Kay Barrera MD. September 4, 2014 SUNY Downstate

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1 Kay Barrera MD September 4, 2014 SUNY Downstate

2 Outline Why are we talking about this SCORE expectations Case Presentation Symptoms Indications for repair Anatomy Operative management

3 #TBT Throwback Thursday The anatomy of the inguinal region is misunderstood by some surgeons of all levels of seniority - Robert Condon MD

4 Hernias For patients with groin mass, the resident can differentiate the anatomic landmarks of a femoral hernia versus inguinal hernia For patient with groin bulge resident can apply demographic features to diagnose Formulate differential diagnoses Accurately describe steps in repair of hernia

5 Case History 56 year old F complains of colicky abdominal pain since 4pm. +Nausea + Bilious vomiting + Distention. Right groin pain and bulge since morning. Last flatus previous evening.

Case History Medical/Surgical/Social history: Non contibutory Vitals: Tm 100 70 125/88 Exam: WDWN RRR, CTAB S, +Distended, NT, no scars

6 Case History Medical/Surgical/Social history: Non contibutory Vitals: Tm /88 Exam: WDWN RRR, CTAB S, +Distended, NT, no scars Right groin bulge, non reducible, tender, non erythematous / edematous Significant Labs: WBC image credit

7 CT Scan

8 CT Scan Imaging: complete SBO, transition point in right inguinal hernia containing a loop of small bowel

9 Now what? A) Recommend admit to medicine follow on consult list B) Take the patient to the OR urgently C) Admit to surgery for observation, elective repair in AM D) Recommend hernia belt

10 Indications for Surgery Incarcerated hernias with SBO usually require urgent operation significant risk for strangulation not likely to resolve spontaneously Especially true for femoral hernias (narrow defect) Reduce? If no signs of strangulation, a gentle attempt at reduction is appropriate If reduced elective repair in near future

11 Strangulated vs Incarcerated There is no way in which external examination can tell whether the blood supply or a piece of bowel is or is not imperiled. Incarceration is too benign a term to be applied to a condition which can be so dangerous Jones, Peter Emergency Surgery 11 th edition

widened, floor weak Femoral hernia arising inferior to inguinal

12 Operative Findings Approach: Incision superior to inguinal ligament Inguinal canal: lipoma, no hernia sac, internal ring widened, floor weak Femoral hernia arising inferior to inguinal ligament. Sac thickened peritoneum, no bowel contents, clear non hemorrhagic fluid

Inguinal Vs Femoral Inguinal Femoral Javid

(Eds), Maingot's Abdominal Operations, 12e.

13 Inguinal Vs Femoral Inguinal Femoral Javid P.J., Greenberg J.A., Brooks D.C. (2013). Chapter 7. Hernias. In Zinner M.J., Ashley S.W. (Eds), Maingot's Abdominal Operations, 12e. Retrieved September 02, 2014 fromhttp://accesssurgery.mhmedical.com.libproxy.usc.edu/content.aspx?bookid=531&sectionid= Essentials of General surgery 5 th edition.

14 Inguinofemoral Anatomy

Inguinofemoral Anatomy Skandalakis P.N., Skandalakis J.E., Colborn G.L., Kingsnorth A.N., Weidman T.A., Skandalakis L.J. (2004). Chapter 9. Abdominal Wall and Hernias.

15 Inguinofemoral Anatomy Skandalakis P.N., Skandalakis J.E., Colborn G.L., Kingsnorth A.N., Weidman T.A., Skandalakis L.J. (2004). Chapter 9. Abdominal Wall and Hernias. InSkandalakis J.E., Colburn G.L., Weidman T.A., Foster R.S., Jr, Kingsworth A.N., Skandalakis L.J., Skandalakis P.N., Mirilas P.S. (Eds), Skandalakis' Surgical Anatomy.

.correlate clinically Compression of the femoral vein Elliptic appearing femoral vein <2/3 diameter of the contralateral vein Direction of the hernia sac is in the direction of the minor diameter of

16 .correlate clinically Compression of the femoral vein Elliptic appearing femoral vein <2/3 diameter of the contralateral vein Direction of the hernia sac is in the direction of the minor diameter of the femoral vein Lateral to the pubic tubercle Inguinal hernias are medial to pubic tubercle Difficult relationship Suzuki et al. Differentiation of Femoral Versus Inguinal Hernias: CT Findings. AJR Am J Roentgenol Aug;189(2):W78-83.

Early Hernia Repair 1552 BC Egyptian Papyrus of Ebers 900 BC Phoenicians use bandage 50 AD Greek / Roman repair 700 Paul of

differentiates inguinal from femoral hernias.

recurrence 100% When you judge a swelling on the surface of the belly caused by coughing Lau WY History of treatment of groin

17 Early Hernia Repair 1552 BC Egyptian Papyrus of Ebers 900 BC Phoenicians use bandage 50 AD Greek / Roman repair 700 Paul of Aegina: Ligate the sac+cord, amputate the testicle 1200s William of Salicet Spare the testicle 1363 Guy de Chauliac differentiates inguinal from femoral hernias. Reduction of hernias in Trendelenberg 1870s- Steele / Czerny Return of hernia sac to abdomen 1890 Billroth reports 4 yr recurrence 100% When you judge a swelling on the surface of the belly caused by coughing Lau WY History of treatment of groin hernia. World J Surg Jun;26(6): Epub 2002 Mar 26. Wikipedia Eber s Papyrus The Medical Age A semi-monthly journal of Medicine and Surgery Dr. G Archie Stockwell ed.

18 Modern Hernia Repair 1887 Bassini reconstructs posterior wall of canal in three layers 1950s Shouldice Canadian Repair Four layers McVay repair Cooper s Ligament Lichtenstein Plug and Patch (modified Lichtenstein) Master Techniques in Surgery: Hernia edited by Daniel B. Jones

19 Modern Hernia Repair Preperitoneal Repairs Laparoscopic Repair TAPP TEP

20 Femoral Hernias Approach Infrainguinal approach Low / Lockwood Transverse incision at the bulge Lateral Incision of the lacular ligament Hey Groves McEvedy Master Techniques in General Surgery: Hernia Surgery

21 Femoral Hernias Types of Repair McVay Purse string Lichtenstein plug LichtenVay Transinguinal (Ruggi) Laparoscopic transabdominal Master Techniques in General Surgery: Hernia Surgery

22 Options for repair? Fem hernia wide int ring weak inguinal floor A) Bassini B) Shouldice C) McVay D) LichtenVay E) Exploratory laparotomy and bowel resection

23 Case Procedure Performed EXPOSURE of HERNIA SAC Division of inguinal ligament REPAIR Medium sized plug to internal ring Mesh Patch Covers the inguinal canal floor and femoral canal Pubic tubercle Coopers ligament Adventitia of femoral vein Lacunar ligament

24 Hospital course POD 1: patient passed gas, tolerated CLD, abdominal distention improved Discharged POD 2 2 week clinic follow up: Patient doing well now without complaints.

25 Hernia Cut Out Project

34 yo M presented in ER of KCH at 7/06/10 Painful lump lt groin + vomiting Pain started 2 hrs before presentation. PMH known left inguinal hernia PSH

Case Presentation 34 yo M presented in ER of KCH at 7/06/10 Painful lump lt groin + vomiting Pain started 2 hrs before presentation. PMH known left inguinal hernia PSH negative NKDA Case Presentation VS: