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Surgery_Schwartz_10602 | Surgery_Schwartz | insensitivity syndromeRobinow’s syndromeSerpentine fibula syndromeAlport’s syndromeTel Hashomer camptodactyly syndromeLeriche’s syndromeTesticular feminization syndromeRokitansky-Mayer-Küster syndromeGoldenhar’s syndromeMorris syndromeGerhardt’s syndromeMenkes’ syndromeKawasaki diseasePfannenstiel syndromeBeckwith-Wiedemann syndromeRubinstein-Taybi syndromeAlopecia-photophobia syndromeDIAGNOSISHistoryWorkup for inguinal hernia begins with a detailed history. The most common symptom of inguinal hernia is a groin mass that protrudes while standing, coughing, or straining. It is sometimes described as reducible while lying down. Symptoms that are extrainguinal such as a change in bowel habits or urinary symptoms are far less common but should be recognized as having the potential to be ominous. The pain is thought to be due to compression of the nerves by the sac, causing generalized pressure, localized sharp pain, or referred pain. Referred pain may involve the scrotum, tes-ticle, or | Surgery_Schwartz. insensitivity syndromeRobinow’s syndromeSerpentine fibula syndromeAlport’s syndromeTel Hashomer camptodactyly syndromeLeriche’s syndromeTesticular feminization syndromeRokitansky-Mayer-Küster syndromeGoldenhar’s syndromeMorris syndromeGerhardt’s syndromeMenkes’ syndromeKawasaki diseasePfannenstiel syndromeBeckwith-Wiedemann syndromeRubinstein-Taybi syndromeAlopecia-photophobia syndromeDIAGNOSISHistoryWorkup for inguinal hernia begins with a detailed history. The most common symptom of inguinal hernia is a groin mass that protrudes while standing, coughing, or straining. It is sometimes described as reducible while lying down. Symptoms that are extrainguinal such as a change in bowel habits or urinary symptoms are far less common but should be recognized as having the potential to be ominous. The pain is thought to be due to compression of the nerves by the sac, causing generalized pressure, localized sharp pain, or referred pain. Referred pain may involve the scrotum, tes-ticle, or |
Surgery_Schwartz_10603 | Surgery_Schwartz | The pain is thought to be due to compression of the nerves by the sac, causing generalized pressure, localized sharp pain, or referred pain. Referred pain may involve the scrotum, tes-ticle, or inner thigh.Important considerations of the patient’s history include the duration and timing of symptoms. Sudden onset symp-toms are more concerning. Questions should also be directed to characterize whether the hernia is reducible. Patients will often reduce the hernia by pushing the contents back into the abdomen, thereby providing temporary relief. As the defect size increases and more intra-abdominal contents fill the hernia sac, the hernia may become harder to reduce and incarcerate, prompting urgent surgical intervention.Certain elements of the review of systems such as chronic constipation, cough, or urinary retention should prompt the sur-geon to perform a thorough workup to rule out any underlying malignancy.elements and hernia formation.20 Although a significant amount of work | Surgery_Schwartz. The pain is thought to be due to compression of the nerves by the sac, causing generalized pressure, localized sharp pain, or referred pain. Referred pain may involve the scrotum, tes-ticle, or inner thigh.Important considerations of the patient’s history include the duration and timing of symptoms. Sudden onset symp-toms are more concerning. Questions should also be directed to characterize whether the hernia is reducible. Patients will often reduce the hernia by pushing the contents back into the abdomen, thereby providing temporary relief. As the defect size increases and more intra-abdominal contents fill the hernia sac, the hernia may become harder to reduce and incarcerate, prompting urgent surgical intervention.Certain elements of the review of systems such as chronic constipation, cough, or urinary retention should prompt the sur-geon to perform a thorough workup to rule out any underlying malignancy.elements and hernia formation.20 Although a significant amount of work |
Surgery_Schwartz_10604 | Surgery_Schwartz | cough, or urinary retention should prompt the sur-geon to perform a thorough workup to rule out any underlying malignancy.elements and hernia formation.20 Although a significant amount of work remains to elucidate the biologic nature of hernias, current evidence suggests they have a multifactorial etiology with both environmental and hereditary influences.Brunicardi_Ch37_p1599-p1624.indd 160629/01/19 2:03 PM 1607INGUINAL HERNIASCHAPTER 37Figure 37-11. Digital examination of the inguinal canal.Table 37-5Differential diagnosis of groin herniaMalignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumorPrimary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicleFemoral artery aneurysm or pseudoaneurysmLymph nodeSebaceous cystHidradenitisCyst of the canal of Nuck (female)Saphenous varixPsoas abscessHematomaAscitesPhysical ExaminationPhysical examination is essential to the diagnosis of inguinal hernia. The patient should be | Surgery_Schwartz. cough, or urinary retention should prompt the sur-geon to perform a thorough workup to rule out any underlying malignancy.elements and hernia formation.20 Although a significant amount of work remains to elucidate the biologic nature of hernias, current evidence suggests they have a multifactorial etiology with both environmental and hereditary influences.Brunicardi_Ch37_p1599-p1624.indd 160629/01/19 2:03 PM 1607INGUINAL HERNIASCHAPTER 37Figure 37-11. Digital examination of the inguinal canal.Table 37-5Differential diagnosis of groin herniaMalignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumorPrimary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicleFemoral artery aneurysm or pseudoaneurysmLymph nodeSebaceous cystHidradenitisCyst of the canal of Nuck (female)Saphenous varixPsoas abscessHematomaAscitesPhysical ExaminationPhysical examination is essential to the diagnosis of inguinal hernia. The patient should be |
Surgery_Schwartz_10605 | Surgery_Schwartz | of the canal of Nuck (female)Saphenous varixPsoas abscessHematomaAscitesPhysical ExaminationPhysical examination is essential to the diagnosis of inguinal hernia. The patient should be examined in a standing position to increase intra-abdominal pressure, with the groin and scro-tum fully exposed. Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the scrotum. If an obvious bulge is not detected, palpation is per-formed to confirm the presence of the hernia.Palpation is performed by advancing the index fin-ger through the scrotum towards the external inguinal ring (Fig. 37-11). This allows the inguinal canal to be explored. The patient is then asked to perform a Valsalva maneuver to increase intraabdominal pressure. These maneuvers will reveal an abnor-mal bulge and allow the clinician to determine whether the her-nia is reducible or not. Examination of the contralateral side affords the clinician the opportunity to compare the | Surgery_Schwartz. of the canal of Nuck (female)Saphenous varixPsoas abscessHematomaAscitesPhysical ExaminationPhysical examination is essential to the diagnosis of inguinal hernia. The patient should be examined in a standing position to increase intra-abdominal pressure, with the groin and scro-tum fully exposed. Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the scrotum. If an obvious bulge is not detected, palpation is per-formed to confirm the presence of the hernia.Palpation is performed by advancing the index fin-ger through the scrotum towards the external inguinal ring (Fig. 37-11). This allows the inguinal canal to be explored. The patient is then asked to perform a Valsalva maneuver to increase intraabdominal pressure. These maneuvers will reveal an abnor-mal bulge and allow the clinician to determine whether the her-nia is reducible or not. Examination of the contralateral side affords the clinician the opportunity to compare the |
Surgery_Schwartz_10606 | Surgery_Schwartz | will reveal an abnor-mal bulge and allow the clinician to determine whether the her-nia is reducible or not. Examination of the contralateral side affords the clinician the opportunity to compare the presence and extent of herniation between sides. This is especially useful in the case of a small hernia. In addition to inguinal hernia, a number of other diagnoses may be considered in the differential of a groin bulge (Table 37-5).While very difficult to ascertain, there are certain physi-cal examination maneuvers that can be performed to help distinguish direct vs. indirect inguinal hernias. The inguinal occlusion test entails the examiner blocking the internal ingui-nal ring with a finger as the patient is instructed to cough. A controlled impulse suggests an indirect hernia, while persistent herniation suggests a direct hernia. Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an impulse palpated on the dorsum of the finger implies a direct | Surgery_Schwartz. will reveal an abnor-mal bulge and allow the clinician to determine whether the her-nia is reducible or not. Examination of the contralateral side affords the clinician the opportunity to compare the presence and extent of herniation between sides. This is especially useful in the case of a small hernia. In addition to inguinal hernia, a number of other diagnoses may be considered in the differential of a groin bulge (Table 37-5).While very difficult to ascertain, there are certain physi-cal examination maneuvers that can be performed to help distinguish direct vs. indirect inguinal hernias. The inguinal occlusion test entails the examiner blocking the internal ingui-nal ring with a finger as the patient is instructed to cough. A controlled impulse suggests an indirect hernia, while persistent herniation suggests a direct hernia. Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an impulse palpated on the dorsum of the finger implies a direct |
Surgery_Schwartz_10607 | Surgery_Schwartz | herniation suggests a direct hernia. Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an impulse palpated on the dorsum of the finger implies a direct hernia. When results of physical examination are com-pared against operative findings, there is a probability some-what higher than chance (i.e., 50%) of correctly diagnosing the type of hernia.21,22External groin anatomy is difficult to assess in obese patients, making the physical diagnosis of inguinal hernia chal-lenging. A further challenge to the physical examination is the identification of a femoral hernia. Femoral hernias should be palpable below the inguinal ligament, lateral to the pubic tubercle. In obese patients, a femoral hernia may be missed or misdiagnosed as a hernia of the inguinal canal. In contrast, a prominent inguinal fat pad in a thin patient, otherwise known as a femoral pseudohernia, may prompt an erroneous diagnosis of femoral hernia.ImagingIn the case of an ambiguous | Surgery_Schwartz. herniation suggests a direct hernia. Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an impulse palpated on the dorsum of the finger implies a direct hernia. When results of physical examination are com-pared against operative findings, there is a probability some-what higher than chance (i.e., 50%) of correctly diagnosing the type of hernia.21,22External groin anatomy is difficult to assess in obese patients, making the physical diagnosis of inguinal hernia chal-lenging. A further challenge to the physical examination is the identification of a femoral hernia. Femoral hernias should be palpable below the inguinal ligament, lateral to the pubic tubercle. In obese patients, a femoral hernia may be missed or misdiagnosed as a hernia of the inguinal canal. In contrast, a prominent inguinal fat pad in a thin patient, otherwise known as a femoral pseudohernia, may prompt an erroneous diagnosis of femoral hernia.ImagingIn the case of an ambiguous |
Surgery_Schwartz_10608 | Surgery_Schwartz | canal. In contrast, a prominent inguinal fat pad in a thin patient, otherwise known as a femoral pseudohernia, may prompt an erroneous diagnosis of femoral hernia.ImagingIn the case of an ambiguous diagnosis, radiologic investigations may be used as an adjunct to history and physical examination. Imaging in obvious cases is unnecessary. The most common radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Each technique has certain advantages over physical examination alone; however, each modality is associated with potential limitations.US is the least invasive technique and does not impart any radiation to the patient. Anatomic structures can be more easily identified by the presence of bony landmarks; however, because there are few bones in the inguinal canal, other structures such as the inferior epigastric vessels are used to define groin anatomy. Positive intra-abdominal pressure is used to elicit the herniation of | Surgery_Schwartz. canal. In contrast, a prominent inguinal fat pad in a thin patient, otherwise known as a femoral pseudohernia, may prompt an erroneous diagnosis of femoral hernia.ImagingIn the case of an ambiguous diagnosis, radiologic investigations may be used as an adjunct to history and physical examination. Imaging in obvious cases is unnecessary. The most common radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Each technique has certain advantages over physical examination alone; however, each modality is associated with potential limitations.US is the least invasive technique and does not impart any radiation to the patient. Anatomic structures can be more easily identified by the presence of bony landmarks; however, because there are few bones in the inguinal canal, other structures such as the inferior epigastric vessels are used to define groin anatomy. Positive intra-abdominal pressure is used to elicit the herniation of |
Surgery_Schwartz_10609 | Surgery_Schwartz | are few bones in the inguinal canal, other structures such as the inferior epigastric vessels are used to define groin anatomy. Positive intra-abdominal pressure is used to elicit the herniation of abdominal contents. Movement of these contents through the canal is essential to making the diagnosis with US, Brunicardi_Ch37_p1599-p1624.indd 160729/01/19 2:03 PM 1608SPECIFIC CONSIDERATIONSPART IIFigure 37-12. Computed tomography scan depicting a large right inguinal hernia (arrow). A smaller left inguinal hernia is also visualized.and lack of this movement may lead to a false negative. A recent meta-analysis demonstrated that ultrasound detects inguinal hernia with a sensitivity of 86%, specificity of 77%.23 In thin patients, normal movement of the spermatic cord and posterior abdominal wall against the anterior abdominal wall may lead to false-positive diagnoses of hernia.24CT and MRI provide static images that are able to delin-eate groin anatomy, to detect groin hernias, and to | Surgery_Schwartz. are few bones in the inguinal canal, other structures such as the inferior epigastric vessels are used to define groin anatomy. Positive intra-abdominal pressure is used to elicit the herniation of abdominal contents. Movement of these contents through the canal is essential to making the diagnosis with US, Brunicardi_Ch37_p1599-p1624.indd 160729/01/19 2:03 PM 1608SPECIFIC CONSIDERATIONSPART IIFigure 37-12. Computed tomography scan depicting a large right inguinal hernia (arrow). A smaller left inguinal hernia is also visualized.and lack of this movement may lead to a false negative. A recent meta-analysis demonstrated that ultrasound detects inguinal hernia with a sensitivity of 86%, specificity of 77%.23 In thin patients, normal movement of the spermatic cord and posterior abdominal wall against the anterior abdominal wall may lead to false-positive diagnoses of hernia.24CT and MRI provide static images that are able to delin-eate groin anatomy, to detect groin hernias, and to |
Surgery_Schwartz_10610 | Surgery_Schwartz | wall against the anterior abdominal wall may lead to false-positive diagnoses of hernia.24CT and MRI provide static images that are able to delin-eate groin anatomy, to detect groin hernias, and to exclude potentially confounding diagnoses (Fig. 37-12). Meta-analysis determined standard CT detects inguinal hernia with a sensitiv-ity of 80%, specificity of 65%. Although direct herniography has a higher sensitivity and specificity than CT, its invasiveness and limited availability restrict its routine use.23 As CT imaging increases in resolution, its sensitivity in detecting inguinal her-nia is expected to expand; however, this has yet to be clinically confirmed by surgical correlation.25MRI is most commonly utilized in cases where physical examination detects a groin bulge, but where ultrasonography is inconclusive. In a 1999 study of 41 patients with clinical find-ings of inguinal hernia, laparoscopy revealed that MRI was an effective diagnostic test with a sensitivity of 95%, | Surgery_Schwartz. wall against the anterior abdominal wall may lead to false-positive diagnoses of hernia.24CT and MRI provide static images that are able to delin-eate groin anatomy, to detect groin hernias, and to exclude potentially confounding diagnoses (Fig. 37-12). Meta-analysis determined standard CT detects inguinal hernia with a sensitiv-ity of 80%, specificity of 65%. Although direct herniography has a higher sensitivity and specificity than CT, its invasiveness and limited availability restrict its routine use.23 As CT imaging increases in resolution, its sensitivity in detecting inguinal her-nia is expected to expand; however, this has yet to be clinically confirmed by surgical correlation.25MRI is most commonly utilized in cases where physical examination detects a groin bulge, but where ultrasonography is inconclusive. In a 1999 study of 41 patients with clinical find-ings of inguinal hernia, laparoscopy revealed that MRI was an effective diagnostic test with a sensitivity of 95%, |
Surgery_Schwartz_10611 | Surgery_Schwartz | ultrasonography is inconclusive. In a 1999 study of 41 patients with clinical find-ings of inguinal hernia, laparoscopy revealed that MRI was an effective diagnostic test with a sensitivity of 95%, specificity of 96%.26 The expense of MRI precludes its routine use to diag-nose inguinal hernias.TREATMENTSurgical repair of hernias can be performed open, laparoscopic, or with robotic assistance. Surgical repair is the definitive treat-ment of inguinal hernias. The most common reason for elective repair is pain. Incarceration and strangulation are the primary indications for urgent repair. Symptomatic hernias should be operated on electively, and minimally symptomatic or asymptomatic hernias should undergo watchful waiting.27 Repair of minimally symptomatic inguinal hernia in patients with significant medical comorbidities surgery should be deferred and the patient medically optimized. If despite optimal management of comorbidities, the patient remains high-risk, open repair under local | Surgery_Schwartz. ultrasonography is inconclusive. In a 1999 study of 41 patients with clinical find-ings of inguinal hernia, laparoscopy revealed that MRI was an effective diagnostic test with a sensitivity of 95%, specificity of 96%.26 The expense of MRI precludes its routine use to diag-nose inguinal hernias.TREATMENTSurgical repair of hernias can be performed open, laparoscopic, or with robotic assistance. Surgical repair is the definitive treat-ment of inguinal hernias. The most common reason for elective repair is pain. Incarceration and strangulation are the primary indications for urgent repair. Symptomatic hernias should be operated on electively, and minimally symptomatic or asymptomatic hernias should undergo watchful waiting.27 Repair of minimally symptomatic inguinal hernia in patients with significant medical comorbidities surgery should be deferred and the patient medically optimized. If despite optimal management of comorbidities, the patient remains high-risk, open repair under local |
Surgery_Schwartz_10612 | Surgery_Schwartz | medical comorbidities surgery should be deferred and the patient medically optimized. If despite optimal management of comorbidities, the patient remains high-risk, open repair under local anesthesia can be safely performed.28 Although the natural history of untreated inguinal hernias is 3poorly defined, the rates of incarceration and strangulation are low in the asymptomatic population. As a result, nonoperative management is an appropriate consideration in minimally symp-tomatic patients. Prospective studies and meta-analyses have demonstrated no difference in intention-to-treat outcomes, qual-ity of life, or cost-effectiveness between watchful waiting and elective repair among healthy inguinal hernia patients.27,29 A 2012 systematic review found that 72% of asymptomatic ingui-nal hernia patients developed symptoms and had surgical repair within 7.5 years of diagnosis.30 Nevertheless, the complication rates of immediate and delayed elective repair are equivalent.29,31 A nonoperative | Surgery_Schwartz. medical comorbidities surgery should be deferred and the patient medically optimized. If despite optimal management of comorbidities, the patient remains high-risk, open repair under local anesthesia can be safely performed.28 Although the natural history of untreated inguinal hernias is 3poorly defined, the rates of incarceration and strangulation are low in the asymptomatic population. As a result, nonoperative management is an appropriate consideration in minimally symp-tomatic patients. Prospective studies and meta-analyses have demonstrated no difference in intention-to-treat outcomes, qual-ity of life, or cost-effectiveness between watchful waiting and elective repair among healthy inguinal hernia patients.27,29 A 2012 systematic review found that 72% of asymptomatic ingui-nal hernia patients developed symptoms and had surgical repair within 7.5 years of diagnosis.30 Nevertheless, the complication rates of immediate and delayed elective repair are equivalent.29,31 A nonoperative |
Surgery_Schwartz_10613 | Surgery_Schwartz | patients developed symptoms and had surgical repair within 7.5 years of diagnosis.30 Nevertheless, the complication rates of immediate and delayed elective repair are equivalent.29,31 A nonoperative strategy is safe for minimally symptomatic inguinal hernia patients.32Nonoperative inguinal hernia treatment targets pain, pres-sure, and protrusion of abdominal contents in the symptomatic patient population. The recumbent position aids in hernia reduc-tion via the effects of gravity and a relaxed abdominal wall. Trusses externally confine hernias to a reduced state and inter-mittently relieve symptoms in up to 65% of patients; however, they do not prevent complications, and they may be associated with an increased rate of incarceration.33 The risks of incarcera-tion and strangulation appear to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of protruding tissue in an | Surgery_Schwartz. patients developed symptoms and had surgical repair within 7.5 years of diagnosis.30 Nevertheless, the complication rates of immediate and delayed elective repair are equivalent.29,31 A nonoperative strategy is safe for minimally symptomatic inguinal hernia patients.32Nonoperative inguinal hernia treatment targets pain, pres-sure, and protrusion of abdominal contents in the symptomatic patient population. The recumbent position aids in hernia reduc-tion via the effects of gravity and a relaxed abdominal wall. Trusses externally confine hernias to a reduced state and inter-mittently relieve symptoms in up to 65% of patients; however, they do not prevent complications, and they may be associated with an increased rate of incarceration.33 The risks of incarcera-tion and strangulation appear to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of protruding tissue in an |
