1. Current trends in the management of hernias
Dr Jaja, P T
Surgical Resident,
Surgery Team F, BMSH
25/11/2016

2. Objectives
Introduce and review the definition of a hernia Review the Aetiopathogenesis of hernias Present the relevant anatomy Management options for hernias Trends in Hernia repair Materials Trends in Hernia repair Techniques Complications of current management Give a concluding statement

3. Introduction and Definition
Hernia: Greek ‘Hernios’; Bud or Shoot
Hernias; abnormal protrusion of viscera from their containing cavity.
Commonest indication for elective surgery (greater than 500,000 annually in the US).

4. Basic Aetiopathogenesis of hernias
Generally, a hernia occurs from either:
A defect or weakness in the cavity wall
Defects (dysgenetic or anatomical)
Weakness (ageing, frequent/multiple pregnancies, obesity, infection)
Persistently increased intra-cavitary pressure ( chronic cough, ascitis,)

6. Relevant Anatomy

10. Management options Dependent on Options Type of hernia
Size of hernia neck / Cavity wall defect
Stage of the hernia
General morbidity of patient
Availability of skills and materials
Options
Herniotomy
Herniorhaphy
Hernioplasty (mesh repair, component seperation)

11. Trends in Hernia repair materials
Primitive treatments
Reducible hernia: Bandages and Girdles
Strangulated hernia: Rest, cold water, purgation, diet
Trusses were noted in Egyptian sarcophaguses
Ancient Greeks used gold wire sutures and silver strand filigrees (as prosthesis)
Theodore Billroth; 1857 envisioned current practice with prostheses
Burke; 1940: Tantalum metal sheet prosthesis

12. Main materials PP, PTFE, ePTFE, POL, Vicryl, Dacron
Nylon; first plastic used as suture and later woven into nylon mesh (albeit, it lost strength over time, required explantation if infected)
Main materials PP, PTFE, ePTFE, POL, Vicryl, Dacron
Characteristics of proposed mesh in 1959
Non-metallic
Synthetic
Non-absorbable
Resistant to infection

13. Theoretical support for mesh repair
Identification of fascial weakness as being from collagen deficiency
Due to failure in hydroxylation of lysine and proline
Hence, Hernial defect reinforcement became the order of the day.

14. Mesh Weight: Heavy (100g/cm2)or Light weight(33g/cm2)
Pore size: For infiltration of Macrophages, Fibroblasts, Angiogenesis
Micro-porous allows bacteria but not macrophages
Pathophysiology
Suture Fixation
Inflammation with infiltration by macrophages and blood vessels
Mesh incorporation and/or degradation

17. Composite meshes These combine more than one material
Require specific orientation
Visceral: micro-porous to prevent adhesions
Non-visceral: macro-porous; permit tissue ingrowth
Three basic materials (PP, POL, ePTFE)

19. Bioprosthesis Uses Issues here include Hybrid meshes
Pedicled or free fascia (eg Fascia lata)
Decellularized grafts from human, porcine and bovine tissue; leaving just a collagen matrix.
Composition: Dermal, Pericardial or Submucosal
Processing: Stripping or Cross-linking
Uses
Grossly contaminated hernias
Burst abdomen
Issues here include
Biocompatibility
Immunogenic potential
Foreign body response (usually less)
Hybrid meshes

20. Trends in Hernia techniques
Prior rudimentary hernia repairs had been executed
19th Century breakthrough in Anaesthesia and Aspesis /Antisepsis (especially mid 19th century)
More robust surgeries were now done

21. Inguinal hernia repairs
Bassini; Posterior wall reinforcement
Halsted; Modified Bassini’s repair
Shouldice; 1940 Four layer suturing
Lichtenstein; 1989 Tension-free (anterior mesh)
Nyhus; Posterior-open-mesh
Davis & Arregui 2003 Laparoscopic repairs
TAPP (transabdominal preperitoneal repair)
TEP(total extraperitoneal repair)

22. Tension-free techniques
Halsted’s Tension free technique 1892
Tanner’s Slide (sliding part of rectus sheath lateral and downwards to inguinal ligament)
Kirschner’s pedicled or free fascia used for closure (inlay as described by Gallie)
Narath; 1896 used Silver Filigree
Moloney nylon darning
Usher; 1958 First Polypropylene mesh
Lichtenstein consolidated on this technique

23. Ramirez et al; 1990 Component separation

25. Complications of current management
Laparoscopy : GA
Longer surgery duration
Higher chance of intra-peritoneal tissue damage
Risk of post-operative adhesions
Mesh related:
Seroma formation
Granuloma formation
Mesh dislocation
Mesh infection
Mesh encapsulation (with stiff scar formation)
Loss of elasticity and shrinkage

26. Fate of a hernia Reducibility Obstruction Incarceration Strangulation
Visceral necrosis / Ischemia

27. Conclusion The Management of hernias has markedly evolved.
Availability of skills and materials is a considerable factor militating against the use of these novel techniques.
The novelity in the techniques have also not come without a price of novel complications.

28. Case I Mrs BI 63 years old multipara
10 year Hx of recurrent painful peri-umbilical swelling, initially intermittent, recently constant
Obese abdomen, 15cm panus in longest diameter, two anterior abd wall defects (8 and 2cm)
Diagnosis of Supraumbilical hernia
Had Mesh repair of Supraumbilical hernia

29. Case II Mrs AA 32 year old primipara
2 months Hx of recurrent painful peri-umbilical swelling,
Obese abdomen, 5cm panus in longest diameter, 2cm anterior abd wall defect just superior to umbilicus
Initial diagnosis : Supraumbilical hernia intraop. diagnosis: Paraumbilical hernia
Had Suture repair of supraumbilical hernia

30. Case III Mr DI esq. 42 year old Legal practitioner
5 years Hx of recurrent epigastric pain; with occasional self-limiting, hard, painful epigastric swelling
Obese abdomen, 4cm panus in longest diameter, 2cm anterior abd wall defect
Diagnosis: Epigastric hernia
Had Suture repair of Epigastric hernia

31. Case IV Mrs UI 50 year old post-menopausal, primipara
8/12 Hx of feacal matter draining from a left inguinal region wound.
Prior hx of left mid-inguinal swelling of 4/12 (drained pus and then feacal matter), intermittent lower abd pains
1x1cm left mid-inguinal sinus, draining feacal matter
Initial diagnosis : Enterocutaneous fistula ? cause intraop. diagnosis: Richter’s type left petit hernia
Had omental plugging of left petit hernia

32. Bibliography
FitzGerald, JF; Kumar, AS. Biologic versus Synthetic Mesh Reinforcement: What are the pros and cons? Clinics in Colon and Rectal Surgery. 2014; 27(4):
Heller, L; McNichols, CH; Ramirez, OM. Component Separations. Seminars in Plastic Surgery. 2012; 26(1): 25-28
Bilsel, Y; Abci I. The search for ideal hernia repair; mesh materials and types. International Journal of Surgery. 2012; 10:
Holzheimer, RG. Inguinal Hernia: Classification, Diagnosis and Treatment; Classic, Traumatic and Sportsman’s Hernia. European Journal of Medical Research. 2005; 10:
Hee, RV. History of Inguinal Hernia repair. Jurnalul de Chirurgie, Iaşi, 2011, Vol. 7, Nr. 3 [ISSN 1584 – 9341]