inguinal hernia, Lichtenstein's repair

1. Surgical anatomy of Inguinal
hernia
Zeeshan

2. Hernia
• A condition in which part of an organ is
displaced and protrudes through the wall of
the cavity containing it.
• Incidence: 25% in males and 2% in females
• 75% of hernias- groin hernias
• 2/3rd indirect and 1/3rd direct.

3. History of inguinal hernia
• Greek (hernios): bud
• or offshoot.

4. • Taxis for reduction of
incarcerated hernias

5. Inflating, inverting and shaking the
patient

8. • Pt with strangulated inguinal hernia
• Purgatives / enemas of no avail
• Following use of “bellows” patient screams
“ YOU ARE BLOWING UP MY PURSE”
• Scrotum was distended with air

9. • Treatment of groin hernias are divided into 5
epochs.
• Oldest epoch- ancient era from ancient egypt till
15th century
• 19 – 20th century: Era of hernia repair under
tension
- Antiseptic/aseptic precautions
- High ligation of hernial sac
- Narrowing of superificial inguinal ring

10. • Bassini : Repair of posterior wall of inguinal
canal
• Shouldice : Imbrication of transverse fascia
and strengthening of posterior wall of inguinal
canal – 4 layer technique
• Currently – Era of tension free hernia repair.

12. Anterior abdominal wall
• External oblique aponeurosis:
- Origin:
• 8 fleshy strips from the outer surface and lower
border of lower 8 ribs
- Insertion:
• Anterior half of outer lip of iliac crest
• Pubic tubercle
• Pubic crest and pecten pubis
• Linea alba

13. External oblique

14. Inguinal ligament
• Known as ?? Poupart’s ligament
- Thickened lower free border of external
oblique aponeurosis
- Extent: Anterior superior iliac spine to pubic
tubercle

15. Modifications of inguinal ligament
• Lacunar ligament (Gimbernat’s ligament)
• Pectineal ligament of Cooper
• Superficial inguinal ring
• Reflected part

18. Importance
• Lacunar ligament:
- Release of ligament required to reduce
femoral hernias
• Pectineal ligament:
- Facilitates reconstruction of floor of inguinal
canal

19. Superficial inguinal ring
• Opening in aponeurosis of external oblique
above the pubic crest
• Triangular opening with superior and inferior
crura
• Intercrural fibres cross over at the apex of the
ring

21. Internal oblique abdominis
• Origin:
- Lateral 2/3rd of inguinal ligament
- Intermediate lip of ventral segment of iliac
crest
- Thoracolumbar fascia at lateral border of
quadratus lumborum

22. Internal oblique aponeurosis
• Insertion:
- Conjoint tendon to pubic crest and pecten
pubis
- Linea alba
- Lower border of lower 4 ribs and costal
cartilages

23. Cremastric muscle and fascia
• Derived from internal oblique aponeurosis
• Forms coverings of spermatic cord and testis
• Nerve supply: Genital branch of genitofemoral
nerve (L1,2)

24. Transversus abdominis
• Origin:
- Lateral 1/3rd of inguinal ligament
- Anterior 1/3rd of inner lip of ventral part of
iliac crest
- Thoracolumbar fascia
- Inner surface of lower six ribs and costal
cartilage

25. • Insertion:
- Conjoint tendon to pubic crest and pecten
pubis
- Linea alba

27. Conjoint tendon
• Formed by fusion of lower most fibres of
internal oblique and transversus abdominus
• Inserts into pubic crest and medial part of
pecten pubis

28. Fascia transversalis
• Lies between peritoneum and inner surface pf
transversus abdominis
• Attaches to upturned part of inguinal
ligament.
• Extends as internal spermatic fascia with the
spermatic cord

29. Deep inguinal ring
• Opening in transversalis fascia
• Lies ½ an inch above midinguinal point
• Inguinal canal begins
• Medial relation : Inferior epigastric artery

31. Inguinal canal
• Musculo-aponeurotic tunnel
• From deep ring to superficial ring
• 4 cm long and 1 cm wide

33. Relations of inguinal canal
• Anterior wall:
- Aponeurosis of external oblique aponeurosis
- Internal oblique in lateral 1/3
- Superficial fascia
- Skin

34. • Posterior wall:
- Conjoint tendon (medial half)
- Transversalis fascia
- Extraperitoneal fat
- Peritoneum

35. • Roof:
- Arched fibres of
Internal oblique and transverse abdominus
aponeurosis
• Floor:
- Inguinal ligament (upturned part)

36. Contents
• Spermatic cord (males)
• Round ligament (females)
• Ilioinguinal nerve ( Enters after piercing
internal oblique and leaves through superficial
inguinal ring)

37. Direct inguinal hernia
• Herniation through the posterior wall
• The inferior epigastric artery is found lateral
to the neck of the hernial sac
• Can happen either medial or lateral to the
medial umblical fold

40. Indirect inguinal hernia
• Congenital
• Inferior epigastric artery medial to sac.

41. Steps of hernia repair

52. Thank-you