3. Introduction
īŽ In US 96% are inguinal, 4% femoral
īŽ 20% bilateral
īŽ Most common in both sexes indirect.
īŽ Femoral hernias more common in elderly
females
īŽ Male to female ratio in 9:1 for inguinal
hernias, 1:3 for femoral hernias
4. Myopectineal Orifice of Fruchaud
The MPO is bordered:
īŽ Above by the arching fibers of the internal
oblique and transversus abdominus Muscles,
īŽ Medially (towards the center or to the right) by
the Rectus Abdominus Muscle and its fascial
Rectus Sheath
īŽ Inferiorly by Coopers Ligament, and
īŽ Laterally by the Ileopsoas Muscle
īŽ Running diagonally thru the MPO is the
inguinal ligament
6. Anatomy
īŽ 4cm in length
īŽ 2-4 cm cephalad to inguinal ligament
īŽ Extends between superficial and deep
rings
īŽ Contains spermatic cord or round
ligament
7. Anatomy
īŽ Bounded superficially by external oblique
īŽ Cephalad by conjoint tendon
īŽ Inferior border is inguinal ligament
īŽ Floor is transversalis fascia
8. Layers
īŽ Skin, subcutaneous, campers, scarpa,
external spermatic fascia, cremaster,, int
spermatic fascia , preperitoneal tissues,
peritoneum
9. Anatomy
īŽ Broadly classified as indirect and direct
depending on relationship to epigastric
vessels.
īŽ Hesselbachâs triangle is inferior epigastric
artery laterally, lateral border of rectus
medially, inguinal ligament inferiorly.
10. Anatomy
īŽ An indirect hernia passes lateral to
Hesselbachâs triangle.
īŽ A direct hernia passes thru Hesselbachâs
triangle.
īŽ Indirect hernia has a congenital
component, from processus vaginalis.
īŽ The processus is supposed to obliterate
after descent of testes.
14. Indirect Inguinal Hernia
īŽ Accepted hypothesis:
incomplete or defective
obliteration of the
processus vaginalis during
the fetal period
īŽ remnant layer of
peritoneum forms a sac
at the internal ring
īŽ more frequently on the
right
18. Direct Inguinal Hernia
īŽ Medial to the inferior
epigastric artery and vein,
and within Hesselbach's
triangle
īŽ acquired weakness in the
inguinal floor
19. Anatomy
īŽ Direct hernias are usually not congenital.
īŽ Acquired by the development of tissue
deficiencies of the transversalis fascia.
īŽ Development of femoral hernia less
understood. Can result from increased
intraabdominal pressure. The sac then
migrates down the femoral vessels into
thigh.
20. AnatomyīŽ Inguinal ligament
(Poupartâs) â inferior edge
of external oblique
īŽ Lacunar ligament â
triangular extension of the
inguinal ligament before
its insertion upon the pubic
tubercle
īŽ conjoined tendon (5-10%)-
Internal oblique fuses with
transversus abdominis
aponeurosis
īŽ Cooperâs Ligament -
formed by the periosteum
and fascia along the
superior ramus of the pubis.
22. Nyhus Classification
īŽ I indirect, internal ring normal (kids)
īŽ II indirect, dilated internal ring
īŽ III posterior wall defects, direct inguinal
hernia, dilated internal ring, massive
scrotal, sliding, femoral hernia
īŽ IV recurrent hernia
23. Terminology
īŽ Reducible â can be replaced within
surrounding musculature
īŽ Incarcerated â cannot be reduced
īŽ Strangulated â compromised blood supply to
its contents
25. Epidemiology
īŽ Prevelance of hernias increases with age
īŽ Most serious complication â strangulation
īŽ 1 to 3% of groin hernias
īŽ Femoral â highest rate of complications 15% to
20%
īŽ recommended all be repaired at time of discovery
28. 28
History
īŽ 1st
century: Surgical treatment
īŽ 15th
century: Castration with wound cauterization or
hernia sac debridement with secondary healing
īŽ Early 18th
century: Sir Astley Cooper:
recommended truss > surgery, only in
strangulation
29. History
īŽ 1881: French surgeon, Lucas-
Championni re: high ligation of indirectŅ
inguinal hernia
īŽ 1844-1924: Edoardo Bassini (father of
modern inguinal hernia surgery): high
ligation and reconstruction of inguinal floor
35. 35
Herniorrhaphy
īŽ Nyhus type II and III
īŽ High ligation + reinforced area of
weakness with patientâs own tissue
īŽ Bassini, Shouldice, McVay
36. 36
Bassini repair
īŽ Transversus abdominis aponeurosis +
transversalis fascia ī inguinal
ligament with nonabsorbable
interrupted sutures
39. 39
Hernioplasty
īŽ High ligation, inverted sac + reinforce
defect with synthetic material
īŽ Tension-free
īŽ Lichtenstein
īŽ Recurrent rate 0.1%
40. Tension-Free Repair
īŽ Same initial approach as anterior repair
īŽ Instead of sewing fascial layers together
to repair defect, a prosthetic mesh onlay
used
īŽ Simple to learn, easy to perform, suited for
local anesthesia, excellent results with
recurrence less than 4%.
41.
42.
43. Techniques
īŽ Coined by Liechtenstein in 1989
īŽ Central feature is polypropylene mesh
over unrepaired floor.
īŽ Gilbert repair uses a cone shaped plug
placed thru deep ring.
īŽ Slit placed in mesh for cord structures
44. Techniques
īŽ Suturing the mesh to the inguinal ligament
is not important.
īŽ Fixing the mesh to the rectus sheath 1-
1.5cm medial and superior to the pubic
tubercle is very important.
īŽ Should have a surplus of mesh over
inguinal ligament, the medial suture
ensures surplus mesh inferiorly
45. Open Posterior Repair
īŽ Divide the layers of the abdominal wall
superior to the internal ring, enter
preperitoneal space. Dissection continues
behind and deep to the entire inguinal
region.
īŽ Suture tension problems.
46. Laparoscopic Procedures
īŽ Increasingly popular, controversial
īŽ Early in the development, hernias were
repaired by placing very large mesh over
entire inguinal region on top of the
peritoneum. Was abandoned because of
contact with bowel.
īŽ Today, most performed TEP or TAPP
47.
48. Laparoscopic Mesh Repair
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.
49. Laparoscopic Procedures
īŽ The argued advantage of these
procedures was less pain and disability,
faster return to work.
īŽ Great for bilateral hernia, with no increase
in morbidity.
īŽ For recurrent hernia
īŽ Disadvantages are cost, time.
-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 â first operation in 1884