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Journal of Minimal Access Surgery, Vol. 2, No. 3, July-September, 2006, pp. 106-109 Symposium Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias Chowbey PradeepK, Khullar Rajesh, Mehrotra Magan, Sharma Anil, Soni Vandana, Baijal Manish Minimal Access and Bariatric Surgery Centre, Sir Ganga Ram Hospital, New Delhi - 110 060 Code Number:ma 06020 Abstract Background: Numerous classifications for groin and ventral hernias have been proposed over the past five to six decades. The old, simple classification of groin hernia in to direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias. The most commonly followed classification for ventral hernias divide them into congenital, acquired, incisional and traumatic, which also does not convey any information regarding the predicted level of difficulty.Aim: All the previous classification systems were based on open hernia repairs and have their own fallacies particularly for uncommon hernias that cannot be classified in these systems. With the advent of laparoscopic/ endoscopic approach, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have thus proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair. Classification: In the proposed classification higher grades signify increasing levels of expected intraoperative difficulty. This functional classification grades groin hernias according to the: a) Pre -operative predictive level of difficulty of endoscopic surgery, and b) Intraoperative factors that lead to a difficult repair. Pre operative factors include multiple or pantaloon hernias, recurrent hernias, irreducible and incarcerated hernias. Intraoperative factors include reducibility at operation, degree of descent of the hernial sac and previous hernia repairs. Hernial defects greater than 7 cm in diameter are categorized one grade higher. Conclusion: Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and is a final classification that predicts the expected level of difficulty for an endoscopic hernia repair. Keywords: Total extraperitoneal repair, SGRH classification, laparoscopic ventral hernia repair
Classification systems for groin hernia Numerous classifications for groin hernia have been proposed over the past five to six decades. The old simple classification of groin hernia into indirect and direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias.[1] In the 1950s and 1960s, many surgical classifications for groin hernias were conceived, such as those by Casten,[2] Fruchaud,[3] Harkins[4] and Halverson et al.[5] However, they have little applicability in the current surgical practice for hernia. In 1988, Gilbert[6] described a detailed classification based on anatomical and functional defects established intraoperatively and created a registry named ′Cooperative Hernia Analysis of Types and Surgeries′(CHATS). In 1991, Nyhus et al[7] introduced a classification system based on anatomical criteria with emphasis on the state of the deep ring and posterior wall of the inguinal canal. In 1993, Bendavid[8] proposed the type, staging and dimension system for classification of hernias. All these classification systems based on open hernia repair techniques have their own shortcomings, particularly noninclusion of uncommon hernias that cannot be classified. Though there have been several classification
systems for groin or inguinal hernias, none have been described for
total classification of all ventral hernias of the abdomen.[9] The
most commonly followed classification system for ventral hernias divides
them into (i) congenital hernias - present at birth, which include omphalocele,
gastroschisis and umbilical hernia; (ii) acquired - including hernias
in the midline, median and paramedian areas, such as Spigelian, epigastric
and paraumbilical hernias; (iii) incisional hernias; and (iv) traumatic
hernias - following penetrating and blunt trauma. SGRH classification With the advent of laparoscopic / endoscopic surgery, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. The change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair. In the proposed classification, higher grades signify increasing levels of expected intraoperative difficulty. A hernial defect> 7 cm in diameter is categorized one grade higher. Classification of inguinal hernia for TEP repair This functional classification grades groin hernias according to the preoperative predictive level of difficulty of endoscopic surgery. For multiple or pantaloon (direct and indirect components) hernias, grading is according to the dominant hernia. Bowel obstruction and strangulation are unsuitable for the total extraperitoneal (TEP) approach. Intraoperatively, the factors considered as predictors of the grade of difficulty include:
Grade I
Grade II
Grade III
Grade IV
Grade V
Notes
Classification of ventral hernia Grade I
Grade II
Grade III
Grade IV
Grade V
Grade VI
Note Patient having colicky intestinal pain or symptoms of SAIO are considered in Grade IV at least. Clinically, on examination bowel loop may give gurgling sensation and reduce partially on palpation. This can be distinguished from omentum on palpation and auscultation. References
Copyright 2006 - Journal of Minimal Access Surgery |
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