Inguinal Hernia PPT
Transcript of Inguinal Hernia PPT
Inguinal Inguinal HerniasHerniasDorothy Sparks, PGY-1c
Historical HerniasHistorical Hernias
Hernias have been documented throughout history with varying success at either reduction or repair.
Trusses & Trusses & TechniquesTechniques
Anatomic Anatomic ConsiderationsConsiderationsThe inguinal region must be understood with regard to its three-dimensional configurationA knowledge of the convergence of tissue planes is essentialIf 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: Size and location of the hernia Degree of adipose tissue
Anatomic Anatomic ConsiderationsConsiderations
The surgeon must also be aware of the precise location of the:Femoral nerveGenitofemoral nerveLateral femoral cutaneous nerves
Pelvic & Inguinal Pelvic & Inguinal AnatomyAnatomyBoth 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 FruchaudFruchaudThe 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 SheathInferiorly by Coopers Ligament, and Laterally by the Ileopsoas MuscleRunning diagonally thru the MPO is the inguinal ligament
Myopectineal Orifice of Myopectineal Orifice of FruchaudFruchaud
Hesselbach's Hesselbach's triangletriangle
Boundaries:Boundaries:
Medial:
Rectus abdominis muscle
medially,
Inferiorly:
Inguinal ligament
Laterally:
Inf. Epigastrics
DiagnosisDiagnosisThe patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal regionThey may describe minor pain or vague discomfort associated with the bulgeExtreme pain usually represents incarceration with intestinal vascular compromiseParesthesias may be present if inguinal nerves are compressed
DiagnosisDiagnosisPhysical exam The patient should be standing and facing the
examiner Visual inspection may reveal a loss of symmetry
in the inguinal area or bulge Having the patient perform valsalva’s maneuver or
cough may accentuate the bulge A fingertip is then placed in the inguinal canal;
Valsalva maneuver is repeated Differentiation between indirect and direct hernias
at the time of examination is not essential
Hernia ExamHernia Exam
DiagnosisDiagnosis
Physical exam Incarcerated hernias sometimes can be
reduced manuallyGentle continuous pressure on the
hernial mass towards the inguinal ring is generally effective (Trendelenburg)
Nyhus Nyhus ClassificationClassification
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 ClassificationType III: Posterior wall defect A. Direct inguinal hernia B. Indirect inguinal hernia- internal inguinal
ring dilated (massive scrotal or sliding hernia) C. Femoral hernia
Type IV: Recurrent hernia A. Direct B. Indirect C. Femoral D. Combined
Inguinal HerniaInguinal Hernia
Indirect inguinal hernia Is a congenital lesionOccurs when bowel, omentum or other
abdominal organs protrudes through the abdominal ring within a patent processus vaginalis
If the processus vaginalis does not remain patent an indirect hernia cannot develop
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 Proceeds directly through the posterior inguinal
wall Direct hernias protrude medial to the inferior
epigastric vessels and are not associated with the processus vaginalis
They are generally believed to be acquired lesions
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.
IncidenceIncidenceApproximately 700,000 hernia repairs are performed as an outpatient procedure each yearApproximately 75% of all hernias occur in the inguinal regionApproximately 50% of hernias are indirect inguinal herniasA vast majority occur in malesHernias more commonly occur on the right side
Causes of Groin Causes of Groin HerniaHerniass
Divided into two categories: congenital & acquired defects Congenital factors are responsible for the
majority of groin hernias Prematurity and low birth weight are
significant risk factors Direct hernias are attributed to the wear and
tear stresses of life Groin hernias have been demonstrated to
occur more frequently in smokers than nonsmokers especially women
Specific Surgical Specific Surgical ProceduresProcedures
Lichenstein (Tension Free) Repair
McVay (Cooper’s Ligament) Repair
Shouldice (Canadian) Repair
Laproscopic Hernia Repair
Bassini Repair
Bassini RepairBassini 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
Bassini RepairBassini Repair
AKA: Cooper’s ligament Repair Is for the repair of large inguinal
hernias, direct inguinal hernias, recurrent hernias and femoral hernias
The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
McVay RepairMcVay Repair
McVay RepairMcVay Repair
Note:
This repair reconstructs the inguinal canal without using a mesh prosthesis.
ShouldiceShouldice Repair Repair
AKA: Canadian Repair A primary repair of the hernia defect
with 4 overlapping layers of tissue. 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
LichtensteinLichtenstein Repair Repair
AKA: Tension-Free RepairOne of the most commonly
performed proceduresA 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.
Laparoscopic Laparoscopic HHernia ernia RRepairepair
Early attempts resulted in exceptionally high reoccurrence rates
Current techniques includeTransabdominal 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.