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Brian Jacob, MD FACS

Brian Jacob, MD FACS

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Brian Jacob, MD FACS

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  1. Not your average inguinal hernia…some unique cases Brian Jacob, MD FACS Assistant Clinical Professor of Surgery Mount Sinai Medical Center Director of the Baricenter Laparoscopic Surgical Center of New York

  2. Remember Indications Patients just want their hernias fixed with minimal morbidity

  3. Unique Case Giant indirect recurrence after lap TEP

  4. Recurrence after lap TEP Open Lichtenstein Lap TEP Lap TAPP Lap IPOM All of the above

  5. Need to assure circumferential fixation and overlap

  6. Tough Recurrences Diagnostic laparoscopy can help in planning Come to the table with multiple plans (requires a variety of skills) Large recurrences after TEP can be done well with IPOM

  7. Unique Cases Giant Inguinal Scrotal

  8. Unique Cases Giant Inguinal Scrotal

  9. Risks associated with GIANT inguinal hernia repairs (informed consent) Respiratory (cardiopulmonary)

  10. Risks associated with GIANT inguinal hernia repairs (informed consent) Respiratory (cardiopulmonary) Enterotomy (early or late)

  11. Risks associated with GIANT inguinal hernia repairs (informed consent) • Respiratory (cardiopulmonary) • Enterotomy (early or late) • Cord injury • Ischemic orchitis – is an orchiectomy indicated?

  12. Risks associated with GIANT inguinal hernia repairs (informed consent) • Respiratory (cardiopulmonary) • Enterotomy (early or late) • Cord injury • Ischemic orchitis – is an orchiectomy indicated? • Urinary

  13. Risks associated with GIANT inguinal hernia repairs (informed consent) • Respiratory (cardiopulmonary) • Enterotomy (early or late) • Cord injury • Ischemic orchitis – is an orchiectomy indicated? • Urinary • Recurrence • Seroma / Hematoma • Infection • Pain

  14. Risks associated with GIANT inguinal hernia repairs (informed consent) • Respiratory (cardiopulmonary) • Enterotomy (early or late) • Cord injury • Ischemic orchitis – is an orchiectomy indicated? • Urinary • Recurrence • Seroma / Hematoma • Infection • Pain • Abdominal Compartment

  15. Preparation – don’t be a hero Pulmonary consult Cardiology consult GU consult Plastics consult SICU consult

  16. Techniques • Open Lichtenstein • With general anesthesia • With local anesthesia • With or without preoperative pneumoperitoneum • With or without simultaneous debulking • Laparoscopic Assisted

  17. Challenging surgical management of a giant inguinoscrotal hernia: report of a case Vasiliadis K, Knaebel HP, Djakovic N, Nyarangi-Dix J, Schmidt J, Büchler M. Surg Today. 2010 Jul;40(7):684-7. (Germany) • Giant inguinoscrotal hernia, which extended below the patient's knees • +/- Patient conditioning • +/- Preoperative pneumoperitoneum over 18 days • +/- Debulking the massive hernia contents • right hemicolectomy and transverse colectomy • Others have also reported omentectomy and tensor fasciae latae flap • Mehendal FV, Taams KO, Kingsnorth ANBr J Plast Surg. 2000 Sep;53(6):525 • repositioning of the small bowel into the abdominal cavity • resection of the giant hernia sac • plastic reconstruction of the penis and scrotal region. • Mesh Repair

  18. Complex inguinal hernia repairs Beitler JC, Gomes SM, Coelho AC, Manso JEHernia. 2009 Feb;13(1):61-6. • open procedure-Nyhus and Stoppa (95%) • Laparoscopic TAPP or TEP (5%) • 255 inguinal hernia repairs • “Progressive preoperative pneumoperitoneum for giant hernias was shown to be an important factor in accomplishing good intraoperative and immediate postoperative results”

  19. Pre-operative Pneumoperitoneum first introduced in 1940 port in the subcutaneous position (first described in 1996 by Naslund, Backman, Melcher of Sweden) air can be injected every few days insufflations performed until the patient complains of some mild discomfort can provide additional intraperitoneal space at time of definitive repair and can test the patient’s pulmonary reserves

  20. Preoperative progressive pneumoperitoneum for giant inguinal hernias Piskin T, Aydin C, Barut B, Dirican A, Kayaalp C. Ann Saudi Med. 2010 Jul-Aug;30(4):317-20, Turkey

  21. Outcomes of giant inguinoscrotal hernia repair with local lidocaine anesthesia Osifo O, Amusan TI. Saudi Med J. 2010 Jan;31(1):53-8. • 134 patients with 136 giant inguinoscrotal hernias were repaired open technique using lidocaine • 10 (7.5%) patients who had incarceration-required sedation, none needed general • Scrotal hematoma(13.5%) • Wound infection (4.5%) • No recurrence with 1-5 years follow-up

  22. Jacob case report from Feb 17 2012

  23. Discharged on POD 5

  24. Hernias to the knee: Summary • Plan ahead • Long discussion with patient and family • Forewarned is forearmed • Optimize patient • (smoking, exercise, respiratory) • Imaging (Ctscan) • Decide on anesthesia • Decide if LOD a factor, • if so consider PreopPneumo • Avoid resection of viscera if possible • Choose repair method • One you are most comfortable with • If you are in over your head, get help

  25. Thank you