Inguinal hernia
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Inguinal Hernia report 2013, during Surgery rotation of my Post Graduate Internship at the Veterans Memorial Medical Center
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Inguinal hernia
- 1. INGUINAL HERNIA Max Angelo G. Terrenal – Post Graduate Medical Intern – Veterans Memorial Medical Center
- 2. WHAT IS AN INGUINAL HERNIA? Protrusion of a peritoneal sac through a musculoaponeurotic barrier Direct or Indirect
- 3. DIRECT INGUINAL HERNIA Within the floor of Hesselbach’s triangle Acquired defect from mechanical breakdown over the years ~1% Lifetime risk
- 4. INDIRECT INGUINAL HERNIA Through the internal ring of inguinal canal Congenital Patent processus vaginalis ~5% Lifetime risk Higher risk of strangulation than direct
- 6. INCARCERATED Hernia which cannot be reduced STRANGULATED Incarcerated hernia with resulting ischemia
- 7. EPIDEMIOLOGY One of the most common surgical procedures Incidence: ~5-10% lifetime 75% of abdominal wall hernias Male > Female Indirect > Direct Right > Left 1/3 may develop a contralateral inguinal hernia
- 8. ETIOLOGY Multifactorial Weakness in abdominal wall musculature PRESUMED CAUSES OF GROIN HERNIATION Coughing Valsalva's maneuvers Chronic obstructive pulmonary disease Ascites Obesity Upright position Straining Congenital connective tissue disorders Constipation Defective collagen synthesis Prostatism Previous right lower quadrant incision Pregnancy Arterial aneurysms Birthweight <1500 g Cigarette smoking Family history of a hernia Heavy lifting Physical exertion (?)
- 11. ABDOMINAL WALL Skin Subcutaneous fat Scarpa’s fascia External oblique muscle Internal oblique muscle Transversus abdominis Transveralis fascia Preperitoneal fat Peritoneum
- 12. INGUINAL CANAL 4-6 cm long Anteroinferior of pelvic basin Cone-shaped Base superolateral margin Apex Inferomedially
- 13. BOUNDARIES Anterior external oblique aponeurosis Lateral Internal oblique muscle Posterior fusion of the transversalis fascia and transversus abdominus muscle, Superior arch formed by the fibers of the internal oblique muscle. Inferior inguinal ligament
- 14. SPERMATIC CORD Cremasteric muscle fibers Vas deferens Testicular artery Testicular pampiniform venous plexus Genital branch of the genitofemoral nerve +/- hernia sac
- 15. HESSELBACH’S TRIANGLE Medial aspect of Rectus abdominis muscle Inferior epigastric vessels Inguinal ligament
- 16. POSTERIOR
- 17. MYOPECTINEAL ORIFICE OF FRUCHAUD Superior Arch of IOM and TA Lateral Iliopsoas muscle Medial Lateral edge of RA and Pubic pectin Iliopubic tract Spermatic cord Iliac vessels
- 18. TRIANGLE OF DOOM External iliac vessels Deep circumflex iliac vein Femoral nerve Genital branch of GF nerve
- 19. TRIANGLE OF PAIN Nerves Lateral femoral cutaneous Femoral branch of GF nerve Femoral nerve
- 21. NYHUS CLASSIFICATION SYSTEM Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the inguinal Type II canal; does not extend to the scrotum DIRECT HERNIA; size is not taken into account Type IIIA INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinal wall; INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in this category because they are Type IIIB commonly associated with EXTENSION TO THE DIRECT SPACE; also includes PANTALOON HERNIAS FEMORAL HERNIA Type IIIC RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO INDIRECT, Type IV DIRECT, FEMORAL, AND MIXED, RESPECTIVELY
- 22. DIAGNOSIS
- 23. HISTORY Groin pain Duration Extrainguinal symptoms Change in bowel habits Urinary symptoms Progressiveness Pressure on nerves Generalized pressure Local sharp pains Referred pain Scrotum, testicle or inner thigh
- 24. PHYSICAL EXAMINATION Inspection Standing Palpation Inguinal Occlusion test Direct Cough Impulse Indirect Manifested Controlled Dorsum of finger Fingertip
- 25. DIFFERENTIAL DIAGNOSIS Malignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor Primary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicle Femoral artery aneurysm or pseudoaneurysm Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of Nuck (female) Saphenous varix Psoas abscess Hematoma Ascites
- 28. MANAGEMENT
- 30. CONSERVATIVE MANAGEMENT Aimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contents Assuming a recumbent position Truss, an elastic belt or brief
- 31. EMERGENT REPAIR Incarcerated hernias Strangulated hernias Sliding hernias
- 32. INCARCERATED HERNIA Reasons for incarceration large amount of intestinal contents within the hernia sac dense and chronic adhesions of hernia contents to the sac small neck of the hernia defect in relation to the sac contents
- 33. INCARCERATED HERNIA An incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency
- 34. INCARCERATED HERNIA Reduction should be attempted before definitive surgical intervention.
