defect which is there now this is typically show going and the quad structures are going into the test is here through that small defect which is the superficial inguinal ring here is the superficial dissection once you remove this external oblique you can see the deep the cord coming out from the deeping one ring this is shown uh the round ligament is shown this is a female patient the round ligament which traverses into the superficial ling vinyl from the deep structure yeah here you can see it better and what compo the deep ring is composed of the internal oblique muscle as well as the cremaster cremaster muscle and the transversus abdominis muscle where uh where is the superficial uh sorry now deeper to this is your transversalis fascia uh which is lies much beneath the cord structures that forms the floor of the inguinal hernia so these these nomenclatures are important because as we go into the surgical aspects of hernia we would like to you would like to picture all this to understand you know how you how one has tried to come across or prevent or treat hernia and also prevent recurrences so this was all the anterior view when you open the skin and go in the groin anterior view what what you see and nowadays because of the advent of because of the introduction of laparoscopy and in inguinal hernia you have both the tapp hernias repair and the tep hernia i'll go into the detail later in the full forms but this is the peritoneal view of the inguinal region once you put a laparoscope inside the abdominal cavity this is what you kind of see if you zoom in uh your the whole base here is the urinary bladder and in the midline is your median umbilical ligament lateral to it are you obliterated or the uh obliterated umbilical uh veins and these form the medial umbilical uh medial umbilical ligament even lateral to it is the lateral umbilical ligament and those are nothing but your inferior epigastric vessels which come in there okay now look at either the left or the right and you'll see how the uh there is uh what is being shown as the iliopubic tract and just above the iliopubic tract there are some structures entering this defect which is the deep inguinal ring so this is all from the inside i'm visualizing the outside it's not from the ground we don't not looking anything we are looking from the abdomen inside into the inguinal region and this is the view what you get it's a very different view once we start once we start operating or laparoscopically these hernias and one has to orient himself well before you even attempt to do these hernias so get oriented with both the tapp and the tep view which are again different slightly next is even more complicated because now it's the pre-peritoneal view which is there which now you take down the peritoneum down and this is what you see is uh is the extra peritoneal bladder uh you'll see the pubic symphysis and you'll better see the the whole deeping vinyl defects the deeping vinyl ring you'll see the cord structures entering you even see pulsations of the femoral vessels in the abdomen they would be called as the iliac vessels yeah and again you should one should appreciate the vast difference which is there and the lateral ligaments or the leg or sorry the nerves which are there which are placed laterally lateral to the deep inguinal ring so so this all needs to come in better i think this is better understood when you see a video when you actually see the whole procedure being done yeah here is again a color diagram to make it more interesting so inferior epigastric vessels on the top which are originating from the femoral vessels then there is uh the vas deferens and also the testicular vessels there are certain ligaments which you need to keep in mind is the cooper's ligament the lacunar ligament and the conjoined tendon and so from below you start the femoral hernia is or the femoral region here is bounded by the lacunar ligament just above it is the cooper which joins the lacula to the conjoined and above this is the conjoint so these areas where the aponeurosis and the muscles kind of fuse they form these ligament and they are all attached to the superior pubic rami or the pubic tubercle so it's all around the same region but what compose comprises in different region may differ and that's why they are named differently so it's all around the medial border of the uh in vinyl region yeah so this is what you see in drop in uh in a tapp or when you put your laproscope inside intraperitoneally this is what you see we have not removed the peritoneal layer and this is what you kind of see okay inf is [Music] your inferior epigastric vessels uh vs is your vas indirect hernia uh these are the testicular vessels ipt is the iliopubic tract so this all basically you start imagining once you know the sketch anatomy now you have to kind of make that sketch onto the real patient while you are operating to understand this amount very important while you're doing these laparoscopic repairs so moving on to the classification of inguinal hernia various classification the hasselbacks being left or right as given his classification european hernia society have their own classification nice uh gilberts started with their own classification way back in late 90s then there is anatomical classification there are various other classification we'll touch upon a few according to the site of exit it can be either direct or indirect uh the indirect hernia is from the deep in vinyl ring and the direct hernia comes out from the floor of the vinyl canal so kanjana it could be congenital or it could be a acquired hernia uh contents can be based on the content it can be an omentocil which is nothing but the momentum and the content is momentum uh then it could be enterocial when the contents are intestine all small and large bubble or it could be the urinary bladder is the content and your bladder mind you can be as a condensed in clinical types you have reducible irreducible they're all self-explanatory they can be obstructed hernias where the intestinal intestines come in but and get the neck of the hernia kind of blocks the intestine and that's why it gets obstructed and when this amounts to so much of obstruction that the vessel supplying those parts of the intestine which have got trapped in the hernia get compromised they land up into a strangulation leading to a gangrenous may lead to a gangrenous bowel if not tackled in time based on the extent it can be bubinosail these are nothing but which you can see only a bulge in the inguinal region a funny killer would go up to the superficial ring or to the roof or the top of the scrotum and once it is complete where it touches the bottom of the scrotum or then it becomes a complete hernia so gilbert or we'll just look into gilbert's classification and there were some additions by root cause and robbins so gilbert had uh made a very simple classification yet important uh because in those times whether to put a mesh not put a mesh was controversial now it's become pretty standard to put a mesh in the adults but in kids it's only herniatomy which has been done so uh so gilbert started with you know when the choice was mesh no mesh it was whether the type one was small indirect hernia or a medium indirect the small and medium if you say is a bit subjective but some books mentioned that he said four centimeter anything more than four centimeters you know a large hernia less than four centimeters two to four centimeters a medium anything less than small would be less than a two centimeter defect in the in uh of the size of the deeping vinyl ring uh then after type three is the type four which is the entire flow which is the direct hernia the whole floor is weakened uh diverticular defect means in the floor or in the deep uh in the floor of the vinyl canal you have a defect and that if you have the defect it comes falls into a type 5 uh hernia it's not a bulge of the posterior wall but it's a proper defect in the posterior wall and combined indirect and direct later on robbins added was a pantaloon type where you have indirect also and direct component also and femoral was a type 7 hernia so this was the gilbert's classification which was introduced i think in 1970s sorry 80s so yeah how do you diagnose a hernia i think this is uh as as i believed some years back that hernia is a 100 percent clinical diagnosis uh but uh with time with and with my experience i do use very very rarely i would say very very rarely again some kind of imaging to confirm my diagnosis so yes i do have started using some imaging not regularly very very really rarely to confirm my diagnosis and that's typically if the person has only pain or some faint bulge in the inguinal region so that is where i use an imaging to confirm my diagnosis before i give him the option of a surgery so if a patient is present symptomatically to me with a bulge which is not very obvious and as described on ex and as you know evaluated during examination you should get a cough impulse either visible or palpable that is not present and the bulge is you know uh you're not sure sometimes it's just the bulge of the posterior wall which is there or actually it is a hernia which is occurred in that case i would like to choose an imaging method we'll come to the imaging method but for now so on history if they say that there is something which comes out uh during the day time and which on lying down or on relaxing and in the morning early it has the swelling has reduced completely or decreased then i i i say it may be a hernia it may be a hernia and the it may may not have pain it may may not have urinary symptom may not have other symptoms which this depends on the structure most of the time it's kind of a dragging kind of pain when the swelling suddenly increases in this region but that would really depend on what kind of contents are there what is the tolerance of the patients for pain and some may be coming with excessive pain i've seen at times and they don't have anything of obstruction or complicated hernia they just complains of pain pain pain so it all depends upon your tolerance also and what kind of structures are there and what is the drag it's the mesentery bowel momentum urinary bladder what it is which really gives rise to pain so something some swelling in the groin going into the scleral area or not going into this brutal area but reduces on its own gives me a very clear uh or is more suggestive of inguinal hernia uh not diagnostic but more suggestive of ignoring hernia because one it's very common the amulet swelling which comes and goes is a varicocele or which which can come in and go so varicoceles increase when you lie down and move work off a strain but when you lie down again that whole swelling kind of decreases but that needs a clinical evaluation again and and patients may tell you that you know the swelling starts from scrotum and comes into the you know groin area that is more suggestive that it's a varicocele but if it comes from the inguinal goes down into the scrotum that is more suggestive of inguinal hernia a persistent swelling which is there in the inguinal region or in the scrotal region may or may not be a hernia less likely but i would say may or may not because the the way you take the history and the way the patient narrates his history you know that the whole language barrier may be there and you you may not elicit a good history because of the language barrier and examination then uh becomes of uh importance or maybe an imaging at times right so on physical examination other than the whole i'm not going to the systemic examination and what you if the patient is fit or not but that is important again if the patient's fitness is of importance and nowadays one of the uh flowchart even mentions that if the patient is not fit if the patient is not fit for anesthesia you may avoid a surgery also provided you tell them how to reduce the hernia when it increases in size so the fitness the systematic systemic symptoms or systemic signs and symptoms are important from the patient's perspective right um physical examination uh the sign symptoms of hernia would be a visible or a palpable cough impulse in the inguinal or in the invinci region and this uh man and this uh bulger swelling reduces or uh by its own when you ask the patient to lie down or uh while giving gentle pressure over it it would reduce on its own it would either if give a doughy feel which suggests of a fat which is there or it may be giving a gurgling kind of sound which suggests uh if the bowel is the contents so uh so these are the findings you would get in vinyl region or in the inguinal hernia other than that there are so many other structures there so you need to really demonstrate these signs and confirm because that's going to be your only time to say that this is hernia or yes you can choose lots of modalities of imaging to confirm but that is going to unnecessarily add cost to the patients so it can be simply done by basic examination and i i insist that if you not you should practice your sign symptoms uh well before you subject the patient for unnecessary investigations so be sure on your diagnosis try to learn better in diagnosing your inguinal hernia how would you say this is hernia sometimes there are mixed entities hernia with an hydrocele hernia with varicose veins lymph node all these could be structures in that area which can be there you know and you need to find out if the hernia is present or not with other swellings yeah so as i said imaging i'm gonna move on and this is the flowchart for imaging it's not that straightforward the flowchart but i would with this flowchart uh kind of summarize and say i would do an inguinal hernia ultrasound and if the ultrasound suggests me that they're using vinyl hernia and if there is pain to the patient then i would i would go ahead with the inguinal hernia surgery so ultrasound and my findings with history of pain that is symptomatic then i would go ahead with a hernia surgery patient is a symptomatic i have a doubt and the ultrasound is equivocal then definitely wait and watch would be my strategy patient is symptomatic patient sorry patient is asymptomatic i have equivocal finding but ultrasound is sure i would again wait if i am not sure of my findings i would ask the patient to follow it after a month give him some analgesia and ask him to follow up after a month even if he is symptomatic i will ask him to follow up and have a close follower uh with that said ct scan is another modality if i need it for uh other things to visualize like assigtees or even ultrasound is good for a scientist but for other structures like liver disease portal hypertension if i'm suspecting or there are other hernias or previous surgeries which are done or if my uh if i if the patient complains of some other symptoms then i might do a ct scan for this patient i have never done an mri for any patient but yes mra is also very specific and sensitive or inguinal hernia so this is on imaging uh yeah there's a long list of differentials as i told you if you have discussed before but you need to understand how each of these differentials would present for you to better rule in or rule out an environmental hernia or better rule in or rule out another diagnosis in that region so yeah in vinyl lymph nodes very common in that region varicocele as we've already discussed hydrocele of the cord i think that's uh you know it's very it's not very common though but sometimes a fixed swelling which does not reduce on lying down it could be you may think it's a you know it's a it's a uh irreducible kind of hernia uh because it reduces will may or may not give a cough impulse but you may think it's a irreducible type of inguinal hernia but you need to understand there could be some entity called as the hydrocele of the cord which is nothing but the tunica vaginalis you know fuses below and above and in the middle it does not fuse in the cord and that gives rise to fluid and that is nothing but the hydrocele of the cord so all that is their aneurysms yeah you need to be careful and if you suspect one then you need to diagnose it with uh sonography again it's rarer than the population still or then femoral animals are rare but can be there so need to be careful about that so a good clinical examination always uh you know helps you with all this otherwise you open a hernia and you know it's it's a bad bloody feel so again all the skin and superficial soft tissue tumors like lipoma sebaceous cysts fibromas all these could be in that region so as abscesses