An up to date review of international guidelines (2017) on which hernia repair: Open or Laparoscopic? Including operative photos and explanatory diagrams. Includes the author (Al-Gailani) technique of "Overlap" to reduce chance of recurrence in TAPP inguinal hernia repair. Finally take home recommendations for inguinal and ventral hernia repair. (A CME lecture in Al Hammadi Hospital, Suwaidi, Riyadh, KSA by Dr. Mohamad Al-Gailani FRCS consultant surgeon).

1. DR. MOHAMAD AL-GAILANI FRCS ‫د‬.‫الكيالني‬ ‫محمد‬
Consultant Surgeon ‫استشاري‬ ‫جراح‬
KSA ‫السعودية‬ ‫العربية‬ ‫المملكة‬
TEL: 00966 11 4250000
WWW.ALHAMMADIHOSPITAL.COM

2. OUTLINE




DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 2

3. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 3

4. HERNIA
DEFINITION
• Hippocrates used the Greek “hernios” for
bud or bulge to describe abdominal hernias.
• A hernia is protrusion of an organ or part of
it through the wall of the cavity in which it is
normally contained.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 4

5. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 5
Epigastric
Umbilical
Incisional
Direct inguinal
Indirect inguinal
Femoral
HERNIA
TYPES
Spigelian
Lumbar
Obturator
75% of all abdominal wall hernias occur in the Groin.

6. HERNIA
PREVALENCE & COMPLICATIONS



DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 6

7. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 7
COMPLICATED HERNIA
GANGRENE SMALL BOWEL

8. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬
5. Internal Oblique
Aponeurosis
6. Transversalis Fascia
7. Cremasteric Fascia
8. Pubic Tubercle
GROIN ANATOMY
1. Inguinal ligament
2. Muscular part of
Transversus
Abdominis
3. Transversus
Abdominis
Aponeurosis
4. Muscular part of
Internal Oblique
8

9. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 9
Inguinal ligament
Spermatic cord
Site for a femoral
hernia
Site for an indirect
inguinal hernia

10. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬
10
Left
Femoral
herniaRight
Direct
Inguinal
/Femoral?
hernia
Open or
Laparoscopic?

11. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 11
RIGHT INGUINO-
SCROTAL HERNIA
Open or
Laparoscopic?

12. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 12
0PEN OR
LAPAROSCOPIC?
VENTRAL-INCISIONAL
HERNIA

13. HERNIA REPAIR MILESTONES

14. 1. OPEN REPAIR:
Bassini
Italy
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 14
Eduardo Bassini

15. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 15
2. TENSION FREE MESH REPAIR:
Irving L. Lichtenstein
(1920-1980) USA
Irving L.
Lichtenstein

16. 3. LAPAROSCOPIC REPAIR (1989)
Bogojavlensky
USA

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 16
Sergei
Bogojavlensk
y

17. THE “DAM” EFFECT PRINCIPLE
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 17
Open
Laparoscopic

18. LAPAROSCOPIC HERNIA REPAIR TYPES:
• Inguinal:
(TAPP)
• Inguinal: (TEP)
• (IPOM)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 18

19. VENTRAL (INCISIONAL) OPEN HERNIA
REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 19

20. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 20
ANATOMY OF THE ANT. ABDOMINAL WALL
AS SEEN IN LAPAROSCOPY
MEDIAL UMBILICAL
LIGAMENT
LATERAL
UMBILICAL
LIGAMENT
DIRECT INGUINAL
HERNIA
INDIRECT INGUINAL
HERNIA

21. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬
21
FEMORAL
DIRECT INGUINAL
INDIRECT INGUINAL
MESH
LAPAROSCOPIC INGUINAL HERNIA REPAIR ANATOMY

22. RIGHT INDIRECT INGUINAL HERNIA
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 22
Lateral Umbilical
Ligament
Right Indirect
inguinal hernia
MEDIAL
UMBILICAL
LIGAMENT

23. DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 23
INGUINAL HERNIA
RECURRENCE
FOLLOWING (TAPP) REPAIRELEVATED LOWER
BORDER OF MESH
RECURRENT
HERNIA