Surgery_Schwartz_10614 | Surgery_Schwartz | to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of protruding tissue in an inguinal hernia does not nec-essarily signify severe morbidity.Femoral and symptomatic inguinal hernias carry higher complication risks, and so surgical repair is performed earlier for these patients. Irrespective of symptoms, one study found the 3-month and 2-year cumulative incidences of strangulation were 2.8% and 4.5%, respectively, for inguinal hernias and 22% and 45%, respectively, for femoral hernias.34 Data from the Swedish Hernia Registry demonstrates that emergent operation is associ-ated with a sevenfold increase in all-cause mortality over that of elective surgery among 107,838 groin hernia repairs.35 For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible.Incarceration occurs when hernia contents fail to | Surgery_Schwartz. to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of protruding tissue in an inguinal hernia does not nec-essarily signify severe morbidity.Femoral and symptomatic inguinal hernias carry higher complication risks, and so surgical repair is performed earlier for these patients. Irrespective of symptoms, one study found the 3-month and 2-year cumulative incidences of strangulation were 2.8% and 4.5%, respectively, for inguinal hernias and 22% and 45%, respectively, for femoral hernias.34 Data from the Swedish Hernia Registry demonstrates that emergent operation is associ-ated with a sevenfold increase in all-cause mortality over that of elective surgery among 107,838 groin hernia repairs.35 For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible.Incarceration occurs when hernia contents fail to |
Surgery_Schwartz_10615 | Surgery_Schwartz | hernia repairs.35 For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible.Incarceration occurs when hernia contents fail to reduce; however, a minimally symptomatic, chronically incarcerated hernia may also be treated nonoperatively. Taxis should be attempted for incarcerated hernias without sequelae of strangulation, and the option of surgical repair should be discussed prior to the maneuver. To perform taxis, analgesics and light sedatives are administered, and the patient is placed in the Trendelenburg position. The hernia sac is elongated with both hands, and while slight countertraction is maintained, reduction of the contents is attempted circumferentially in a small stepwise fashion to ease their reduction into the abdomen.The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangu-lation of hernia contents is a surgical emergency. Clinical signs that | Surgery_Schwartz. hernia repairs.35 For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible.Incarceration occurs when hernia contents fail to reduce; however, a minimally symptomatic, chronically incarcerated hernia may also be treated nonoperatively. Taxis should be attempted for incarcerated hernias without sequelae of strangulation, and the option of surgical repair should be discussed prior to the maneuver. To perform taxis, analgesics and light sedatives are administered, and the patient is placed in the Trendelenburg position. The hernia sac is elongated with both hands, and while slight countertraction is maintained, reduction of the contents is attempted circumferentially in a small stepwise fashion to ease their reduction into the abdomen.The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangu-lation of hernia contents is a surgical emergency. Clinical signs that |
Surgery_Schwartz_10616 | Surgery_Schwartz | the abdomen.The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangu-lation of hernia contents is a surgical emergency. Clinical signs that indicate strangulation include tenderness, fever, leukocy-tosis, and hemodynamic instability. The hernia bulge is usu-ally warm, tender, and the overlying skin is often erythematous or discolored. Symptoms of bowel obstruction in patients with sliding or incarcerated inguinal hernias may also indicate stran-gulation. Taxis should not be performed when strangulation is suspected, as reduction of potentially gangrenous tissue into the abdomen may result in an intra-abdominal catastrophe. Preop-eratively, the patient should receive fluid resuscitation, naso-gastric decompression, and prophylactic intravenous antibiotics.Brunicardi_Ch37_p1599-p1624.indd 160829/01/19 2:03 PM 1609INGUINAL HERNIASCHAPTER 37Prophylactic AntibioticsThe debate as to whether or not to administer preoperative | Surgery_Schwartz. the abdomen.The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangu-lation of hernia contents is a surgical emergency. Clinical signs that indicate strangulation include tenderness, fever, leukocy-tosis, and hemodynamic instability. The hernia bulge is usu-ally warm, tender, and the overlying skin is often erythematous or discolored. Symptoms of bowel obstruction in patients with sliding or incarcerated inguinal hernias may also indicate stran-gulation. Taxis should not be performed when strangulation is suspected, as reduction of potentially gangrenous tissue into the abdomen may result in an intra-abdominal catastrophe. Preop-eratively, the patient should receive fluid resuscitation, naso-gastric decompression, and prophylactic intravenous antibiotics.Brunicardi_Ch37_p1599-p1624.indd 160829/01/19 2:03 PM 1609INGUINAL HERNIASCHAPTER 37Prophylactic AntibioticsThe debate as to whether or not to administer preoperative |
Surgery_Schwartz_10617 | Surgery_Schwartz | intravenous antibiotics.Brunicardi_Ch37_p1599-p1624.indd 160829/01/19 2:03 PM 1609INGUINAL HERNIASCHAPTER 37Prophylactic AntibioticsThe debate as to whether or not to administer preoperative prophylactic antibiotics in elective inguinal hernia repair still remains controversial as elective hernia repair is considered a clean procedure and as such are exempt from SCIP surgical prophylaxis guidelines. A Cochrane review of 17 randomized controlled trials in 2012 revealed an overall decrease in infec-tion rates (3.1% vs. 4.5%, odds ratio [OR] 0.64, 95% confi-dence interval [CI] 0.50–0.82) when prophylactic antibiotics are administered in patients. In subgroup analyses, the differ-ence was smaller in patients without mesh placement (3.5% vs. 4.9%, OR 0.71, 95% CI 0.51–1.00) than in those with mesh placement (2.4% vs. 4.2%, OR 0.56, 95% CI 0.38–0.81). However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result, | Surgery_Schwartz. intravenous antibiotics.Brunicardi_Ch37_p1599-p1624.indd 160829/01/19 2:03 PM 1609INGUINAL HERNIASCHAPTER 37Prophylactic AntibioticsThe debate as to whether or not to administer preoperative prophylactic antibiotics in elective inguinal hernia repair still remains controversial as elective hernia repair is considered a clean procedure and as such are exempt from SCIP surgical prophylaxis guidelines. A Cochrane review of 17 randomized controlled trials in 2012 revealed an overall decrease in infec-tion rates (3.1% vs. 4.5%, odds ratio [OR] 0.64, 95% confi-dence interval [CI] 0.50–0.82) when prophylactic antibiotics are administered in patients. In subgroup analyses, the differ-ence was smaller in patients without mesh placement (3.5% vs. 4.9%, OR 0.71, 95% CI 0.51–1.00) than in those with mesh placement (2.4% vs. 4.2%, OR 0.56, 95% CI 0.38–0.81). However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result, |
Surgery_Schwartz_10618 | Surgery_Schwartz | with mesh placement (2.4% vs. 4.2%, OR 0.56, 95% CI 0.38–0.81). However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result, they were unable to definitively recommend for or against antimicrobial prophylaxis.36,37 Although there is no uni-versal guideline regarding the administration of prophylactic antibiotics for open elective hernia repair, the routine indexing of cases for quality improvement databases have resulted in the routine administration of prophylactic perioperative antibiotics in inguinal hernia repairs.Open ApproachThe most commonly performed type of hernia operation still remains the open inguinal hernia repair. These repairs can be performed tension-free with mesh or by reconstruction of the floor with tissue. Tissue repairs are less common and are pri-marily indicated in infected fields.Exposure of the anterior inguinal region is common to the open approaches. An oblique or horizontal incision | Surgery_Schwartz. with mesh placement (2.4% vs. 4.2%, OR 0.56, 95% CI 0.38–0.81). However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result, they were unable to definitively recommend for or against antimicrobial prophylaxis.36,37 Although there is no uni-versal guideline regarding the administration of prophylactic antibiotics for open elective hernia repair, the routine indexing of cases for quality improvement databases have resulted in the routine administration of prophylactic perioperative antibiotics in inguinal hernia repairs.Open ApproachThe most commonly performed type of hernia operation still remains the open inguinal hernia repair. These repairs can be performed tension-free with mesh or by reconstruction of the floor with tissue. Tissue repairs are less common and are pri-marily indicated in infected fields.Exposure of the anterior inguinal region is common to the open approaches. An oblique or horizontal incision |
Surgery_Schwartz_10619 | Surgery_Schwartz | tissue. Tissue repairs are less common and are pri-marily indicated in infected fields.Exposure of the anterior inguinal region is common to the open approaches. An oblique or horizontal incision is performed over the groin (Fig. 37-13). The incision begins two fingerbreadths inferior and medial to the anterior superior iliac spine. It is then extended medially for approximately 6 to 8 cm. The subcutaneous tissue is dissected using electrocautery. Scarpa’s fascia is divided to expose the external oblique aponeurosis. A small incision is made in the external oblique aponeurosis parallel to the direction of the muscle fibers. Standard groin incisionEx. obliqueSpermatic cordCamper’sfasciaScarpa’sfasciaHemostatExternal ringInguinalfloorSQ fatARepaireddefect intransversalisfasciaDirect herniasacIndirect herniasacIllioinguinal nerveBFigure 37-13. A. Layers of the abdominal wall in the anterior open approach to hernia repair. B. Identification of indirect and direct hernia sacs with | Surgery_Schwartz. tissue. Tissue repairs are less common and are pri-marily indicated in infected fields.Exposure of the anterior inguinal region is common to the open approaches. An oblique or horizontal incision is performed over the groin (Fig. 37-13). The incision begins two fingerbreadths inferior and medial to the anterior superior iliac spine. It is then extended medially for approximately 6 to 8 cm. The subcutaneous tissue is dissected using electrocautery. Scarpa’s fascia is divided to expose the external oblique aponeurosis. A small incision is made in the external oblique aponeurosis parallel to the direction of the muscle fibers. Standard groin incisionEx. obliqueSpermatic cordCamper’sfasciaScarpa’sfasciaHemostatExternal ringInguinalfloorSQ fatARepaireddefect intransversalisfasciaDirect herniasacIndirect herniasacIllioinguinal nerveBFigure 37-13. A. Layers of the abdominal wall in the anterior open approach to hernia repair. B. Identification of indirect and direct hernia sacs with |
Surgery_Schwartz_10620 | Surgery_Schwartz | herniasacIndirect herniasacIllioinguinal nerveBFigure 37-13. A. Layers of the abdominal wall in the anterior open approach to hernia repair. B. Identification of indirect and direct hernia sacs with retraction of the spermatic cord and ilioinguinal nerve. Ex. = external; SQ = subcutaneous.Brunicardi_Ch37_p1599-p1624.indd 160929/01/19 2:03 PM 1610SPECIFIC CONSIDERATIONSPART IIFigure 37-14. Anterior open exposure of the inguinal canal. m. = muscle; n. = nerve; v. = vein.Metzenbaum scissors are introduced and spread beneath the fibers to sweep away the underlying ilioinguinal nerve. The scissors are then used to incise the aponeurosis superior to the inguinal ligament, splitting the external inguinal ring.The flaps of the external oblique aponeurosis are elevated with Hemostat clamps. The internal oblique fibers are dissected bluntly from the overlying external oblique flaps. Dissection of the inferior flap reveals the shelving edge of the inguinal ligament. The iliohypogastric and | Surgery_Schwartz. herniasacIndirect herniasacIllioinguinal nerveBFigure 37-13. A. Layers of the abdominal wall in the anterior open approach to hernia repair. B. Identification of indirect and direct hernia sacs with retraction of the spermatic cord and ilioinguinal nerve. Ex. = external; SQ = subcutaneous.Brunicardi_Ch37_p1599-p1624.indd 160929/01/19 2:03 PM 1610SPECIFIC CONSIDERATIONSPART IIFigure 37-14. Anterior open exposure of the inguinal canal. m. = muscle; n. = nerve; v. = vein.Metzenbaum scissors are introduced and spread beneath the fibers to sweep away the underlying ilioinguinal nerve. The scissors are then used to incise the aponeurosis superior to the inguinal ligament, splitting the external inguinal ring.The flaps of the external oblique aponeurosis are elevated with Hemostat clamps. The internal oblique fibers are dissected bluntly from the overlying external oblique flaps. Dissection of the inferior flap reveals the shelving edge of the inguinal ligament. The iliohypogastric and |
Surgery_Schwartz_10621 | Surgery_Schwartz | internal oblique fibers are dissected bluntly from the overlying external oblique flaps. Dissection of the inferior flap reveals the shelving edge of the inguinal ligament. The iliohypogastric and ilioinguinal nerves are iden-tified and preserved. Effort should be made to avoid remov-ing nerves from their natural bed and disrupting the protective investing fascia. The pubic tubercle is identified, and the cord structures are dissected off of the pubis, encircled, and elevated with a Penrose drain. The cord is elevated 2 cm over the pubic symphysis in an avascular plane, and cremasteric fibers are pre-served to avoid injuring cord structures (Fig. 37-14).An indirect hernia sac will generally be found on the antero-medial surface of the spermatic cord after division of the crem-asteric muscle in the direction of its fibers. The genital nerve is visualized along the inferolateral surface of the cord adjacent to the external spermatic vein. The floor of the inguinal canal is fully | Surgery_Schwartz. internal oblique fibers are dissected bluntly from the overlying external oblique flaps. Dissection of the inferior flap reveals the shelving edge of the inguinal ligament. The iliohypogastric and ilioinguinal nerves are iden-tified and preserved. Effort should be made to avoid remov-ing nerves from their natural bed and disrupting the protective investing fascia. The pubic tubercle is identified, and the cord structures are dissected off of the pubis, encircled, and elevated with a Penrose drain. The cord is elevated 2 cm over the pubic symphysis in an avascular plane, and cremasteric fibers are pre-served to avoid injuring cord structures (Fig. 37-14).An indirect hernia sac will generally be found on the antero-medial surface of the spermatic cord after division of the crem-asteric muscle in the direction of its fibers. The genital nerve is visualized along the inferolateral surface of the cord adjacent to the external spermatic vein. The floor of the inguinal canal is fully |
Surgery_Schwartz_10622 | Surgery_Schwartz | muscle in the direction of its fibers. The genital nerve is visualized along the inferolateral surface of the cord adjacent to the external spermatic vein. The floor of the inguinal canal is fully assessed for direct hernias. If a hernia is not visualized upon entry into the inguinal canal, the preperitoneal space should be explored for a femoral hernia. In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identi-fied to allow dissection of the sac from the cord. Blunt dissection facilitates dissection of the sac from the cord. The dissection is carried proximally toward the deep inguinal ring.In cases where the viability of sac contents is in question, the sac should be incised, and hernia contents should be evalu-ated for signs of ischemia. The defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents resected. In elective cases, the sac may be | Surgery_Schwartz. muscle in the direction of its fibers. The genital nerve is visualized along the inferolateral surface of the cord adjacent to the external spermatic vein. The floor of the inguinal canal is fully assessed for direct hernias. If a hernia is not visualized upon entry into the inguinal canal, the preperitoneal space should be explored for a femoral hernia. In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identi-fied to allow dissection of the sac from the cord. Blunt dissection facilitates dissection of the sac from the cord. The dissection is carried proximally toward the deep inguinal ring.In cases where the viability of sac contents is in question, the sac should be incised, and hernia contents should be evalu-ated for signs of ischemia. The defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents resected. In elective cases, the sac may be |
Surgery_Schwartz_10623 | Surgery_Schwartz | defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents resected. In elective cases, the sac may be amputated at the internal inguinal ring or inverted into the preperitoneum. Both methods are effective; however, patients undergoing sac exci-sion had significantly increased postoperative pain in a prospec-tive trial.38 Dissection of a densely adherent sac may result in injury to cord structures and should be avoided; however, sac ligation at the internal inguinal ring is necessary in these cases. A hernia sac that extends into the scrotum may require division within the inguinal canal as extensive dissection and reduction risks injury to the testicular blood supply, resulting in testicular swelling, orchitis, and atrophy.At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of | Surgery_Schwartz. defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents resected. In elective cases, the sac may be amputated at the internal inguinal ring or inverted into the preperitoneum. Both methods are effective; however, patients undergoing sac exci-sion had significantly increased postoperative pain in a prospec-tive trial.38 Dissection of a densely adherent sac may result in injury to cord structures and should be avoided; however, sac ligation at the internal inguinal ring is necessary in these cases. A hernia sac that extends into the scrotum may require division within the inguinal canal as extensive dissection and reduction risks injury to the testicular blood supply, resulting in testicular swelling, orchitis, and atrophy.At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of |
Surgery_Schwartz_10624 | Surgery_Schwartz | swelling, orchitis, and atrophy.At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of tissue-based and prosthetic-based reconstructions.Tissue Repairs. Tissue-based herniorrhaphy is a suitable alter-native when prosthetic materials cannot be used safely. Indica-tions for tissue repairs include operative field contamination, emergency surgery, and when the viability of hernia contents is uncertain.Bassini Repair The Bassini repair was a historic advancement in operative technique. Its current use is limited as modern tech-niques reduce recurrence. The original repair includes dissection of the spermatic cord, dissection of the hernia sac with high liga-tion, and extensive reconstruction of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal | Surgery_Schwartz. swelling, orchitis, and atrophy.At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of tissue-based and prosthetic-based reconstructions.Tissue Repairs. Tissue-based herniorrhaphy is a suitable alter-native when prosthetic materials cannot be used safely. Indica-tions for tissue repairs include operative field contamination, emergency surgery, and when the viability of hernia contents is uncertain.Bassini Repair The Bassini repair was a historic advancement in operative technique. Its current use is limited as modern tech-niques reduce recurrence. The original repair includes dissection of the spermatic cord, dissection of the hernia sac with high liga-tion, and extensive reconstruction of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal |
Surgery_Schwartz_10625 | Surgery_Schwartz | of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal fat is bluntly dissected from the upper margin of the posterior side of the transversalis fascia to permit adequate tissue mobilization. A triple-layer repair is then performed. The internal oblique, transversus abdominis, and transversalis fascia are fixed to the shelving edge of the inguinal ligament and pubic periosteum with interrupted sutures. The lateral aspect of the repair reinforces the medial border of the internal inguinal ring.Shouldice Repair The Shouldice repair recapitulates principles of the Bassini repair, and its distribution of tension over several tissue layers results in lower recurrence rates (Fig. 37-16). Dur-ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the | Surgery_Schwartz. of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal fat is bluntly dissected from the upper margin of the posterior side of the transversalis fascia to permit adequate tissue mobilization. A triple-layer repair is then performed. The internal oblique, transversus abdominis, and transversalis fascia are fixed to the shelving edge of the inguinal ligament and pubic periosteum with interrupted sutures. The lateral aspect of the repair reinforces the medial border of the internal inguinal ring.Shouldice Repair The Shouldice repair recapitulates principles of the Bassini repair, and its distribution of tension over several tissue layers results in lower recurrence rates (Fig. 37-16). Dur-ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the |
Surgery_Schwartz_10626 | Surgery_Schwartz | rates (Fig. 37-16). Dur-ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the mons pubis and labium majus in women. With the posterior inguinal floor exposed, an incision in the transversalis fascia is made between the pubic tubercle and internal ring. Care is taken to avoid injury to preperitoneal struc-tures, which are bluntly dissected to mobilize the upper and lower fascial flaps. At the pubic tubercle, the iliopubic tract is sutured to the lateral edge of the rectus sheath using a synthetic, nonab-sorbable, monofilament suture. This continuous suture progresses laterally, approximating the edge of the inferior transversalis flap to the posterior aspect of the superior flap. At the internal inguinal ring, the suture continues back in the medial direction, approxi-mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At | Surgery_Schwartz. rates (Fig. 37-16). Dur-ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the mons pubis and labium majus in women. With the posterior inguinal floor exposed, an incision in the transversalis fascia is made between the pubic tubercle and internal ring. Care is taken to avoid injury to preperitoneal struc-tures, which are bluntly dissected to mobilize the upper and lower fascial flaps. At the pubic tubercle, the iliopubic tract is sutured to the lateral edge of the rectus sheath using a synthetic, nonab-sorbable, monofilament suture. This continuous suture progresses laterally, approximating the edge of the inferior transversalis flap to the posterior aspect of the superior flap. At the internal inguinal ring, the suture continues back in the medial direction, approxi-mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At |
Surgery_Schwartz_10627 | Surgery_Schwartz | At the internal inguinal ring, the suture continues back in the medial direction, approxi-mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At the pubic tubercle, this suture is tied to the tail of the original stitch. The next suture begins at the internal inguinal ring, and it continues medially, apposing the aponeuroses of the internal oblique and transversus abdominis to the external oblique aponeurotic fibers. At the pubic tubercle, the suture doubles back through the same structures lat-erally towards the tightened internal ring.McVay Repair The McVay repair addresses both inguinal and femoral ring defects. This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of | Surgery_Schwartz. At the internal inguinal ring, the suture continues back in the medial direction, approxi-mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At the pubic tubercle, this suture is tied to the tail of the original stitch. The next suture begins at the internal inguinal ring, and it continues medially, apposing the aponeuroses of the internal oblique and transversus abdominis to the external oblique aponeurotic fibers. At the pubic tubercle, the suture doubles back through the same structures lat-erally towards the tightened internal ring.McVay Repair The McVay repair addresses both inguinal and femoral ring defects. This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of |
Surgery_Schwartz_10628 | Surgery_Schwartz | (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of underlying tissue. Cooper’s ligament is bluntly dissected to expose its surface. A 2 to 4 cm relaxing incision is made in the anterior rectus sheath vertically from the Brunicardi_Ch37_p1599-p1624.indd 161029/01/19 2:03 PM 1611INGUINAL HERNIASCHAPTER 37SpermaticcordPoupart'sligament Internal abdominaloblique muscleExternal abdominaloblique aponeurosisPreperitoneal fatTransversalis fasciaABEOTATFILIOFigure 37-15. Bassini repair. A. The transversalis fascia is opened. B. Reconstruction of the posterior wall by suturing the transver-salis fascia (TF), the transversus abdominis muscle (TA), and the internal oblique muscle (IO) medially to the inguinal ligament (IL) laterally. EO = external oblique aponeurosis.ABFigure 37-16. Shouldice repair. A. The iliopubic tract is sutured to the | Surgery_Schwartz. (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of underlying tissue. Cooper’s ligament is bluntly dissected to expose its surface. A 2 to 4 cm relaxing incision is made in the anterior rectus sheath vertically from the Brunicardi_Ch37_p1599-p1624.indd 161029/01/19 2:03 PM 1611INGUINAL HERNIASCHAPTER 37SpermaticcordPoupart'sligament Internal abdominaloblique muscleExternal abdominaloblique aponeurosisPreperitoneal fatTransversalis fasciaABEOTATFILIOFigure 37-15. Bassini repair. A. The transversalis fascia is opened. B. Reconstruction of the posterior wall by suturing the transver-salis fascia (TF), the transversus abdominis muscle (TA), and the internal oblique muscle (IO) medially to the inguinal ligament (IL) laterally. EO = external oblique aponeurosis.ABFigure 37-16. Shouldice repair. A. The iliopubic tract is sutured to the |
Surgery_Schwartz_10629 | Surgery_Schwartz | and the internal oblique muscle (IO) medially to the inguinal ligament (IL) laterally. EO = external oblique aponeurosis.ABFigure 37-16. Shouldice repair. A. The iliopubic tract is sutured to the medial flap of the transversalis fascia and the internal oblique and transverse abdominis muscles. B. The second of the four suture lines, reversing toward the pubic tubercle approximating the inter-nal oblique and transversus muscles to the inguinal ligament. Two more suture lines affix the internal oblique and transversus muscles medially.Cooper’s ligamentFigure 37-17. McVay Cooper’s ligament repair.pubic tubercle. This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation. Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin-ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral | Surgery_Schwartz. and the internal oblique muscle (IO) medially to the inguinal ligament (IL) laterally. EO = external oblique aponeurosis.ABFigure 37-16. Shouldice repair. A. The iliopubic tract is sutured to the medial flap of the transversalis fascia and the internal oblique and transverse abdominis muscles. B. The second of the four suture lines, reversing toward the pubic tubercle approximating the inter-nal oblique and transversus muscles to the inguinal ligament. Two more suture lines affix the internal oblique and transversus muscles medially.Cooper’s ligamentFigure 37-17. McVay Cooper’s ligament repair.pubic tubercle. This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation. Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin-ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral |
Surgery_Schwartz_10630 | Surgery_Schwartz | or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin-ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament. The transversalis is then sutured to the inguinal ligament laterally to the internal ring.Desarda Repair The Desarda hernia repair was recently described in 2001, and it consists of a mesh-free repair utilizing a strip of external oblique aponeurosis.An oblique skin incision is made, and dissection is carried down to the external oblique fascia. The integrity of the fascia is preserved as much as possible. The cremasteric muscle is then incised, and the spermatic cord along with the cremasteric muscle is separated from the inguinal floor. Excision of the sac is done in all cases except in small direct hernias, where it is inverted.The medial leaf of the external oblique aponeurosis is | Surgery_Schwartz. or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin-ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament. The transversalis is then sutured to the inguinal ligament laterally to the internal ring.Desarda Repair The Desarda hernia repair was recently described in 2001, and it consists of a mesh-free repair utilizing a strip of external oblique aponeurosis.An oblique skin incision is made, and dissection is carried down to the external oblique fascia. The integrity of the fascia is preserved as much as possible. The cremasteric muscle is then incised, and the spermatic cord along with the cremasteric muscle is separated from the inguinal floor. Excision of the sac is done in all cases except in small direct hernias, where it is inverted.The medial leaf of the external oblique aponeurosis is |
Surgery_Schwartz_10631 | Surgery_Schwartz | muscle is separated from the inguinal floor. Excision of the sac is done in all cases except in small direct hernias, where it is inverted.The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament from the pubic tubercle to the abdominal ring using 1–0 Ethilon or Prolene interrupted sutures. The first two sutures are taken at the junction of the anterior rec-tus sheath and EOA. The last suture is taken so as to sufficiently Brunicardi_Ch37_p1599-p1624.indd 161129/01/19 2:03 PM 1612SPECIFIC CONSIDERATIONSPART IInarrow the abdominal ring without constricting the spermatic cord (Fig. 37-18). Each suture is passed first through the ingui-nal ligament, then the transversalis fascia, and then the EOA. The index finger of the left hand is used to protect the femo-ral vessels and retract the cord structures laterally while taking lateral sutures. A splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended | Surgery_Schwartz. muscle is separated from the inguinal floor. Excision of the sac is done in all cases except in small direct hernias, where it is inverted.The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament from the pubic tubercle to the abdominal ring using 1–0 Ethilon or Prolene interrupted sutures. The first two sutures are taken at the junction of the anterior rec-tus sheath and EOA. The last suture is taken so as to sufficiently Brunicardi_Ch37_p1599-p1624.indd 161129/01/19 2:03 PM 1612SPECIFIC CONSIDERATIONSPART IInarrow the abdominal ring without constricting the spermatic cord (Fig. 37-18). Each suture is passed first through the ingui-nal ligament, then the transversalis fascia, and then the EOA. The index finger of the left hand is used to protect the femo-ral vessels and retract the cord structures laterally while taking lateral sutures. A splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended |
Surgery_Schwartz_10632 | Surgery_Schwartz | vessels and retract the cord structures laterally while taking lateral sutures. A splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended medially up to the pubic symphysis and laterally 1 to 2 cm beyond the reconstructed abdominal ring.The free border of the strip of the EOA is now sutured to the internal oblique or conjoined tendon lying close to it with 1–0 Ethilon or Prolene interrupted sutures. This is followed by closure of the superficial fascia and the skin as usual.39-41Prosthetic Repairs. The popularization of tension-free pros-thetic mesh repairs signified a paradigm shift in the surgical concept of inguinal hernia pathophysiology. Mesh-based her-nioplasty is the most commonly performed general surgical procedure, owing to the technique’s efficacy and improved out-comes. The techniques of the most commonly performed pros-thetic repairs are presented in this section.Lichtenstein Tension-Free Repair The Lichtenstein | Surgery_Schwartz. vessels and retract the cord structures laterally while taking lateral sutures. A splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended medially up to the pubic symphysis and laterally 1 to 2 cm beyond the reconstructed abdominal ring.The free border of the strip of the EOA is now sutured to the internal oblique or conjoined tendon lying close to it with 1–0 Ethilon or Prolene interrupted sutures. This is followed by closure of the superficial fascia and the skin as usual.39-41Prosthetic Repairs. The popularization of tension-free pros-thetic mesh repairs signified a paradigm shift in the surgical concept of inguinal hernia pathophysiology. Mesh-based her-nioplasty is the most commonly performed general surgical procedure, owing to the technique’s efficacy and improved out-comes. The techniques of the most commonly performed pros-thetic repairs are presented in this section.Lichtenstein Tension-Free Repair The Lichtenstein |
Surgery_Schwartz_10633 | Surgery_Schwartz | to the technique’s efficacy and improved out-comes. The techniques of the most commonly performed pros-thetic repairs are presented in this section.Lichtenstein Tension-Free Repair The Lichtenstein technique allows for a tension-free repair of the inguinal floor by buttressing the floor with a prosthetic mesh (Fig. 37-18). Initial exposure and mobilization of cord structures is identical to other open approaches. The inguinal canal is dissected to expose the shelving edge of the inguinal ligament, the pubic tubercle, and sufficient area for mesh. The most commonly used mesh is “flat iron” shaped with a keyhole for cord egress, it is available in several sizes. It should be noted that when selecting the size, it must be large enough to extend 2 to 3 cm superior to Figure 37-18. The Desarda repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf, 2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 | Surgery_Schwartz. to the technique’s efficacy and improved out-comes. The techniques of the most commonly performed pros-thetic repairs are presented in this section.Lichtenstein Tension-Free Repair The Lichtenstein technique allows for a tension-free repair of the inguinal floor by buttressing the floor with a prosthetic mesh (Fig. 37-18). Initial exposure and mobilization of cord structures is identical to other open approaches. The inguinal canal is dissected to expose the shelving edge of the inguinal ligament, the pubic tubercle, and sufficient area for mesh. The most commonly used mesh is “flat iron” shaped with a keyhole for cord egress, it is available in several sizes. It should be noted that when selecting the size, it must be large enough to extend 2 to 3 cm superior to Figure 37-18. The Desarda repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf, 2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 |
Surgery_Schwartz_10634 | Surgery_Schwartz | repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf, 2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 pubic tubercle, 4 abdominal ring, 5 spermatic cord, 6 lateral leaf B. Undetached strip of the external oblique aponeurosis forming the posterior wall. 1 Reflected medial leaf after a strip has been separated, 2 internal oblique muscle seen through the splitting incision made in the medial leaf, 3 interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscle, 4 interrupted sutures between the lower border of the strip and the inguinal ligament, 5 pubic tubercle, 6 abdominal ring, 7 spermatic cord, 8 lateral leaf.64123568751234Hesselbach’s Triangle. The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial | Surgery_Schwartz. repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf, 2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 pubic tubercle, 4 abdominal ring, 5 spermatic cord, 6 lateral leaf B. Undetached strip of the external oblique aponeurosis forming the posterior wall. 1 Reflected medial leaf after a strip has been separated, 2 internal oblique muscle seen through the splitting incision made in the medial leaf, 3 interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscle, 4 interrupted sutures between the lower border of the strip and the inguinal ligament, 5 pubic tubercle, 6 abdominal ring, 7 spermatic cord, 8 lateral leaf.64123568751234Hesselbach’s Triangle. The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial |
Surgery_Schwartz_10635 | Surgery_Schwartz | The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial recurrence.42For fixation of the inferior margin of the mesh, a per-manent, synthetic, monofilament suture is used taking care to avoid placing sutures directly into the periosteum of the pubic tubercle. Fixation is continued along the shelving edge of the inguinal ligament from medial to lateral, ending at the internal ring. The upper tail of the mesh is then fixed to the internal oblique aponeurosis and the medial edge to the rectus sheath using a synthetic, absorbable suture.In the case of a femoral hernia, a triangular extension of the inferior aspect of the mesh is sutured to Cooper’s ligament medially and to the inguinal ligament laterally. The lateral tails of the mesh are tailored to fit snugly around the cord at the internal ring, but not too tight to strangulate it. The tails are | Surgery_Schwartz. The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm. This refinement to the original Lichtenstein technique minimizes medial recurrence.42For fixation of the inferior margin of the mesh, a per-manent, synthetic, monofilament suture is used taking care to avoid placing sutures directly into the periosteum of the pubic tubercle. Fixation is continued along the shelving edge of the inguinal ligament from medial to lateral, ending at the internal ring. The upper tail of the mesh is then fixed to the internal oblique aponeurosis and the medial edge to the rectus sheath using a synthetic, absorbable suture.In the case of a femoral hernia, a triangular extension of the inferior aspect of the mesh is sutured to Cooper’s ligament medially and to the inguinal ligament laterally. The lateral tails of the mesh are tailored to fit snugly around the cord at the internal ring, but not too tight to strangulate it. The tails are |
Surgery_Schwartz_10636 | Surgery_Schwartz | medially and to the inguinal ligament laterally. The lateral tails of the mesh are tailored to fit snugly around the cord at the internal ring, but not too tight to strangulate it. The tails are then sutured to the inguinal ligament with an interrupted stitch and placed beneath the external oblique aponeurosis.Plug and Patch Technique. A modification of the Lichtenstein repair, the Plug and Patch technique was developed by Gilbert and later popularized by Rutkow and Robbins.43 Prior to placing the prosthetic mesh patch over the inguinal floor, a three-dimensional prosthetic plug is placed in the space previously occupied by the hernia sac (Fig. 37-19). In the case of an indirect hernia, the plug is placed alongside the spermatic cord through the internal ring. Prosthetic plugs of various sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s | Surgery_Schwartz. medially and to the inguinal ligament laterally. The lateral tails of the mesh are tailored to fit snugly around the cord at the internal ring, but not too tight to strangulate it. The tails are then sutured to the inguinal ligament with an interrupted stitch and placed beneath the external oblique aponeurosis.Plug and Patch Technique. A modification of the Lichtenstein repair, the Plug and Patch technique was developed by Gilbert and later popularized by Rutkow and Robbins.43 Prior to placing the prosthetic mesh patch over the inguinal floor, a three-dimensional prosthetic plug is placed in the space previously occupied by the hernia sac (Fig. 37-19). In the case of an indirect hernia, the plug is placed alongside the spermatic cord through the internal ring. Prosthetic plugs of various sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s |
Surgery_Schwartz_10637 | Surgery_Schwartz | sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s ligament, the inguinal ligament, and Brunicardi_Ch37_p1599-p1624.indd 161229/01/19 2:03 PM 1613INGUINAL HERNIASCHAPTER 37Figure 37-19. Lichtenstein tension-free hernioplasty. m. = muscle; n. = nerve; v. = vein.the internal oblique aponeurosis. While the technique has good overall outcomes, there have been some isolated case report series of complications involving the presence of the plug, including bowel obstruction and chronic pain.Wound Closure Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic posi-tion. The external oblique aponeurosis is then reapproximated continuously from medial to lateral using an absorbable suture. The external ring should be reconstructed in close apposition to the spermatic cord to avoid the | Surgery_Schwartz. sizes are available, and one of appropriate size is fixed to the margins of the internal ring with interrupted sutures.44 For direct hernias, the sac is reduced, and the plug is sutured to Cooper’s ligament, the inguinal ligament, and Brunicardi_Ch37_p1599-p1624.indd 161229/01/19 2:03 PM 1613INGUINAL HERNIASCHAPTER 37Figure 37-19. Lichtenstein tension-free hernioplasty. m. = muscle; n. = nerve; v. = vein.the internal oblique aponeurosis. While the technique has good overall outcomes, there have been some isolated case report series of complications involving the presence of the plug, including bowel obstruction and chronic pain.Wound Closure Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic posi-tion. The external oblique aponeurosis is then reapproximated continuously from medial to lateral using an absorbable suture. The external ring should be reconstructed in close apposition to the spermatic cord to avoid the |
Surgery_Schwartz_10638 | Surgery_Schwartz | aponeurosis is then reapproximated continuously from medial to lateral using an absorbable suture. The external ring should be reconstructed in close apposition to the spermatic cord to avoid the appearance of recurrence on future examination. Scarpa’s fascia and skin are appropriately closed.Laparoscopic ApproachLaparoscopic inguinal hernia repairs have become increas-ingly popular given the noninferiority studies, improved aes-thetics, and increased surgeon experience with the procedure. Principal endoscopic methods include the transabdominal preperitoneal (TAPP) repair, the totally extraperitoneal (TEP) repair, and the less-commonly performed intraperitoneal onlay mesh (IPOM) repair.Of note, awake patients do not tolerate abdominal insuffla-tion well; therefore, laparoscopic repair necessitates the admin-istration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. | Surgery_Schwartz. aponeurosis is then reapproximated continuously from medial to lateral using an absorbable suture. The external ring should be reconstructed in close apposition to the spermatic cord to avoid the appearance of recurrence on future examination. Scarpa’s fascia and skin are appropriately closed.Laparoscopic ApproachLaparoscopic inguinal hernia repairs have become increas-ingly popular given the noninferiority studies, improved aes-thetics, and increased surgeon experience with the procedure. Principal endoscopic methods include the transabdominal preperitoneal (TAPP) repair, the totally extraperitoneal (TEP) repair, and the less-commonly performed intraperitoneal onlay mesh (IPOM) repair.Of note, awake patients do not tolerate abdominal insuffla-tion well; therefore, laparoscopic repair necessitates the admin-istration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. |
Surgery_Schwartz_10639 | Surgery_Schwartz | necessitates the admin-istration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. Occasionally, induction of general anesthesia may result in reduction of an incarcer-ated or strangulated inguinal hernia. If the surgeon suspects this might have occurred, the abdomen should be explored for non-viable tissue either via laparoscopy or upon conversion to an open laparotomy.The indications for laparoscopic inguinal hernia repair are similar to those for open repair. Most surgeons would agree that the endoscopic approach to bilateral or recurrent inguinal hernias is superior to the open approach.45 Concurrent inguinal hernia repair can be considered if a hernia patient is scheduled to undergo another laparoscopic procedure without gross contamination, such as prostatectomy.46,47 International Endohernia Society (IEHS) guidelines offer a grade A recommendation that TEP and TAPP | Surgery_Schwartz. necessitates the admin-istration of general anesthesia and its inherent risks. Any patient with a contraindication to the use of general anesthesia should not undergo laparoscopic hernia repair. Occasionally, induction of general anesthesia may result in reduction of an incarcer-ated or strangulated inguinal hernia. If the surgeon suspects this might have occurred, the abdomen should be explored for non-viable tissue either via laparoscopy or upon conversion to an open laparotomy.The indications for laparoscopic inguinal hernia repair are similar to those for open repair. Most surgeons would agree that the endoscopic approach to bilateral or recurrent inguinal hernias is superior to the open approach.45 Concurrent inguinal hernia repair can be considered if a hernia patient is scheduled to undergo another laparoscopic procedure without gross contamination, such as prostatectomy.46,47 International Endohernia Society (IEHS) guidelines offer a grade A recommendation that TEP and TAPP |
Surgery_Schwartz_10640 | Surgery_Schwartz | to undergo another laparoscopic procedure without gross contamination, such as prostatectomy.46,47 International Endohernia Society (IEHS) guidelines offer a grade A recommendation that TEP and TAPP are preferred alternatives to Lichtenstein repair for recurrent hernias after open anterior repair.48,49 The possibility of bilateral repair should be discussed with all patients undergoing endoscopic inguinal hernia surgery.The operating room configuration is identical for TAPP, TEP, and IPOM procedures. The patient is placed in the Trendelenburg position, and video screens are placed at the foot of the bed. The surgeon stands contralateral to the hernia, and the assistant stands opposite the surgeon. The patient’s arms are tucked to the sides. Figure 37-20 demonstrates a typical operating room setup for endoscopic inguinal hernia repair. The following sections outline the most commonly performed endoscopic inguinal hernia repair techniques.Transabdominal Preperitoneal Procedure. The | Surgery_Schwartz. to undergo another laparoscopic procedure without gross contamination, such as prostatectomy.46,47 International Endohernia Society (IEHS) guidelines offer a grade A recommendation that TEP and TAPP are preferred alternatives to Lichtenstein repair for recurrent hernias after open anterior repair.48,49 The possibility of bilateral repair should be discussed with all patients undergoing endoscopic inguinal hernia surgery.The operating room configuration is identical for TAPP, TEP, and IPOM procedures. The patient is placed in the Trendelenburg position, and video screens are placed at the foot of the bed. The surgeon stands contralateral to the hernia, and the assistant stands opposite the surgeon. The patient’s arms are tucked to the sides. Figure 37-20 demonstrates a typical operating room setup for endoscopic inguinal hernia repair. The following sections outline the most commonly performed endoscopic inguinal hernia repair techniques.Transabdominal Preperitoneal Procedure. The |
Surgery_Schwartz_10641 | Surgery_Schwartz | room setup for endoscopic inguinal hernia repair. The following sections outline the most commonly performed endoscopic inguinal hernia repair techniques.Transabdominal Preperitoneal Procedure. The transab-dominal approach confers the advantage of an intraperitoneal perspective, which is useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery. The abdominal cavity is accessed using a dissecting trocar or open Hasson technique. Pneumoperitoneum to a level of 15 mmHg is achieved. Two 5-mm trocars are placed lateral and slightly inferior to the umbilical trocar, avoiding injury to the inferior epigastric vessels (Fig. 37-21). The patient is then placed in the Trendelenburg position, and the pelvis is inspected.The bladder, median and medial umbilical ligaments, external iliac, and inferior epigastric vessels are visualized. An incision is made in the peritoneum at the medial umbilical liga-ment, 3 to 4 cm superior to the hernia defect, and | Surgery_Schwartz. room setup for endoscopic inguinal hernia repair. The following sections outline the most commonly performed endoscopic inguinal hernia repair techniques.Transabdominal Preperitoneal Procedure. The transab-dominal approach confers the advantage of an intraperitoneal perspective, which is useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery. The abdominal cavity is accessed using a dissecting trocar or open Hasson technique. Pneumoperitoneum to a level of 15 mmHg is achieved. Two 5-mm trocars are placed lateral and slightly inferior to the umbilical trocar, avoiding injury to the inferior epigastric vessels (Fig. 37-21). The patient is then placed in the Trendelenburg position, and the pelvis is inspected.The bladder, median and medial umbilical ligaments, external iliac, and inferior epigastric vessels are visualized. An incision is made in the peritoneum at the medial umbilical liga-ment, 3 to 4 cm superior to the hernia defect, and |
Surgery_Schwartz_10642 | Surgery_Schwartz | ligaments, external iliac, and inferior epigastric vessels are visualized. An incision is made in the peritoneum at the medial umbilical liga-ment, 3 to 4 cm superior to the hernia defect, and it is carried lat-erally to the anterior superior iliac spine. For bilateral inguinal hernia repair, bilateral peritoneal incisions are advisable, leav-ing a midline bridge of tissue to avoid injuring a potential patent urachus. The inferior edge of incised peritoneum is retracted, and the preperitoneum is dissected to expose the spermatic cord. If a direct hernia is encountered, the sac is inverted and fixed to Cooper’s ligament to prevent development of hematoma or seroma. An indirect hernia sac will usually protrude anterior to the spermatic cord. In this case, the sac is grasped and elevated superiorly from the cord and the space below is developed bluntly to allow for mesh placement. The sac is dissected from its adhesions, and the cord is skeletonized.The mesh usually measures 10 × 15 cm | Surgery_Schwartz. ligaments, external iliac, and inferior epigastric vessels are visualized. An incision is made in the peritoneum at the medial umbilical liga-ment, 3 to 4 cm superior to the hernia defect, and it is carried lat-erally to the anterior superior iliac spine. For bilateral inguinal hernia repair, bilateral peritoneal incisions are advisable, leav-ing a midline bridge of tissue to avoid injuring a potential patent urachus. The inferior edge of incised peritoneum is retracted, and the preperitoneum is dissected to expose the spermatic cord. If a direct hernia is encountered, the sac is inverted and fixed to Cooper’s ligament to prevent development of hematoma or seroma. An indirect hernia sac will usually protrude anterior to the spermatic cord. In this case, the sac is grasped and elevated superiorly from the cord and the space below is developed bluntly to allow for mesh placement. The sac is dissected from its adhesions, and the cord is skeletonized.The mesh usually measures 10 × 15 cm |
Surgery_Schwartz_10643 | Surgery_Schwartz | from the cord and the space below is developed bluntly to allow for mesh placement. The sac is dissected from its adhesions, and the cord is skeletonized.The mesh usually measures 10 × 15 cm to completely cover the myopectineal orifice (Fig. 37-22). It is rolled length-wise and placed through the 12-mm trocar. It is unrolled in the preperitoneal space and secured medially to Cooper’s ligament using an endoscopic tacker. During this fixation, the surgeon palpates the end of the tacker from the abdominal surface to ensure its proper angle and to stabilize the pelvis. The mesh is then pulled taut and fixed laterally to the anterior superior iliac spine. Tacks are placed above the iliopubic tract to avoid injury to the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve. The peritoneal edges are reapproxi-mated using tacks or intracorporeal sutures as the mesh is sta-bilized. The peritoneum should be closed completely to avoid contact between the mesh | Surgery_Schwartz. from the cord and the space below is developed bluntly to allow for mesh placement. The sac is dissected from its adhesions, and the cord is skeletonized.The mesh usually measures 10 × 15 cm to completely cover the myopectineal orifice (Fig. 37-22). It is rolled length-wise and placed through the 12-mm trocar. It is unrolled in the preperitoneal space and secured medially to Cooper’s ligament using an endoscopic tacker. During this fixation, the surgeon palpates the end of the tacker from the abdominal surface to ensure its proper angle and to stabilize the pelvis. The mesh is then pulled taut and fixed laterally to the anterior superior iliac spine. Tacks are placed above the iliopubic tract to avoid injury to the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve. The peritoneal edges are reapproxi-mated using tacks or intracorporeal sutures as the mesh is sta-bilized. The peritoneum should be closed completely to avoid contact between the mesh |
Surgery_Schwartz_10644 | Surgery_Schwartz | nerve. The peritoneal edges are reapproxi-mated using tacks or intracorporeal sutures as the mesh is sta-bilized. The peritoneum should be closed completely to avoid contact between the mesh and the intestine. The abdomen is desufflated, and the trocars are removed. The fascial defect of the 12-mm port and the skin incisions are appropriately closed.Totally Extraperitoneal Procedure. The advantage of the TEP repair is the access to the preperitoneal space without intra-peritoneal infiltration. Consequently, this approach minimizes the risk of injury to intra-abdominal organs and port site hernia-tion through an iatrogenic defect in the abdominal wall. As with TAPP, TEP is indicated for repair of bilateral inguinal hernias or Brunicardi_Ch37_p1599-p1624.indd 161329/01/19 2:03 PM 1614SPECIFIC CONSIDERATIONSPART IIFigure 37-20. Operating room setup for laparoscopic inguinal hernia repair.for unilateral hernias when scarring makes the anterior approach challenging.A small horizontal | Surgery_Schwartz. nerve. The peritoneal edges are reapproxi-mated using tacks or intracorporeal sutures as the mesh is sta-bilized. The peritoneum should be closed completely to avoid contact between the mesh and the intestine. The abdomen is desufflated, and the trocars are removed. The fascial defect of the 12-mm port and the skin incisions are appropriately closed.Totally Extraperitoneal Procedure. The advantage of the TEP repair is the access to the preperitoneal space without intra-peritoneal infiltration. Consequently, this approach minimizes the risk of injury to intra-abdominal organs and port site hernia-tion through an iatrogenic defect in the abdominal wall. As with TAPP, TEP is indicated for repair of bilateral inguinal hernias or Brunicardi_Ch37_p1599-p1624.indd 161329/01/19 2:03 PM 1614SPECIFIC CONSIDERATIONSPART IIFigure 37-20. Operating room setup for laparoscopic inguinal hernia repair.for unilateral hernias when scarring makes the anterior approach challenging.A small horizontal |
Surgery_Schwartz_10645 | Surgery_Schwartz | CONSIDERATIONSPART IIFigure 37-20. Operating room setup for laparoscopic inguinal hernia repair.for unilateral hernias when scarring makes the anterior approach challenging.A small horizontal incision is made inferior to the umbi-licus. Subcutaneous tissue is dissected to the level of the ante-rior rectus sheath, which is then incised lateral to the linea alba. The rectus muscle is retracted superolaterally, and a dissecting balloon is advanced through the incision toward the pubic sym-physis. Under direct visualization with a 30° laparoscope, the balloon is inflated slowly to bluntly dissect the preperitoneal space (Fig. 37-23). The dissecting balloon is replaced with a 12-mm balloon trocar, and pneumopreperitoneum is achieved by insufflation to 15 mmHg. A 5-mm trocar is placed suprapubically in the midline, and another is placed inferior to the insufflation port (see Fig. 37-21). The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion | Surgery_Schwartz. CONSIDERATIONSPART IIFigure 37-20. Operating room setup for laparoscopic inguinal hernia repair.for unilateral hernias when scarring makes the anterior approach challenging.A small horizontal incision is made inferior to the umbi-licus. Subcutaneous tissue is dissected to the level of the ante-rior rectus sheath, which is then incised lateral to the linea alba. The rectus muscle is retracted superolaterally, and a dissecting balloon is advanced through the incision toward the pubic sym-physis. Under direct visualization with a 30° laparoscope, the balloon is inflated slowly to bluntly dissect the preperitoneal space (Fig. 37-23). The dissecting balloon is replaced with a 12-mm balloon trocar, and pneumopreperitoneum is achieved by insufflation to 15 mmHg. A 5-mm trocar is placed suprapubically in the midline, and another is placed inferior to the insufflation port (see Fig. 37-21). The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion |
Surgery_Schwartz_10646 | Surgery_Schwartz | in the midline, and another is placed inferior to the insufflation port (see Fig. 37-21). The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion to TAPP. No modifications are necessary to repair bilateral ingui-nal hernias with the TEP approach. Any peritoneal rents should be repaired prior to desufflation to prevent mesh from contact-ing intraperitoneal structures. Following mesh placement, the preperitoneal space is desufflated slowly under direct vision to ensure proper mesh positioning. Trocars are removed, and the anterior rectus sheath is closed with an interrupted suture. If there Brunicardi_Ch37_p1599-p1624.indd 161429/01/19 2:03 PM 1615INGUINAL HERNIASCHAPTER 37BA Figure 37-21. Trocar placement for (A) transabdominal preperitoneal repair and (B) totally extraperitoneal repair.Figure 37-22. View of mesh placement in posterior repairs. A large mesh overlaps the myopectineal orifice.Figure 37-23. Balloon dissection of the | Surgery_Schwartz. in the midline, and another is placed inferior to the insufflation port (see Fig. 37-21). The patient is placed in the Trendelenburg position, and the operation proceeds in an identical fashion to TAPP. No modifications are necessary to repair bilateral ingui-nal hernias with the TEP approach. Any peritoneal rents should be repaired prior to desufflation to prevent mesh from contact-ing intraperitoneal structures. Following mesh placement, the preperitoneal space is desufflated slowly under direct vision to ensure proper mesh positioning. Trocars are removed, and the anterior rectus sheath is closed with an interrupted suture. If there Brunicardi_Ch37_p1599-p1624.indd 161429/01/19 2:03 PM 1615INGUINAL HERNIASCHAPTER 37BA Figure 37-21. Trocar placement for (A) transabdominal preperitoneal repair and (B) totally extraperitoneal repair.Figure 37-22. View of mesh placement in posterior repairs. A large mesh overlaps the myopectineal orifice.Figure 37-23. Balloon dissection of the |
Surgery_Schwartz_10647 | Surgery_Schwartz | repair and (B) totally extraperitoneal repair.Figure 37-22. View of mesh placement in posterior repairs. A large mesh overlaps the myopectineal orifice.Figure 37-23. Balloon dissection of the preperitoneal space in a totally extraperitoneal inguinal hernia repair.Brunicardi_Ch37_p1599-p1624.indd 161529/01/19 2:04 PM 1616SPECIFIC CONSIDERATIONSPART IIis violation of the peritoneum during insufflation of the dissec-tion balloon and subsequent pneumoperitoneum, visualization can be compromised. To address this, a Veress needle or angio-catheter can be placed in the LUQ, which will allow desufflation of the peritoneum and restore visualization.Intraperitoneal Onlay Mesh Procedure. In contrast to TAPP and TEP, the IPOM procedure permits the posterior approach without preperitoneal dissection. It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent her-nias that are refractory to other approaches, or where extensive preperitoneal scarring would | Surgery_Schwartz. repair and (B) totally extraperitoneal repair.Figure 37-22. View of mesh placement in posterior repairs. A large mesh overlaps the myopectineal orifice.Figure 37-23. Balloon dissection of the preperitoneal space in a totally extraperitoneal inguinal hernia repair.Brunicardi_Ch37_p1599-p1624.indd 161529/01/19 2:04 PM 1616SPECIFIC CONSIDERATIONSPART IIis violation of the peritoneum during insufflation of the dissec-tion balloon and subsequent pneumoperitoneum, visualization can be compromised. To address this, a Veress needle or angio-catheter can be placed in the LUQ, which will allow desufflation of the peritoneum and restore visualization.Intraperitoneal Onlay Mesh Procedure. In contrast to TAPP and TEP, the IPOM procedure permits the posterior approach without preperitoneal dissection. It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent her-nias that are refractory to other approaches, or where extensive preperitoneal scarring would |
Surgery_Schwartz_10648 | Surgery_Schwartz | It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent her-nias that are refractory to other approaches, or where extensive preperitoneal scarring would make TEP or TAPP challenging. Port placement and inguinal hernia identification are identical to TAPP. Hernia sac contents are reduced; however, the sac itself is not inverted from the preperitoneal space. Instead, mesh is placed directly over the defect and fixed in place with sutures or spiral tacks. Because these anchors are placed through the peritoneum without preperitoneal inspection, the lateral cutane-ous nerve of the thigh and the genitofemoral nerve are especially prone to injury. Furthermore, intraperitoneal mesh migration is a documented phenomenon that can lead to postoperative mor-bidity, recurrence, and reoperation.Robot-Assisted Inguinal Hernia RepairApplication of a robotic platform to hernia repair has been adapted by general surgeons across the country. The endowrist | Surgery_Schwartz. It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent her-nias that are refractory to other approaches, or where extensive preperitoneal scarring would make TEP or TAPP challenging. Port placement and inguinal hernia identification are identical to TAPP. Hernia sac contents are reduced; however, the sac itself is not inverted from the preperitoneal space. Instead, mesh is placed directly over the defect and fixed in place with sutures or spiral tacks. Because these anchors are placed through the peritoneum without preperitoneal inspection, the lateral cutane-ous nerve of the thigh and the genitofemoral nerve are especially prone to injury. Furthermore, intraperitoneal mesh migration is a documented phenomenon that can lead to postoperative mor-bidity, recurrence, and reoperation.Robot-Assisted Inguinal Hernia RepairApplication of a robotic platform to hernia repair has been adapted by general surgeons across the country. The endowrist |
Surgery_Schwartz_10649 | Surgery_Schwartz | mor-bidity, recurrence, and reoperation.Robot-Assisted Inguinal Hernia RepairApplication of a robotic platform to hernia repair has been adapted by general surgeons across the country. The endowrist capabilities provides greatly improved manual dexterity and a relatively short learning curve. Though both total extraperito-neal repair and transabdominal preperitoneal repair can be adapted to a robotic platform, the latter has gained more traction among surgeons.Many papers have explored the efficacy and cost-effectiveness of robot-assisted herniorraphy. Retrospective data have had mixed results when comparing robot-assisted surgery vs. laparoscopy. One recent study has shown longer operative time,50 another analysis has shown increased cost.51 It should be noted, however, that there is a decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that the costs will ever converge to that of laparoscopic surgery. A | Surgery_Schwartz. mor-bidity, recurrence, and reoperation.Robot-Assisted Inguinal Hernia RepairApplication of a robotic platform to hernia repair has been adapted by general surgeons across the country. The endowrist capabilities provides greatly improved manual dexterity and a relatively short learning curve. Though both total extraperito-neal repair and transabdominal preperitoneal repair can be adapted to a robotic platform, the latter has gained more traction among surgeons.Many papers have explored the efficacy and cost-effectiveness of robot-assisted herniorraphy. Retrospective data have had mixed results when comparing robot-assisted surgery vs. laparoscopy. One recent study has shown longer operative time,50 another analysis has shown increased cost.51 It should be noted, however, that there is a decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that the costs will ever converge to that of laparoscopic surgery. A |
Surgery_Schwartz_10650 | Surgery_Schwartz | there is a decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that the costs will ever converge to that of laparoscopic surgery. A retrospective, single-institution study has shown greatly reduced complication rates with robotic assisted surgery in obese patients; however, this was compared against open inguinal hernia repair (10.8% vs. 3.2%, P = 0.047), the two groups were covariate matched for preoperative risk.52 Studies have also shown excellent long-term (36-month) quality of life indicators in robot-assisted TAPP, though this was a single surgeon survey.53 Further randomized trials will shed more light into cost issues as surgeons gain more experience with robotic application that would lead to shorter operative time and minimize additional instrument use.Similar to laparoscopy, robot-assisted repair is ideal for recurrent inguinal hernia patients who had previous anterior repair and bilateral hernias. | Surgery_Schwartz. there is a decrease in cost with robotic surgery as the volume of procedures increases at each center, though it is still unlikely that the costs will ever converge to that of laparoscopic surgery. A retrospective, single-institution study has shown greatly reduced complication rates with robotic assisted surgery in obese patients; however, this was compared against open inguinal hernia repair (10.8% vs. 3.2%, P = 0.047), the two groups were covariate matched for preoperative risk.52 Studies have also shown excellent long-term (36-month) quality of life indicators in robot-assisted TAPP, though this was a single surgeon survey.53 Further randomized trials will shed more light into cost issues as surgeons gain more experience with robotic application that would lead to shorter operative time and minimize additional instrument use.Similar to laparoscopy, robot-assisted repair is ideal for recurrent inguinal hernia patients who had previous anterior repair and bilateral hernias. |
Surgery_Schwartz_10651 | Surgery_Schwartz | time and minimize additional instrument use.Similar to laparoscopy, robot-assisted repair is ideal for recurrent inguinal hernia patients who had previous anterior repair and bilateral hernias. Contraindications to robotic her-nia repair are the same as for laparoscopic repair and include coagulopathy and/or severe cardiopulmonary disease precluding induction of general anesthesia and pneumoperitoneum. Previ-ous preperitoneal repair is a relative contraindication along with the presence of a large incarcerated inguinal hernia.Patient evaluation should proceed similarly to workup for laparoscopic inguinal herniorraphy.Technique. Patients are instructed to void in preoperative area to avoid Foley catheter placement, though some surgeons advocate 4routine Foley catheter placement. Ideally, the operating table should have capability of synchronization with robotic arms to prevent injury to the patient during repositioning during the pro-cedure. The patient is placed in supine position | Surgery_Schwartz. time and minimize additional instrument use.Similar to laparoscopy, robot-assisted repair is ideal for recurrent inguinal hernia patients who had previous anterior repair and bilateral hernias. Contraindications to robotic her-nia repair are the same as for laparoscopic repair and include coagulopathy and/or severe cardiopulmonary disease precluding induction of general anesthesia and pneumoperitoneum. Previ-ous preperitoneal repair is a relative contraindication along with the presence of a large incarcerated inguinal hernia.Patient evaluation should proceed similarly to workup for laparoscopic inguinal herniorraphy.Technique. Patients are instructed to void in preoperative area to avoid Foley catheter placement, though some surgeons advocate 4routine Foley catheter placement. Ideally, the operating table should have capability of synchronization with robotic arms to prevent injury to the patient during repositioning during the pro-cedure. The patient is placed in supine position |
Surgery_Schwartz_10652 | Surgery_Schwartz | the operating table should have capability of synchronization with robotic arms to prevent injury to the patient during repositioning during the pro-cedure. The patient is placed in supine position with arms tucked at both sides. Appropriate padding of extremities is important to avoid neuropraxia and trauma from robotic arm movements. Three trocars are typically used for TAPP repair. Open Hasson technique is employed for initial trocar placement at umbilicus; this can be an 8-mm trocar or alternatively a 12-mm with a tele-scoped 8-mm trochar. Additionally, two 8-mm trocars are placed in each side of the mid-abdomen, slightly above the level of umbi-licus. After trocar placement, the robot is docked and targeted, and the patient is placed in Trendelenburg position. Typically, the surgeon will use robotic shears attached to electrocautery, Cadiere forceps, and a needle holder as the primary instruments. This combination provides optimal cost-effectiveness because the majority of the | Surgery_Schwartz. the operating table should have capability of synchronization with robotic arms to prevent injury to the patient during repositioning during the pro-cedure. The patient is placed in supine position with arms tucked at both sides. Appropriate padding of extremities is important to avoid neuropraxia and trauma from robotic arm movements. Three trocars are typically used for TAPP repair. Open Hasson technique is employed for initial trocar placement at umbilicus; this can be an 8-mm trocar or alternatively a 12-mm with a tele-scoped 8-mm trochar. Additionally, two 8-mm trocars are placed in each side of the mid-abdomen, slightly above the level of umbi-licus. After trocar placement, the robot is docked and targeted, and the patient is placed in Trendelenburg position. Typically, the surgeon will use robotic shears attached to electrocautery, Cadiere forceps, and a needle holder as the primary instruments. This combination provides optimal cost-effectiveness because the majority of the |
Surgery_Schwartz_10653 | Surgery_Schwartz | will use robotic shears attached to electrocautery, Cadiere forceps, and a needle holder as the primary instruments. This combination provides optimal cost-effectiveness because the majority of the cost associated with robotic application is due to disposable instruments. Exposure starts with incising the parietal peritoneum from the medial umbilical ligament to the anterior superior iliac spine. A peritoneal flap is developed by blunt and sharp dissection with robotic shears in the prepreitoneal space. Special care is taken to leave the preperitoneal fat pad contain-ing nerves and vessels with the anterior abdominal wall. Small vessels can be coagulated with application of electrocautery with scissors. With the aid of pneumoperitoneum, the preference is first to perform a lateral dissection in the space of Bogros. Dissection continues in this plane laterally towards the anterior superior iliac spine. The generous development of a peritoneal flap will ensure successful mesh placement | Surgery_Schwartz. will use robotic shears attached to electrocautery, Cadiere forceps, and a needle holder as the primary instruments. This combination provides optimal cost-effectiveness because the majority of the cost associated with robotic application is due to disposable instruments. Exposure starts with incising the parietal peritoneum from the medial umbilical ligament to the anterior superior iliac spine. A peritoneal flap is developed by blunt and sharp dissection with robotic shears in the prepreitoneal space. Special care is taken to leave the preperitoneal fat pad contain-ing nerves and vessels with the anterior abdominal wall. Small vessels can be coagulated with application of electrocautery with scissors. With the aid of pneumoperitoneum, the preference is first to perform a lateral dissection in the space of Bogros. Dissection continues in this plane laterally towards the anterior superior iliac spine. The generous development of a peritoneal flap will ensure successful mesh placement |
Surgery_Schwartz_10654 | Surgery_Schwartz | in the space of Bogros. Dissection continues in this plane laterally towards the anterior superior iliac spine. The generous development of a peritoneal flap will ensure successful mesh placement at the end. Then the space of Retzius is entered medially exposing the pubic symphysis. In the absence of haptic feedback, visual recognition of the pubic symphysis is crucial as this serves as an important landmark for further dis-section. Inferior epigastric vessels are readily identified. Next, an inferior peritoneal flap is developed to avoid rolling of mesh during closure. Direct, indirect, and femoral spaces are carefully examined. Cadiere forceps are then used to grasp the hernia sac to provide traction. Any cord lipoma is carefully dissected free from the cord structures, and the testicular vessels, pampiniform plexus, and ductus deferens are separated from hernia sac. These structures can usually be identified at the neck of sac. Reduction is successful when the sac stays reduced | Surgery_Schwartz. in the space of Bogros. Dissection continues in this plane laterally towards the anterior superior iliac spine. The generous development of a peritoneal flap will ensure successful mesh placement at the end. Then the space of Retzius is entered medially exposing the pubic symphysis. In the absence of haptic feedback, visual recognition of the pubic symphysis is crucial as this serves as an important landmark for further dis-section. Inferior epigastric vessels are readily identified. Next, an inferior peritoneal flap is developed to avoid rolling of mesh during closure. Direct, indirect, and femoral spaces are carefully examined. Cadiere forceps are then used to grasp the hernia sac to provide traction. Any cord lipoma is carefully dissected free from the cord structures, and the testicular vessels, pampiniform plexus, and ductus deferens are separated from hernia sac. These structures can usually be identified at the neck of sac. Reduction is successful when the sac stays reduced |
Surgery_Schwartz_10655 | Surgery_Schwartz | vessels, pampiniform plexus, and ductus deferens are separated from hernia sac. These structures can usually be identified at the neck of sac. Reduction is successful when the sac stays reduced after traction is released. The next step is placement of the mesh. Lightweight barbed mesh and anatomically preshaped mesh are routinely used. Mesh should be an appropriate size to cover the myopectineal orifice entirely, and the peritoneal dissection will need to be large enough to accommodate this size mesh. It is rolled and placed through one of the ports by the bedside assistant. Then it is unrolled and placed in the pelvis overlapping the pubic symphysis by several centimeters medially; this is essential as the majority of recur-rences occur in this area. Utilization of tacking devices are not necessary, which helps to reduce procedural cost; however, this is surgeon preference. Finally, the peritoneal flap is placed back over the mesh layer and sutured back into place with a running | Surgery_Schwartz. vessels, pampiniform plexus, and ductus deferens are separated from hernia sac. These structures can usually be identified at the neck of sac. Reduction is successful when the sac stays reduced after traction is released. The next step is placement of the mesh. Lightweight barbed mesh and anatomically preshaped mesh are routinely used. Mesh should be an appropriate size to cover the myopectineal orifice entirely, and the peritoneal dissection will need to be large enough to accommodate this size mesh. It is rolled and placed through one of the ports by the bedside assistant. Then it is unrolled and placed in the pelvis overlapping the pubic symphysis by several centimeters medially; this is essential as the majority of recur-rences occur in this area. Utilization of tacking devices are not necessary, which helps to reduce procedural cost; however, this is surgeon preference. Finally, the peritoneal flap is placed back over the mesh layer and sutured back into place with a running |
Surgery_Schwartz_10656 | Surgery_Schwartz | not necessary, which helps to reduce procedural cost; however, this is surgeon preference. Finally, the peritoneal flap is placed back over the mesh layer and sutured back into place with a running locking suture that is facilitated by the increased intracorporeal dexterity of the robotic instruments. Then the fascia of the umbili-cal trochar site is closed with 0-absorbable suture (Fig 37-24), and the skin is closed with absorbable monofilament suture.Prosthesis ConsiderationsThe success of prosthetic repairs has generated considerable debate about the desirable physical attributes of mesh and their fixation. An ideal mesh should be easy to handle, flexible, Brunicardi_Ch37_p1599-p1624.indd 161629/01/19 2:04 PM 1617INGUINAL HERNIASCHAPTER 37Figure 37-24. Steps in robotic TAPP repair. A. Image of a direct inguinal hernia. B. There is no visible hernia on the contralateral side. C. Hernia contents and sac are dissected and cleared for mesh placement. D. Unrolling and placement of | Surgery_Schwartz. not necessary, which helps to reduce procedural cost; however, this is surgeon preference. Finally, the peritoneal flap is placed back over the mesh layer and sutured back into place with a running locking suture that is facilitated by the increased intracorporeal dexterity of the robotic instruments. Then the fascia of the umbili-cal trochar site is closed with 0-absorbable suture (Fig 37-24), and the skin is closed with absorbable monofilament suture.Prosthesis ConsiderationsThe success of prosthetic repairs has generated considerable debate about the desirable physical attributes of mesh and their fixation. An ideal mesh should be easy to handle, flexible, Brunicardi_Ch37_p1599-p1624.indd 161629/01/19 2:04 PM 1617INGUINAL HERNIASCHAPTER 37Figure 37-24. Steps in robotic TAPP repair. A. Image of a direct inguinal hernia. B. There is no visible hernia on the contralateral side. C. Hernia contents and sac are dissected and cleared for mesh placement. D. Unrolling and placement of |
Surgery_Schwartz_10657 | Surgery_Schwartz | A. Image of a direct inguinal hernia. B. There is no visible hernia on the contralateral side. C. Hernia contents and sac are dissected and cleared for mesh placement. D. Unrolling and placement of mesh E. Satisfactory placement of mesh. F. Closure of peritoneum. G. Completed repair of hernia with comparison to contralateral side.ABCDEFGBrunicardi_Ch37_p1599-p1624.indd 161729/01/19 2:04 PM 1618SPECIFIC CONSIDERATIONSPART IIstrong, immunologically inert, contraction-resistant, infection-resistant, and inexpensive to manufacture.54 The following section reviews the most common types of mesh and fixatives currently available.Synthetic Mesh Material. Polypropylene and polyester are the most common synthetic prosthetic materials used in her-nia repair. These materials are permanent and hydrophobic, and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with | Surgery_Schwartz. A. Image of a direct inguinal hernia. B. There is no visible hernia on the contralateral side. C. Hernia contents and sac are dissected and cleared for mesh placement. D. Unrolling and placement of mesh E. Satisfactory placement of mesh. F. Closure of peritoneum. G. Completed repair of hernia with comparison to contralateral side.ABCDEFGBrunicardi_Ch37_p1599-p1624.indd 161729/01/19 2:04 PM 1618SPECIFIC CONSIDERATIONSPART IIstrong, immunologically inert, contraction-resistant, infection-resistant, and inexpensive to manufacture.54 The following section reviews the most common types of mesh and fixatives currently available.Synthetic Mesh Material. Polypropylene and polyester are the most common synthetic prosthetic materials used in her-nia repair. These materials are permanent and hydrophobic, and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with |
Surgery_Schwartz_10658 | Surgery_Schwartz | and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with the goals of minimizing postoperative pain and preventing infection or recurrence. In selecting mesh material, considerations include mesh absorbability, thickness, weight, porosity, and strength.Variations in the fiber diameter and fiber count of mesh materials categorize them as heavyweight or lightweight in den-sity, though there does not seem to be a universally agreed upon set of criteria for either. Commonly used lightweight mesh materi-als include β-d-glucan, titanium-coated polypropylene, and poly-propylene–poliglecaprone. These materials have greater elasticity and less theoretical surface area contact with surrounding tissues than their heavyweight counterparts.55 They are hypothesized to reduce scarring and chronic pain without compromising the strength of the repair. The use of | Surgery_Schwartz. and they promote a local inflammatory response that results in cellular infiltration and scarring with slight contraction in size. Other synthetic mesh materials are under investigation with the goals of minimizing postoperative pain and preventing infection or recurrence. In selecting mesh material, considerations include mesh absorbability, thickness, weight, porosity, and strength.Variations in the fiber diameter and fiber count of mesh materials categorize them as heavyweight or lightweight in den-sity, though there does not seem to be a universally agreed upon set of criteria for either. Commonly used lightweight mesh materi-als include β-d-glucan, titanium-coated polypropylene, and poly-propylene–poliglecaprone. These materials have greater elasticity and less theoretical surface area contact with surrounding tissues than their heavyweight counterparts.55 They are hypothesized to reduce scarring and chronic pain without compromising the strength of the repair. The use of |
Surgery_Schwartz_10659 | Surgery_Schwartz | area contact with surrounding tissues than their heavyweight counterparts.55 They are hypothesized to reduce scarring and chronic pain without compromising the strength of the repair. The use of lightweight mesh use in TEP and TAPP repairs is associated with fewer 3-month cumulative mesh-related complications.54 A 2012 meta-analysis of 2310 patients undergoing open or laparoscopic hernia repairs found a lower incidence of chronic pain (relative risk [RR] 0.61, CI 0.50–0.74) following use of lightweight mesh versus heavyweight mesh and no significant difference in rates of recurrence.55When available, lightweight mesh should be considered for all prosthetic repairs to minimize postoperative chronic pain. A disadvantage of currently available commercial pros-theses is their high cost. In settings where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive and ubiquitous in sub-Saharan Africa and | Surgery_Schwartz. area contact with surrounding tissues than their heavyweight counterparts.55 They are hypothesized to reduce scarring and chronic pain without compromising the strength of the repair. The use of lightweight mesh use in TEP and TAPP repairs is associated with fewer 3-month cumulative mesh-related complications.54 A 2012 meta-analysis of 2310 patients undergoing open or laparoscopic hernia repairs found a lower incidence of chronic pain (relative risk [RR] 0.61, CI 0.50–0.74) following use of lightweight mesh versus heavyweight mesh and no significant difference in rates of recurrence.55When available, lightweight mesh should be considered for all prosthetic repairs to minimize postoperative chronic pain. A disadvantage of currently available commercial pros-theses is their high cost. In settings where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive and ubiquitous in sub-Saharan Africa and |
Surgery_Schwartz_10660 | Surgery_Schwartz | where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive and ubiquitous in sub-Saharan Africa and India, and they have similar mechanical properties to commercially available hernio-plasty meshes. Meta-analysis of 577 hernioplasties performed using sterilized mosquito nets demonstrated similar rates of short-term mesh-related complications (6.1%) and recurrence (0.17%) to those using commercial meshes.56 Furthermore, the disability-adjusted life years (DALYs) prevented by inguinal hernia repair signify a comparable impact to that of vaccination in sub-Saharan Africa.57,58 Expensive prostheses are not neces-sarily needed for hernia surgery, whether in resource-limited or in resource-abundant settings, and the anticipated benefits should be evaluated with consideration of increased costs.Biologic Mesh. Although indications for the use of biologic prostheses have not been absolutely defined, | Surgery_Schwartz. where resources are limited, prosthetic repairs are performed using alternative materials. Polypropylene and polyethylene mosquito nets are inexpensive and ubiquitous in sub-Saharan Africa and India, and they have similar mechanical properties to commercially available hernio-plasty meshes. Meta-analysis of 577 hernioplasties performed using sterilized mosquito nets demonstrated similar rates of short-term mesh-related complications (6.1%) and recurrence (0.17%) to those using commercial meshes.56 Furthermore, the disability-adjusted life years (DALYs) prevented by inguinal hernia repair signify a comparable impact to that of vaccination in sub-Saharan Africa.57,58 Expensive prostheses are not neces-sarily needed for hernia surgery, whether in resource-limited or in resource-abundant settings, and the anticipated benefits should be evaluated with consideration of increased costs.Biologic Mesh. Although indications for the use of biologic prostheses have not been absolutely defined, |
Surgery_Schwartz_10661 | Surgery_Schwartz | and the anticipated benefits should be evaluated with consideration of increased costs.Biologic Mesh. Although indications for the use of biologic prostheses have not been absolutely defined, they are commonly reserved for contaminated cases or when domain expansion is necessary in the face of high infection risk. This is partially on account of their high cost and high recurrence rates. There are numerous biologic materials available with differing properties, but in general, they have a lower tensile strength and subse-quently higher rates of rupture than synthetic prostheses.59 They also have varying degrees of tensile strength and tissue biocom-patibility between them. In ventral hernia repairs, xenograft material was associated with a lower rate of recurrence than allograft material.60 A review of biologic materials concludes cross-linked graft materials are more durable and less prone to failure than non–cross-linked grafts.61 Nevertheless, their 5diminished ability to remodel | Surgery_Schwartz. and the anticipated benefits should be evaluated with consideration of increased costs.Biologic Mesh. Although indications for the use of biologic prostheses have not been absolutely defined, they are commonly reserved for contaminated cases or when domain expansion is necessary in the face of high infection risk. This is partially on account of their high cost and high recurrence rates. There are numerous biologic materials available with differing properties, but in general, they have a lower tensile strength and subse-quently higher rates of rupture than synthetic prostheses.59 They also have varying degrees of tensile strength and tissue biocom-patibility between them. In ventral hernia repairs, xenograft material was associated with a lower rate of recurrence than allograft material.60 A review of biologic materials concludes cross-linked graft materials are more durable and less prone to failure than non–cross-linked grafts.61 Nevertheless, their 5diminished ability to remodel |
Surgery_Schwartz_10662 | Surgery_Schwartz | A review of biologic materials concludes cross-linked graft materials are more durable and less prone to failure than non–cross-linked grafts.61 Nevertheless, their 5diminished ability to remodel adversely affects rates of infec-tion and incorporation. While new prosthetic materials continue to be developed, no single biologic warrants routine use. These materials will continue to evolve, and they remain an important tool for challenging cases when used judiciously.Fixation Technique. Independent of prosthesis material, the method of its fixation remains disputed. Suturing, stapling, and tacking prostheses entail tissue perforation, which may cause inflammation, neurovascular injury, and chronic pain devel-opment. Conversely, improper prosthesis fixation may result in mesh migration, repair failure, meshoma pain, and hernia recurrence. Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to minimize trauma to surrounding tissues and to reduce the risk | Surgery_Schwartz. A review of biologic materials concludes cross-linked graft materials are more durable and less prone to failure than non–cross-linked grafts.61 Nevertheless, their 5diminished ability to remodel adversely affects rates of infec-tion and incorporation. While new prosthetic materials continue to be developed, no single biologic warrants routine use. These materials will continue to evolve, and they remain an important tool for challenging cases when used judiciously.Fixation Technique. Independent of prosthesis material, the method of its fixation remains disputed. Suturing, stapling, and tacking prostheses entail tissue perforation, which may cause inflammation, neurovascular injury, and chronic pain devel-opment. Conversely, improper prosthesis fixation may result in mesh migration, repair failure, meshoma pain, and hernia recurrence. Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to minimize trauma to surrounding tissues and to reduce the risk |
Surgery_Schwartz_10663 | Surgery_Schwartz | failure, meshoma pain, and hernia recurrence. Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to minimize trauma to surrounding tissues and to reduce the risk for entrapment neuropathy. For hernias repaired via a strictly preperitoneal approach, prosthesis fixation may not be necessary at all.Fibrin glue fixation is a successful alternative to tack fixation in hernia repair with a synthetic prosthesis. Recent studies comparing fibrin glue fixation and suture fixation in open hernia repair show superior rates of chronic pain with both Lichtenstein and Plug and Patch techniques.62,63 Meta-analyses of endoscopic hernia repair determined the incidence of chronic postoperative pain after tacker fixation was significantly higher than after fibrin glue fixation, with one showing a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between both fixation methods.62,63 Glue fixation is a promising | Surgery_Schwartz. failure, meshoma pain, and hernia recurrence. Mesh may be fixed with fibrin-derived glue, and self-gripping mesh has been developed to minimize trauma to surrounding tissues and to reduce the risk for entrapment neuropathy. For hernias repaired via a strictly preperitoneal approach, prosthesis fixation may not be necessary at all.Fibrin glue fixation is a successful alternative to tack fixation in hernia repair with a synthetic prosthesis. Recent studies comparing fibrin glue fixation and suture fixation in open hernia repair show superior rates of chronic pain with both Lichtenstein and Plug and Patch techniques.62,63 Meta-analyses of endoscopic hernia repair determined the incidence of chronic postoperative pain after tacker fixation was significantly higher than after fibrin glue fixation, with one showing a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between both fixation methods.62,63 Glue fixation is a promising |
Surgery_Schwartz_10664 | Surgery_Schwartz | with one showing a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between both fixation methods.62,63 Glue fixation is a promising technical refinement, and several studies have shown long-term benefit; however, its questionable efficacy in larger hernias and cost remain considerations.In TEP repairs, fixation of mesh may not be compulsory. A prospective randomized trial comparing fixation and no fixation in TEP repairs found a significant increase in new pain and equiv-alent recurrence rates in the fixation group several months after repair.64 A 2012 meta-analysis comparing laparoscopic tacker mesh fixation to no mesh fixation found no statistically signifi-cant differences in operative duration, pain, mesh-related compli-cations, recurrence, or length of stay between the two methods.65 Studies of three-dimensional, ergonomically contoured mesh without fixation, as well as self-gripping meshes, have yielded similar | Surgery_Schwartz. with one showing a relative risk of 4.64 (CI 1.9–11.7). Rates of other postoperative complications and recurrence were similar between both fixation methods.62,63 Glue fixation is a promising technical refinement, and several studies have shown long-term benefit; however, its questionable efficacy in larger hernias and cost remain considerations.In TEP repairs, fixation of mesh may not be compulsory. A prospective randomized trial comparing fixation and no fixation in TEP repairs found a significant increase in new pain and equiv-alent recurrence rates in the fixation group several months after repair.64 A 2012 meta-analysis comparing laparoscopic tacker mesh fixation to no mesh fixation found no statistically signifi-cant differences in operative duration, pain, mesh-related compli-cations, recurrence, or length of stay between the two methods.65 Studies of three-dimensional, ergonomically contoured mesh without fixation, as well as self-gripping meshes, have yielded similar |
Surgery_Schwartz_10665 | Surgery_Schwartz | recurrence, or length of stay between the two methods.65 Studies of three-dimensional, ergonomically contoured mesh without fixation, as well as self-gripping meshes, have yielded similar results.66 In the preperitoneal approach, the reapproxi-mation of surrounding tissues and physiologic intra-abdominal pressure hypothetically prevent mesh migration. Due to higher theoretical risk of mesh migration, repair without fixation is not recommended for anterior or transperitoneal approaches.COMPLICATIONSAs with other clean operations, the most common complications of inguinal hernia repair include bleeding, infection, seroma, urinary retention, ileus, and injury to adjacent structures (Table 37-6). Complications specific to herniorrhaphy include hernia recurrence, chronic inguinal and pubic pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section.Hernia RecurrenceWhen a patient develops pain, | Surgery_Schwartz. recurrence, or length of stay between the two methods.65 Studies of three-dimensional, ergonomically contoured mesh without fixation, as well as self-gripping meshes, have yielded similar results.66 In the preperitoneal approach, the reapproxi-mation of surrounding tissues and physiologic intra-abdominal pressure hypothetically prevent mesh migration. Due to higher theoretical risk of mesh migration, repair without fixation is not recommended for anterior or transperitoneal approaches.COMPLICATIONSAs with other clean operations, the most common complications of inguinal hernia repair include bleeding, infection, seroma, urinary retention, ileus, and injury to adjacent structures (Table 37-6). Complications specific to herniorrhaphy include hernia recurrence, chronic inguinal and pubic pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section.Hernia RecurrenceWhen a patient develops pain, |
Surgery_Schwartz_10666 | Surgery_Schwartz | pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section.Hernia RecurrenceWhen a patient develops pain, bulging, or a mass at the site of an inguinal hernia repair, clinical entities such as seroma, persistent cord lipoma, and hernia recurrence should be considered. Com-mon medical issues associated with recurrence include malnu-trition, immunosuppression, diabetes, steroid use, and smoking. Technical causes of recurrence include improper mesh size, tissue Brunicardi_Ch37_p1599-p1624.indd 161829/01/19 2:04 PM 1619INGUINAL HERNIASCHAPTER 37Table 37-6Complications of groin hernia repairsRecurrenceChronic groin pain Nociceptive Somatic Visceral Neuropathic Iliohypogastric Ilioinguinal Genitofemoral Lateral cutaneous FemoralCord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descentBladder injuryWound | Surgery_Schwartz. pain, and injury to the spermatic cord or testis. The incidence, prevention, and treatment of these complications are discussed in the ensuing section.Hernia RecurrenceWhen a patient develops pain, bulging, or a mass at the site of an inguinal hernia repair, clinical entities such as seroma, persistent cord lipoma, and hernia recurrence should be considered. Com-mon medical issues associated with recurrence include malnu-trition, immunosuppression, diabetes, steroid use, and smoking. Technical causes of recurrence include improper mesh size, tissue Brunicardi_Ch37_p1599-p1624.indd 161829/01/19 2:04 PM 1619INGUINAL HERNIASCHAPTER 37Table 37-6Complications of groin hernia repairsRecurrenceChronic groin pain Nociceptive Somatic Visceral Neuropathic Iliohypogastric Ilioinguinal Genitofemoral Lateral cutaneous FemoralCord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descentBladder injuryWound |
Surgery_Schwartz_10667 | Surgery_Schwartz | cutaneous FemoralCord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descentBladder injuryWound infectionSeromaHematoma Wound Scrotal RetroperitonealOsteitis pubisProsthetic complications Contraction Erosion Infection Rejection FractureLaparoscopic Vascular injury Intra-abdominal Retroperitoneal Abdominal wall Gas embolism Visceral injury Bowel perforation Bladder perforation Trocar site complications Hematoma Hernia Wound infection Keloid Bowel obstruction Trocar or peritoneal closure site hernia Adhesions Miscellaneous Diaphragmatic dysfunction HypercapniaGeneral Urinary Paralytic ileus Nausea and vomiting Aspiration pneumonia Cardiovascular and respiratory insufficiencyischemia, infection, and tension in the reconstruction. A focused physical examination should be performed. As with primary her-nias, US, CT, or MRI can elucidate ambiguous physical findings. When a recurrent hernia is | Surgery_Schwartz. cutaneous FemoralCord and testicular Hematoma Ischemic orchitis Testicular atrophy Dysejaculation Division of vas deferens Hydrocele Testicular descentBladder injuryWound infectionSeromaHematoma Wound Scrotal RetroperitonealOsteitis pubisProsthetic complications Contraction Erosion Infection Rejection FractureLaparoscopic Vascular injury Intra-abdominal Retroperitoneal Abdominal wall Gas embolism Visceral injury Bowel perforation Bladder perforation Trocar site complications Hematoma Hernia Wound infection Keloid Bowel obstruction Trocar or peritoneal closure site hernia Adhesions Miscellaneous Diaphragmatic dysfunction HypercapniaGeneral Urinary Paralytic ileus Nausea and vomiting Aspiration pneumonia Cardiovascular and respiratory insufficiencyischemia, infection, and tension in the reconstruction. A focused physical examination should be performed. As with primary her-nias, US, CT, or MRI can elucidate ambiguous physical findings. When a recurrent hernia is |
Surgery_Schwartz_10668 | Surgery_Schwartz | and tension in the reconstruction. A focused physical examination should be performed. As with primary her-nias, US, CT, or MRI can elucidate ambiguous physical findings. When a recurrent hernia is discovered and warrants reoperation, an approach through a virgin plane facilitates its dissection and exposure. Extensive dissection of the scarred field and mesh may result in injury to cord structures, viscera, large blood ves-sels, and nerves. After an initial anterior approach, the posterior endoscopic approach will usually be easier and more effective than another anterior dissection. Conversely, failed preperitoneal repairs should be approached using an open anterior repair.PainPain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms: nociceptive (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain | Surgery_Schwartz. and tension in the reconstruction. A focused physical examination should be performed. As with primary her-nias, US, CT, or MRI can elucidate ambiguous physical findings. When a recurrent hernia is discovered and warrants reoperation, an approach through a virgin plane facilitates its dissection and exposure. Extensive dissection of the scarred field and mesh may result in injury to cord structures, viscera, large blood ves-sels, and nerves. After an initial anterior approach, the posterior endoscopic approach will usually be easier and more effective than another anterior dissection. Conversely, failed preperitoneal repairs should be approached using an open anterior repair.PainPain after inguinal hernia repair is classified into acute or chronic manifestations of three mechanisms: nociceptive (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain |
Surgery_Schwartz_10669 | Surgery_Schwartz | (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction. Treat-ment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and reassurance as it resolves spontaneously in most cases. Neuropathic pain occurs as a result of direct nerve dam-age or entrapment. It may present early or late, and it mani-fests as a localized, sharp, burning, or tearing sensation. It may respond to pharmacologic therapy and to local steroid or anes-thetic injections when indicated. Visceral pain refers to pain conveyed through afferent autonomic pain fibers. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury.Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases.67-69 | Surgery_Schwartz. (somatic), neuropathic, and visceral pain. Nociceptive pain is the most common of the three. Because it is usually a result of ligamentous or muscular trauma and inflammation, nociceptive pain is reproduced with abdominal muscle contraction. Treat-ment consists of rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and reassurance as it resolves spontaneously in most cases. Neuropathic pain occurs as a result of direct nerve dam-age or entrapment. It may present early or late, and it mani-fests as a localized, sharp, burning, or tearing sensation. It may respond to pharmacologic therapy and to local steroid or anes-thetic injections when indicated. Visceral pain refers to pain conveyed through afferent autonomic pain fibers. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury.Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases.67-69 |
Surgery_Schwartz_10670 | Surgery_Schwartz | as a result of sympathetic plexus injury.Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases.67-69 Despite the significant anatomic variation in the three inguinal nerves, literature reviews suggest identification of all three nerves is possible in 70% to 90% of cases.70 Meticulous nerve identification may prevent injury that results in debilitating chronic postoperative pain syndromes. Notwithstanding, moderate-to-severe pain adversely affects physical activity, social interactions, health care utilization, employment, and productivity in 6% to 8% of patients.67,68,71-74 Pain in this subset of patients comprises a tremendous individ-ual and societal burden.Postherniorrhaphy inguinodynia is a debilitating chronic complication. Its incidence is independent of the method of her-nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-femoral neurolysis/neurectomy, removal of mesh | Surgery_Schwartz. as a result of sympathetic plexus injury.Chronic postoperative pain remains an important measure of clinical outcome that has been reported in as many as 63% of inguinal hernia repair cases.67-69 Despite the significant anatomic variation in the three inguinal nerves, literature reviews suggest identification of all three nerves is possible in 70% to 90% of cases.70 Meticulous nerve identification may prevent injury that results in debilitating chronic postoperative pain syndromes. Notwithstanding, moderate-to-severe pain adversely affects physical activity, social interactions, health care utilization, employment, and productivity in 6% to 8% of patients.67,68,71-74 Pain in this subset of patients comprises a tremendous individ-ual and societal burden.Postherniorrhaphy inguinodynia is a debilitating chronic complication. Its incidence is independent of the method of her-nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-femoral neurolysis/neurectomy, removal of mesh |
Surgery_Schwartz_10671 | Surgery_Schwartz | a debilitating chronic complication. Its incidence is independent of the method of her-nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-femoral neurolysis/neurectomy, removal of mesh and fixation material, and revision of the repair are the three most common options for treatment. Nevertheless, anatomic variation and cross-innervation of the inguinal nerves in the retroperitoneum and inguinal canal make selective neurectomy less reliable.75-78 When inguinodynia is refractory to pharmacologic and interven-tional measures, triple neurectomy with removal of meshoma is routinely performed with acceptable outcomes in the majority of patients.74,76,77,79-84 Refractory inguinodynia with concurrent orchialgia also requires resection of the paravasal nerves.84A relatively newly described technique that has cited good outcomes is the laparoscopic triple neurectomy. This involves laparoscopic approach to and division of the main trunks of the ilioinguinal and iliohypogastric | Surgery_Schwartz. a debilitating chronic complication. Its incidence is independent of the method of her-nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-femoral neurolysis/neurectomy, removal of mesh and fixation material, and revision of the repair are the three most common options for treatment. Nevertheless, anatomic variation and cross-innervation of the inguinal nerves in the retroperitoneum and inguinal canal make selective neurectomy less reliable.75-78 When inguinodynia is refractory to pharmacologic and interven-tional measures, triple neurectomy with removal of meshoma is routinely performed with acceptable outcomes in the majority of patients.74,76,77,79-84 Refractory inguinodynia with concurrent orchialgia also requires resection of the paravasal nerves.84A relatively newly described technique that has cited good outcomes is the laparoscopic triple neurectomy. This involves laparoscopic approach to and division of the main trunks of the ilioinguinal and iliohypogastric |
Surgery_Schwartz_10672 | Surgery_Schwartz | described technique that has cited good outcomes is the laparoscopic triple neurectomy. This involves laparoscopic approach to and division of the main trunks of the ilioinguinal and iliohypogastric nerves and additional division of the genitofemoral nerve in the lumbar plexus.84,85 Several studies with moderate numbers of patients treated showed dura-ble reduction in pain scores.Other chronic pain syndromes include local nerve entrapment, meralgia paresthesia, and osteitis pubis. At greatest Brunicardi_Ch37_p1599-p1624.indd 161929/01/19 2:04 PM 1620SPECIFIC CONSIDERATIONSPART IIrisk of entrapment are the ilioinguinal and iliohypogastric nerves in anterior repairs and the genitofemoral and lateral femoral cutaneous nerves in endoscopic repairs. Clinical manifestations of nerve entrapment mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthesia, a condition characterized by persistent | Surgery_Schwartz. described technique that has cited good outcomes is the laparoscopic triple neurectomy. This involves laparoscopic approach to and division of the main trunks of the ilioinguinal and iliohypogastric nerves and additional division of the genitofemoral nerve in the lumbar plexus.84,85 Several studies with moderate numbers of patients treated showed dura-ble reduction in pain scores.Other chronic pain syndromes include local nerve entrapment, meralgia paresthesia, and osteitis pubis. At greatest Brunicardi_Ch37_p1599-p1624.indd 161929/01/19 2:04 PM 1620SPECIFIC CONSIDERATIONSPART IIrisk of entrapment are the ilioinguinal and iliohypogastric nerves in anterior repairs and the genitofemoral and lateral femoral cutaneous nerves in endoscopic repairs. Clinical manifestations of nerve entrapment mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthesia, a condition characterized by persistent |
Surgery_Schwartz_10673 | Surgery_Schwartz | mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthesia, a condition characterized by persistent paresthesia of the lateral thigh. Initial treatment of nerve entrapment consists of rest, ice, NSAIDs, physical therapy, and possible local corticosteroid and anesthetic injection. This can be followed by a trial of gabapentin86 or its analogues. Osteitis pubis is characterized by inflammation of the pubic symphysis and usually presents as medial groin or symphyseal pain that is reproduced by thigh adduction. Avoiding the pubic periosteum when placing sutures and tacks reduces the risk of developing osteitis pubis. CT scan or MRI excludes hernia recurrence, and bone scan is confirmatory for the diagnosis. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage. | Surgery_Schwartz. mimic acute neuropathic pain, and they occur with a dermatomal distribution. Injury to the lateral femoral cutaneous nerve results in meralgia paresthesia, a condition characterized by persistent paresthesia of the lateral thigh. Initial treatment of nerve entrapment consists of rest, ice, NSAIDs, physical therapy, and possible local corticosteroid and anesthetic injection. This can be followed by a trial of gabapentin86 or its analogues. Osteitis pubis is characterized by inflammation of the pubic symphysis and usually presents as medial groin or symphyseal pain that is reproduced by thigh adduction. Avoiding the pubic periosteum when placing sutures and tacks reduces the risk of developing osteitis pubis. CT scan or MRI excludes hernia recurrence, and bone scan is confirmatory for the diagnosis. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage. |
Surgery_Schwartz_10674 | Surgery_Schwartz | Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage. Irrespective of treatment, the condition often takes six months to resolve.87Cord and Testes InjuryInjury to spermatic cord structures may result in ischemic orchitis or testicular atrophy. Ischemic orchitis is most com-monly caused by injury to the pampiniform plexus and not to the testicular artery. It usually manifests within 1 week of ingui-nal hernia repair as an enlarged, indurated, and painful testis, and it is almost certainly self-limited. It occurs in <1% of pri-mary hernia repairs; however, this figure is larger for recurrent inguinal hernia repairs.88 US will demonstrate testicular blood flow to differentiate between ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery itself may lead to testicular atrophy, which is | Surgery_Schwartz. Initial treatment is identical to that of nerve entrapment; however, if pain remains intractable, orthopedic surgery consultation should be sought for possible bone resection and curettage. Irrespective of treatment, the condition often takes six months to resolve.87Cord and Testes InjuryInjury to spermatic cord structures may result in ischemic orchitis or testicular atrophy. Ischemic orchitis is most com-monly caused by injury to the pampiniform plexus and not to the testicular artery. It usually manifests within 1 week of ingui-nal hernia repair as an enlarged, indurated, and painful testis, and it is almost certainly self-limited. It occurs in <1% of pri-mary hernia repairs; however, this figure is larger for recurrent inguinal hernia repairs.88 US will demonstrate testicular blood flow to differentiate between ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery itself may lead to testicular atrophy, which is |
Surgery_Schwartz_10675 | Surgery_Schwartz | flow to differentiate between ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery itself may lead to testicular atrophy, which is manifest over a protracted period but does not always lead to testicular necrosis. This is because despite compromise of the artery, there is collateral flow from the inferior epigastric, vesi-cal, prostatic, and scrotal arteries that supply the testes, and in the case of insufficiency, there is atrophy. Treatment for isch-emic orchitis most frequently consists of reassurance, NSAIDs, and comfort measures. Intraoperatively, proximal ligation of large hernia sacs to avoid cord manipulation minimizes the risk of injury.Injury to the vas deferens within the cord may lead to infertility. In open inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. In endoscopic approach, grasping the vas may result in a | Surgery_Schwartz. flow to differentiate between ischemia and necrosis. Emergent orchiectomy is only necessary in the case of necrosis. Injury to the testicular artery itself may lead to testicular atrophy, which is manifest over a protracted period but does not always lead to testicular necrosis. This is because despite compromise of the artery, there is collateral flow from the inferior epigastric, vesi-cal, prostatic, and scrotal arteries that supply the testes, and in the case of insufficiency, there is atrophy. Treatment for isch-emic orchitis most frequently consists of reassurance, NSAIDs, and comfort measures. Intraoperatively, proximal ligation of large hernia sacs to avoid cord manipulation minimizes the risk of injury.Injury to the vas deferens within the cord may lead to infertility. In open inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. In endoscopic approach, grasping the vas may result in a |
Surgery_Schwartz_10676 | Surgery_Schwartz | inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. In endoscopic approach, grasping the vas may result in a crush injury. Transections of the vas deferens should be addressed with a urologic consult and early anastomosis, if possible. Historically, surgeons and their patients speculated that synthetic material would increase the risks of mesh rejection, carcinogenesis, and inflammation; however, as mesh became used more frequently, these concerns did not manifest. Nevertheless, one study found prosthetic mesh may exert long-term deleterious effects upon the vas deferens, causing azoospermia.89 Similar studies report varied results, though. A recent prospective study from the Swedish Hernia Registry discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair.90 Chronic scarring may | Surgery_Schwartz. inguinal hernia repairs, isolating the vas deferens along with the cord structures using digital manipulation may cause injury or disruption. In endoscopic approach, grasping the vas may result in a crush injury. Transections of the vas deferens should be addressed with a urologic consult and early anastomosis, if possible. Historically, surgeons and their patients speculated that synthetic material would increase the risks of mesh rejection, carcinogenesis, and inflammation; however, as mesh became used more frequently, these concerns did not manifest. Nevertheless, one study found prosthetic mesh may exert long-term deleterious effects upon the vas deferens, causing azoospermia.89 Similar studies report varied results, though. A recent prospective study from the Swedish Hernia Registry discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair.90 Chronic scarring may |
Surgery_Schwartz_10677 | Surgery_Schwartz | discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair.90 Chronic scarring may lead to vas deferens obstruction, resulting in decreased fertility rates and a dysejaculation syndrome. Pain and burning during ejaculation are usually self-limited, and more common causes, such as sexually transmitted diseases, should be excluded.In females, the round ligament is the analog to the sper-matic cord, and it maintains uterine anteversion. Injury to the artery of the round ligament does not result in clinically signifi-cant morbidity.Laparoscopic ComplicationsIn general, the risks of the TEP technique mirror those of open anterior repairs, as the peritoneal space is not violated. Com-plications of transabdominal laparoscopy include urinary reten-tion, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and | Surgery_Schwartz. discovered no difference in rates of patient-reported infertility between the general population and patients who underwent either mesh or tissue-based inguinal hernia repair.90 Chronic scarring may lead to vas deferens obstruction, resulting in decreased fertility rates and a dysejaculation syndrome. Pain and burning during ejaculation are usually self-limited, and more common causes, such as sexually transmitted diseases, should be excluded.In females, the round ligament is the analog to the sper-matic cord, and it maintains uterine anteversion. Injury to the artery of the round ligament does not result in clinically signifi-cant morbidity.Laparoscopic ComplicationsIn general, the risks of the TEP technique mirror those of open anterior repairs, as the peritoneal space is not violated. Com-plications of transabdominal laparoscopy include urinary reten-tion, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and |
Surgery_Schwartz_10678 | Surgery_Schwartz | Com-plications of transabdominal laparoscopy include urinary reten-tion, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and pneumothorax. The most common complications of endoscopic inguinal hernia repair are presented in this section.Urinary Retention. The most common cause of urinary reten-tion after hernia repair is general anesthesia, which is routine in endoscopic hernia repairs. Among 880 patients undergoing inguinal hernia repair with local anesthesia only, 0.2% devel-oped urinary retention, while the rate of urinary retention was 13% among 200 patients undergoing repair with general or spinal anesthesia.91 Overall, the risk of development of postop-erative urinary retention is 2% to 3%.92-95 Other risk factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with | Surgery_Schwartz. Com-plications of transabdominal laparoscopy include urinary reten-tion, paralytic ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and pneumothorax. The most common complications of endoscopic inguinal hernia repair are presented in this section.Urinary Retention. The most common cause of urinary reten-tion after hernia repair is general anesthesia, which is routine in endoscopic hernia repairs. Among 880 patients undergoing inguinal hernia repair with local anesthesia only, 0.2% devel-oped urinary retention, while the rate of urinary retention was 13% among 200 patients undergoing repair with general or spinal anesthesia.91 Overall, the risk of development of postop-erative urinary retention is 2% to 3%.92-95 Other risk factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with |
Surgery_Schwartz_10679 | Surgery_Schwartz | factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with short-term catheterization. Patients will generally require an overnight admission and trial of normal voiding before discharge. Failure to void normally requires reinsertion of the catheter for up to a week. Chronic requirement of a urinary catheter is rare, though older patients may require prolonged catheterization. Risk of urinary retention can be minimized by ensuring voiding prior to surgery and minimization of perioperative fluid administration.96Ileus and Bowel Obstruction. The laparoscopic transab-dominal approach is associated with a higher incidence of ileus than other modes of repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intra-venous fluid maintenance, and possibly nasogastric decom-pression. Abdominal imaging may be | Surgery_Schwartz. factors for postoperative urinary retention include pain, narcotic analgesia, and perioperative bladder distention. Initial treatment of urinary retention requires decompression of the bladder with short-term catheterization. Patients will generally require an overnight admission and trial of normal voiding before discharge. Failure to void normally requires reinsertion of the catheter for up to a week. Chronic requirement of a urinary catheter is rare, though older patients may require prolonged catheterization. Risk of urinary retention can be minimized by ensuring voiding prior to surgery and minimization of perioperative fluid administration.96Ileus and Bowel Obstruction. The laparoscopic transab-dominal approach is associated with a higher incidence of ileus than other modes of repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intra-venous fluid maintenance, and possibly nasogastric decom-pression. Abdominal imaging may be |
Surgery_Schwartz_10680 | Surgery_Schwartz | repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intra-venous fluid maintenance, and possibly nasogastric decom-pression. Abdominal imaging may be helpful to confirm the diagnosis and to exclude bowel obstruction. Prolonged absence of bowel function, in conjunction with a suspicious abdominal series, should raise concern for obstruction. In this case, CT of the abdomen is helpful to distinguish anatomic sites of obstruc-tion, inflammation, and ischemia. In TAPP repairs, obstruction occurs most commonly secondary to herniation of bowel loops through peritoneal defects or large trocar insertion sites; how-ever, the use of smaller trocars and the preponderance of TEP repairs have reduced the frequency of this complication. True obstruction warrants reoperation.Visceral Injury. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intra-abdominal adhesions from previous surgeries may | Surgery_Schwartz. repair. This complication is self-limited; however, it necessitates sustained inpatient observation, intra-venous fluid maintenance, and possibly nasogastric decom-pression. Abdominal imaging may be helpful to confirm the diagnosis and to exclude bowel obstruction. Prolonged absence of bowel function, in conjunction with a suspicious abdominal series, should raise concern for obstruction. In this case, CT of the abdomen is helpful to distinguish anatomic sites of obstruc-tion, inflammation, and ischemia. In TAPP repairs, obstruction occurs most commonly secondary to herniation of bowel loops through peritoneal defects or large trocar insertion sites; how-ever, the use of smaller trocars and the preponderance of TEP repairs have reduced the frequency of this complication. True obstruction warrants reoperation.Visceral Injury. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intra-abdominal adhesions from previous surgeries may |
Surgery_Schwartz_10681 | Surgery_Schwartz | warrants reoperation.Visceral Injury. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intra-abdominal adhesions from previous surgeries may predispose to visceral injuries. Direct bowel injuries may also result from tro-car placement. In reoperative abdominal surgery, open Hasson technique and direct visualization of trocars are recommended to reduce the likelihood of visceral injury. Bowel injury may also occur secondary to electrocautery and instrument trauma outside of the camera field. Missed bowel injuries are associated with increased mortality. If injury to the bowel is suspected, its entire length should be examined, and conversion to open repair may be necessary.Brunicardi_Ch37_p1599-p1624.indd 162029/01/19 2:04 PM 1621INGUINAL HERNIASCHAPTER 37Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder dis-tention or extensive dissection of perivesical adhesions. | Surgery_Schwartz. warrants reoperation.Visceral Injury. Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. The presence of intra-abdominal adhesions from previous surgeries may predispose to visceral injuries. Direct bowel injuries may also result from tro-car placement. In reoperative abdominal surgery, open Hasson technique and direct visualization of trocars are recommended to reduce the likelihood of visceral injury. Bowel injury may also occur secondary to electrocautery and instrument trauma outside of the camera field. Missed bowel injuries are associated with increased mortality. If injury to the bowel is suspected, its entire length should be examined, and conversion to open repair may be necessary.Brunicardi_Ch37_p1599-p1624.indd 162029/01/19 2:04 PM 1621INGUINAL HERNIASCHAPTER 37Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder dis-tention or extensive dissection of perivesical adhesions. |
Surgery_Schwartz_10682 | Surgery_Schwartz | HERNIASCHAPTER 37Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder dis-tention or extensive dissection of perivesical adhesions. As with bladder injuries encountered in open surgery, cystotomies must be repaired in several layers with 1 to 2 weeks of Foley catheter decompression. A confirmatory cystogram may be performed before catheter removal to confirm healing of the injury.Vascular Injury. The most severe vascular injuries usually occur in iliac or femoral vessels, either by misplaced sutures in anterior repairs, endoscopic tacker use, or by trocar injury or direct dissection in laparoscopic repairs. In these cases, exsan-guination may be swift. Conversion to an open approach may be necessary, and bleeding should be temporarily controlled with mechanical compression until vascular control is obtained.The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliac | Surgery_Schwartz. HERNIASCHAPTER 37Bladder injuries are less common than visceral injuries, and they are usually associated with perioperative bladder dis-tention or extensive dissection of perivesical adhesions. As with bladder injuries encountered in open surgery, cystotomies must be repaired in several layers with 1 to 2 weeks of Foley catheter decompression. A confirmatory cystogram may be performed before catheter removal to confirm healing of the injury.Vascular Injury. The most severe vascular injuries usually occur in iliac or femoral vessels, either by misplaced sutures in anterior repairs, endoscopic tacker use, or by trocar injury or direct dissection in laparoscopic repairs. In these cases, exsan-guination may be swift. Conversion to an open approach may be necessary, and bleeding should be temporarily controlled with mechanical compression until vascular control is obtained.The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliac |
Surgery_Schwartz_10683 | Surgery_Schwartz | controlled with mechanical compression until vascular control is obtained.The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliac arter-ies. Although apparent upon initial approach, these vessels may be obscured during mesh positioning, and tacks or staples may injure them. Oftentimes, due to tamponade effect, injury to the inferior epigastric vessels is not apparent until the adjacent tro-car is removed. If injured, the inferior epigastrics may be ligated with a percutaneous suture passer or endoscopic vessel clips.If the tissue pressure exerted by pneumoperitoneum is greater than an injured vessel’s hydrostatic intraluminal pres-sure, bleeding will not manifest until pneumoperitoneum is released. The presentation of an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Accordingly, the surgeon should be aware of this intraoperative | Surgery_Schwartz. controlled with mechanical compression until vascular control is obtained.The most commonly injured vessels in laparoscopic hernia repair include the inferior epigastrics and external iliac arter-ies. Although apparent upon initial approach, these vessels may be obscured during mesh positioning, and tacks or staples may injure them. Oftentimes, due to tamponade effect, injury to the inferior epigastric vessels is not apparent until the adjacent tro-car is removed. If injured, the inferior epigastrics may be ligated with a percutaneous suture passer or endoscopic vessel clips.If the tissue pressure exerted by pneumoperitoneum is greater than an injured vessel’s hydrostatic intraluminal pres-sure, bleeding will not manifest until pneumoperitoneum is released. The presentation of an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Accordingly, the surgeon should be aware of this intraoperative |
Surgery_Schwartz_10684 | Surgery_Schwartz | an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Accordingly, the surgeon should be aware of this intraoperative consideration.Hematomas and SeromasHematomas may present as localized collections or as dif-fuse bruising over the operative site. Injury to spermatic cord vessels may result in a scrotal hematoma. Although they are self-limited, characteristic dark blue discoloration of the entire scrotum may alarm patients. Intermittent warm and cold com-pression aids in resolution. Hematomas may also develop in the incision, retroperitoneum, rectus sheath, and peritoneal cavity. The latter three sites are more frequently associated with lapa-roscopic repair. Bleeding within the peritoneum or preperitoneal space may not be readily apparent on physical examination. For this reason, close monitoring of subjective complaints, vital signs, urine output, and physical parameters is necessary.Seromas are fluid | Surgery_Schwartz. an inferior epigastric vein injury is often delayed because of this effect, and it may result in a significant rectus sheath hematoma. Accordingly, the surgeon should be aware of this intraoperative consideration.Hematomas and SeromasHematomas may present as localized collections or as dif-fuse bruising over the operative site. Injury to spermatic cord vessels may result in a scrotal hematoma. Although they are self-limited, characteristic dark blue discoloration of the entire scrotum may alarm patients. Intermittent warm and cold com-pression aids in resolution. Hematomas may also develop in the incision, retroperitoneum, rectus sheath, and peritoneal cavity. The latter three sites are more frequently associated with lapa-roscopic repair. Bleeding within the peritoneum or preperitoneal space may not be readily apparent on physical examination. For this reason, close monitoring of subjective complaints, vital signs, urine output, and physical parameters is necessary.Seromas are fluid |
Surgery_Schwartz_10685 | Surgery_Schwartz | may not be readily apparent on physical examination. For this reason, close monitoring of subjective complaints, vital signs, urine output, and physical parameters is necessary.Seromas are fluid collections that most commonly develop within one week of synthetic mesh repairs. Large hernia sac remnants may fill with physiologic fluid and mimic seromas. Patients often mistake seromas for early recurrence. Treatment consists of reassurance and warm compression to accelerate resolution. To avoid secondary infection, seromas should not be aspirated unless they cause discomfort or they restrict activ-ity for a prolonged time.OUTCOMESThe incidence of recurrence is the most-cited measure of post-operative outcome following inguinal hernia repair. In evaluat-ing the various available techniques, other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various | Surgery_Schwartz. may not be readily apparent on physical examination. For this reason, close monitoring of subjective complaints, vital signs, urine output, and physical parameters is necessary.Seromas are fluid collections that most commonly develop within one week of synthetic mesh repairs. Large hernia sac remnants may fill with physiologic fluid and mimic seromas. Patients often mistake seromas for early recurrence. Treatment consists of reassurance and warm compression to accelerate resolution. To avoid secondary infection, seromas should not be aspirated unless they cause discomfort or they restrict activ-ity for a prolonged time.OUTCOMESThe incidence of recurrence is the most-cited measure of post-operative outcome following inguinal hernia repair. In evaluat-ing the various available techniques, other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various |
Surgery_Schwartz_10686 | Surgery_Schwartz | other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various approaches to inguinal hernia repair.Among tissue repairs, the Shouldice operation is the most commonly performed technique, and it is most frequently executed at specialized centers. A 2012 meta-analysis from the Cochrane database demonstrated significantly lower rates of hernia recurrence (OR 0.62, CI 0.45–0.85) in patients undergoing Shouldice operations when compared with other open tissue-based methods.97 In experienced hands, the overall recurrence rate for the Shouldice repair is about 1%.98 Although it is an elegant procedure, its meticulous nature requires significant technical expertise to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4% to 2.5% | Surgery_Schwartz. other salient signifiers of outcome include complication rates, operative duration, hospital stay, and quality of life. The following section summarizes the evidence-based outcomes of the various approaches to inguinal hernia repair.Among tissue repairs, the Shouldice operation is the most commonly performed technique, and it is most frequently executed at specialized centers. A 2012 meta-analysis from the Cochrane database demonstrated significantly lower rates of hernia recurrence (OR 0.62, CI 0.45–0.85) in patients undergoing Shouldice operations when compared with other open tissue-based methods.97 In experienced hands, the overall recurrence rate for the Shouldice repair is about 1%.98 Although it is an elegant procedure, its meticulous nature requires significant technical expertise to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4% to 2.5% |
Surgery_Schwartz_10687 | Surgery_Schwartz | to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4% to 2.5% after surgeons performed the repair six times.99 Compared with mesh repairs, the Shouldice technique resulted in significantly higher rates of recurrence (OR 3.65, CI 1.79–7.47); however, it is the most effective tissue-based repair when mesh is unavailable or contraindicated.97Hernia recurrence is drastically reduced as a result of the Lichtenstein tension-free repair.100 Compared with open elective tissue-based repairs, mesh repair is associated with fewer recur-rences (OR 0.37, CI 0.26–0.51) and with shorter hospital stay and faster return to usual activities.101,102 In a multi-institutional series, 3019 inguinal hernias were repaired using the Lichten-stein technique, with an overall recurrence rate of 0.2%.103 Among other tension-free repairs, the Lichtenstein technique remains the most | Surgery_Schwartz. to achieve favorable outcomes, and it is associated with longer operative duration and longer hospital stay. One study found the recurrence rate for Shouldice repairs decreased from 9.4% to 2.5% after surgeons performed the repair six times.99 Compared with mesh repairs, the Shouldice technique resulted in significantly higher rates of recurrence (OR 3.65, CI 1.79–7.47); however, it is the most effective tissue-based repair when mesh is unavailable or contraindicated.97Hernia recurrence is drastically reduced as a result of the Lichtenstein tension-free repair.100 Compared with open elective tissue-based repairs, mesh repair is associated with fewer recur-rences (OR 0.37, CI 0.26–0.51) and with shorter hospital stay and faster return to usual activities.101,102 In a multi-institutional series, 3019 inguinal hernias were repaired using the Lichten-stein technique, with an overall recurrence rate of 0.2%.103 Among other tension-free repairs, the Lichtenstein technique remains the most |
Surgery_Schwartz_10688 | Surgery_Schwartz | 3019 inguinal hernias were repaired using the Lichten-stein technique, with an overall recurrence rate of 0.2%.103 Among other tension-free repairs, the Lichtenstein technique remains the most commonly performed procedure worldwide. Meta-analysis demonstrates no significant differences in out-comes between the Lichtenstein and the Plug and Patch tech-niques; however, intra-abdominal plug migration and erosion into contiguous structures occurs in approximately 6% of cases.101,104,105 The Stoppa technique results in longer operative duration than the Lichtenstein technique. Nevertheless, postop-erative acute pain, chronic pain, and recurrence rates are similar between the two methods.106 Perhaps the most compelling advan-tage of the Lichtenstein technique is that nonexpert surgeons rapidly achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilat-eral inguinal | Surgery_Schwartz. 3019 inguinal hernias were repaired using the Lichten-stein technique, with an overall recurrence rate of 0.2%.103 Among other tension-free repairs, the Lichtenstein technique remains the most commonly performed procedure worldwide. Meta-analysis demonstrates no significant differences in out-comes between the Lichtenstein and the Plug and Patch tech-niques; however, intra-abdominal plug migration and erosion into contiguous structures occurs in approximately 6% of cases.101,104,105 The Stoppa technique results in longer operative duration than the Lichtenstein technique. Nevertheless, postop-erative acute pain, chronic pain, and recurrence rates are similar between the two methods.106 Perhaps the most compelling advan-tage of the Lichtenstein technique is that nonexpert surgeons rapidly achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilat-eral inguinal |
Surgery_Schwartz_10689 | Surgery_Schwartz | achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilat-eral inguinal hernias as the preferred open technique.102 Com-pared to open approaches, endoscopic primary inguinal hernia repair produces equivalent recurrence rates and improved recov-ery time, pain prevention, and return to normal activities.107 In a study of 168 patients randomized to either TEP or Lichtenstein repair, the 5-year recurrence rates were extremely low in both groups.108,109 Similarly, a study of 200 male patients randomized to either ambulatory TEP or Lichtenstein repair demonstrated no recurrences in either group after one year.110 Because endoscopic surgery requires specialized instruments and longer operative times, its cost is higher than conventional open repair; however, the potential financial benefit of shorter recovery and decreased pain may offset these costs in the | Surgery_Schwartz. achieve similar outcomes to their expert counterparts. Guidelines issued by the European Hernia Society recommend the Lichtenstein repair for adults with either unilateral or bilat-eral inguinal hernias as the preferred open technique.102 Com-pared to open approaches, endoscopic primary inguinal hernia repair produces equivalent recurrence rates and improved recov-ery time, pain prevention, and return to normal activities.107 In a study of 168 patients randomized to either TEP or Lichtenstein repair, the 5-year recurrence rates were extremely low in both groups.108,109 Similarly, a study of 200 male patients randomized to either ambulatory TEP or Lichtenstein repair demonstrated no recurrences in either group after one year.110 Because endoscopic surgery requires specialized instruments and longer operative times, its cost is higher than conventional open repair; however, the potential financial benefit of shorter recovery and decreased pain may offset these costs in the |
Surgery_Schwartz_10690 | Surgery_Schwartz | instruments and longer operative times, its cost is higher than conventional open repair; however, the potential financial benefit of shorter recovery and decreased pain may offset these costs in the long-term.Perhaps the most salient difference between open and endo-scopic techniques is the number of cases needed to develop techni-cal proficiency. In a randomized controlled trial performed by the VA Cooperative Study, two-year recurrence rates were 10.1% in patients undergoing endoscopic repair and 4.9% in those undergo-ing open repair, and the outcomes of endoscopic repairs improved after each surgeon performed at least 250 cases.111 More recently, Lal and colleagues found that surgeons sustained a decrease from 9% to 2.9% in postoperative recurrences after performing 100 TEP operations.112 Other studies also suggest surgeons develop proficiency in these endoscopic techniques after performing 30 67Brunicardi_Ch37_p1599-p1624.indd 162129/01/19 2:04 PM 1622SPECIFIC | Surgery_Schwartz. instruments and longer operative times, its cost is higher than conventional open repair; however, the potential financial benefit of shorter recovery and decreased pain may offset these costs in the long-term.Perhaps the most salient difference between open and endo-scopic techniques is the number of cases needed to develop techni-cal proficiency. In a randomized controlled trial performed by the VA Cooperative Study, two-year recurrence rates were 10.1% in patients undergoing endoscopic repair and 4.9% in those undergo-ing open repair, and the outcomes of endoscopic repairs improved after each surgeon performed at least 250 cases.111 More recently, Lal and colleagues found that surgeons sustained a decrease from 9% to 2.9% in postoperative recurrences after performing 100 TEP operations.112 Other studies also suggest surgeons develop proficiency in these endoscopic techniques after performing 30 67Brunicardi_Ch37_p1599-p1624.indd 162129/01/19 2:04 PM 1622SPECIFIC |
Surgery_Schwartz_10691 | Surgery_Schwartz | TEP operations.112 Other studies also suggest surgeons develop proficiency in these endoscopic techniques after performing 30 67Brunicardi_Ch37_p1599-p1624.indd 162129/01/19 2:04 PM 1622SPECIFIC CONSIDERATIONSPART IIto 100 cases; however, this estimate has decreased precipitously since laparoscopic technique was first introduced.111,113,114Although controversy persists regarding the utility of TEP versus TAPP, reviews to date find no significant differences in operative duration, length of stay, time to recovery, or short-term recurrence rate between the two approaches. In TAPP repair, the risk of intra-abdominal injury is higher than in TEP repair. This finding prompted the IEHS to recommend TAPP should only be attempted by surgeons with sufficient experience.49 A Cochrane systematic review found rates of port-site hernias and visceral injuries were higher for the TAPP technique, while TEP may be associated with a higher rate of conversion to an alternative approach; however, | Surgery_Schwartz. TEP operations.112 Other studies also suggest surgeons develop proficiency in these endoscopic techniques after performing 30 67Brunicardi_Ch37_p1599-p1624.indd 162129/01/19 2:04 PM 1622SPECIFIC CONSIDERATIONSPART IIto 100 cases; however, this estimate has decreased precipitously since laparoscopic technique was first introduced.111,113,114Although controversy persists regarding the utility of TEP versus TAPP, reviews to date find no significant differences in operative duration, length of stay, time to recovery, or short-term recurrence rate between the two approaches. In TAPP repair, the risk of intra-abdominal injury is higher than in TEP repair. This finding prompted the IEHS to recommend TAPP should only be attempted by surgeons with sufficient experience.49 A Cochrane systematic review found rates of port-site hernias and visceral injuries were higher for the TAPP technique, while TEP may be associated with a higher rate of conversion to an alternative approach; however, |
Surgery_Schwartz_10692 | Surgery_Schwartz | review found rates of port-site hernias and visceral injuries were higher for the TAPP technique, while TEP may be associated with a higher rate of conversion to an alternative approach; however, neither finding was sufficiently compelling to recommend one technique over the other.114The frequency with which the aforementioned ingui-nal hernia repair techniques are performed reinforces the importance of broad experience. The authors recommend that surgeons become proficient in several techniques to address dif-ferent manifestations of inguinal hernias. Surgeons should tailor this experience to optimize outcomes for each patient.REFERENCESEntries highlighted in bright blue are key references. 1. National Center for Health Statistics. National Hospital Discharge Survey and National Survey of Ambulatory Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index .htm. Accessed August 4, 2018. 2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of inguinal hernia. A survey in | Surgery_Schwartz. review found rates of port-site hernias and visceral injuries were higher for the TAPP technique, while TEP may be associated with a higher rate of conversion to an alternative approach; however, neither finding was sufficiently compelling to recommend one technique over the other.114The frequency with which the aforementioned ingui-nal hernia repair techniques are performed reinforces the importance of broad experience. The authors recommend that surgeons become proficient in several techniques to address dif-ferent manifestations of inguinal hernias. Surgeons should tailor this experience to optimize outcomes for each patient.REFERENCESEntries highlighted in bright blue are key references. 1. National Center for Health Statistics. National Hospital Discharge Survey and National Survey of Ambulatory Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index .htm. Accessed August 4, 2018. 2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of inguinal hernia. A survey in |
Surgery_Schwartz_10693 | Surgery_Schwartz | of Ambulatory Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index .htm. Accessed August 4, 2018. 2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of inguinal hernia. A survey in western Jerusalem. J Epidemiol Community Health. 1978;32(1):59-67. 3. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am 1998;78(6):941-951, v-vi. 4. Johnson J, Roth JS, Hazey JW, et al. The history of open inguinal hernia repair. Curr Surg. 2004;61(1):49-52. 5. Gil J, Rodriguez JM, Hernandez Aguera Q, et al. The usefulness of international cooperation in the repair of inguinal hernias in Sub-Saharan Africa. World J Surg. 2015;39(11):2622-2629. 6. Shulman AG, Amid PK, Lichtenstein IL. A survey of non-expert surgeons using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc | Surgery_Schwartz. of Ambulatory Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index .htm. Accessed August 4, 2018. 2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of inguinal hernia. A survey in western Jerusalem. J Epidemiol Community Health. 1978;32(1):59-67. 3. Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am 1998;78(6):941-951, v-vi. 4. Johnson J, Roth JS, Hazey JW, et al. The history of open inguinal hernia repair. Curr Surg. 2004;61(1):49-52. 5. Gil J, Rodriguez JM, Hernandez Aguera Q, et al. The usefulness of international cooperation in the repair of inguinal hernias in Sub-Saharan Africa. World J Surg. 2015;39(11):2622-2629. 6. Shulman AG, Amid PK, Lichtenstein IL. A survey of non-expert surgeons using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc |
Surgery_Schwartz_10694 | Surgery_Schwartz | using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg. 1991;1(5):269-277. 8. Scheuermann U, Niebisch S, Lyros O, Jansen-Winkeln B, Gockel I. Transabdominal preperitoneal (TAPP) versus Lichtenstein operation for primary inguinal hernia repair—a systematic review and meta-analysis of randomized controlled trials. BMC Surg. 2017;17(1):55. 9. Fitzgibbons RJ, Jr, Salerno GM, Filipi CJ, Hunter WJ, Watson P. A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia. Ann Surg. 1994;219(2):144-156. 10. Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg. 1996;6(6):375-386. 11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal | Surgery_Schwartz. using the open tension-free mesh patch repair for primary inguinal hernias. Int Surg. 1995;80(1):35-36. 7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the anatomic basis. J Laparoendosc Surg. 1991;1(5):269-277. 8. Scheuermann U, Niebisch S, Lyros O, Jansen-Winkeln B, Gockel I. Transabdominal preperitoneal (TAPP) versus Lichtenstein operation for primary inguinal hernia repair—a systematic review and meta-analysis of randomized controlled trials. BMC Surg. 2017;17(1):55. 9. Fitzgibbons RJ, Jr, Salerno GM, Filipi CJ, Hunter WJ, Watson P. A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia. Ann Surg. 1994;219(2):144-156. 10. Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg. 1996;6(6):375-386. 11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal |
Surgery_Schwartz_10695 | Surgery_Schwartz | onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg. 1996;6(6):375-386. 11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc. 1992;2(1):53-58. 12. Dulucq JL. Treatment of inguinal hernia by insertion of a subperitoneal patch under pre-peritoneoscopy (in French). Chirurgie. 1992;118(1-2):83-85. 13. Burcharth J, Pommergaard HC, Rosenberg J. The inheritance of groin hernia: a systematic review. Hernia. 2013;17(2):183-189. 14. Van Wessem KJ, Simons MP, Plaisier PW, Lange JF. The etiology of indirect inguinal hernias: congenital and/or acquired? Hernia. 2003;7(2):76-79. 15. Weaver KL, Poola AS, Gould JL, Sharp SW, St Peter SD, Holcomb GW 3rd. The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis. J Pediatr Surg. 2017;52(1):60-64. 16. Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain | Surgery_Schwartz. onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg. 1996;6(6):375-386. 11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc. 1992;2(1):53-58. 12. Dulucq JL. Treatment of inguinal hernia by insertion of a subperitoneal patch under pre-peritoneoscopy (in French). Chirurgie. 1992;118(1-2):83-85. 13. Burcharth J, Pommergaard HC, Rosenberg J. The inheritance of groin hernia: a systematic review. Hernia. 2013;17(2):183-189. 14. Van Wessem KJ, Simons MP, Plaisier PW, Lange JF. The etiology of indirect inguinal hernias: congenital and/or acquired? Hernia. 2003;7(2):76-79. 15. Weaver KL, Poola AS, Gould JL, Sharp SW, St Peter SD, Holcomb GW 3rd. The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis. J Pediatr Surg. 2017;52(1):60-64. 16. Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain |
Surgery_Schwartz_10696 | Surgery_Schwartz | inguinal hernia in children with an asymptomatic patent processus vaginalis. J Pediatr Surg. 2017;52(1):60-64. 16. Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain risk factors. Eur J Epidemiol. 1992;8(2):277-282. 17. Lau H, Fang C, Yuen WK, Patil NG. Risk factors for inguinal hernia in adult males: a case-control study. Surgery. 2007;141(2):262-266. 18. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol. 2007;165(10):1154-1161. 19. Klinge U, Binnebösel M, Mertens PR. Are collagens the culprits in the development of incisional and inguinal hernia disease? Hernia. 2006;10(6):472-477. 20. Franz MG. The biology of hernias and the abdominal wall. Hernia. 2006;10(6):462-471. 21. Ralphs DN, Brain AJ, Grundy DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J. 1980;280(6220):1039-1040. 22. Cameron AE. Accuracy of clinical diagnosis of direct and indirect | Surgery_Schwartz. inguinal hernia in children with an asymptomatic patent processus vaginalis. J Pediatr Surg. 2017;52(1):60-64. 16. Flich J, Alfonso JL, Delgado F, Prado MJ, Cortina P. Inguinal hernia and certain risk factors. Eur J Epidemiol. 1992;8(2):277-282. 17. Lau H, Fang C, Yuen WK, Patil NG. Risk factors for inguinal hernia in adult males: a case-control study. Surgery. 2007;141(2):262-266. 18. Ruhl CE, Everhart JE. Risk factors for inguinal hernia among adults in the US population. Am J Epidemiol. 2007;165(10):1154-1161. 19. Klinge U, Binnebösel M, Mertens PR. Are collagens the culprits in the development of incisional and inguinal hernia disease? Hernia. 2006;10(6):472-477. 20. Franz MG. The biology of hernias and the abdominal wall. Hernia. 2006;10(6):462-471. 21. Ralphs DN, Brain AJ, Grundy DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J. 1980;280(6220):1039-1040. 22. Cameron AE. Accuracy of clinical diagnosis of direct and indirect |
Surgery_Schwartz_10697 | Surgery_Schwartz | DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J. 1980;280(6220):1039-1040. 22. Cameron AE. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg. 1994;81(2):250. 23. Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11-18. 24. Jamadar DA, Jacobson JA, Morag Y, et al. Sonography of inguinal region hernias. AJR Am J Roentgenol. 2006;187(1): 185-190. 25. Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 2011;31(2):E1-E12. 26. van den Berg JC, de Valois JC, Go PM, Rosenbusch G. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34(12):739-743. 27. Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. | Surgery_Schwartz. DJ, Hobsley M. How accurately can direct and indirect inguinal hernias be distinguished? Br Med J. 1980;280(6220):1039-1040. 22. Cameron AE. Accuracy of clinical diagnosis of direct and indirect inguinal hernia. Br J Surg. 1994;81(2):250. 23. Robinson A, Light D, Kasim A, Nice C. A systematic review and meta-analysis of the role of radiology in the diagnosis of occult inguinal hernia. Surg Endosc. 2013;27(1):11-18. 24. Jamadar DA, Jacobson JA, Morag Y, et al. Sonography of inguinal region hernias. AJR Am J Roentgenol. 2006;187(1): 185-190. 25. Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ. Diagnosis of inguinal region hernias with axial CT: the lateral crescent sign and other key findings. Radiographics. 2011;31(2):E1-E12. 26. van den Berg JC, de Valois JC, Go PM, Rosenbusch G. Detection of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34(12):739-743. 27. Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. |
Surgery_Schwartz_10698 | Surgery_Schwartz | of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34(12):739-743. 27. Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. Watch-ful waiting vs repair of inguinal hernia in minimally symp-tomatic men: a randomized clinical trial. JAMA. 2006;295(3): 285-292. 28. Chen T, Zhang Y, Wang H, et al. Emergency inguinal hernia repair under local anesthesia: a 5-year experience in a teaching hospital. BMC Anesthesiol. 2015;16:17. 29. van den Heuvel B, Dwars BJ, Klassen DR, Bonjer HJ. Is surgical repair of an asymptomatic groin hernia appropriate? A review. Hernia. 2011;15(3):251-259. 30. Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg. 2012;147(3):277-281. 31. Thompson JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008;195(1):89-93. 32. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 | Surgery_Schwartz. of groin hernia with physical examination, ultrasound, and MRI compared with laparoscopic findings. Invest Radiol. 1999;34(12):739-743. 27. Fitzgibbons RJ, Jr, Giobbie-Hurder A, Gibbs JO, et al. Watch-ful waiting vs repair of inguinal hernia in minimally symp-tomatic men: a randomized clinical trial. JAMA. 2006;295(3): 285-292. 28. Chen T, Zhang Y, Wang H, et al. Emergency inguinal hernia repair under local anesthesia: a 5-year experience in a teaching hospital. BMC Anesthesiol. 2015;16:17. 29. van den Heuvel B, Dwars BJ, Klassen DR, Bonjer HJ. Is surgical repair of an asymptomatic groin hernia appropriate? A review. Hernia. 2011;15(3):251-259. 30. Mizrahi H, Parker MC. Management of asymptomatic inguinal hernia: a systematic review of the evidence. Arch Surg. 2012;147(3):277-281. 31. Thompson JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008;195(1):89-93. 32. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 |
Surgery_Schwartz_10699 | Surgery_Schwartz | JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008;195(1):89-93. 32. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014;18(2):151-163. 33. Law NW, Trapnell JE. Does a truss benefit a patient with inguinal hernia? BMJ. 1992;304(6834):1092. 34. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991;78(10): 1171-1173. 35. Nilsson H, Stylianidis G, Haapamäki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg. 2007;245(4):656-660.Brunicardi_Ch37_p1599-p1624.indd 162229/01/19 2:04 PM 1623INGUINAL HERNIASCHAPTER 37 36. Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibi-otic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769. 37. Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients | Surgery_Schwartz. JS, Gibbs JO, Reda DJ, et al. Does delaying repair of an asymptomatic hernia have a penalty? Am J Surg. 2008;195(1):89-93. 32. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014;18(2):151-163. 33. Law NW, Trapnell JE. Does a truss benefit a patient with inguinal hernia? BMJ. 1992;304(6834):1092. 34. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of strangulation in groin hernias. Br J Surg. 1991;78(10): 1171-1173. 35. Nilsson H, Stylianidis G, Haapamäki M, Nilsson E, Nordin P. Mortality after groin hernia surgery. Ann Surg. 2007;245(4):656-660.Brunicardi_Ch37_p1599-p1624.indd 162229/01/19 2:04 PM 1623INGUINAL HERNIASCHAPTER 37 36. Sanchez-Manuel FJ, Lozano-García J, Seco-Gil JL. Antibi-otic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769. 37. Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients |
Surgery_Schwartz_10700 | Surgery_Schwartz | Lozano-García J, Seco-Gil JL. Antibi-otic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769. 37. Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg. 2012;78(3):359-365. 38. Delikoukos S, Lavant L, Hlias G, Palogos K, Gikas D. The role of hernia sac ligation in postoperative pain in patients with elective tension-free indirect inguinal hernia repair: a prospective randomized study. Hernia. 2007;11(5):425-428. 39. Desarda MP. Inguinal herniorrhaphy with an undetached strip of external oblique aponeurosis: a new approach used in 400 patients. Eur J Surg. 2001;167(6):443-448. 40. Desarda MP. New method of inguinal hernia repair: a new solution. ANZ J Surg. 2001;71(4):241-244. 41. Desarda MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146. 42. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the | Surgery_Schwartz. Lozano-García J, Seco-Gil JL. Antibi-otic prophylaxis for hernia repair. Cochrane Database Syst Rev. 2012;(2):CD003769. 37. Yin Y, Song T, Liao B, Luo Q, Zhou Z. Antibiotic prophylaxis in patients undergoing open mesh repair of inguinal hernia: a meta-analysis. Am Surg. 2012;78(3):359-365. 38. Delikoukos S, Lavant L, Hlias G, Palogos K, Gikas D. The role of hernia sac ligation in postoperative pain in patients with elective tension-free indirect inguinal hernia repair: a prospective randomized study. Hernia. 2007;11(5):425-428. 39. Desarda MP. Inguinal herniorrhaphy with an undetached strip of external oblique aponeurosis: a new approach used in 400 patients. Eur J Surg. 2001;167(6):443-448. 40. Desarda MP. New method of inguinal hernia repair: a new solution. ANZ J Surg. 2001;71(4):241-244. 41. Desarda MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146. 42. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the |
Surgery_Schwartz_10701 | Surgery_Schwartz | MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146. 42. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open “tension-free” hernioplasty. Am J Surg. 1993;165(3):369-371. 43. Gilbert AI. Sutureless repair of inguinal hernia. Am J Surg. 1992;163(3):331-335. 44. Millikan KW, Cummings B, Doolas A. The Millikan modified mesh-plug hernioplasty. Arch Surg. 2003;138(5):525-529; discussion 529-530. 45. Voyles CR, Hamilton BJ, Johnson WD, Kano N. Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis. Am J Surg. 2002;184(1):6-10. 46. Antunes AA, Dall’oglio M, Crippa A, Srougi M. Inguinal hernia repair with polypropylene mesh during radical retropubic prostatectomy: an easy and practical approach. BJU Int. 2005;96(3):330-333. 47. Lee BC, Rodin DM, Shah KK, Dahl DM. Laparoscopic inguinal hernia repair during laparoscopic radical prostatectomy. BJU Int. | Surgery_Schwartz. MP. Physiological repair of inguinal hernia: a new technique (study of 860 patients). Hernia. 2006;10(2):143-146. 42. Amid PK, Shulman AG, Lichtenstein IL. Critical scrutiny of the open “tension-free” hernioplasty. Am J Surg. 1993;165(3):369-371. 43. Gilbert AI. Sutureless repair of inguinal hernia. Am J Surg. 1992;163(3):331-335. 44. Millikan KW, Cummings B, Doolas A. The Millikan modified mesh-plug hernioplasty. Arch Surg. 2003;138(5):525-529; discussion 529-530. 45. Voyles CR, Hamilton BJ, Johnson WD, Kano N. Meta-analysis of laparoscopic inguinal hernia trials favors open hernia repair with preperitoneal mesh prosthesis. Am J Surg. 2002;184(1):6-10. 46. Antunes AA, Dall’oglio M, Crippa A, Srougi M. Inguinal hernia repair with polypropylene mesh during radical retropubic prostatectomy: an easy and practical approach. BJU Int. 2005;96(3):330-333. 47. Lee BC, Rodin DM, Shah KK, Dahl DM. Laparoscopic inguinal hernia repair during laparoscopic radical prostatectomy. BJU Int. |
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