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Inguinal Hernias. Dorothy Sparks, PGY-1c. Historical Hernias. Hernias have been documented throughout history with varying success at either reduction or repair. Trusses & Techniques. Anatomic Considerations.

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inguinal hernias

Inguinal Hernias

Dorothy Sparks, PGY-1c

historical hernias
Historical Hernias

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

anatomic considerations
Anatomic Considerations
  • 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:
    • Size and location of the hernia
    • Degree of adipose tissue
anatomic considerations5
Anatomic Considerations
  • The surgeon must also be aware of the precise location of the:
    • Femoral nerve
    • Genitofemoral nerve
    • Lateral femoral cutaneous nerves
pelvic inguinal anatomy
Pelvic & 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 fruchaud
Myopectineal Orifice of Fruchaud

The 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 Sheath
  • Inferiorly by Coopers Ligament, and
  • Laterally by the Ileopsoas Muscle
  • Running diagonally thru the MPO is the inguinal ligament
hesselbach s triangle
Hesselbach's triangle

Boundaries:

Medial:

Rectus abdominis muscle medially,

Inferiorly:

Inguinal ligament

Laterally:

Inf. Epigastrics

diagnosis
Diagnosis
  • 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
diagnosis11
Diagnosis
  • Physical 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
diagnosis13
Diagnosis
  • Physical exam
    • Incarcerated hernias sometimes can be reduced manually
    • Gentle continuous pressure on the hernial mass towards the inguinal ring is generally effective (Trendelenburg)
nyhus classification
Nyhus 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 classification15
Nyhus Classification
  • Type 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 hernia
Inguinal Hernia
  • Indirect inguinal hernia
    • Is a congenital lesion
    • Occurs 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 route
Indirect Hernia Route

Note:

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

inguinal hernia18
Inguinal 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 route
Direct Hernia Route

Note:

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

incidence
Incidence
  • 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
causes of groin hernia s
Causes of Groin Hernias
  • 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 procedures
Specific Surgical Procedures
  • Lichenstein (Tension Free) Repair
  • McVay (Cooper’s Ligament) Repair
  • Shouldice (Canadian) Repair
  • Laproscopic Hernia Repair
  • Bassini Repair
bassini repair
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
mcvay repair
McVay Repair
  • AKA: Cooper’s ligamentRepair
    • 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 repair26
McVay Repair

Note:

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

shouldice repair
Shouldice 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.
lichtenstein repair
Lichtenstein 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

lichtenstein repair30
Lichtenstein Repair

Note:

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

laparoscopic h ernia r epair
Laparoscopic Hernia Repair
  • Early attempts resulted in exceptionally high reoccurrence rates
  • Current techniques include
    • Transabdominal preperitoneal repair (TAPP)
    • Totally extraperitoneal approach (TEPA)
laparoscopic mesh r epair
Laparoscopic MeshRepair

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.