- 35. INCARCERATED HERNIA Hernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.
- 36. TAXIS The patient is sedated and placed in a Trendelenburg position. The hernia sac is grasped with both hands, elongated, and then milked back through the hernia defect. Pressure applied to the most distal portion of the sac will cause the contents to mushroom and prevent reduction.
- 37. STRANGULATED HERNIA Femoral > Indirect > Direct Fever, leukocytosis, and hemodynamic instability. The hernia bulge usually is very tender, warm, and may exhibit red discoloration. Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressed
- 39. ANTERIOR REPAIR NON PROSTHETIC Inguinal hernia
- 40. OPEN APPROACH
- 41. OPEN APPROACH
- 42. BASSINI REPAIR Is frequently used for indirect inguinal hernias and small direct hernias The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
- 43. MCVAY REPAIR inguinal and femoral canal defects The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
- 44. SHOULDICE REPAIR
- 47. LAPAROSCOPIC HERNIA REPAIR Transabdominal Preperitoneal Procedure (TAPP) Totally Extraperitoneal (TEP) Repair Indications include bilateral inguinal hernia, recurring hernia, need for early recovery
- 48. RECURRENCE Around 1% for Shouldice repair Most recurrences are of the same type as the original hernia Recurrence Factors Patient Technical Tissue
- 49. RECURRENCE Patient factors malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors wound infection, tissue ischemia, and increased tension within the surgical repair
- 50. COMPLICATIONS The overall risk of complications of inguinal hernia repair is low. Common Complications Pain, injury to the spermatic cord and testes, wound infection, seroma, hematoma, bladder injury, osteitis pubis, and urinary retention
- 51. EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA
- 52. EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES 1. What is the recommended treatment for inguinal hernia? Mesh repair, Laparoscopic or the Open 2. If laparoscopic mesh repair is the preferred technique for inguinal hernias, what is the recommended laparoscopic technique? Transabdominal Preperitoneal or Total Extra Preperitoneal 3. Is fixation of the mesh necessary in laparoscopic repair? No 4. If open mesh repair, what is the recommended technique Lichtenstein, plug and mesh or Prolene Hernia System
- 53. EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES 5. What is the recommended treatment for recurrent inguinal hernia? Mesh repair, either laparoscopic or open method 6. What is the recommended treatment for bilateral inguinal hernia? Mesh repair, either laparoscopic or open method 7. Is antimicrobial prophylaxis recommended for elective groin hernia surgery? Not routinely recommended using mesh
- 54. THANK YOU
Notes de l'éditeur
- During the normal course of developmentthe testes descend from the intra-abdominal space into the scrotum in the third trimester. preceded by the gubernaculum and a diverticulum of peritoneum, which protrudes through the inguinal canal and ultimately becomes the processusvaginalis. Between 36 and 40 weeks, the processusvaginalis closes and eliminates the peritoneal opening at the internal inguinal ring.Failure of the peritoneum to close results in a patent processusvaginalis (PPV) and thus explains the high incidence of indirect inguinal hernias in preterm babiesThe difference in timing of testicular descent results in closure of the left processusvaginalis before the right. Consequently, right-sided hernias are more common than left-sided hernias, with approximately 10% of hernias presenting as bilateral.
