Groin HerniasSameh Shehata
Definition Abnormal protrusion of a peritoneal linedsac thru the musculoaponeurotic coveringof the abdomen
Introduction In US 96% are inguinal, 4% femoral 20% bilateral Most common in both sexes indirect. Femoral hernias more...
Myopectineal Orifice of FruchaudThe MPO is bordered: Above by the arching fibers of the internaloblique and transversus a...
Myopectineal Orifice of Fruchaud
Anatomy 4cm in length 2-4 cm cephalad to inguinal ligament Extends between superficial and deeprings Contains spermati...
Anatomy Bounded superficially by external oblique Cephalad by conjoint tendon Inferior border is inguinal ligament Flo...
Layers Skin, subcutaneous, campers, scarpa,external spermatic fascia, cremaster,, intspermatic fascia , preperitoneal tis...
Anatomy Broadly classified as indirect and directdepending on relationship to epigastricvessels. Hesselbach’s triangle i...
Anatomy An indirect hernia passes lateral toHesselbach’s triangle. A direct hernia passes thru Hesselbach’striangle. In...
Hesselbach’s Triangle
Indirect Inguinal hernia Abdominal contents protrude through internal inguinalring
Indirect Hernia
Indirect Inguinal Hernia Accepted hypothesis:incomplete or defectiveobliteration of theprocessus vaginalis duringthe feta...
15
Direct Hernia
Direct Inguinal Hernia
Direct Inguinal Hernia Medial to the inferiorepigastric artery and vein,and within Hesselbachstriangle acquired weakness...
Anatomy Direct hernias are usually not congenital. Acquired by the development of tissuedeficiencies of the transversali...
Anatomy Inguinal ligament(Poupart’s) – inferior edgeof external oblique Lacunar ligament –triangular extension of theing...
Inguinal herniaMale inguinal hernia Female inguinal hernia
Nyhus Classification I indirect, internal ring normal (kids) II indirect, dilated internal ring III posterior wall defe...
Terminology Reducible – can be replaced withinsurrounding musculature Incarcerated – cannot be reduced Strangulated – c...
24Hernia complicationsBowel obstruction: usually not partial,look at groinIrreducibility .Strangulation: serious, life-...
Epidemiology Prevelance of hernias increases with age Most serious complication – strangulation 1 to 3% of groin hernia...
Treatment
27
28History 1stcentury: Surgical treatment 15thcentury: Castration with wound cauterization orhernia sac debridement with ...
History 1881: French surgeon, Lucas-Championni re: high ligation of indirectѐinguinal hernia 1844-1924: Edoardo Bassini ...
Father of Modern Inguinal Hernia RepairEDUARDO BASSINI
Surgical Techniques Open anterior repair (Bassini, McVay,Shouldice). Tension-free repair withmesh(Liechtenstein, Rutkow)
 Posterior repair Open : Nyhus Laparoscopic
Open anterior repair Herniotomy Herniorrhaphy (repair) Hernioplasty .
34Herniotomy Patent processus vaginalis ligated atorigin at internal ring (high ligation) Nyhus type I Children
35Herniorrhaphy Nyhus type II and III High ligation + reinforced area ofweakness with patient’s own tissue Bassini, Sho...
36Bassini repair Transversus abdominis aponeurosis +transversalis fascia  inguinalligament with nonabsorbableinterrupted...
37Shouldice repair 4 rows of suture
38McVay repair Inguinal and femoral hernias,Transversus abdominis aponeurosis +transversalis fascia  Cooper’sligament + ...
39Hernioplasty High ligation, inverted sac + reinforcedefect with synthetic material Tension-free Lichtenstein Recurre...
Tension-Free Repair Same initial approach as anterior repair Instead of sewing fascial layers togetherto repair defect, ...
Techniques Coined by Liechtenstein in 1989 Central feature is polypropylene meshover unrepaired floor. Gilbert repair u...
Techniques Suturing the mesh to the inguinal ligamentis not important. Fixing the mesh to the rectus sheath 1-1.5cm medi...
Open Posterior Repair Divide the layers of the abdominal wallsuperior to the internal ring, enterpreperitoneal space. Dis...
Laparoscopic Procedures Increasingly popular, controversial Early in the development, hernias wererepaired by placing ve...
