Brief description of inguinal hernia anatomy, pathophysiology and surgery options

1. Inguinal Hernia:
Options for Surgery
Syed Fahad Ali Zaidi
PGR SU II BBH

3. Incidence
• Approximately 700,000 hernia repairs are performed
as an outpatient procedure each year
• Approximately 75% of all hernias occur in the
inguinal region
• Approximately 50% of hernias are indirect inguinal
hernias
• A vast majority occur in males
• Hernias more commonly occur on the right side

4. The Anatomy

5. Historical Hernias
Hernias have been
documented
throughout history
with varying
success at either
reduction or
repair.

6. Trusses & Techniques

7. Anatomic
Considerations
• The inguinal region must be understood with
regard to its three-dimensional configuration
• A knowledge of the convergence of tissue
planes is essential
• If repairing the hernia laparoscopically, the
anatomy must be well understood from the
peritoneal surface outward
• There is a considerable amount of anatomic
variability with regard to:
o Size and location of the hernia
o Degree of adipose tissue

8. Pelvic & Inguinal Anatomy
• Both the ilioinguinal nerve and the
genitofemoral nerve traverse the usual
hernia-repair operative field. The femoral
vein also runs just deep to the inguinal floor
laterally.

10. Myopectineal Orifice of Fruchaud
The MPO is bordered:
• Above by the arching fibers of the internal
oblique and transversus abdominus Muscles,
• Medially by the Rectus Abdominus Muscle
and its fascial Rectus Sheath
• Inferiorly by Coopers Ligament, and
• Laterally by the Ileopsoas Muscle
• Running diagonally thru the MPO is the
inguinal ligament

11. Myopectineal Orifice of Fruchaud

12. Hesselbach's triangle
Boundaries:
Medial:
Rectus abdominis
muscle
medially,
Inferiorly:
Inguinal ligament
Laterally:
Inf. Epigastrics

13. Diagnosis
• The patient usually presents (for groin hernia)
with the complaint of a bulge in the inguinal
region
• They may describe minor pain or vague
discomfort associated with the bulge
• Extreme pain usually represents
incarceration with intestinal vascular
compromise
• Paresthesias may be present if inguinal
nerves are compressed

14. Diagnosis
• Physical exam
o The patient should be standing and facing the
examiner
o Visual inspection may reveal a loss of symmetry in
the inguinal area or bulge
o Having the patient perform valsalva’s maneuver
or cough may accentuate the bulge
o A fingertip is then placed in the inguinal canal;
Valsalva maneuver is repeated
o Differentiation between indirect and direct
hernias at the time of examination is not essential

15. Nyhus Classification
• Type I: Indirect inguinal hernia Internal inguinal
ring normal (simple pediatric hernia)
• Type II: Indirect inguinal hernia
Internal inguinal ring dilated but posterior inguinal
wall intact (inferior deep epigastric vessels not
displaced)

16. Nyhus Classification
• Type III: Posterior wall defect
o A. Direct inguinal hernia
o B. Indirect inguinal hernia- internal inguinal ring
dilated (massive scrotal or sliding hernia)
o C. Femoral hernia
• Type IV: Recurrent hernia
o
o
o
o
A. Direct
B. Indirect
C. Femoral
D. Combined

17. Inguinal Hernia
• Indirect inguinal hernia
o Is a congenital lesion
o Occurs when bowel, omentum or other
abdominal organs protrudes through the
abdominal ring within a patent processus
vaginalis
o If the processus vaginalis does not remain patent
an indirect hernia cannot develop
o Most common type of hernia

18. Indirect Hernia Route
Note:
The hernia sac
passes outside
the boundaries
of Hesselbach's
triangle and
follows the
course of the
spermatic cord.

19. Inguinal Hernia
• Direct inguinal hernia
o Proceeds directly through the posterior inguinal
wall
o Direct hernias protrude medial to the inferior
epigastric vessels and are not associated with
the processus vaginalis
o They are generally believed to be acquired
lesions
o Usually occur in older males as a result of pressure
and tension on the muscles and fascia

20. Direct Hernia Route
Note:
The hernia sac
passes directly
through
Hesselbach's
triangle and
may disrupt the
floor of the
inguinal canal.

21. Specific Surgical Procedures
• Lichenstein (Tension Free) Repair
• McVay (Cooper’s Ligament) Repair
• Halstead’s Repair
• Shouldice (Canadian) Repair
• Laproscopic Hernia Repair
• Bassini Repair

22. Bassini Repair
o Is frequently used for
indirect inguinal
hernias and small
direct hernias
o The conjoined
tendon of the
transversus
abdominis and the
internal oblique
muscles is sutured to
the inguinal
ligament

23. McVay Repair
• AKA: Cooper’s ligament Repair
o Is for the repair of large inguinal hernias, direct
inguinal hernias, recurrent hernias and femoral
hernias
o The conjoined tendon is sutured to Cooper’s
ligament from the pubic tubercle laterally to
femoral vein, and to inguinal ligament laterally
from here

24. McVay Repair
This repair
reconstructs
the inguinal
canal without
using a mesh
prosthesis.
• It requires a
relaxing
incision
•

25. Halstead’s Repair
• In this repair, (which otherwise resembles Bassini)
external oblique aponeurosis is used to strengthen
the posterior wall.
• This exteriorizes the spermatic cord, placing it
beneath the layers of abdominal wall facia

26. Halstead’s Repair
• Technique not
appreciated
because of high
incidence of
hydrocoels, and
testicular atrophy as
well as recurrence
post-operatively.

27. Shouldice Repair
• AKA: Canadian Repair
o A primary repair of the hernia defect
with 4 overlapping layers of tissue.
o Two continuous back-and-forth
sutures of permanent suture material
are employed. The closure can be
under tension, leading to swelling
and patient discomfort.

28. Shouldice Repair

29. Shouldice Repair
• At the shouldice hospital, steel wires are used for
the closure of all layers upto subcutaneous fat, and
recurrence rates of less than one percent are
reported
• Other centers which practiced this technique do
not report similar success rates

30. Lichtenstein Repair
AKA: Tension-Free Repair
• One of the most
commonly performed
procedures
• A mesh patch is sutured
over the defect with a slit
to allow passage of the
spermatic cord

31. Lichtenstein Repair
Note:
Open mesh
repair. Mesh is
used to
reconstruct the
inguinal canal.
Minimal tension
is used to bring
tissue together.

32. Other repairs using Mesh
• Patch & plug technique involvs placementof a
preformed mesh plug in the hernia defect that is
sutured to the facial margins of defect.
• Stoppa ‘s Repair uses posterior approach for
implanting a mesh in the preperitoneal plane
without closing peritoneal defect per se
• Kugel’s repair is a preperitoneal repair in which a
preformed mesh with a stiff ring around the edges is
placed in the preperitoneal space.

33. Laparoscopic Hernia Repair
o Early attempts resulted in exceptionally high
reoccurrence rates
o Current techniques include
• Transabdominal preperitoneal repair (TAPP)
• Totally extraperitoneal approach (TEPA)

35. Laparoscopic Mesh Repair
Note:
Viewed from inside the pelvis toward the direct and
indirect sites. A broad portion of mesh is stapled to
span both hernia defects. Staples are not used in
proximity to neurovascular structures.

36. Laparoscopic Mesh
Repair

37. TAPP Repair

38. TEP Repair

39. • Contraindication to laparoscopic repair is :
o Patients with large inguinoscrotal hernias
o Patients with previous abdominal surgeries