yeah so so as abscess again it presents here on in the medial side of the thigh uh so need to be careful about so as absolutely good history examination systemic signs and symptoms do help you to get to a psoas abscess hematoma history of injury hematoma or on blood thinners can give rise to these kind of findings in the inguinal region safina uh because of the valve being incompleted between the uh great saphenous vein and the femoral vein that can give rise to a bulge in the great saphenous vein which is looks like a s this varying would be below the vinyl ligament so that's what the difference is even the femoral hernia the bulge would be below the vinyl ligament and inguinal would be inguinal hernias would have a bulge above the inguinal undescended or ectopic test is very common so don't forget during examination to even palpate for the testis always expose the patient mid thigh at least and do a good palpation of the testes you may miss an undescended ectopic testis it's never been there patient has never realized he comes to you for hernia you diagnose a hernia an interrupt you don't know but you remove some part of the hernia and the test is also along with it uh and then the patient finds there is no and uh test is there a patient i had actually never had a testis but now when he has to you know he gets married or he wants to have children and there is some you know some problem with the sperm and then someone examines they say there is no testis you got a hernia surgery probably they knocked off your test so all these possibilities are there so you should be careful about examination and mentioning in your document about absence of testis or ectopic test is there in these cases also you would do a ultrasonography to see if there is an undescended test is you should do an ultrasound if it's ectopic undescended it may be inside the abdomen so be very careful when you find a undescended or ectopic test treatment options yes i think this has been the last part and um i don't have much to say because there are so many treatment but i'm just going to touch upon one of the treatment which we standardly do regarding tapp and tp i'm just going to tell you briefly what is there what is tapp what is tp but the other repairs what we normally do in emergency or in elective is what i would discuss so yeah either it's open laparoscopic now there there are other methods also to do it by laparoscopy only it is called a single incision laparoscopic and that's nothing but sills and you uh basically it's laparoscopy but through a single incision and nowadays with the advent of robot we have a robotic hernia repair also so the in the open repair uh prosthesis is been commonly used and in the prosthesis either it's the lycanstein repair and the standard of care for most surgeons now is leicenstein's repair there could be a mesh plug and patch repair which has been done revistopa wants repair and a google's repair so likenstein is what we are going to cover later on uh regarding uh plug and patch uh it's just you know putting in a plug in the deep ring if it is a wide deep ring uh make a cone of the mesh and pierce it in the deep ring and that's the repair and you try to fix it around the structures there and that's the repair after you have of course reduced the hernia uh one stopper uh reviews and reviews uh basically they're all they're all different three surgeons one did it by an inguinal approach one did it by a laparotomy one did some muscle relaxing and cut on the aponeurosis and so together it's termed as the one stopper reviews uh different people or uh you know all the hernia surgery mixed together it's called the one stop reviews but nowadays it's the reviews topa is commonly known as uh revis topa hernia that's been done with the lower midline incision and you go into the pre-peritoneal space and then do the you know dissection there and place your mesh in that space uh so that's the one stopper reviews repair you girls is something like a a cone-like thing but he designed his own uh not a patch-like thing but he designed his own patch very place some part into the deeper structure and some uh some kind of went into the deeping vinyl ring so it's like the mesh from the deeping ring you insert it goes into the pre-peritoneal space after of course the dissection of the pre-peritoneal space and some part comes out and bulges into the deep inguinal ring so yeah so regarding laparoscopic approach we have two approaches laparoscopically one would be the tep and the other tapp so it's the the difference is that in tp you'll see it's totally extra peritoneal and actually this is not laparoscopy this is endoscopic hernia surgery because lapros means abdomen or peritoneal cavity and you don't breach the abdominal peritoneal cavity you go outside that and you do an endoscopic repair of the hernia you use the same laparoscopic laparoscope and the whole same camera system monitor everything but you go extra peritoneally so uh you you go from the umbilical region your camera port comes from there and you make a small incision there and from there you without you open the anterior rectus sheath you take the recti muscle laterally before you can you don't open the posterior rectus sheath and in that plane you put in your scope or your port first and then the scope and then do the dissection in that and that leads to the pre-peritoneal space directly it's it's the whole disadvantage is that it's got a limited amount of space it's not the whole abdominal cavity you can bulge uh