Laparoscopic Mesh RepairNote:Viewed from inside thepelvis toward the directand indirect sites. Abroad portion of mesh isst...
Laparoscopic Procedures The argued advantage of theseprocedures was less pain and disability,faster return to work. Grea...
RecurrenceType of repair RecurrenceMcVay 9%Shouldice 7-11%Liechtenstein 0-4%Laparoscopic 0-1%
Groin hernia 4th year
Groin hernia 4th year
Groin hernia 4th year
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Groin hernia 4th year

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  • -through which intra-abdominal contents may herniate -where descent of the gonads occurs later during fetal development.)
  • This structure is posterior to the iliopubic tract and forms the posterior border of the femoral canal
  • (more in large hernias that have small necks obstructing arterial flow and/or venous drainage)
  • (increases with age)
  • Bassini revolutionized the surgical repair of the groin hernia with his novel anatomical dissection and low recurrence rates – first operation in 1884
  • Groin hernia 4th year

    1. 1. Groin HerniasSameh Shehata
    2. 2. Definition Abnormal protrusion of a peritoneal linedsac thru the musculoaponeurotic coveringof the abdomen
    3. 3. Introduction In US 96% are inguinal, 4% femoral 20% bilateral Most common in both sexes indirect. Femoral hernias more common in elderlyfemales Male to female ratio in 9:1 for inguinalhernias, 1:3 for femoral hernias
    4. 4. Myopectineal Orifice of FruchaudThe MPO is bordered: Above by the arching fibers of the internaloblique and transversus abdominus Muscles, Medially (towards the center or to the right) bythe Rectus Abdominus Muscle and its fascialRectus Sheath Inferiorly by Coopers Ligament, and Laterally by the Ileopsoas Muscle Running diagonally thru the MPO is theinguinal ligament
    5. 5. Myopectineal Orifice of Fruchaud
    6. 6. Anatomy 4cm in length 2-4 cm cephalad to inguinal ligament Extends between superficial and deeprings Contains spermatic cord or roundligament
    7. 7. Anatomy Bounded superficially by external oblique Cephalad by conjoint tendon Inferior border is inguinal ligament Floor is transversalis fascia
    8. 8. Layers Skin, subcutaneous, campers, scarpa,external spermatic fascia, cremaster,, intspermatic fascia , preperitoneal tissues,peritoneum
    9. 9. Anatomy Broadly classified as indirect and directdepending on relationship to epigastricvessels. Hesselbach’s triangle is inferior epigastricartery laterally, lateral border of rectusmedially, inguinal ligament inferiorly.
    10. 10. Anatomy An indirect hernia passes lateral toHesselbach’s triangle. A direct hernia passes thru Hesselbach’striangle. Indirect hernia has a congenitalcomponent, from processus vaginalis. The processus is supposed to obliterateafter descent of testes.
    11. 11. Hesselbach’s Triangle
    12. 12. Indirect Inguinal hernia Abdominal contents protrude through internal inguinalring
    13. 13. Indirect Hernia
    14. 14. Indirect Inguinal Hernia Accepted hypothesis:incomplete or defectiveobliteration of theprocessus vaginalis duringthe fetal period remnant layer ofperitoneum forms a sacat the internal ring more frequently on theright
    15. 15. 15
    16. 16. Direct Hernia
    17. 17. Direct Inguinal Hernia
    18. 18. Direct Inguinal Hernia Medial to the inferiorepigastric artery and vein,and within Hesselbachstriangle acquired weakness in theinguinal floor
    19. 19. Anatomy Direct hernias are usually not congenital. Acquired by the development of tissuedeficiencies of the transversalis fascia. Development of femoral hernia lessunderstood. Can result from increasedintraabdominal pressure. The sac thenmigrates down the femoral vessels intothigh.
    20. 20. Anatomy Inguinal ligament(Poupart’s) – inferior edgeof external oblique Lacunar ligament –triangular extension of theinguinal ligament beforeits insertion upon the pubictubercle conjoined tendon (5-10%)-Internal oblique fuses withtransversus abdominisaponeurosis Cooper’s Ligament -formed by the periosteumand fascia along thesuperior ramus of the pubis.
