SURGICAL OPTIONS IN
THE MANAGEMENT OF
INGUINAL HERNIAS
Mohammed Al-Saffar

outlines
 Definition
 Epidemiology
 Anatomy
 Surgical management options

Hernia
 A hernia is defined as an abnormal
protrusion of an organ or tissue through a
defect in its surrounding walls.
 Groin hernia
 Inguinal
 Direct
 Indirect
 femoral

Epidemiology

Epidemiology

Predisposing factors

Epidemiology
 Bimodal peak age : < 1 year then > 40
years
 Right-sided groin hernias are more
common than those on the left.

Types of hernia - Condition

Inguinal Canal Anatomy
 No disease of the human body, belonging
to the province of the surgeon, requires in
its treatment a better combination of
accurate, anatomical knowledge with
surgical skill than Hernia in all its varieties.
Sir Astley Cooper, 1804

Inguinal Canal Anatomy
 The inguinal canal is an oblique space
measuring 4 cm in length that lies above
the medial half of the inguinal ligament.
 Inguinal canal has 4 walls : anterior,
posterior, roof, and floor

Important ligaments

Contents of the inguinal canal
 Males : spermatic cord and ilioinguinal
nerve
 Females : round ligament and the
ilioinguinal nerve

The spermatic cord
 It consists of
 Three coverings
 Three arteries
 Three other structures.
 Nerves

The Spermatic Cord

Preperitoneal space
 Space of Retzius
 Space of Bogros
 Inf. Epigastric
 Vas deferens
 the lateral femoral
cutaneous nerve
 the genitofemoral
nerve.

Management
 Uncomplicated hernias require either :
 No treatment
 Support with a truss
 Operative treatment
 complicated hernias :
 always require surgery, often urgently.

Should we repair ?
Inguinal hernia :
should we repair ?

Inguinal hernia : should we
repair ?

Surgical approaches
 For any hernia the surgical option
comprises 2 components :
 Herniotomy
 Herniorrhaphy or hernioplasty
 It is either :
 Open repair
 Laparascopic repair

Surgery
 Surgery aims to
 Reduce the hernial contents
 Excise the sac (herniotomy) in most cases
 Repair and close the defect either by
herniorrhaphy or hernioplasty

Components of the hernia

Hernial Sac Dissection

Types of open repair
 Repairing the floor of the inguinal canal :
 Bassinirepair
 Shouldice repair
 Tension free mesh repair

Bassini repair
 The conjoined tendon is retracted upward
 the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract
that lies adjacent to the inguinal ligament
with several interrupted 3-0 silk sutures.
 The second layer of the repair involves
suturing the conjoined tendon to the inguinal
ligament with interrupted 2-0 silk sutures.
 This suture line extends from the pubic
tubercle to the medial border of the internal
ring.

Shouldice Repair
 With a no. 15 scalpel an incision is made in
the transversalis fascia. This incision is
extended from the internal ring to the
pubic tubercle.
 The repair involves placing four lines of
sutures.

Shouldice repair
 The first suture line
 is started at the pubic tubercle using 3-0
continuous polypropylene, and the white line is
approximated to the free edge of the inferior
transversalis fascial flap.
 The 2nd suture line :
 At the internal ring the suture is tied and then
continued medially by approximating the free
edge of the superior flap to the shelving edge of
the inguinal ligament. When the pubic tubercle is
reached, the suture is tied and divided.

Shouldice repair
 The third suture line is started at the level of
the internal ring where the conjoined
tendon is approximated to the inguinal
ligament and tied when the pubic
tubercle is reached.
 Using the same suture, the fourth suture
line attaches these same structures to one
another and is tied at the level of the
internal ring.

Shouldice repair
 The cord is replaced within the inguinal
canal, and the external inguinal
aponeurosis is reapproximated with
continuous 2-0 absorbable sutures

Tension – free repair
 There are several options for placement of
mesh during anterior inguinal
herniorrhaphy, including
 The Lichtenstein approach
 The plug-and-patch technique
 The sandwich technique with both an
anterior and preperitoneal piece of mesh.

Tension – free repair

Tension – free repair

Prolene hernial system

Comparison of open approachs

Recurrence rate “ PGY “

Laparoscopic Repair

Indications for laparoscopic
repair
 Bilateral inguinal hernia
 When the diagnosis of inguinal hernia is
uncertain
 When the patient want to return to normal
physical life

Contraindications
 The patient medical condition makes
general anesthesia more risky
 Patient who have planned pelvic or
extraperitoneal operations (eg, radical
prostatectomy)
 Patient who have had a recurrence from
a prior laparoscopic repair
 Patient presented with strangulated hernia

Advantages of laparoscopic
 Less acute postoperative pain
 Shorter convalescence
 Earlier return to work

Disadvantages
 increased risk of femoral nerve injury and
 Increased risk of spermatic cord damage
 risk of developing intraperitoneal
adhesions with the TAPP
 greater cost and duration of the
operation.

Laparoscopic Approaches
 Laparoscopic repair is done by 2
approaches :
1. Transabdominal preperitoneal “TAPP”
2. Totally extraperitoneally “TEP”

Transabdominal Preperitoneal
 The TAPP approach, first described by
Arregui and colleagues in 1992
 It requires laparoscopic access into the
peritoneal cavity and placement of mesh
in the preperitoneal space after reducing
the hernia sac.

Totally extraperitoneally
 The first TEP inguinal hernia repair was
described by McKernan and Laws in1993.
 This approach involves preperitoneal
dissection and mesh placement without
entering into the abdominal cavity.

The Mercedes Benz sign

Thank You

Complication
 Urinary retention
 Nerve injury
 Testicular ischemia and atrophy
 Injury to vas deferens
 recurrence