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General Surgery
Hernias
Built from Maingot's Abdominal Operations
What’s inside
12 sections · 186 slides
Overview
- Topics covered
Understanding hernias
Definition, distribution, and how repair evolved
- Definition of a hernia
- Distribution and lifetime risk of hernia
- Congenital and acquired hernia, and the effect of age
- Early history of groin hernia treatment
- Bassini's repair
- Cooper's ligament repair and the drive to reduce tension
- From darns and silver filigree to polypropylene mesh
- Shouldice and the laparoscopic era
Anatomy and classification of groin hernia
The landmarks that name every groin hernia
- Hesselbach's triangle
- Classification of groin hernia by the inferior epigastric vessels
- Indirect inguinal hernia and the processus vaginalis
- Direct inguinal hernia
- Femoral hernia: the defect and its urgency
- Femoral hernia in women
- Boundaries of the inguinal canal and its rings
- Layers encountered in open groin dissection
- Layers, nerves and muscles of the inguinal canal
- The preperitoneal space
- Causes of hernia formation
- Inherited collagen disorders and smoking
Recognising a groin hernia
Symptoms, complications and the physical examination
- Spectrum of presentation
- Mechanism of pain in a groin hernia
- Incarceration, strangulation and bowel obstruction
- Progression from reducible hernia to necrosis
- Incarcerated versus strangulated hernia
- Groin hernia in pregnancy
- Principles of examination, and the male patient
- Examination in the female patient and the infant
- Examination for femoral hernia
- Indications for repair and the risk of delay
- Incarceration risk over time
- Anaesthesia options for groin hernia repair
- Infiltration, nerve block and the randomised evidence
Open inguinal hernia repair
Tension-free closure, tissue repairs and mesh
- Tension-free closure and opening the canal
- Skin incisions for open groin hernia repair
- Protecting the nerves and mobilising the cord
- Opening the external oblique and exposing the cord
- Defining the hernia at operation
- Skeletonised cord and dissected hernia sac
- Freeing the sac from the cord structures
- The freed sac held up at the internal ring
- The Shouldice technique and opening the transversalis fascia
- Incising and elevating the transversalis fascia
- First and second suture layers
- First and second layers of the Shouldice repair
- Third and fourth layers, and closing the canal
- Third and fourth layers of the Shouldice repair
- External oblique closed in front of the cord
- The four continuous layers of the Shouldice repair
- Results of the Shouldice repair
- Cochrane comparison and the current place of Shouldice
- The Cooper ligament (McVay) repair
- Steps of the Cooper ligament repair
- The relaxing incision, and the limits of the repair
- Choice of mesh in groin hernia repair
- Evidence for mesh in open groin repair
- The Lichtenstein repair
- The plug and patch repair
- Mesh plug being placed in the internal ring
- Mesh patch laid on the inguinal floor around the cord
- Fixation options for plug and patch
- Rationale for the preperitoneal approach
- Preperitoneal repair: incision and exposure
- Lower line of mesh fixation in the Rives repair
- Lateral and upper mesh fixation in the Rives repair
- Preperitoneal mesh with an anterior tissue repair
- Repairing direct and indirect defects from behind
- Midline preperitoneal incision and mesh placement
Laparoscopic inguinal hernia repair
TAPP, TEP and IPOM, and what the trials show
- Development, current use and the key anatomical difference
- Three laparoscopic routes to the groin hernia
- Transabdominal preperitoneal repair: access and landmarks
- Transabdominal preperitoneal repair: the sac and the mesh
- Concerns with the transabdominal repair
- Totally extraperitoneal repair
- Intraperitoneal onlay mesh and its drawbacks
- Comparing the laparoscopic techniques with each other
- Laparoscopic versus open repair: meta-analyses
- Surgeon experience and recurrence
- The space of Retzius
Complications of groin hernia surgery
Recurrence, infection, neuralgia and organ injury
- Early recurrence
- Tension as the primary cause of recurrence
- Defect size, emergency surgery and smoking
- Wound and mesh infection
- Seroma, pseudohernia and haematoma
- Postoperative groin neuralgia
- Preventing nerve injury
- Treating postoperative neuralgia
- Bladder injury
- Testicular injury
- The testis in paediatric repair, and the vas deferens
- Risk of strangulation over time
- Timing of surgery for the incarcerated hernia
- Operating on an incarcerated inguinal hernia
Femoral hernia
A tight defect with a high risk of strangulation
- Frequency and boundaries of the femoral canal
- Structures behind the inguinal ligament
- Femoral hernia passing through the femoral canal
- Strangulation risk in femoral hernia
- Cause and presentation of femoral hernia
- Operative options for a reducible femoral hernia
- Mesh plug repair of a femoral hernia
Umbilical and epigastric hernia
Midline defects of the anterior abdominal wall
- Umbilical hernia defined
- Umbilical hernia in children
- Embryology of the umbilical defect
- Clinical features of umbilical hernia
- Course of umbilical hernia in the adult
- Umbilical bulge and the skin crease incision
- Hernia sac exposed at the umbilical defect
- Sutures placed across the umbilical defect
- Umbilical hernia repair in an adult
- Epigastric hernia defined
- Cause and contents of an epigastric hernia
- Clinical features and diagnosis of epigastric hernia
- Repair of the epigastric hernia
- Exposing an epigastric hernia and its contents
- Closing the epigastric defect and the outcome
- Suture techniques for epigastric hernia repair
Rare hernias of the abdominal and pelvic wall
Obturator, perineal, spigelian, lumbar and sciatic
- Obturator hernia defined, and who develops it
- Anatomy of the obturator canal
- Direction of an obturator hernia
- Four cardinal findings of obturator hernia
- The Howship-Romberg sign
- Urgency and approach in obturator hernia
- The lower midline transperitoneal approach
- Completing the transperitoneal repair
- The midline extraperitoneal approach
- Thigh approach to the obturator hernia
- Results after obturator hernia repair
- Perineal hernia defined
- Causes of perineal hernia
- Anatomy of the pelvic outlet
- Anterior and posterior perineal hernia defects
- Anterior and posterior perineal hernia
- Clinical features of perineal hernia
- Repair of perineal hernia
- Repair after abdominoperineal resection
- Spigelian hernia and the semilunar line
- Where spigelian hernias occur
- Sites of spigelian hernia along the semilunar line
- Interparietal course of the spigelian hernia
- Types of spigelian hernia
- Clinical features and imaging of spigelian hernia
- Repair of spigelian hernia
- The superior and inferior lumbar triangles
- Causes and presentation of lumbar hernia
- Repair of lumbar hernia
- Mesh and minimally invasive repair of lumbar hernia
- The greater and lesser sciatic foramina
- Clinical features of sciatic hernia
- Repair of sciatic hernia
- The transgluteal approach
Incisional hernia
The commonest late complication of laparotomy
- Incisional hernia defined
- Incidence of incisional hernia
- Risk factors for incisional hernia
- Risk factors for incisional hernia
- Technical factors in wound closure
- Clinical features and assessment of incisional hernia
- Three classes of repair
- Randomised comparison of suture and mesh repair
- Primary suture repair
- Separation of components
- Separation of components of the abdominal wall
- Results of component separation
- Mesh repair of incisional hernia
- Variations of prosthetic mesh placement for incisional hernia
- Open mesh repair: technique
- Synthetic meshes for ventral hernia
- Biological meshes
- Properties and cross-linking of dermal grafts
- Laparoscopic repair: rationale and access
- Laparoscopic repair: inserting and fixing the mesh
- Recurrence after incisional hernia repair
- Seroma, drains, infection and laparoscopic complications
- Comparing open and laparoscopic incisional hernia repair
Key points and references
What to carry away, and the sources behind it
- Key points: anatomy and classification
- Key points: assessment and timing
- Key points: repair and its complications
- References
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- Maingot's Abdominal Operations, 12th Edition