    21. 21. Inguinal herniaMale inguinal hernia Female inguinal hernia
    22. 22. Nyhus Classification I indirect, internal ring normal (kids) II indirect, dilated internal ring III posterior wall defects, direct inguinalhernia, dilated internal ring, massivescrotal, sliding, femoral hernia IV recurrent hernia
    23. 23. Terminology Reducible – can be replaced withinsurrounding musculature Incarcerated – cannot be reduced Strangulated – compromised blood supply toits contents
    24. 24. 24Hernia complicationsBowel obstruction: usually not partial,look at groinIrreducibility .Strangulation: serious, life-threatening Inflammation.
    25. 25. Epidemiology Prevelance of hernias increases with age Most serious complication – strangulation 1 to 3% of groin hernias Femoral – highest rate of complications 15% to20% recommended all be repaired at time of discovery
    26. 26. Treatment
    27. 27. 27
    28. 28. 28History 1stcentury: Surgical treatment 15thcentury: Castration with wound cauterization orhernia sac debridement with secondary healing Early 18thcentury: Sir Astley Cooper:recommended truss > surgery, only instrangulation
    29. 29. History 1881: French surgeon, Lucas-Championni re: high ligation of indirectѐinguinal hernia 1844-1924: Edoardo Bassini (father ofmodern inguinal hernia surgery): highligation and reconstruction of inguinal floor
    30. 30. Father of Modern Inguinal Hernia RepairEDUARDO BASSINI
    31. 31. Surgical Techniques Open anterior repair (Bassini, McVay,Shouldice). Tension-free repair withmesh(Liechtenstein, Rutkow)
    32. 32.  Posterior repair Open : Nyhus Laparoscopic
    33. 33. Open anterior repair Herniotomy Herniorrhaphy (repair) Hernioplasty .
    34. 34. 34Herniotomy Patent processus vaginalis ligated atorigin at internal ring (high ligation) Nyhus type I Children
    35. 35. 35Herniorrhaphy Nyhus type II and III High ligation + reinforced area ofweakness with patient’s own tissue Bassini, Shouldice, McVay
    36. 36. 36Bassini repair Transversus abdominis aponeurosis +transversalis fascia  inguinalligament with nonabsorbableinterrupted sutures
    37. 37. 37Shouldice repair 4 rows of suture
    38. 38. 38McVay repair Inguinal and femoral hernias,Transversus abdominis aponeurosis +transversalis fascia  Cooper’sligament + iliopubic tract
    39. 39. 39Hernioplasty High ligation, inverted sac + reinforcedefect with synthetic material Tension-free Lichtenstein Recurrent rate 0.1%
    40. 40. Tension-Free Repair Same initial approach as anterior repair Instead of sewing fascial layers togetherto repair defect, a prosthetic mesh onlayused Simple to learn, easy to perform, suited forlocal anesthesia, excellent results withrecurrence less than 4%.
    41. 41. Techniques Coined by Liechtenstein in 1989 Central feature is polypropylene meshover unrepaired floor. Gilbert repair uses a cone shaped plugplaced thru deep ring. Slit placed in mesh for cord structures
    42. 42. Techniques Suturing the mesh to the inguinal ligamentis not important. Fixing the mesh to the rectus sheath 1-1.5cm medial and superior to the pubictubercle is very important. Should have a surplus of mesh overinguinal ligament, the medial sutureensures surplus mesh inferiorly
    43. 43. Open Posterior Repair Divide the layers of the abdominal wallsuperior to the internal ring, enterpreperitoneal space. Dissection continuesbehind and deep to the entire inguinalregion. Suture tension problems.
    44. 44. Laparoscopic Procedures Increasingly popular, controversial Early in the development, hernias wererepaired by placing very large mesh overentire inguinal region on top of theperitoneum. Was abandoned because ofcontact with bowel. Today, most performed TEP or TAPP
    45. 45. Laparoscopic Mesh RepairNote:Viewed from inside thepelvis toward the directand indirect sites. Abroad portion of mesh isstapled to span bothhernia defects. Staplesare not used inproximity toneurovascularstructures.
    46. 46. Laparoscopic Procedures The argued advantage of theseprocedures was less pain and disability,faster return to work. Great for bilateral hernia, with no increasein morbidity. For recurrent hernia Disadvantages are cost, time.
    47. 47. RecurrenceType of repair RecurrenceMcVay 9%Shouldice 7-11%Liechtenstein 0-4%Laparoscopic 0-1%

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