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am i the only one who thinks inguinal anatomy is confusing? sometimes i think i finally got it down cold, only to realize i don't know it as well as i thought. i did very well in anatomy during med school too. i have heard an inguinal hernia repair is an intern level case. does that mean u should be able to do an inguinal hernia repair independently by the time u finish internship?
 

Buzz Me

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I studied the inguinal region (via dissections and Netter's) over and over again...and was still confused during my first several inguinal hernia repairs. I don't think I truly felt comfortable with the anatomy until my 15th hernia, and didn't feel comfortable taking a junior through the case until around my 30th.
 

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Wait until u see it a lap hernia repair, u wnt knw ur heads form toes lol
But i second Buzz Me's reply, really hard to learn the anatomy even when it's right in front of ya
 

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am i the only one who thinks inguinal anatomy is confusing? sometimes i think i finally got it down cold, only to realize i don't know it as well as i thought. i did very well in anatomy during med school too. i have heard an inguinal hernia repair is an intern level case. does that mean u should be able to do an inguinal hernia repair independently by the time u finish internship?
The inguinal canal is very difficult anatomy. I recommend the Nyhus Hernia book, by Fitzgibbons (Creighton). I read it as an intern and it really helped me to understand things better. It can usually be found in your school's library.

Can an intern do a hernia? Sure. Can he do it well, and stay out of trouble? Usually not. There are a lot of problems such as chronic pain and recurrence that can be mostly avoided with good technique and a strong understanding of the anatomy. Also, it is quite possible that the interns "doing" the case are getting a lot of help from the staff.

As a side note, I think discussing the chance of chronic pain should be a part of informed consent in all inguinal hernia cases.
 

njbmd

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am i the only one who thinks inguinal anatomy is confusing? sometimes i think i finally got it down cold, only to realize i don't know it as well as i thought. i did very well in anatomy during med school too. i have heard an inguinal hernia repair is an intern level case. does that mean u should be able to do an inguinal hernia repair independently by the time u finish internship?
Yes, inguinal hernia repairs are junior cases because of the skills used but that doesn't mean that you KNOW the case well enough to perform it without complications. I did loads of hernia repairs both lap and open as an intern but my faculty member was always assisting and always teaching on these.

I studied the inguinal region (via dissections and Netter's) over and over again...and was still confused during my first several inguinal hernia repairs. I don't think I truly felt comfortable with the anatomy until my 15th hernia, and didn't feel comfortable taking a junior through the case until around my 30th.
This was my experience too.

The inguinal canal is very difficult anatomy. I recommend the Nyhus Hernia book, by Fitzgibbons (Creighton). I read it as an intern and it really helped me to understand things better. It can usually be found in your school's library.

Can an intern do a hernia? Sure. Can he do it well, and stay out of trouble? Usually not. There are a lot of problems such as chronic pain and recurrence that can be mostly avoided with good technique and a strong understanding of the anatomy. Also, it is quite possible that the interns "doing" the case are getting a lot of help from the staff.

As a side note, I think discussing the chance of chronic pain should be a part of informed consent in all inguinal hernia cases.
This was part of my consent process for hernia repair and still is for any case that I perform. Agree with this and am happy that I had all of those cases with great faculty across from me to allow me to benefit from their experience. Also happy that I don't perform these repairs anymore as dead feet are my friends. :thumbup:

Hernias are a good example of why a case that looks simple from a technical standpoint is loaded with potential "mine fields". One can't just look at a book(though Nyhus is good for learning the surgical anatomy) and feel confident that they know how to do any case no matter how "junior". On every hernia, I learned something new and different.
 

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Agree. Loved the Nyhus book when I was getting it down. I think the best teaching for inguinal anatomy comes from doing true tissue repairs (e.g. Cooper's Ligament/McVay and Shouldice) Until you've touched each layer with your finger it's hard to get the sense of the 3-D nature of it. If there is a cadaver anatomy class still going, it's worth it to go try one with a surgical atlas in front of you and do it from anterior (for open) and posterior approaches (to understand the lap hernia) to get a sense of it. Now that everyone only does mesh repairs, I'm not sure how anyone is going to really master this stuff personally (even while recognizing that the mesh repair provides for an easier operation and equivalent to superior results in most hands). When giving orals, I am always shocked at how many residents don't even consider a tissue repair as an option in their mental algorithm without an excruiating level of prompting if at all, even when faced with gross contamination.
 

