Surgical Management
of the Inguinal Hernia
Jerry G Gaston DO FACOS
Mid-Year Meeting ACOS
April 2014
Surgeon Disclaimer
The following presentation is made on behalf of Davol Inc., and
contains the opinions of, and personal surgical techniques practiced
by Dr. Gaston. Any discussion regarding Davol products during the
presentation is limited to information that is consistent with the
FDA approvals or clearances for those products. The opinions and
techniques presented herein are for informational purposes only
and the decision of which techniques to use in a particular surgical
application should be made by the surgeon based on the individual
facts and circumstances of the patient and previous surgical
experience.
Consult product labels and insert for any indications,
contraindications, hazards, warnings, precautions, and instructions
for use.
Dr. Gsston is a paid consultant for Davol, Takeda, and Myraid.
2
General
770,000 performed in US each year
Indirect inguinal hernia most common
Tension free
Mesh
Reoccurrence
Chronic pain
Anatomy
Classification
Direct
Enters canal through posterior wall
Weakening of the abdominal musculature
Medial to the inferior epigastric vessels
Indirect
Enters canal through the deep inguinal ring
Congenital – failure of the processus vaginalis to regress and fuse
Femoral
Inferior to Inguinal ligament
Multiple presentations
Nerves
Iliohypogastric
L1-L2 nerve roots
Just medially and superior to ASIS
Lies beneath the aponeurosis of the external oblique
Supplies sensation to the skin of the suprapubic area
Ilioinguinal
L1 nerve root
2cm medial to the ASIS
Lies beneath the aponeurosis of the external oblique
Supplies sensation to the skin of the pubic region and
the upper part of the scrotum or labia majoria
Nerves
Genitofemoral
Genital branch and femoral branch
L2-L3nerves
Enters at the deep ring
Genital branch-scrotum and medial aspect of the thigh
Femoral branch-skin of the proximal anterior thigh
Repairs
Bassini
Marcy
Shouldice
McVay (Cooper Ligament)
Laparoscopic
Lichtenstein
Mesh
Kugel
Plug and patch
PHS
Repairs
To fix or not to fix
Mesh
Approach
Fix or not to fix
Data confirms that a strategy of watchful waiting is a
safe and acceptable option for men with minimally
symptomatic or asymptomatic hernias.
Fitzgibbons group trial
Glasgow group in UK
Mesh
Cochrane data 2001 – 50-75% reduction in the risk of
recurrence with the use of mesh
PTFE
Mesh plug and patch
Prolene hernia system
Kugel
3D max
Approach
Anterior
Posterior
Anterior
Plug and Patch
Posterior
Kugel
Posterior approach
No fixation
Ring
Nerve avoidance
Previous repair preperitoneal
Laparoscopic
3D Max
Laparoscopic
TAPP vs TEP
Nerve injury
Lateral femoral cutaneous
Closure of peritoneum
Bilateral
Complications
Reoccurrence
Chronic pain
Mesh erosion
Hemorrhage
Nerve injury
Vas Deferens injury
Complications
Reoccurrence
Mesh vs no mesh
Cochrane data 2001 – 50-75% reduction in the risk of
recurrence with the use of mesh
Less than 5%
Complications
Chronic Pain
Nerve injury vs non nerve injury
Long term
Short term
Work compensation
Complications
Mesh Erosion
Bowel
Bladder
omentum
Complications
Hemorrhage
Testicular vessels
Inferior epigastric
Cremestaric vessels
Femoral
Complications
Nerve Injury
Transection
Manipulation
Triple neurectomy
Meshoma
Complications
Vas Deferens
Difficult dissection
Previous mesh
Informed consent
Scrotal hernia
Conclusion
Multiple different approaches
Need a variety of tricks in the bag
Do what you feel comfortable and can reproduce
Know the surgical history
Don’t be afraid to pull the NO CARD