ETIOLOGY OF HERNIA & EVOLUTION OF HERNIA SURGERY

1. ETIOLOGY OF HERNIA & EVOLUTION OF HERNIA SURGERY Dr Sanjay De Bakshi MS;FRCS. Consultant Surgeon Examiner and Surgical Tutor; Royal College of Surgeons; Edinburgh. Tutor for DNB Genl. Surgery and G.I. Surgery; Calcutta Medical Research Institute.

2. THE ABDOMINAL WALL-COMES IN VARIOUS SHAPES AND SIZESSERVE VARIOUS FUNCTIONS

3. THE ABDOMINAL WALL-HATE IT-LOVE IT

4. YOU SIMPLY CANNOT –IGNORE IT!!!!

5. “HERNIA” But What is a Hernia?

6. THE HISTORY OF HERNIA SURGERY IS ALMOST AS OLD AS TIME ITSELF. Hippocrates used the Greek term – “hernios”for budorbulgeto describe abdominal hernias.

7. CLOSEST ANALOGY IS TO THE STATE OF AN MUCH USED OLD-STYLE FOOTBALL!!

8. Definition • An abnormal protrusion of the contents of a closed cavity through a potential or an abnormal opening.

9. Famous hernia patient Galileo Galilei (1564-1642) was incapacitated by an irreducible inguinal hernia in his later life.

10. First forays An illustration from Caspar Stromayr's Practica Copiosa(1559). The manuscript covered repair of hernias and hydroceles

11. Types of Abdominal Hernias • Inguinal. • Umbilical • Incisional • Epigastric • Femoral • Hiatus hernia

12. INCIDENCE OF DIFFERENT TYPES OF HERNIAS

13. CAUSE OF THE HIGH INCIDENCE OF INGUINAL HERNIA MOTION PATH OF THE GONADS:- FROM CONCEPTION TO BIRTH.

14. PROBLEM OF EVOLUTIONBorn from a need to “Run” food down on the plains of Africa AND IN DOING SO, THE HOMO ERECTUS DEVELOPED THE “NUCHAL RIDGE”OF FAST FOUR-LEGGED ANIMALS TO KEEP THE HEAD STEADY WHILE RUNNING.

15. PROBLEM OF EVOLUTIONBorn from a need to “Run” food down on the plains of Africa BUT ALSO PROBABLY OPENED UP AND WEAKENED THE GROIN.

16. PROBLEM OF EVOLUTIONBorn from a need to “Run” food down on the plains of Africa -THE “STRETCH” LEADING TO A WEAKNESS AT THE GROIN NOT ADEQUATELY COVERED BY MUSCLES OR LIGAMENTS CALLED- “THE MYOPECTINEAL ORIFICE”

17. First forays

18. TRUSS • PROBLEM OF BEING DANGEROUS AS IT SOMETIMES CAUSES PRESSURE AT THE NECK OF THE HERNIA CUTTING OFF THE BLOOD SUPPLY.

19. So I Have a Hernia.Why Should I Have Surgery?Operation ? • There is pressure at the neck of the sac which can cutoffthe blood supply causing strangulation.

20. Causes Of Increased Pressure

21. Causes of Weakness in the Covering Layers

22. Tissue Repair – Bassini Defect repaired by stitches Tension –Pain-Recurrence

23. PROBLEM OF STITCHINGA STRETCHABLE MATERIAL LIKE SOCKS IS THAT IT TEARS UNLESS “DARNED’

24. Darning with non- absorbable stitches • Good but entirely dependent on the “yarn” and the “darner”. • So, the “yarn” and the “darn” had to be “darn good”!!! Defect repaired by Darning

25. TO STANDARDISE “DARNING” • Lichtenstein devised a mesh made of polypropelene. • This effectively was a pre-prepared“darn”.

26. Tension Free – Lichtenstein • Pioneered in 1984. • Covering the defect of the hernia with a patch of mesh, instead of sewing the edges together • PAIN FREE repair • Return to full activities at the earliest

27. Lichtenstein Tension Free Single Flat Mesh Flat Mesh in a Single Anterior Layer of Protection

28. Lichtenstein Tension Free Single Flat Mesh • Ease of use. • Tension-free repair. • Dramatic reduction in the incidence of recurrence. • However, the mesh was situated above the defect. • Recurrence could occur between the mesh and the defect.

29. Concept of Posterior Repair It is far more difficult to break open a door againstthe direction it is opened It is far easier to do this inthe direction the door is opened

30. KICKING IN A DOOR!!!

31. Present Status of Inguinal Hernia Repair LICHTENSTEIN OVERLAY MESH LAPAROSCOPIC REPAIR GILBERT COMBINATION MESH

32. POSTERIOR SUPPORT-EitherLaparoscopy or by PHS Mesh1)ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW2) BASED ON SOUND APPLICATION OF PHYSICS

33. May be either through the general abdominal cavity or just outside the membranous covering. • Needs general anaesthesia. • Needs wide dissection and difficult to do for large irreducible hernias and where previous abdominal surgery has been carried out. • Needs intensive training. • Sometime difficult to fix lower edge of the mesh and this can lead to reccurence. • Sometimes complicated by nerve entrapment pain, bleeding. Repair by Laparoscopy Membranous covering

34. WIDE DISSECTION Therefore – Requires G.A.

35. DIIFICULT TO TEACH AND DANGEROUS ANATOMY TRIANGLE OF DOOM TRIANGLE OF PAIN CIRCLE OF DEATH

36. THEREFORE FIXATION OF THE MESH IS –AT BEST PARTIAL

37. THE MESH IS PRONE TO BEING “ROLLED UP”-LEADING TO RECC.

38. POSTERIOR SUPPORT-Either Laparoscopy or by PHS Mesh1)ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW2) BASED ON SOUND APPLICATION OF PHYSICSFOR THE DIRECT INGUINAL HERNIA

39. POSTERIOR SUPPORT-Either Laparoscopy or by PHS Mesh1)ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW2) BASED ON SOUND APPLICATION OF PHYSICSFOR THE INDIRECT INGUINAL HERNIA

40. Tension-Free Repairs - The PHS • Combines the three most common repairs (overlay, plug, underlay). • Can be done under local anaesthesia. • Non-Suture intensive. • Posterior support. Protects Femoral Canal from anterior approach. • Conforms to anatomy in posterior space. • To date, only few reported cases of recurrence !! • Is an open operation, though the incision is small. • Mesh is expensive. Defect repaired by PHS

41. ANTERIOR SUPPORT --------The mechanical analysis of a THRUST!!! THE THRUST MAY CAUSE A LOSS OF CONTACT BETWEEN THE “MESH” AND THE “HERNIAL GAP”

42. POSTERIOR SUPPORT-Either Laparoscopyor by PHS Mesh1) ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW 2)BASED ON SOUND APPLICATION OF PHYSICS TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT BETWEEN THE “MESH” AND THE “HERNIAL GAP”

43. POSTERIOR SUPPORT-Either Laparoscopy or by PHS Mesh1) ONLY WAY TO COVER ENTIRE ILEO- PECTINEAL WINDOW 2)BASED ON SOUND APPLICATION OF PHYSICS TO PREVENT THE THRUST CAUSING A LOSS OF CONTACT BETWEEN THE “MESH” AND THE “HERNIAL GAP”

44. PHS MESH REPAIR AN ANIMATION

45. 600+ PATIENTS IN EASTERN INDIAHAPPILY SAY YES!!