SLUser11

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When giving orals, I am always shocked at how many residents don't even consider a tissue repair as an option in their mental algorithm without an excruiating level of prompting if at all, even when faced with gross contamination.
Should it really be an option? Outside of the Shouldice Clinic, I doubt anyone can justify a tissue repair when there's not a contra-indication to mesh.

That being said, I have to agree that the skillset to do a tissue repair is going away. In peds, I've always done high ligation. In adults, if there was contamination, we'd use biologics or delay the repair. I've never personally done a McVay or Bassini, so if it came up in my algorithm during the orals, it would only be because I thought that's what you wanted to hear.
 

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We have an attending here who does a Bassini repair WITH an onlay mesh. I have never heard of anyone else doing this type of repair but it's pretty slick and at least we get some experience with Bassini.
 

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I do believe it should still be an option. Biologics are not universally available, and its recurrence rates are still unknown in this setting in terms of large trials (at least that I know of). Tissue repairs do offer reasonable recurrence rates (5-15% depending on the study), which while higher than mesh repairs (1-5%) has the advantage of being unlikely to have to deal with an infected foreign body, which while biologics are somewhat resistant to contamination, it can still melt in the face of gross contamination and need removal (seen it, got to present the M&M).

Thus, while I think it is an acceptable answer to use a biologic, one should still be able to describe at least 1 tissue repair in case that is not available or that has already failed, just as you have to be able to describe a portocaval shunt for variceal bleeding when nothing else works, or a Vagotomy/Antrectomy for recalcitrant ulcer disease.

Our residents here rarely if ever do an elective true tissue repair (excluding Peds high ligations, which don't really count in the context of this discussion), but having said that, it would be hard for me to recommend that we go back to doing them when it is in the patients' best interest (for overwhelming majority of cases) to have a mesh repair. However, I believe the still need to have the theory at their fingertips should it ever become needed in the emergent situation.
 

SLUser11

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I do believe it should still be an option. Biologics are not universally available, and its recurrence rates are still unknown in this setting in terms of large trials (at least that I know of). Tissue repairs do offer reasonable recurrence rates (5-15% depending on the study), which while higher than mesh repairs (1-5%) has the advantage of being unlikely to have to deal with an infected foreign body, which while biologics are somewhat resistant to contamination, it can still melt in the face of gross contamination and need removal (seen it, got to present the M&M).

Thus, while I think it is an acceptable answer to use a biologic, one should still be able to describe at least 1 tissue repair in case that is not available or that has already failed, just as you have to be able to describe a portocaval shunt for variceal bleeding when nothing else works, or a Vagotomy/Antrectomy for recalcitrant ulcer disease.

Our residents here rarely if ever do an elective true tissue repair (excluding Peds high ligations, which don't really count in the context of this discussion), but having said that, it would be hard for me to recommend that we go back to doing them when it is in the patients' best interest (for overwhelming majority of cases) to have a mesh repair. However, I believe the still need to have the theory at their fingertips should it ever become needed in the emergent situation.
It absolutely needs to be in our algorithm for contaminated cases, and I can describe a Bassini or McVay when pushed, but I have to admit that I doubt I'd do one very well in real life.....
 

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For the purposes of memorizing only one repair, while the Bassini is easier to do, learning the McVay simplifies your studying because you can use it in the question for the incarcerated femoral hernia as well as inguinal hernias, but you can't use the Bassini for femoral. Just a thought for us people who have limited memory space to store stuff we don't use every day.
 

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For the purposes of memorizing only one repair, while the Bassini is easier to do, learning the McVay simplifies your studying because you can use it in the question for the incarcerated femoral hernia as well as inguinal hernias, but you can't use the Bassini for femoral. Just a thought for us people who have limited memory space to store stuff we don't use every day.
Agreed.:thumbup: