S.02 Ep.01 Inguinal hernia surgeries: Brief history & Various types

Welcome to another episode of Surgery from Snazi Surgeon. Today, we're going deep into the world of Inglinal Hernia Repair. As surgeons, I mean, we all see these pretty frequently, right? - Yeah, yeah, for sure. - But have you ever stopped to think about all the different ways we've learned to fix them over the years? - It's pretty amazing when you think about it. - It really is. - How we've gone from just using tissue to now using mesh and even doing these minimally invasive techniques. - It's like a whole evolution of surgical approaches. - Absolutely. - I feel aimed at getting those recurrence rates as close to zero as possible. - Exactly. - So, to kick things off, let's go back to the basics. - Okay, sounds good. - Way back to the late 1800s, with that foundational open tissue repair, the Bessini. - Ah, Bessini, the classic. - But they're 1887, to be exact. - The one that started it all. - It's all about approximating the conjoined tendon, right? - Right, bringing that internal oblique and transverse abdominis together. - Up to the Inglinal ligament. - Using those interrupted silk sutures. - Seems simple enough in theory. - It is in a way. - But you know what's interesting? - What's that? - Even back then, there were variations. - Oh, there are always variations. - Some surgeons were all about opening up the fascia transversalus. - To get a really good, tight approximation. - While others thought it was better to leave it alone. - It's fascinating how even the early techniques had different schools of thought. - It shows that surgeons have always been looking for ways to improve even back then. - Absolutely. - And then, of course, we can't forget about Tanner's slide. - Uh, yes, Tanner's slide. - That clever little trick to help with tension. - A simple, but effective way to reduce strain on the repair. - For those who might not remember. - It's basically a vertical or sometimes curvilinear incision. - In the anterior rectus sheath. - And it's all about releasing that rectus muscle. - So that the conjoined muscles can relax and slide immediately. - Exactly. - Or leaving the pull on that suture line. - It's like giving those muscles a bit of breathing room. - It was pretty ingenious for its time. - It was. - Though we don't really use it that much anymore. - Not really. - It's more of a historical curiosity now. - A reminder of how we used to approach the problem. - Speaking of history, the next big step was Shuldus in 1945. - Ah, Shuldus, the master of the layered closure. - That was a game changer. - It really was. - It's known for its meticulous four-layer, continuous wire suture technique. - Continuous wire, can you imagine? - It sounds incredibly precise. - It is, it takes a lot of skill and practice to master it. - So let's break it down. - Sure. - What are the key steps in a Shuldus repair? - Okay, so first, you start by dividing the fascia transfer cellus longitudinally. - Okay, cut it. - Then you suture the lower edge of that divided fascia to the deep surface of the upper flap. - Using a continuous wire. - Right, that's the first layer. - Wow, that's already pretty intricate. - And that's just the beginning. - What comes next? - The second layer involves bringing the upper edge of the transfer cellus fascia down to the inguinal ligament. - Okay, so we've got two layers down. - Two down, two to go. - Bring on layer three. - The third layer brings the conjoint tendon down to the inguinal ligament. - So we're basically reinforcing that whole area. - Precisely. - And finally. - Finally, we close the external oblique uponerosis. - Four distinct layers, all with continuous wire. - It's a beautiful thing when it's done well. - It sounds like it takes a lot of practice. - Oh, absolutely. - Surgeons have to go through a whole apprenticeship to master it. - It's not something you learn overnight. - But the results speed for themselves. - That they do. - Recurrence rates of just one to two percent. - Which is incredibly low even compared to some of the newer techniques. - It proves that a well-done tissue repair can still hold its own. - Absolutely. - Now let's move on to the McVey repair. Also notice the Cooper's ligament repair. - Another classic technique. - What sets it apart? - The McVey is all about addressing the femoral canal. So it's not just about reinforcing the inguinal ligament. - Right. - It's specifically designed to strengthen that area where femoral hernia is occur. - Exactly. - And how does it achieve that? - By suturing the conjoint tendon directly to Cooper's ligament. - Ah, I see. - This direct attachment provides extra support to prevent those femoral hernias from popping through. - It's like a targeted reinforcement. - Exactly. - But like with some basini modification, sometimes you need a little extra help to reduce tension. - You're talking about a relaxing incision in the rectus sheath. - Exactly. - It's a common addition, especially when dealing with larger hernias. - It allows for a more tension-free repair. - Which is always the goal, no matter the technique. - Now, things took a dramatic turn with the introduction of mesh. - Ah, yes, the mesh revolution. - Selected Stein in 1984 really changed the game. - It was a complete paradigm shift. - Moving away from relying solely on tissue. - And embracing the concept of attention-free repair. - It must have been a big deal at the time. - It was. It was a major advance in hernias surgery. - So what's the basic idea behind the Lichtenstein technique? - Well, it involves using a polypropylene