PHS 2006 complete

La Chirurgia dell’ Ernia Inguinale Con Protesi PHS®: 

La Chirurgia dell’ Ernia Inguinale Con Protesi PHS ® Corso di Aggiornamento “Security Patch” Firenze 6 Aprile 2006 Dr. Giorgio Vasquez Istituto di Chirurgia Generale Azienda Ospedaliera-Universitaria S. Anna di Ferrara Vsg@unife.it 0532 237150 Dipartimento di Scienze Chirurgiche, Anestesiologiche e Radiologiche Sezione di Chirurgia Generale (Direttore Prof. A. Liboni)

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Diretta: 

Ernia Inguinale Diretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

Ernia Inguinale Indiretta: 

Ernia Inguinale Indiretta

PHS® repair in femoral hernia surgery: 

PHS ® repair in femoral hernia surgery Giorgio Vasquez +39 0532 237150 +39 0532 236525 e-mail vsg@unife.it

PHS repair in femoral hernia surgery: 

Femoral hernia Represents 3-5% of all groin hernias Mikkelsen T. Br J Surg 2000; 89: 486 – 8 Diagnosis is quite difficult. Emergency surgery is required in about 40 % of cases with up to 30 % of bowelresection Sanchez-Bustos F. Eur J Surg 1998; 164:191-3 Mortality rate in emergency setting ranges from 3 % to 9 % Sanchez-Bustos F. Eur J Surg 1998; 164:191-3 - McGugan E. R Coll Surg Edinb 2000;45:183 -6 PHS repair in femoral hernia surgery

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery There are three open approaches to femoral hernia: Low (Lockwood - Bassini { 1885 } ) Inguinal (Lotheissen {1898} - McVay {1942} ) High (McEvedy { 1950 } - Nyhus {1960} )

Femoral Hernia – Low Approach (Lockwood – Bassini) 1) reduction of hernia stump 2) suture of the inguinal ligament to the Cooper’s ligament : 

Femoral Hernia – Low Approach ( Lockwood – Bassini) 1) reduction of hernia stump 2) suture of the inguinal ligament to the Cooper’s ligament Socin 1879 - Ruggi 1892 - Marcy 1892 Recurrence rate more than 5 % Hachisuka T. Surg Clin North Am 2003;83:1189-205 PHS repair in femoral hernia surgery The low approach (Lockwood - Bassini { 1885 } ), represents the oldest but quite easy surgical procedure. Unfortunately it doesn’t provide good results in terms of comfort & recurrences

PHS repair in femoral hernia surgery : 

PHS repair in femoral hernia surgery The femoral (low) approach has more recently become popular by Lichtenstein & Shore that in 1974 introduced the “tension free” femoral hernioplasty. Rutkow & Robbins in 1993 designed a preshaped plug that rapidly rose as preferred surgical device for prosthetic anterior repair of femoral hernias. Rutkow I M. Hernia 1998;2:73-5 – Sanchez-Bustos F. Eur J Surg 1998;164:191-3 – Hachisuka T. Surg Clin North Am 2003;83:1189-205 - Pikoulis E. World J Surg 2005;29:231-4

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery 1974 Lichtenstein IL, Shore JM - Hand rolled “cigarette” plug 1993 Rutkow IM, Robbins AW - “Perfix ® ” mesh plug hernioplasty

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery December 2000: a 55 years old woman with a large strangulated right femoral hernia was admitted at our Institution

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery Once opened the hernia sac, a small bowel necrotic loop was found

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery After bowel resection, closure and reduction of the peritoneal stump, the wall defect appeared too large for an usual mesh plug repair, so an underlay of a PHS ® device was placed deeply in the properitoneal space

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery The onlay component of the PHS ® was cut off and removed. The connector was fixed with four prolene ® 3-0 stitches (slow absorbable sutures in the last 16 repairs), to the lower edge of the inguinal ligament and to the pectineal fascia

PowerPoint Presentation: 

PHS repair in femoral hernia surgery Since then we used this technique in 20 more patients in emergency setting with 7 more small bowel resections

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery …….and in 23 elective procedures as well

PHS repair in femoral hernia surgery: 

I’d like to stress some procedure steps A right incarcerated femoral hernia without bowel obstruction in a 85 years old man is presented PHS repair in femoral hernia surgery 1) Wide incision of the inguinal ligament and true inner femoral ring is required. The hernia sac must be completely cleared for an easy handling 2) The preperitoneal space must be accurately dissected by inserting a gauze sponge that actualized the Bogros space 3) A PHS ® device is deeply introduced in preperitoneal space and the underlay is deployed with a finger 4) The connector device is secured to the inguinal and Cooper’s ligament and the onlay mesh is cut around the connector. The procedure will be completed placing one or two more stitches if needed

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery December 2000 – April 2005 44 patients (30 Females / 14 Males) Mean age: 67 years (range: 25 - 96 years) 21 emergency procedures (47.7%) (8 bowel resections – 38% ) 23 elective procedures Mean hospital stay: 3.2 days (range: 1- 8 days) Mean follow-up: 14 months (range: 1- 54 months)

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery Results Infection none Discomfort 1 case * Recurrence none Other complications 1 case ** * A 25 year old woman with mild/moderate cruralgia which required medications for more than 24 hours (elective surgery) ** A 70 year old man with a femoroiliac aneurism disruption occurred 48 hours later PHS repair (uncleared)

PHS repair in femoral hernia surgery: 

Femoral hernia is a low rate wall defect (3.1% in our series) , that can lead to an high rate of complications PHS ® technique can reduce complications PHS repair in femoral hernia surgery Conclusions

PHS repair in femoral hernia surgery: 

PHS repair in femoral hernia surgery PHS ® Technique Usual well known low anterior approach even in cases of acutely incarcerated and obstructed hernia (emergency and elective) Safe, effective, and simple technique with low rate of complications Provides a “tension-free” properitoneal repair Permits the reinforcement of the m yopectineal region (direct inguinal hernias prophylaxis) No risk of prosthesis migration No recurrences High postoperative comfort Conclusions

PowerPoint Presentation: 

Greetings from Ferrara Dipartimento di Scienze Chirurgiche, Anestesiologiche e Radiologiche Sezione di Chirurgia Generale (Direttore Prof. A. Liboni)