you can make use of it's got limited amount of space so that's why the whole extension below you'll see a e t e p rs but that's nothing but extended tap that that incision near the umbilicus is moved up in the abdomen and you get just to get one more wider space in that region you've extended the incision up and you made you would dissect even more and revise topa because you're going into the ravi stopper plane which is nothing but the pre-peritoneal uh plane typically laparoscopic surgery or hernia or endoscopic surgery hernia repair is done for a bilateral hernia or for a unilateral hernia which has ricard after an open inguinal approach repair so you don't do it for a unilateral upfront but nowadays it's optional you would do it for that based on the patient's demand also some people do it the recommendations also say that you can do it based on the page if the patient wishes because the whole pain factor immediate post-op because of the recovery to normal activities is significantly better in a laparoscopic as per the data it's significantly better the recurrence rates are similar in fact the complication rates in laparoscopy with a person who's not because the learning curve is lot much more steeper is much more the complication rates with laparoscopic or endoscopic hernia repair than with open hernia repair so if you're well-versed you do a laparoscopy it's fine but if you are not always only give the option of opening one hernia repair to your patients the learning curve is less steep and it's got lesser complication rates so yeah now the other hernia is a tapp which is a trans abdominal so you enter the abdomen once you have entered the abdomen through your laparoscope then you cut on the peritoneum and then you go to a pre-peritoneal space so again you land up in the same space as you would have done in tp but in this case you go inside the abdomen cut the peritoneum and then go into that space it's this approach is done not because it's difficult to get into the pre-peritoneal space like in tp but you get much more area to operate with a tapp so the learning curve is less steep than a tp tp mind you has a much more steeper learning curve so tapp and tp these are the subtle differences and one of the things uh we would do is if it's a very large hernia we do not take chance with a tep we would rather do a tapp because reduction of the contents of the hernia also becomes more easy with the tapp than a tep so that's one lapras the new techniques are robotic and cells i i shouldn't be talking because uh it's got its own advantage disadvantage and i don't really do it so it's just for your understanding these are the methods which are done but i wouldn't be talking on something which i don't do so yeah this is the lichenstein repair and after you have dissected this is a step after you've opened up the external uh oblique aponeurosis uh this these are the arteries which are holding the external opaque aponeurosis a ring like the instrument is there which is covering the schematic cord and the sutures what you see is you're doing a posterior wall repair so you've done the posterior wall repair by you know by closing the uh upturned part of the vinyl ligament with the transverses and the internal oblique muscle which are there superiorly so that's uh you push in the hernia if there is a direct hernia you push it in and you would repair this wall and in the next slide you will see that he is placed a mesh in there so that mesh is being sutured to the upturned part of the vinyl ligament and some uh then it's fishtailed uh where the deep ring is there and you make a new deeping winery so few points in likenstein hernia would like to share likens time when he started uh this repair uh people were doing uh mesh plasties but they were trying to you know uh just bridge that defect which was not able which was not easily sutured or which was getting cut through through the sutures by doing a shoulder bassines or something and then they put a patch in there you know a small little patch to cover that there was fears about infection foreign body foreign body sensation lot of other fears were there in that era so and typically likenstein saw that there is a lot of recurrence which is happening by you know by doing this and mostly in the medial region mostly uh on near the pubic tubercle is where the whole recurrence is happening so what he did of course initially if you see his curve of recurrence it was much higher it was going to 70 80 percent but as he kind of followed these up patients and did the recurrent surgeries and saw where all these patients are getting recovered then he said that you have to go beyond the the only the posterior wall and fix your mesh much more beyond this so he said you cover around one third of the inguinal ligament starting from the upturned part above and around two thirds of the internal oblique in the transverses abdominis superiorly and you go beyond around two centimeter beyond the pubic tubercle your mesh should be placed beyond the pubic tubercle two centimeter and also when you do a fish tail you make sure that the tail is long enough to and form a snugly fitting uh deeping vinyl ring so that of course you shouldn't tighten it too much because the cord will have edema but just that you can admit your tip of your little finger uh you keep that much space so after all doing all these kind of modifications he published a five-year result of zero percent recurrence now uh if you ask me in today's era if someone says zero percent i would not believe that person at all okay surgeries are a recurrence rate zero percent in that era i would still not believe even more so but yes likenstein has changed the way with these modifications which we still practice there are minimal recurrences but it's not that it's zero then people started doing this and they found uh around point four to point seven percent of recurrence in england which is mind you much much much lower than what was before when bassanis came in he had a ten percent recurrence and chord ice is brought down to one to four percent and then it came down to point four to point five percent some books will mention one percent four percent sold isis it had its own problem should isis repair uh but yeah lichenstein or the mesh plasti did a huge difference now there are lots of variations and lots of other surgeries i would like just like to mention two of the indian surgeons uh modification with all this and one is desada uh i know i'm running uh there's only seven minutes i have to quickly wind up so one is disarra doesn't use a mesh he's a pune based surgeon he doesn't use a mesh what he does he using the external oblique aponeurosis and he stitched and he after sorry after suturing after doing this step of suturing the uh posterior wall what he does he cuts open the external oblique opponenerosis and he brings it down around two centimeter width he brings it down and sutures it to the inguinal ligament and that forms and he kind of does some other steps but to keep it short this is what he does on the net his technique next is um um the surgeon who introduced the fish net our special maker mention because of the cost of these measures are much more the rural people in india couldn't afford this kind of cost so what he did he used the proline on a polypropylene fishnet which is available they are slightly wide openings in them but he has managed to publish this in the british journal of surgery with excellent results and he's a he's a small surgeon forgetting his name sorry he's from dorinda north of maharashtra beyond uh i think so beyond um nasik so this surgeon uh now no longer there is sun practices there but this surgeon used a fish net i would just make a pension you'll just see british german surgery fishnet in inguinal honey you'll get it so these are the mentions i would like to make for the indian surgeon's contributions towards hernia the conservation uh conservative surgery i would typically say no but if comorbidities which are there which are much more and you would rather kill the patient you these were the things which were designed either you asked taxes or a hernia belt to keep it reduced your tax is nothing but if it bulges you you know flex the knee flex the hip joint internally rotate and then gently maneuver the hernia and reduce the hernia so yeah these are the conservative approaches i'm not sure if i have no slides yeah complications or we haven't spoken about obstructed and sangulation so quick point about obstruction and strangulations they would not reduce they would be inflamed tender and when you approach these hernia normally you would you know go to the inguinal ring but in cases obstruction in strangulated hernias you decompress or you open the sac or the body of the hernia first to see the content if the bowel is gangrene or not because at times the bowel may just get reduced and you may take the infection inside the abdomen so quick points about obstructed and strangulated and running short of time lots of recurrence lots of complications recurrence is one major complication chronic groaning groin pain in zinc vinodynya most of the time it's the trapped nervillo hypogastric or yellowing vinyl nerve and damage to the surrounding structures testicular artery was bowel bladder whatever it may be surgical side infection is one of the worry or nightmare for every surgeon sorry and thank you that's the question that's okay so that's totally fine uh thank you for this amazing um session uh we do have one question it's from um dr kangsha she has asked you if you can uh explain the distinguishing features between tep and tapp uh again yeah so uh okay so tep is actually a total extra peritoneal repair so you don't enter the peritoneum at all you don't breach the peritoneum at all okay so the approach is extra peritoneal so it's all from the posterior rectus sheath if you go below or inferiorly on the abdominal wall which is deficient in the posterior rectus sheath you enter what is called as the pre-peritoneal or extra-peritoneal space and that's where you put in your laparoscope there okay so that's why we call it an endoscopic approach and not a laparoscopic approach whereas in tapp you go through the umbilicus but you go inside the abdomen and now once you're inside the abdomen you turn upwards you cut the peritoneum and now you're trying to go extra peritoneal so and the main uh advantage of tapp is that you get much more space to operate uh than a tp space so this is the major difference between a tep and a tapp thank you so i hope that answers your question dr um thank you so much sir for this wonderful session we would love to have you on our platform once again you

BEING ATTENDED BY

Dr. Darius Justus & 552 others

SPEAKERS

dr. Monty Khajanchi

Dr. Monty Khajanchi

Assistant Professor, KEM Hospital, Mumbai

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dr. Monty Khajanchi

Dr. Monty Khajanchi

Assistant Professor, KEM Hospital, Mumbai

+ Details

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