mesh. - Polypropylene, that's the key, right? - It's strong, durable, and the body tolerates it well. - And they typically use a piece that's about seven and a half by 15 centimeters. - With a special little slit in it. - For this dramatic chord. - Right, we don't want to be compressing that. - And this mesh essentially acts as a reinforcement patch for the posterior wall. - Exactly, it takes the strain off the tissues, preventing that tension that can lead to recurrence. - And it's secured in a very specific way, right? - It is, it's all about those fixation points. - Tell me about those. - Okay, so the mesh is fixed immediately to the rectus sheath. - Got it. - Inferiorally to the inguinal ligament. - Okay. - And superiorly to the conjoined tendon. - So it's firmly anchored in place. - Nice and secure, providing that broad support to the weakened area. - And the results have been pretty impressive, haven't they? - They have, recurrence rates with lictinstein are less than 1%. - That's remarkable. - It's why it's considered the gold standard for open inguinal hernia repair. - It's the workhorse for a lot of surgeons. - Well, a good reason. - Now, following lictinstein, we had the development of plug and patch techniques. - Another step in the evolution. - How do they differ from lictinstein? - Well, the plug and patch was designed to tackle smaller defects. - So it's like a more focused approach. - Feed away, yes. - And how does it work? - The idea is to use a mesh plug to actually occlude the hernia defect from within. - So you're plugging the hole, so to speak? - Exactly. - And then the patch part. - The patch is an onlay piece of mesh that provides additional reinforcement around the plug. - So it's like a double layer of protection. - That's a good way to put it. - And initially they used cone-shaped plugs, right? But there's been a shift towards using flatter mesh configurations for the plug. - Why is that? - Well, there were concerns that those cone-shaped plugs could sometimes migrate or cause problems. - So the flatter plugs are less likely to move around? - That's the thinking. - Makes sense. - Now, let's talk about open pre-paratoneal approaches. - Pre-paratoneal, that means we're going behind the abdominal muscles, right? - Exactly. We're accessing the space behind the peritoneal. - Where the hernia is actually occurring. - Right. - And there are a couple of key techniques here. - There are. The stop-a and the rives are the main ones. - Let's start with stop-a, also known as GPR-VS. - Giant prosthetic reinforcement of the visceral sack. - That sounds pretty intense. - It is. It's typically reserved for those really challenging cases. - The big, complex hernia is the ones that have come back after previous repairs. - It's a fact. - So what's the key to stop-a? - It's all about the mesh, the sheer size of it. - How big are we talking? - 20 by 30 centimeters. - That's huge. - It needs to be, it's designed to cover the entire myopectinial orifice. - So it's like a giant shield. - A big, strong barrier to prevent any further hernias. - Now, what about rives? How is it different? - Rives is also a pre-paritonial approach. - But instead of that giant mesh covering everything. - Rives focuses on placing the mesh behind the rectus abdominis muscle. - So it's more targeted. - Win away, yes. - And the goal is still attention-free repair. - Always. - Just in a different anatomical plane. - That's right. - Now let's move on to the minimally invasive revolution. - Lapper scopic herniar repair, a whole new way of thinking. - It's become so common now. - It's hard to imagine going back to the days before it. - So let's start with TAPP, the trans-abdominal pre-paritonial approach. - One of the most popular techniques. - How does it work? - Well, we access the pre-paritonial space through the abdominal cavity. - So we go through the belly to get behind the abdominal wall. - Exactly, we create a paritonial entry, develop a flap, place the mesh, and then close the paritonium back up. - It sounds straightforward enough. - It is imprincible, but it does require a good understanding of the laparoscopic anatomy. - And there's always the risk of damaging something inside the abdomen, right? - That's always a concern. Anytime you're working inside the paritonial cavity. - Now what about TAPP, the totally extra paritonial approach? - TAPPT, that's the one where we stay completely outside the paritonium. - Avoiding the abdominal cavity altogether. - Exactly, no risk of ball injuries or adhesions. - But I hear it's a lot more technically challenging. - It can be, it definitely has a steeper learning curve. - How many cases do you think it takes to really master TAPP? - Some say 50, some say a hundred. It really depends on the surgeon and their experience. - So what makes it so challenging? - Well, it involves creating a working space in the space of retzius. - Which is the space between the pubic bone and the bladder. - Right. - And how do you create that space? - Through meticulous balloon dissection. - So you're basically inflating a balloon to create a space to work in? - That's the idea. - So it's pretty delicate. - It is, it requires a lot of precision and patience. - And once you've created the space. - Then we can place the mesh. - And they often use self-expanding meshes for TAPI, right? - They do, they're easier to position in that confined space. - So with TAPI, it's a trade-off, right? - It is. - Less risk of abdominal complications. - But a more technically demanding procedure. - And a longer learning curve. - That's the balance. - Now, where does robotic