3. 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
9. 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
10. 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
22. Preperitoneal space
Space of Retzius
Space of Bogros
Inf. Epigastric
Vas deferens
the lateral femoral
cutaneous nerve
the genitofemoral
nerve.
23. Management
Uncomplicated hernias require either :
No treatment
Support with a truss
Operative treatment
complicated hernias :
always require surgery, often urgently.
26. Surgical approaches
For any hernia the surgical option
comprises 2 components :
Herniotomy
Herniorrhaphy or hernioplasty
It is either :
Open repair
Laparascopic repair
27. 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
30. Types of open repair
Repairing the floor of the inguinal canal :
Bassinirepair
Shouldice repair
Tension free mesh repair
31. 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.
32. 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.
33. 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.
34. 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.
35. Shouldice repair
The cord is replaced within the inguinal
canal, and the external inguinal
aponeurosis is reapproximated with
continuous 2-0 absorbable sutures
36.
37.
38.
39.
40.
41. 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.
49. 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
50. 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
52. 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.
53. Laparoscopic Approaches
Laparoscopic repair is done by 2
approaches :
1. Transabdominal preperitoneal “TAPP”
2. Totally extraperitoneally “TEP”
54. 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.
55. 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.
