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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

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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



Rectus abdominis muscle medially,


Inguinal ligament


Inf. Epigastrics

  • 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
  • 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
  • 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


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


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

  • 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


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


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


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.