assisted hernia repair fit into all of this? - Robotics is a fascinating and evolving area in hernia surgery. - It seems like it's gaining popularity. - It is, but there's still a lot of debate about its true value. - In terms of outcomes, how does compared to laparoscopic repair? - The current evidence suggests that they're pretty much the same. - So similar recurrence rates, similar complication rates. - Well, that's what the studies are showing. - So what's the appeal of robotics then? - Well, the proponents argue that it offers enhanced dexterity and visualization. Because of those robotic arms in the 3D camera system? - Exactly. - So it can potentially make surgery easier for the surgeon. - Especially in those complex cases where the anatomy is distorted. - But the big elephant in the ring is the cost, right? - Absolutely. Robotics surgery is significantly more expensive. - How much more are we talking? - It can be anywhere from $3,000 to $5,000 more per case. - That's a big difference. - It is, and that's a major factor that hospitals and surgeons have to consider. - So the question is, do those ergonomic and visualization benefits justify the extra cost? - That's the million dollar question. - And it's one that we don't have a clear answer to yet. - More research is needed. - Now, let's shift gears a bit and talk about some special circumstances. - Okay, sounds good. - Like pediatric hernia repairs. - Kids are a whole different ball game. - How so? - Well, in children, we typically only do a herniautomy. We just like eat the hernia sack at the internal ring. - And no mesh, no big reconstruction. - Nope, kids usually have strong abdominal muscles so they don't need all that extra reinforcement. - It's much less invasive. - Much less, it's usually a quick and straightforward procedure. - Now, on the other end of the spectrum, what about giant hernias? - Giant hernias, those can be quite the challenge. - They can be massive. - They can be, and they often involve a lot of redundant skin and tissue. - So how do you approach those? - Well, sometimes we need to use component separation techniques. - component separation, what's that? - It's basically a way to mobilize more tissue to help close that huge abdominal wall defect. - So you're creating more space to work with? - Exactly. - And a common component separation technique is external oblique release, right? - Right, that's where we divide the external oblique muscle to gain more laxity. - And often they'll combine that with a panic electomy. - Oh, yes, especially if there's a large panacems that hanging abdominal fat. - So you're removing that excess tissue to improve the contour. - And to make the repair more durable. - Looks like a two for one. - Now, what about emergencies? - Emergencies like an incarcerated or strangulated hernia? - Those are always high stakes. - Absolutely, time is of the essence in those cases. - So how does your approach change in an emergency setting? - Well, the first priority is always to assess the viability of the bowel. - Because if it's strangulated, it could be dead. - Exactly. - And if it is, then we need to do a bowel resection. - Remove the dead portion. - Right, and then repair the hernia. - And in those cases, they often use biologic mesh, right? - They do, especially if there's any concern about contamination. - Because biologic mesh is less likely to get infected. - That's the thinking. - It's like a safer option in a high-risk situation. - Exactly. - Finally, let's touch on some of the emerging technologies in hernia repair. - The field is always advancing. - What are some of the exciting new developments? - Well, there's a lot of interest in self-gripping meshes. - Self-gripping meaning? - They have these little micro hooks that grab onto the tissue. - So you don't need to use tags or sutures to fix them in place? - Right, less need for fixation, potentially less pain for the patient. - Sounds promising. - It is, but long-term data is still needed. - And what about lightweight meshes? I've heard some buzz about those. - Lightweight meshes, they're designed to reduce that foreign body sensation that some patients experience. - Because they're thinner and more flexible. - Exactly. - So less bulk, less discomfort. - That's the hope. - And then there's robotics, which we talked about earlier. - Robotics is constantly evolving. - What's the next big thing in robotic hernia repair? - Single-port robotics. - Meaning? - All the instruments and the camera go through a single incision in the belly button. - So even less invasive than current robotic techniques? - Theoretically yes. - It's like science fiction becoming reality. - It is, but single-port robotics is still in its early stages. - So it'll be a while before we see it widely adopted? - Probably. - Well it's been an incredible journey through the world of inguinal hernia repair. - It has, we've covered a lot of ground. - From the early days of tissue repairs to the modern era of mesh and minimally invasive surgery? - It's a testament to the ingenuity of surgeons. - Always striving to improve outcomes for our patients. - Absolutely. - So as we've seen, there's no one size fits all approach to inguinal hernia repair. - Each technique has its own strengths and weaknesses. And the best choice depends on a variety of factors. - The patient's anatomy, their medical history, the surgeon's experience. - It's about making informed decisions based on the best available evidence. - And always keeping the patient's best interest set heart. - Thank you for listening to our podcast. See you in the next episode.