Inguinal Hernia PPT

33
Inguinal Inguinal Hernias Hernias Dorothy Sparks, PGY-1c

Transcript of Inguinal Hernia PPT

Page 1: Inguinal Hernia PPT

Inguinal Inguinal HerniasHerniasDorothy Sparks, PGY-1c

Page 2: Inguinal Hernia PPT

Historical HerniasHistorical Hernias

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

Page 3: Inguinal Hernia PPT

Trusses & Trusses & TechniquesTechniques

Page 4: Inguinal Hernia PPT

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

Page 5: Inguinal Hernia PPT

Anatomic Anatomic ConsiderationsConsiderations

The surgeon must also be aware of the precise location of the:Femoral nerveGenitofemoral nerveLateral femoral cutaneous nerves

Page 6: Inguinal Hernia PPT

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.

Page 7: Inguinal Hernia PPT

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

Page 8: Inguinal Hernia PPT

Myopectineal Orifice of Myopectineal Orifice of FruchaudFruchaud

Page 9: Inguinal Hernia PPT

Hesselbach's Hesselbach's triangletriangle

Boundaries:Boundaries:

Medial:

Rectus abdominis muscle

medially,

Inferiorly:

Inguinal ligament

Laterally:

Inf. Epigastrics

Page 10: Inguinal Hernia PPT

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

Page 11: Inguinal Hernia PPT

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

Page 12: Inguinal Hernia PPT

Hernia ExamHernia Exam

Page 13: Inguinal Hernia PPT

DiagnosisDiagnosis

Physical exam Incarcerated hernias sometimes can be

reduced manuallyGentle continuous pressure on the

hernial mass towards the inguinal ring is generally effective (Trendelenburg)

Page 14: Inguinal Hernia PPT

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)

Page 15: Inguinal Hernia PPT

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

Page 16: Inguinal Hernia PPT

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

Page 17: Inguinal Hernia PPT

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.

Page 18: Inguinal Hernia PPT

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

Page 19: Inguinal Hernia PPT

Direct Hernia RouteDirect Hernia RouteNote:

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

Page 20: Inguinal Hernia PPT

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

Page 21: Inguinal Hernia PPT

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

Page 22: Inguinal Hernia PPT

Specific Surgical Specific Surgical ProceduresProcedures

Lichenstein (Tension Free) Repair

McVay (Cooper’s Ligament) Repair

Shouldice (Canadian) Repair

Laproscopic Hernia Repair

Bassini Repair

Page 23: Inguinal Hernia PPT

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

Page 24: Inguinal Hernia PPT

Bassini RepairBassini Repair

Page 25: Inguinal Hernia PPT

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

Page 26: Inguinal Hernia PPT

McVay RepairMcVay Repair

Note:

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

Page 27: Inguinal Hernia PPT

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.

Page 28: Inguinal Hernia PPT

ShouldiceShouldice Repair Repair

Page 29: Inguinal Hernia PPT

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

Page 30: Inguinal Hernia PPT

LichtensteinLichtenstein Repair Repair

Note:

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

Page 31: Inguinal Hernia PPT

Laparoscopic Laparoscopic HHernia ernia RRepairepair

Early attempts resulted in exceptionally high reoccurrence rates

Current techniques includeTransabdominal preperitoneal repair (TAPP)Totally extraperitoneal approach (TEPA)

Page 32: Inguinal Hernia PPT
Page 33: Inguinal Hernia PPT

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.