24. Author’s Modification (Al-Gailani)
“OVERLAP”
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 24
Right Spermatic
Cord
OVERLAP
Spermatic Cord by
mesh

25. VIDEO 1:
LAPAROSCOPIC (TAPP) (R) INGUINAL HERNIA REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 25

26. PARA UMBILICAL HERNIA
(PUH)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 26
Greater Omentum
herniated

27. PUH
RELEASE OF HERNIA CONTAINTS
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 27

28. PUH
MESH FIXATION
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 28

29. PUH
Mesh In Situ
Repair Completed
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 29

30. VIDEO 2:
LAPAROSCOPIC (PUH) REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 30

31. INCISIONAL HERNIA REPAIR
following
Kocher Incision (Open Cholecystectomy)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 31
Omental Adhesions
to Incisional Hernia

32. INCISIONAL HERNIA
RELEASE OF ADHESIONS
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 32

33. INCISIONAL HERNIA
Adhesolysis Completed
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 33
Old nylon suture of
previous Kocher
incision closure

34. INCISIONAL HERNIA
Mesh Fixation with “Protac”
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 34

35. Recommended Mesh Overlap
(5 cm)
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 35
OVERLAP 5CM (ALL
AROUND)
DEFECT
OVERLAP 5CM (ALL
AROUND)

36. VIDEO 3:
LAPAROSCOPIC INCISIONAL HERNIA REPAIR
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 36

37. HERNIA REPAIR GUIDELINES

38. 2001
NATIONAL INSTITUTE CLINICAL EXCELLENCE (NICE)
HERNIA REPAIR GUIDELINES
• 4.1%
•
•
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 38

39. 2004
NICE GUIDELINES
1.
2.
3.
4.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 39

40. 2004
NICE GUIDELINES



DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 40

41. 2008
ETHICON: U.K Hernia Repairs
• 15-20%
(4.1% 2001)
• 20%
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 41

42. 2013
ASSOCIATION of SURGEONS GB & IRELAND (ASGBI)
INDICATIONS
LAPAROSCOPIC

Chronic Pain
 Women
(may be Femoral?)
OPEN (L.A)
Older
 Co-
morbidity
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 42

43. 2013
ASGBI
Recurrent Inguinal Hernia:
• Open
Laparoscopic
• Laparoscopic
Open
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 43

44. 2016
SOCIETY AMERICAN GASTROINTESTINAL ENDOSCOPIC
SURGEONS (SAGES)
VENTRAL HERNIA
Laparoscopic V Open Repair:
•
•
•
1.
2.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 44

45. 2016
SAGES
(LAP) CLOSURE OF HERNIA DEFECT
•
•
• discretion
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 45

46. 2016
SAGES
SEROMA POST OPERATIVE (LAP)
• Common and should be anticipated!
• Reduced by:
1.
2.
3.
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 46

47. COMPLICATIONS
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 47

48. LAPAROSCOPIC HERNIA REPAIR
COMPLICATIONS
•
•
•
•
•
•
•
•
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 48
IMMEDIATE LATE

49. SUMMARY
LAPAROSCOPIC
HERNIA REPAIR




CHRONIC GROIN PAIN
COST
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 49

50. TAKE HOME MESSAGE

51. INGUINAL
Hernia Repair
LAPAROSCOPIC
Bilateral


Recurrent Open
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 51

52. INGUINAL
Hernia Repair
OPEN MESH
Unfit for GA
Recurrent Laparoscopic

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 52

53. VENTRAL
Hernia Repair
Open Mesh
Laparoscopic

DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 53

54. Customized Surgery…
DR. MOHAMAD AL-GAILANI 2017 WWW.ALHAMMADIHOSPITAL.COM KSA ‫د‬.‫الكيالني‬ ‫محمد‬ 54
Which Hernia
Repair?

55. CONSULTANT BREAST & GENERAL SURGEON
WWW.ALHAMMADIHOSPITAL.COM
TEL: 00966 11 4250000