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
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 (?)
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
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
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
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
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
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
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
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
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.