- The inguinal canal is approximately 4 to 6 cm long and is situated in the anteroinferior portion of the pelvic basin Shaped like a cone, its base is at the superolateral margin of the basinwith its apex pointed inferomedially toward the symphysis pubis. The canal begins intra-abdominally on the deep aspect of the abdominal wall, where the spermatic cord passes through a hiatus in the transversalis fascia (in females, this is the round ligament). This hiatus is termed the deep or internal inguinal ring
- Anteriorly, the boundary of the canal is comprised of the external oblique aponeurosis and internal oblique muscle laterally. Posteriorly, fusion of the transversalis fascia and transversusabdominus muscle, one fourth of subjects are found to have only the transversalis fascia The superior boundary is an arch formed by the fibers of the internal oblique muscle. the inferior margin consists of the inguinal ligament
- Spermatic Cord contains the following
- A defect medial to the inferior epigastric vessels is considered direct, whereas a lateral defect is an indirect hernia
- Since laparoscopic procedures have been adapted as a treatment for inguinal hernias, surgeons have been required to reconceptualize the groin anatomy from the posterior perspective
- The arch of the internal oblique muscle and transversusabdominis muscle constitute the superior marginthe iliopsoas muscle the lateral marginthe lateral edge of rectus abdominis medially, and the pubic pecten medially. The iliopubic tract divides the orifice into a superior portion housing the spermatic cord and an inferior portion containing the iliac vessels.The posterior perspective has also resulted in the characterization of important areas to avoid, known as the triangle of doom, triangle of pain, and the circle of death
- The triangle of doom is bordered medially by the vas deferens laterally by the vessels of the spermatic cord, thereby pointing its apex superiorly. The contents of the space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve.
- The triangle of pain can be conceptualized as the space bordered by the iliopubic tract and gonadal vessels. The structures within this space include nerves such as the lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral. The circle of death is a vascular continuation formed by the common iliac, internal iliac, obturator, aberrant obturator, inferior epigastric, and external iliac vessels. Basic knowledge of the boundaries of these triangles allows one to avert the dangers associated with injury to their contents.
- A defect medial to the inferior epigastric vessels is considered direct, whereas a lateral defect is an indirect hernia
- The definitive treatment of all hernias is surgical repair.A hernia defect will not decrease in size, but likely increase and possibly progress to incarceration or strangulation of the sac's contents. Surgery can be delayed or avoided in situations where the patient's medical status prohibits operative treatment. Conservative management is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents. Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia. 4A truss, an elastic belt or brief that aims to keep the hernia reduced, may also be worn; however, its use does not prevent hernia progression or incarceration. A truss may provide relief in up to 65% of patients; however, many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration
- However, once the patient demonstrates bowel obstruction secondary to incarceration or a sliding inguinal hernia, operative intervention becomes expedited. Patients will often present with vomiting, constipation, obstipation, a distended abdomen, or combination thereof
- Before attempting taxis, the patient should be made aware of potential surgery in the case of failure of the maneuver.
- If the blood supply to incarcerated contents becomes compromised, an incarcerated hernia becomes a strangulated hernia. These pose a significant risk to life because the strangulated contents are ischemic and may quickly lose viability.Clinical signs that indicate strangulation include
- An oblique or horizontal incision is performed over the groin.A point two fingerbreadths inferior and medial to the anterior superior iliac spine is chosen as the most lateral point of the incisionIt is then progressed medially for approximately 6 to 8 cm
- The iliohypogastric and ilioinguinal nerves are identified and retracted from the operative field by placing a hemostat beneath their course and then grasping one of the edges of the aponeurosisSome surgeons obtain preoperative consent to cut the ilioinguinal nerve to avoid possible entrapment and post operative pain however, the patient may experience numbness of inner thigh or lateral scrotum which usually goes away in 6 monthsWith the contents of the inguinal canal completely encircled, identification of cord contents and the hernia sac can be effectedDirect hernias will become evident as the floor of the inguinal canal is dissected. An indirect hernia sac will generally be found on the anterolateral surface of the spermatic cord. In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identified to allow dissection of the sac from the cordOnce the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic positionsmall enough to contain the contents of the inguinal canal and prevent a future false-positive diagnosis of recurrent herniaThe new external ring should be small enough to contain the contents of the inguinal canal and prevent a future false-positivenot be tight and should allow entrance of a finger
- The advantage of the McVay (Cooper's ligament) repair is the ability to address both inguinal and femoral canal defects
- The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia and the internal oblique and transverse abdominis muscles. This is the second of the four suture lines. After the stump of the cremaster muscle is picked up, the suture is reversed back toward the pubic tubercle approximating the internal oblique and transversus muscles to the inguinal ligament. Two more suture lines will eventually be created suturing the internal oblique and transversus muscles medially to an artificially created "pseudo" inguinal ligament developed from superficial fibers of the inferior flap of the external oblique aponeurosis parallel to the true ligament.
- Common causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair.
- Common causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair.