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Resident Conference Open Inguinal & Ventral Hernia Repair Andrew Gassman 8/3/11

Inguinal Hernia

Inguinal Hernia Epidemiology • Worldwide: 20 million groin hernias are repaired each year. • In the US • 1,000,000 abdominal wall herniorrhaphies are performed each year • 750,000 - inguinal, 166,000 – umbilical, 97,000 -incisional, 25,000 - femoral, • 75% of all abdominal wall hernias occur in the groin. • R > L • M > F (7-FOLD) • In Men: Indirect >> Direct >>>>Femoral • In Women Indirect > Femoral > Direct • Femoral hernias account for fewer than 10% of all groin hernias • 40% present as emergencies (i.e., with incarceration or strangulation) • Mortality is higher for emergency repair than for elective repair Emergency operations are more frequently required for female patients.

Natural HistoryRJ Fitzgibbons, A Giobbie-Hurder, JO Gibbs, Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006 vol:295 page:285 • Randomized, controlled trial from 2006, • Minimally symptomatic inguinal hernia was addressed in a in which • 364 men were assigned to 'watchful waiting' (WW) • 356 men underwent routine operation. • Only two patients in the WW group required emergency operations for strangulation over the follow-up period of 2 to 4.5 years. • This result is about 1/5 of 1% for each year that the hernia remains unrepaired. • The two patients who required emergency operations recovered uneventfully. • At the conclusion of the study, functional status, as measured by quality-of-life instruments and pain scales, was identical in the two groups. • Postoperative complication rates were the same in patients who underwent immediate surgery as in those who were assigned to watchful waiting but had to cross over to surgical treatment.

Physiology / Pathophysiology • Inguinal Hernia • Either indirect or direct • Indirect inguinal hernia • Passes through internal inguinal ring, traverses inguinal canal to external ring • May extend into scrotum in males and labia majora in females • Passes lateral to inferior epigastric vessels and has an oblique inferior course • Considered a congenital defect and associated with a patent processusvaginalis • 5x more common than direct inguinal hernias • Direct inguinal hernia • Protrusion through Hesselbach triangle • Generally does not extend into scrotum • Passes medial to inferior epigastric vessels • Considered an acquired defect • Inguinal hernias 5-10x more common in men

Anatomy • Anterior Pelvis • Muscles: • External Oblique – Most superficial • Course Inferiomedial • Internal Oblique – Middle Flat • Course Superiomedial • Transversus Abdominus – Inner Most Flat muscle • Course Transversely • Rectus Abdominus • Vertical Strap Muscle • Inguinal Boundaries: • Superior – Aponeurosis of Tansversus Abdominus (Falx Inguinalis) • Fuses with internal oblique aponeurosis to form conjoined tendon medially • Inferior – Inguinal Ligament • Medial portion – attached on pectineal/ Cooper’s ligament • Posterior – Tansversalis Fascia • Fuses anteriorly and inferior as the ileopubic tract • Anterior – External oblique Aponeurosis • Forms shelving edge when traveling inferiorly and posteriorly cradling cord structures • Inserts into inguinal ligament and travels posteriorly to ileopubic tract.

Canal Anatomy

Fascial Anatomy • Transversalis fascia • attached to the iliac crest laterally • inserts on the pubic tubercle medially • Forms anatomic landmarks • iliopectineal arch, • iliopubic tract, • the thickened band of the transversalis fascia that courses parallel to the more superficially located inguinal ligament • crura of the deep inguinal ring, • Continues into insert into Cooper's ligament (i.e., the pectineal ligament) a condensation of the periosteum .

Fascial Anatomy • Between the transversalis fascia and the peritoneum is the preperitoneal space. • In the midline behind the pubis - The space of Retzius; • Laterally - The space of Bogros. • The preperitoneal many of the inguinal hernia repairs are performed in this area. • Within the preperitoneal space: • inferior epigastric vessels • deep inferior epigastric vein • iliopubic vein • retropubic vein • internal spermatic vessels • vas deferens

Inguinal Anatomy • Inguinal Canal • Passage through anterior abdominal wall • Conveys spermatic cord in males and round ligament in females • Formed embryologically by evagination of processusvaginalis through anterior abdominal wall • Internal or deep ring • Opening through transversalisfasciaLocated above mid-portion of inguinal ligament • Lateral to inferior epigastric artery • External or superficial ring • Triangular opening of external oblique aponeurosisJust lateral to pubic tubercle • Hesselbach triangle Area of weakness in pelvic wall • Site of direct inguinal hernias • Medial border: Lateral edge of rectus sheath • Lateral border: Inferior epigastric artery • Inferior border: Inguinal ligament

Inguinal Anatomy

Inguinal Nerves

Types of Repair

Marcy Repair • Children and young adults Concern about the long-term prosthetic material. • High ligation of the sac and narrowing of the internal ring. • Displacing the cord structures laterally allows the placement of sutures through the muscular and fascial layers

Bassini Repair • Reconstruction of the inguinal floor by opening the transversalis fascia from the internal inguinal ring to the pubic tubercle, thereby exposing the preperitoneal fat, • Bluntly dissected undersurface of the superior flap of the transversalis fascia • 'triple layer' approximation • The layer of transversalis fascia and the transversus abdominis is sutured, with the internal oblique muscle, to the reflected inguinal ligament

Shouldice Repair • 2 layers • A continuous running suture re-approximates the inguinal floor • A second layer is started near the internal ring, approximating the internal oblique muscle and the transversus abdominis to a band of external oblique aponeurosis superficial and parallel to Poupart's ligament • This suture line ends at the pubic crest. • A fourth suture line may be added

Shouldice Repair

McVay Repair • Similar to the Bassini repair, • Except that it uses Cooper's ligament instead of the inguinal ligament • Interrupted sutures are placed from the pubic tubercle laterally along Cooper's ligament, progressively narrowing the femoral ring • Treatment of Femoral Hernia • The last stitch in Cooper's ligament is known as a transition stitch and includes the inguinal ligament. • Relaxing Incision

McVay Repair

Lichtenstein Repair

Femoral Anatomy • Femoral Hernia • Begins posterior to medial portion of inguinal ligament • Traverses femoral canal to fossa ovalis • Herniated contents are below inguinal ligament, lateral to pubic tubercle and medial to femoral vessels • More common in older women

Femoral Anatomy • Below the iliopubic tract • Iliopectineal arch separates the vascular compartment (femoral vessels) from the neuromuscular compartment (iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous nerve) • Vascular compartment • 3 subcompartments: • (1) the lateral, containing the femoral artery and the femoral branch of the genitofemoral nerve; • (2) the middle, containing the femoral vein; • (3) the medial, which is the cone-shaped cul-de-sac known as the femoral canal. • The femoral canal is normally a 1 to 2 cm blind pouch that begins at the femoral ring and extends to the level of the fossaovalis. • normally contains preperitoneal fat, connective tissue, and lymph nodes (including Cloquet's node at the femoral ring) • The femoral ring is bordered by the superior pubic ramus inferiorly, the femoral vein laterally, and the iliopubic tract (with its curved insertion onto the pubic ramus) anteriorly and medially. • A femoral hernia exists when the blind end of the femoral canal becomes an opening (the femoral orifice) through which a peritoneal sac can protrude.

Femoral Anatomy

Ventral Hernia

Fascial Anatomy • Linea alba • Raphe of the flat abdominal muscles • Rectus sheath • Invests • Rectus abdominis muscles • Epigastric vessels • Aponeuroses of external oblique, internal oblique and transversus abdominis muscles • Internal oblique aponeurosis splits: • Upper abdominal wall: • Anterior portion and joins external oblique aponeurosis to form anterior rectus sheath • Posterior portion joins transversus abdominis aponeurosis to form posterior rectus sheath • Lower third of abdominal wall (below anterior superior iliac spine) • all aponeurosis join and course anterior to rectus abdominis muscles • Creates arcuate line on posterior surface of abdominal wall • Below arcuate line covered only by transversalis fascia, which is separated from parietal peritoneum by extraperitoneal fat

Fascial Anatomy

Ventral Hernia Epidemiology • Incidence of incisional hernia after laparotomy varies in reports 3-20% • Doubles with presence of infection • Upper midline incisions are associated with the highest incidence of ventral hernia formation • Transverse or oblique incisions with the lowest. • Most incisional hernias are detected within 1 year of surgery • Male-to-female incidence ratio is 1:1, • Early evisceration is more common in males.

Incisional hernia • Risk factors for (Re/O)ccurrence: • Male sex, • age, • obesity, • jaundice, • underlying disease process, • wound infection, • abdominal distension, • pulmonary diseases

Timeline • Prior to 1960’s • Primary repair wit natural materials • Transposition of tissue • 1959 - Advent of synthetic material – Polyproplene suture and mesh • Materials and positions for mesh closure • 1983 PTFE used for mesh closure • 1980’s Rives and Stoppa separately described Subfascial/ pre-peritoneal placement of mesh • 1990 – Ramirez, described a method to close incisional hernia defects by separating the muscle planes of the abdominal wall termed, component separation.

Primary vs. Mesh-based repairs: • Sahlin and Roberts - primary repair. • No difference in recurrence rate for primary repairs performed with either monofilament or braided suture. • No difference for repairs performed in a running or interrupted fashion • Luijendijk et al. • at 3-years, regardless of hernia size, mesh repair was statistically superior to suture repair (43% vs. 24%) in the recurrence of midline abdominal incisional hernias.(21) • Burger et al. • Follow-up work by documented a 10-year cumulative recurrence rate of 63% for suture repair and 32% for underlay mesh repairs of first time midline incisional hernia defects <6cm. (22) • Tension is a feature common to both primary and mesh repairs • Excessive tension at the time of wound closure is a significant contributor to repair failure, local swelling, and wound separation. • A general agreement that the overlap of mesh with autogenous abdominal tissue needs to be at the very least 3 cm.

Mesh placement in relation to fascia • Hawn et al., • The effectiveness of mesh repair varied by its position. • Compared to suture repair: • open underlay mesh repair (hazard ratio = 0.72) and laparoscopic intraperitoneal repair (hazard ratio = 0.49) significantly reduced the risk of recurrence. • Mesh onlay or inlay had no improvement over primary suture repair. • Rives and Stoppa independently described a method of repairing ventral hernias. • When Rives and Stoppa described their pre-peritoneal reconstruction method only synthetic meshes with a high tendency to erode intra-abdominal organs were available. • Composite synthetic materials have been develop specifically to prevent visceral injury and adhesion formation. • Wiliams et al., demonstrated that the Rives-Stoppa method, could be accomplished intra-peritoneally. • Specifically, they performed open incisional hernia repairs using an intraperitoneal mesh underlay. In their study, the repairs were completed with a variety materials designed to limit visceral erosion including ePTFE, coated polyester, coated polypropylene, and biologic meshes.

Component Separation Repairs: • Ramirez et al. • Separating the muscles of the abdominal wall and transposing their position to closure a hernia defect. • Elevation of extensive lateral skin flaps • External oblique muscle is detached from its medial insertion on the rectus sheath along the entire semi-lunar line. T • The external oblique muscle is subsequently elevated off of the internal oblique muscle. • The horizontal translation of the musculature allows for greater approximation of the midline fascial elements. • Additionally, separation of the posterior rectus sheath from the rectus muscle itself may be performed for additional intra-abdominal domain recovery. • De VriesReilingh et al. • Described the use of this technique for complex ventral hernia repair in both clean and contaminated surgical fields. • Over a 1 to 4 year follow-up period, their work documented a recurrence rate that ranged from 4-30%. Additionally, wound complication (i.e. seroma, surgical site infection, etc.) rates varied from 1-84%. • This variation was owed in part to variation in technique between the studies described. The higher wound complications were owed in part to the subsequent vascular compromise to the overlying skin flaps inherent the extensive surgical dissection.

Component Separation Repairs:

Questions

Question 1 • The Shelving portion of the inguinal ligament used for open inguinal hernia repair: • A) is formed from the external oblique aponeurosis • B) Arises from the transversalis fascia • C) Inserts directly on to creamasteric fascia • D) represents the superior border of the iliopubic tract • E) is usually sutured to the transversus aponeurosis arch (flax inguinalis), which lies inferior to it , to complete a primary open repair

Question 2 • Which is true of the anatomy of the Abdominal Wall: • A) The origin of the external oblique muscle is the 5 lowest ribs • B) Embryologic origin of the Rectus Abdominus is the ectoderm • C) The Majority of the neurovascular structures that supply the abdominal wall lie between the external and internal oblique muscles • D) An abdominal hernia requires a defect in transversus abdominus • E) Lymphatic Drainage of the abdominal wall above the umbilicus goes to the ipselateral axillary lymph nodes.

Question 3 • Thirty years after having a right open inguinal hernia repair, a 67 year old man with hypertension presents with new onset bulge in his right groin. The bulge is apparent throughout the day and causes discomfort with valsalva. Five years ago, he had a radical retropubic prostatectomy and open cholecystectomy. On Exam, he has a moderately sized reducible right inguinal hernia. The most appropriate next step in management would be: • A) Open Primary Herniorrhapy • B) Open Mesh Hernioplasty • C) Transabdominal Preperitoneal (TAPP) repair • D) Total Extraperitoneal (TEP) repair • E) Watchful Waiting

Question 3 - SESAP

Question 4 • A) systemic Corticosteroids • B) Local injection of Corticosteroids • C) Inguinal Exploration • D) Laparotomy • E) Pubic Ramus Plating

Question 4 - SESAP

Question 5 • Which statement about watchful waiting of inguinal hernia is true? • A) More Likely to limit physical activity due to pain • B) More likely to encounter complications if subsequent repair is required • C) Have a 10% chance of incarceration in 2 years time. • D) More cost effective • E) 20% require operative repair in 2 years

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