The Role Of Narrowing Of The Internal Ring In The Outcome Of Laparoscopic Treatment Of Indirect Inguinal Hernia.

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The Role Of Narrowing Of The Internal Ring In
The Outcome Of Laparoscopic Treatment Of Indirect
Inguinal Hernia.

• By
• Mohammed Saleh Al-dawbali
• MD (Egy.), MRCS (Eng.)
• Ass. Prof Of Surgery (Sana'a University)

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Introduction

• -- Hernia is a frequent disease in the community
  so that it produce a sizable part of many
  general surgeons practice.
• -- The success of laparoscopic cholecystectomy
  has resulted in the enthusiasm to modify other
  abdominal procedures so that they can be
  performed laparoscopically.
• -- laparoscopic Inguinal hernioplasty is one of
  such procedure.

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Introduction (cont.)

• Over the past 20 years, several hernia repair
  techniques have been introduced .The main cause
  for the development of these new techniques was
  to reduce the recurrence rate.
• The introduction of the Lichtenstein tension-free
  hernioplasty, which uses a mesh to reinforce the
  abdominal wall, has decreased recurrence rates
  greatly.
• However, certain types such as recurrent,
  bilateral hernias are particularly suited for a
  laparoscopic approach .
• Laparoscopic inguinal hernioplasty is associated
  with shorter recovery periods, earlier return to
  daily activities and work, and decreased
  postoperative pain.

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Indications

• Certain types of hernia such as
• - Recurrent,
• - Bilateral, are particularly suited for
  a laparoscopic approach .
• BUT also it can be done for primary unilateral
  hernias as first patient preference

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Approach

• Laparoscopic hernia repair can be done either
  through
• 1. Transabdominal Preperitoneal Approach (TAPP
  )or
• 2. Total Extra-peritoneal Approach (TEP).

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Aim Of The Work

• Our study aim to assess whether the addition of
  the closure of internal ring to the classical
  TAPP has a better short outcome on regard to post
  operative pain, bulging, seroma or haematoma
  formation and on the long term outcome in regard
  to recurrence .

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Patients And Methods

• - A total of 40 patients were selected from
  those presented to the Outpatient Clinic with
  indirect inguinal hernia from the period May 2009
  to April 2011

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Patients And Methods

• Exclusion criteria for patient selection were as
  follows-
• - younger than 12 years of age
• - severe obesity (BMI gt35).
• - associated medical problems that
  contraindicate safe induction of general
  anesthesia or elective surgery

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Patients And Methods

• The forty Patients were randomly divided into
  two groups , group A contain 20 patients and
  were treated by closure of the ring and
  classical TAPP ,while group B contain 20
  patients and was treated by Classical TAPP Only.

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Operation

• In the theater, neither nasogastric tube nor
  urinary catheter were needed (patient were
  instructed to evacuate their bladder before
  coming to the theater).

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Op. Technique (cont.)

• Insertion Of The Trocar (open tech.)
• Induction Of Pneumoperitoneum (14mmHg)
• abdominal cavity and viscera are inspected in a
  systematic order

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• Two working ports were further introduced at a
  level just caudal to the umbilicus and lateral to
  the rectus muscle of both right and left lower
  quadrants.
• N.B This array of trocars was used in either
  unilateral or bilateral cases.

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EXPLORATION
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Peritoneal incision (Right)
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Left peritoneal incision
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Right side dissection
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Left side dissection
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Ring closure
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Mesh fixation
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Peritoneal closure
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Results

• Patients characteristics
• The patients ages ranged from 25?55 years old
• The mean age was 33 years in Group A and 30 years
  in Group B
• All of our pt were male (no female)

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Distribution of Hernia site

• 24 cases (60) were right side , 6 cases ( 15)
  were left side and 10 cases (25 ) were bilateral
  .

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Average Operative Time
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Intra-Operative Complications

• Intra-operative complication occur in a single
  case (2.5 ) in the form of urinary bladder
  injury during reduction of the structure from a
  left hernia defect in a patient with bilateral
  hernia. The injury was recognized at the time
  of operation and dealing with it was done in the
  form of repair in two layer after putting of
  urinary catheter. The hernia repair was completed
  then as usual .The patient recover post
  operatively without further complication

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Post Operative Care.

• The patients were shifted from the operating
  theater to the surgical ward and were discharged
  in the next day (except when complications were
  suspected). In the surgical ward recording of the
  postoperative pain using the Visual analogue
  scale (VAS) was used .
• Patients were seen after 1 week , then after 1
  month and then after 6th months postoperatively
  and they were told to contact us if they face any
  problem regarding their hernia. During the follow
  up of these patients they were examined
  clinically to assess the post operative pain and
  to look for the presence of odema, seroma ,
  hematoma , wound infection ,post operative bulge,
  recurrence or any other complications.

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Hospital Stay

• -All patient of both group were ambulated in the
  same day of operation and discharged in the next
  day of the operation.
• -Only 1 case (2.5 ) who discharged in the 3rd
  POD.

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Follow up

• Postoperative pain . there was no significant
  difference between patients of both groups (P
  value lt 0.01) and the pain score was ranged from
  VAS 1 to VAS 3 (mild ) and in more than 90 of
  cases pain was overcomed with simple analgesics
  . The causes of pain seems to be multifactorial
  (dissection , fixation of the mesh, foreign body
  reactionetc)

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• Visual analogue scale (VAS)

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• - Seroma occur in two cases (10 ) of the second
  group and was treated conservatively . No
  seroma occur in pts of the first group

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• Post operative bulging was noted in 16 case (80
  ) of the second group and it last for a period
  of around two months postoperatively , while in
  the first group there were No bulging neither in
  the early nor in the late postoperative period.
  This make the patients of the first group more
  satisfy .

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• The follow-up period ranged from 1 to 1.5 year
  postoperatively ( average 1 year)
• The results of follow up show
• On clinical basis all patients of both
  groups were relived of the symptoms of hernia
• No recurrence have been reported in all cases of
  both group.

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Conclusion

• Laparoscopic surgery is becoming widely
  accepted as an alternative to conventional
  procedures. With-miniaturization of instrument it
  is becoming more and more evident that
  laparoscopic techniques can be applied safely and
  successfully to hernia patients. The selection
  criteria for patients who are eligible for
  laparoscopic procedures is dynamic and as skills
  and technologies improve fewer patients are found
  to have absolute exclusion criteria

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• Result show that Laparoscopic narrowing of the
  internal inguinal ring was found to be safe ,
  effective and low cost procedure for treatment
  of oblique inguinal hernia with better outcome
  regarding post operative serohematoma and
  postoperative bulging which are annoying
  problem to hernia patients .

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• However, the important Question is Whether the
  closure of the internal ring will be an
  auxiliary step in the classical TAPP procedures
  in the light of these substantial benefits as
  regard to less postoperative complications. More
  studies needed to answer this question but in our
  study narrowing of the internal ring with
  hernioplasty was simple, sufficient and
  effective .

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• Thank you !

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Numerical rating scale (NRS)
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• Faces rating scale (FRS)

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Pain rating scales instructions

• Subjective pain score
• All patients are to have a functional activity
  score recorded in addition to the chosen
  subjective score.
• Visual analogue scale (VAS)
• Instruct the patient to point to the position on
  the line between the faces to indicate how much
  pain they are currently feeling. The far left
  end indicates No pain and the far right end
  indicates Worst pain ever.
• Numerical rating scale (NRS)
• Instruct the patient to choose a number from 0 to
  10 that best describes their current pain. 0
  would mean No pain and 10 would mean Worst
  possible pain.
• Faces rating scale (FRS)
• Adults who have difficulty using the numbers on
  the visual/numerical rating scales can be
  assisted with the use of the six facial
  expressions suggesting various pain intensities.
  Ask the patient to choose the face that best
  describes how they feel. The far left face
  indicates No hurt and the far right face
  indicates Hurts worst. Document number below
  the face chosen.
• Behavioural rating scale
• The behavioural pain assessment scale is designed
  for use with non-verbal patients unable to
  provide self-reports of pain.
• Rate each of the five measurement categories (0,1
  or 2).
• Add these together.
• Document the total pain score out of 10.
• Functional activity score
• This is an activity-related score. Ask your
  patient to perform an activity related to their
  painful area (for example, deep breathe and cough
  for thoracic injury or move affected leg for
  lower limb pain).
• Observe your patient during the chosen activity
  and score A, B or C.
• A No limitation meaning the patients activity
  is unrestricted by pain
• B Mild limitation means the patients activity
  is mild to moderately restricted by pain
• C - Severe limitation means the patient ability
  to perform the activity is severely limited by
  pain