3. Introduction
In US 96% are inguinal, 4% femoral
20% bilateral
Most common in both sexes indirect.
Femoral hernias more common in elderly
females
Male to female ratio in 9:1 for inguinal
hernias, 1:3 for femoral hernias
4. Myopectineal Orifice of Fruchaud
The MPO is bordered:
Above by the arching fibers of the internal
oblique and transversus abdominus Muscles,
Medially (towards the center or to the right) 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
6. Anatomy
4cm in length
2-4 cm cephalad to inguinal ligament
Extends between superficial and deep
rings
Contains spermatic cord or round
ligament
7. Anatomy
Bounded superficially by external oblique
Cephalad by conjoint tendon
Inferior border is inguinal ligament
Floor is transversalis fascia
8. Layers
Skin, subcutaneous, campers, scarpa,
external spermatic fascia, cremaster,, int
spermatic fascia , preperitoneal tissues,
peritoneum
9. Anatomy
Broadly classified as indirect and direct
depending on relationship to epigastric
vessels.
Hesselbach’s triangle is inferior epigastric
artery laterally, lateral border of rectus
medially, inguinal ligament inferiorly.
10. Anatomy
An indirect hernia passes lateral to
Hesselbach’s triangle.
A direct hernia passes thru Hesselbach’s
triangle.
Indirect hernia has a congenital
component, from processus vaginalis.
The processus is supposed to obliterate
after descent of testes.
14. Indirect Inguinal Hernia
Accepted hypothesis:
incomplete or defective
obliteration of the
processus vaginalis during
the fetal period
remnant layer of
peritoneum forms a sac
at the internal ring
more frequently on the
right
18. Direct Inguinal Hernia
Medial to the inferior
epigastric artery and vein,
and within Hesselbach's
triangle
acquired weakness in the
inguinal floor
19. Anatomy
Direct hernias are usually not congenital.
Acquired by the development of tissue
deficiencies of the transversalis fascia.
Development of femoral hernia less
understood. Can result from increased
intraabdominal pressure. The sac then
migrates down the femoral vessels into
thigh.
20. Anatomy Inguinal ligament
(Poupart’s) – inferior edge
of external oblique
Lacunar ligament –
triangular extension of the
inguinal ligament before
its insertion upon the pubic
tubercle
conjoined tendon (5-10%)-
Internal oblique fuses with
transversus abdominis
aponeurosis
Cooper’s Ligament -
formed by the periosteum
and fascia along the
superior ramus of the pubis.
22. Nyhus Classification
I indirect, internal ring normal (kids)
II indirect, dilated internal ring
III posterior wall defects, direct inguinal
hernia, dilated internal ring, massive
scrotal, sliding, femoral hernia
IV recurrent hernia
23. Terminology
Reducible – can be replaced within
surrounding musculature
Incarcerated – cannot be reduced
Strangulated – compromised blood supply to
its contents
25. Epidemiology
Prevelance of hernias increases with age
Most serious complication – strangulation
1 to 3% of groin hernias
Femoral – highest rate of complications 15% to
20%
recommended all be repaired at time of discovery
28. 28
History
1st
century: Surgical treatment
15th
century: Castration with wound cauterization or
hernia sac debridement with secondary healing
Early 18th
century: Sir Astley Cooper:
recommended truss > surgery, only in
strangulation
29. History
1881: French surgeon, Lucas-
Championni re: high ligation of indirectѐ
inguinal hernia
1844-1924: Edoardo Bassini (father of
modern inguinal hernia surgery): high
ligation and reconstruction of inguinal floor
39. 39
Hernioplasty
High ligation, inverted sac + reinforce
defect with synthetic material
Tension-free
Lichtenstein
Recurrent rate 0.1%
40. Tension-Free Repair
Same initial approach as anterior repair
Instead of sewing fascial layers together
to repair defect, a prosthetic mesh onlay
used
Simple to learn, easy to perform, suited for
local anesthesia, excellent results with
recurrence less than 4%.
41.
42.
43. Techniques
Coined by Liechtenstein in 1989
Central feature is polypropylene mesh
over unrepaired floor.
Gilbert repair uses a cone shaped plug
placed thru deep ring.
Slit placed in mesh for cord structures
44. Techniques
Suturing the mesh to the inguinal ligament
is not important.
Fixing the mesh to the rectus sheath 1-
1.5cm medial and superior to the pubic
tubercle is very important.
Should have a surplus of mesh over
inguinal ligament, the medial suture
ensures surplus mesh inferiorly
45. Open Posterior Repair
Divide the layers of the abdominal wall
superior to the internal ring, enter
preperitoneal space. Dissection continues
behind and deep to the entire inguinal
region.
Suture tension problems.
46. Laparoscopic Procedures
Increasingly popular, controversial
Early in the development, hernias were
repaired by placing very large mesh over
entire inguinal region on top of the
peritoneum. Was abandoned because of
contact with bowel.
Today, most performed TEP or TAPP
47.
48. 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.
49. Laparoscopic Procedures
The argued advantage of these
procedures was less pain and disability,
faster return to work.
Great for bilateral hernia, with no increase
in morbidity.
For recurrent hernia
Disadvantages are cost, time.
