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‫صدق هللا العظيم‬
The Role Of Narrowing Of The Internal
Ring In The Outcome Of Laparoscopic
Treatment Of Indirect Inguinal Hernia.
By
Mohammed Saleh Al-dawbali
MD (Egy.), MRCS (Eng.)
Ass. Prof Of Surgery (Sana'a University)
Introduction
-- Hernia is a frequent disease in the community
so that it produce a sizable part of many general
surgeons practice.
-- The success of laparoscopic cholecystectomy has
resulted in the enthusiasm to modify other
abdominal procedures so that they can be
performed laparoscopically.
-- laparoscopic Inguinal hernioplasty is one of such
procedure.
Introduction (cont.)

Over the past 20 years, several hernia repair techniques
have been introduced .The main cause for the
development of these new techniques was to reduce the
recurrence rate.

The introduction of the Lichtenstein tension-free
hernioplasty, which uses a mesh to reinforce the abdominal
wall, has decreased recurrence rates greatly.

However, certain types such as recurrent, bilateral hernias
are particularly suited for a laparoscopic approach .

Laparoscopic inguinal hernioplasty is associated with
shorter recovery periods, earlier return to daily activities
and work, and decreased postoperative pain.
Indications
 Certain
types of hernia such as
- Recurrent,
- Bilateral, are particularly suited
for a laparoscopic approach .
BUT also it can be done for primary
unilateral hernias as first patient
preference
Approach
 Laparoscopic
hernia repair can be done
either through:
 1. Transabdominal Preperitoneal Approach
(TAPP )or
 2. Total Extra-peritoneal Approach (TEP).
Aim Of The Work
 Our
study aim to assess whether the
addition of the closure of internal ring to the
classical TAPP has a better short outcome
on regard to post operative pain, bulging,
seroma or haematoma formation and on the
long term outcome in regard to recurrence .
Patients And Methods
- A total of 40 patients were selected from 
those presented to the Outpatient Clinic with
indirect inguinal hernia from the period May
2009 to April 2011
Patients And Methods
Exclusion criteria for patient selection were as
follows: - younger than 12 years of age
 - severe obesity (BMI >35).
 - associated medical problems that
contraindicate safe induction of general
anesthesia or elective surgery
Patients And Methods
 The
forty Patients were randomly divided
into two groups , group A contain 20
patients and were treated by closure of
the ring and classical TAPP ,while group
B contain 20 patients and was treated by
Classical TAPP Only.
Operation
 In
the theater, neither nasogastric tube nor
urinary catheter were needed (patient
were instructed to evacuate their bladder
before coming to the theater).
Op. Technique (cont.)
 Insertion
Of The Trocar (open tech.)
 Induction Of Pneumoperitoneum (14mmHg)
 abdominal cavity and viscera are
inspected in a systematic order
 Two
working ports were further
introduced at a level just caudal to the
umbilicus and lateral to the rectus muscle
of both right and left lower quadrants.
 N.B This array of trocars was used in
either unilateral or bilateral cases.
EXPLORATION
Peritoneal incision (Right)
Left peritoneal incision
Right side dissection
Left side dissection
Ring closure
Mesh fixation
Peritoneal closure
Results
Patients characteristics:
 The patient’s ages ranged from 25→55
years old
 The mean age was 33 years in Group A and
30 years in Group B
 All of our pt were male (no female)
Distribution of Hernia site
 24
cases (60%) were right side , 6 cases
( 15%) were left side and 10 cases (25 %)
were bilateral .
Hernia Site
0%
25%
1
2
3
4
15%
60%
Average Operative Time
Intra-Operative Complications

Intra-operative complication occur in a single
case (2.5 %) in the form of urinary bladder injury
during reduction of the structure from a left
hernia defect in a patient with bilateral hernia.
The injury was recognized at the time of
operation and dealing with it was done in the
form of repair in two layer after putting of urinary
catheter. The hernia repair was completed then
as usual .The patient recover post operatively
without further complication
Post Operative Care.


The patients were shifted from the operating theater to
the surgical ward and were discharged in the next day
(except when complications were suspected). In the
surgical ward recording of the postoperative pain using
the Visual analogue scale (VAS) was used .
Patients were seen after 1 week , then after 1 month and
then after 6th months postoperatively and they were told
to contact us if they face any problem regarding their
hernia. During the follow up of these patients they were
examined clinically to assess the post operative pain
and to look for the presence of odema, seroma ,
hematoma , wound infection ,post operative bulge,
recurrence or any other complications.
Hospital Stay
-All patient of both group were ambulated in
the same day of operation and discharged
in the next day of the operation.
-Only 1 case (2.5 %) who discharged in the
3rd POD.
Follow up
 Postoperative
pain . there was no
significant difference between patients of
both groups (P value < 0.01) and the pain
score was ranged from VAS 1 to VAS 3
(mild ) and in more than 90% of cases
pain was overcomed with simple
analgesics . The causes of pain seems to
be multifactorial (dissection , fixation of the
mesh, foreign body reaction……etc)
 Visual
analogue scale (VAS)
-
Seroma occur in two cases (10 %) of the
second group and was treated
conservatively . No seroma occur in pts of
the first group
 Post
operative bulging was noted in 16
case (80 %) of the second group and it
last for a period of around two months
postoperatively , while in the first group
there were No bulging neither in the early
nor in the late postoperative period. This
make the patients of the first group more
satisfy .
The follow-up period ranged from 1 to 1.5
year postoperatively ( average 1 year)
 The results of follow up show:
On clinical basis all patients of both groups
were relived of the symptoms of hernia
 No recurrence have been reported in all
cases of both group.
Conclusion

Laparoscopic surgery is becoming widely accepted as
an alternative to conventional procedures. Withminiaturization of instrument it is becoming more and
more evident that laparoscopic techniques can be
applied safely and successfully to hernia patients. The
selection criteria for patients who are eligible for
laparoscopic procedures is dynamic and as skills and
technologies improve fewer patients are found to have
absolute exclusion criteria
 Result
show that Laparoscopic narrowing
of the internal inguinal ring was found to
be safe , effective and low cost
procedure for treatment of oblique
inguinal hernia with better outcome
regarding post operative serohematoma
and postoperative bulging which are
annoying problem to hernia patients .

However, the important Question is
Whether the closure of the internal ring
will be an auxiliary step in the classical
TAPP procedures in the light of these
substantial benefits as regard to less
postoperative complications. More
studies needed to answer this question
but in our study narrowing of the internal
ring with hernioplasty was simple,
sufficient and effective .
Thank you !
Numerical rating scale (NRS)
 Faces
rating scale (FRS)
Pain rating scales instructions
Subjective pain score
All patients are to have a functional activity score recorded in addition to the chosen subjective
score.
Visual analogue scale (VAS)

Instruct the patient to point to the position on the line between the faces to indicate how much pain
they are currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst
pain ever’.
Numerical rating scale (NRS)

Instruct the patient to choose a number from 0 to 10 that best describes their current pain. 0
would mean ‘No pain’ and 10 would mean ‘Worst possible pain’.
Faces rating scale (FRS)

Adults who have difficulty using the numbers on the visual/numerical rating scales can be assisted
with the use of the six facial expressions suggesting various pain intensities. Ask the patient to
choose the face that best describes how they feel. The far left face indicates ‘No hurt’ and the far
right face indicates ‘Hurts worst’. Document number below the face chosen.
Behavioural rating scale

The behavioural pain assessment scale is designed for use with non-verbal patients unable to
provide self-reports of pain.

Rate each of the five measurement categories (0,1 or 2).

Add these together.

Document the total pain score out of 10.
Functional activity score

This is an activity-related score. Ask your patient to perform an activity related to their painful area
(for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain).

Observe your patient during the chosen activity and score A, B or C.

A – No limitation meaning the patient’s activity is unrestricted by pain

B – Mild limitation means the patient’s activity is mild to moderately restricted by pain

C - Severe limitation means the patient ability to perform the activity is severely limited by pain

*Relative to baseline refers to any restriction above any pre–existing condition the patient may
