Inguinal Inguinal HerniHernia:a:

Options for SurgeryOptions for SurgerySyed Fahad Ali Zaidi

PGR SU II BBH

IncidenceIncidence• 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

The AnatomyThe Anatomy

Historical HerniasHistorical Hernias

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

Trusses & TechniquesTrusses & Techniques

Anatomic Anatomic ConsiderationsConsiderations

• 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 herniao Degree of adipose tissue

Pelvic & Inguinal AnatomyPelvic & 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.

Myopectineal Orifice of Myopectineal Orifice of

FruchaudFruchaud

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

Myopectineal Orifice of Myopectineal Orifice of FruchaudFruchaud

Hesselbach's triangleHesselbach's triangle

Boundaries:Boundaries:

Medial:Rectus abdominis

muscle medially,

Inferiorly:Inguinal ligament

Laterally:Inf. Epigastrics

DiagnosisDiagnosis• 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

DiagnosisDiagnosis• 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

Nyhus ClassificationNyhus 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)

Nyhus ClassificationNyhus Classification• Type III: Posterior wall defect

o A. Direct inguinal herniao B. Indirect inguinal hernia- internal inguinal

ring dilated (massive scrotal or sliding hernia)o C. Femoral hernia

• Type IV: Recurrent herniao A. Directo B. Indirecto C. Femoralo D. Combined

Inguinal HerniaInguinal Hernia• Indirect inguinal hernia

o Is a congenital lesiono 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

Indirect Hernia Indirect Hernia RouteRoute

Note: The hernia sac

passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.

Inguinal HerniaInguinal 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

Direct Hernia RouteDirect Hernia RouteNote: The hernia sac

passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.

Specific Surgical Specific Surgical ProceduresProcedures

• Lichenstein (Tension Free) Repair

• McVay (Cooper’s Ligament) Repair

• Halstead’s Repair

• Shouldice (Canadian) Repair

• Laproscopic Hernia Repair

• Bassini Repair

Bassini RepairBassini Repairo 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

McVay RepairMcVay Repair

• AKA: Cooper’s ligament Repairo 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

McVay RepairMcVay Repair

• This repair reconstructs the inguinal canal without using a mesh prosthesis.

• It requires a relaxing incision

Halstead’s RepairHalstead’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

Halstead’s RepairHalstead’s Repair• Technique not

appreciated because of high incidence of hydrocoels, and testicular atrophy as well as recurrence post-operatively.

ShouldiceShouldice Repair 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.

ShouldiceShouldice Repair Repair

ShouldiceShouldice Repair 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

LichtensteinLichtenstein Repair 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

LichtensteinLichtenstein Repair Repair

Note: Open mesh

repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

OOther repairs using ther repairs using MeshMesh

• 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.

Laparoscopic Laparoscopic HHernia ernia RRepairepair

o Early attempts resulted in exceptionally high reoccurrence rates

o Current techniques include• Transabdominal preperitoneal repair

(TAPP)• Totally extraperitoneal approach (TEPA)

Laparoscopic Laparoscopic MeshMesh RRepairepair

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.

Laparoscopic Laparoscopic MeshMesh RRepairepair

TAPP RepairTAPP Repair

TEP RepairTEP Repair

• Contraindication to laparoscopic repair is :o Patients with large inguinoscrotal herniaso Patients with previous abdominal surgeries