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Traditional Hernia Repair. Basic Format Herniorrhapy. Objectives. Assess the anatomy, physiology, and pathophysiology of the abdomenal wall. Analyze the diagnostic and surgical interventions for a patient undergoing a herniorrhapy.

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traditional hernia repair

Traditional Hernia Repair

Basic Format

Herniorrhapy

objectives
Objectives
  • Assess the anatomy, physiology, and pathophysiology of the abdomenal wall.
  • Analyze the diagnostic and surgical interventions for a patient undergoing a herniorrhapy.
  • Plan the intraoperative course for a patient undergoing inguinal herniorrhapy.
  • Assemble supplies, equipment, and instrumentation needed for the procedure.
objectives3
Objectives
  • Choose the appropriate patient position
  • Identify the incision used for the procedure
  • Analyze the procedural steps for inguinal herniorrhaphy.
  • Describe the care of the specimen
  • Discuss the postoperative considerations for a patient undergoing pt w/inguinal herniorrhaphy.
terms and definitions
Terms and Definitions
  • Hernioplasty or herniorrhaphy
  • Hesselbach’s Triangle
  • Transversalis fascia
  • Reducible hernia
  • Incarcerated hernia
  • Strangulated hernia
definition purpose of procedure
Definition/Purpose of Procedure
  • Definition
    • A sac lined by peritoneum that protrudes thru a defect n the layers of the abdominal wall; congenital, acquired, traumatic; generally covered by tissues, a peritoneal sac, and any contained viscera
  • Purpose
    • To repair the defect and strengthen the supporting structures
relevant a p tissue layers
Relevant A & P: Tissue Layers
  • (STST p. 404 descending order)
    • Skin and subcutaneous
    • Scarpa’s fascia
    • Innominate fascia
    • Interparietal fascia
    • Internal oblique muscle
    • Transverse abdominal muscle
    • Transverse fascia
    • Cooper’s ligament
    • Rectus Abdominis muscle
    • Peritoneum
relevant a p other structures
Relevant A & P: Other structures
  • Superficial & inferior epigastric muscles
  • Iliofemoral vessels
  • Spermatic cord and blood supply
  • Ilioinguinal nerve
  • Lacunar ligament
  • Inguinal ligament (Poupart)
  • Conjoined ligament (Falx inguinalis)
  • Cremaster muscle & fascia
  • Hesselbach’s Triangle
  • Femoral canal
  • Iliopubic tract
pathophysiology
Pathophysiology
  • Protrusion of an organ or part of an organ through a defect in the supporting structures which normally contain it
  • Transverse fascia is the man focus of groin herniation and separates the abdominal musculature from the preperitoneal fat. It is a continuation of the fascia completely containing the abdominal cavity and is inherently weak in the area of Cooper’s Ligament and the iliopubic tract, lending to inguinal herniation.
what is a direct hernia
What is a Direct Hernia?
  • Direct
    • Acquired weaknesses in transversalis fascia
    • Location: Hesselbach’s triangle
    • Causes
    • Emerge between the deep epigastric artery and rectus abdominus muscle and protrude into the inguinal canal but not into the spermatic cord
    • More difficult to repair
    • Men
what is an indirect hernia
What is an Indirect Hernia?
  • Congenital or acquired weaknesses in transversalis fascia
  • Location: lateral to deep epigastric vessels
  • Protrude through inguinal ring and pass with the spermatic cord structures down the inguinal canal; may descend into the scrotum
  • Men
diagnostics
Diagnostics
  • Exams: asked to stand and cough during physical exam: can see outpouched area; fingertip palpation –can feel edges of external ring and or abd wall. Pt most likely will have pain; may be described as burning. Compare both sides for protrusions.
  • Preoperative Testing: Routine CBC, ECG or chest as applicable; can employ CT, herniography, & std radiography if dx not confirmed
surgical intervention special considerations
Surgical Intervention:Special Considerations
  • Patient Factors
    • Possibly in pain
  • Room Set-up : Routine
surgical intervention anesthesia
Surgical Intervention: Anesthesia
  • Method: Various: General, Spinal, Epidural, Regional w/sedation, Local
    • *Surgeon may ask for pt to cooperate by coughing or bearing down
  • Equipment
surgical intervention positioning
Surgical Intervention: Positioning
  • Position during procedure
    • Supine w/arm boards
  • Supplies and equipment
  • Special considerations: high risk areas
surgical intervention skin prep
Surgical Intervention: Skin Prep
  • Method of hair removal—at least on side of hernia down to groin—ask
  • Anatomic perimeters—table side to table side; upper abdomen to mid thigh
  • Solution options—Routine (Betadine vs Hibclens)
surgical intervention draping incision
Surgical Intervention: Draping/Incision
  • Types of drapes: Lap Sheet
  • Order of draping: 4 towels & sheet
  • Special considerations
  • State/Describe incision: Anterior Groin/oblique inguinal incision
surgical intervention supplies
Surgical Intervention: Supplies
  • General
    • Lap pack, gowns, raytex, disposamag
  • Specific
    • Suture: Various (Mayo and Ferguson taper type needles)
      • After the hernia repair, finer sutures will be used for other layers of tissue
      • Examples: 3-0 silk ties, 2-0 silk SH (GI), 3-0 silk, 0 silk (GI needle); 3-0 vicryl ; Other possible: 2-0 Prolene SH, 0 Ethibond, 4-0 Vicryl undyed
      • For mesh: 0 Prolene CT-1 or CT-2
    • Kittners
    • Blades: # 10 x 2
    • 35 R stapler (hold)
surgical intervention supplies cont d
Surgical Intervention: Supplies cont’d
  • Medications on field (name & purpose)
    • For local: Example: Xylocaine .5% w/Marcaine .25% w/epi
    • 20 cc syringe, 25 g needle, possibly 22 g spinal needle
  • Catheters & Drains: A ½ in penrose drain is used to retract spermatic cord structures
surgical intervention instruments
Surgical Intervention: Instruments
  • General
    • Minor set
  • Specific
    • A hemostat is placed on the penrose drain before passing to the surgeon
    • Med debakeys
    • Med rt angles
    • Gelpies x 2
surgical intervention equipment
Surgical Intervention: Equipment
  • General: Standard
  • Specific
procedure highlights
Procedure Highlights
  • 1. Layers of the abdominal wall are incised
  • 2. The spermatic cord is identified & dissected free
  • 3. The hernia sac is identified
  • 4. The sac is ligated and removed.
  • 5. Layers of the wound are closed individually.
surgical intervention procedure steps
Surgical Intervention: Procedure Steps
  • After prep, pt is draped with groin area exposed on affected side
  • Incision is made over hernia site and electrocautery used for hemostasis
  • Surgeon incises fascia lying over the spermatic cord and retracts w/several hemostats on the edge of the incised fascia
  • Surgeon identifies spermatic cord and separates it from the surrounding tissue
  • STSR mounts moistened Penrose drain on a med clamp & passes it to the surgeon, who passes it around the spermatic cord for retraction
surgical intervention procedure steps cont d
Surgical Intervention: Procedure Steps Cont’d
  • Dissection continues until hernia is located
  • Hernia repair
    • Direct
      • Surgeon sutures transversalis fascial defect using heavy interrupted sutures as STSR initiates first closing count
      • Surgeon closes external oblique fascia as SRST initiates second closing count
surgical intervention procedure steps cont d29
Surgical Intervention: Procedure Steps Cont’d
  • Hernia repair
    • Indirect
      • Surgeon dissects sac away from the spermatic cord using Metzenbaum scissors
      • The sac is opened & edges grasped with hemostats
      • Surgeon pushes contents of sac back toward the abdomen w/ a finger or a small sponge on instrument
surgical intervention procedure steps cont d30
Surgical Intervention: Procedure Steps Cont’d
  • Surgeon ligates small sac, uses purse-string suture, or oversews to close large sac as STSR initiates first closing count
  • Surgeon sutures transversalis fascial defect using heavy (0, 2-0) interrupted sutures as STSR initiates second closing count.
classic procedures
Classic Procedures
  • Marcy repair
    • Closure of inguinal ring
  • Bassini or Bassini-Shouldice Repair
    • A new inguinal canal is made by uniting the edge of the internal oblique muscle to the inguinal ligament
  • McVay/Lotheissen
    • The transverse abdominis muscle & its associated fasciae (transverse layer) are sutured to the pectineal ligament (Cooper’s ligament repair)
summary for hernias
Summary for Hernias
  • Dissection: Identify the structures
  • Repair : Reduce the hernia; Repair the defect
  • Closure
counts
Counts
  • Initial
  • First closing
  • Final closing
    • Sponges
    • Sharps
    • Instruments

The peritoneal cavity may be entered when the hernia sac is opened—Counts must be done!

dressing
Dressing
  • Types & sizes
    • 2x2 or 4x4, ½ in steri strips, Small Tegaderm
  • Type of tape or method of securing
    • May use Mastisol or Benzoin
specimen care
Specimen & Care
  • Identified as Peritoneal hernia sac (Indirect)
  • Handled: Routine in formalin fixative
postoperative care
Postoperative Care
  • Destination
    • PACU
  • Expected prognosis (Good)
postoperative care37
Postoperative Care
  • Potential complications
    • Hemorrhage
    • Infection
    • Other: Damage to…neural and vascular structures
    • Recurrence
    • Ischemic orchitis & testicular atrophy
    • Loss of bowel function
  • Surgical wound classification: 1
resources
Resources
  • Alexanders: pp. 433-439
  • Berry & Kohn pp. 668
  • Lemone and Burke Ch 24, pp. 677-679
  • MAVCC Unit 3 pp. 45-81
  • STST Ch 14 pp. 405-407