Inguinal hernia
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Inguinal hernia

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Brief description of inguinal hernia anatomy, pathophysiology and surgery options

Brief description of inguinal hernia anatomy, pathophysiology and surgery options

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  • 1. Inguinal Hernia: Options for Surgery Syed Fahad Ali Zaidi PGR SU II BBH
  • 2. Incidence • Approximately 700,000 hernia repairs are performed as an outpatient procedure each year • Approximately 75% of all hernias occur in the inguinal region • Approximately 50% of hernias are indirect inguinal hernias • A vast majority occur in males • Hernias more commonly occur on the right side
  • 3. The Anatomy
  • 4. Historical Hernias Hernias have been documented throughout history with varying success at either reduction or repair.
  • 5. Trusses & Techniques
  • 6. Anatomic Considerations • The inguinal region must be understood with regard to its three-dimensional configuration • A knowledge of the convergence of tissue planes is essential • If repairing the hernia laparoscopically, the anatomy must be well understood from the peritoneal surface outward • There is a considerable amount of anatomic variability with regard to: o Size and location of the hernia o Degree of adipose tissue
  • 7. Pelvic & Inguinal Anatomy • Both the ilioinguinal nerve and the genitofemoral nerve traverse the usual hernia-repair operative field. The femoral vein also runs just deep to the inguinal floor laterally.
  • 8. Myopectineal Orifice of Fruchaud The MPO is bordered: • Above by the arching fibers of the internal oblique and transversus abdominus Muscles, • Medially by the Rectus Abdominus Muscle and its fascial Rectus Sheath • Inferiorly by Coopers Ligament, and • Laterally by the Ileopsoas Muscle • Running diagonally thru the MPO is the inguinal ligament
  • 9. Myopectineal Orifice of Fruchaud
  • 10. Hesselbach's triangle Boundaries: Medial: Rectus abdominis muscle medially, Inferiorly: Inguinal ligament Laterally: Inf. Epigastrics
  • 11. Diagnosis • The patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal region • They may describe minor pain or vague discomfort associated with the bulge • Extreme pain usually represents incarceration with intestinal vascular compromise • Paresthesias may be present if inguinal nerves are compressed
  • 12. Diagnosis • Physical exam o The patient should be standing and facing the examiner o Visual inspection may reveal a loss of symmetry in the inguinal area or bulge o Having the patient perform valsalva’s maneuver or cough may accentuate the bulge o A fingertip is then placed in the inguinal canal; Valsalva maneuver is repeated o Differentiation between indirect and direct hernias at the time of examination is not essential
  • 13. Nyhus Classification • Type I: Indirect inguinal hernia Internal inguinal ring normal (simple pediatric hernia) • Type II: Indirect inguinal hernia Internal inguinal ring dilated but posterior inguinal wall intact (inferior deep epigastric vessels not displaced)
  • 14. Nyhus Classification • Type III: Posterior wall defect o A. Direct inguinal hernia o B. Indirect inguinal hernia- internal inguinal ring dilated (massive scrotal or sliding hernia) o C. Femoral hernia • Type IV: Recurrent hernia o o o o A. Direct B. Indirect C. Femoral D. Combined
  • 15. Inguinal Hernia • Indirect inguinal hernia o Is a congenital lesion o Occurs when bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalis o If the processus vaginalis does not remain patent an indirect hernia cannot develop o Most common type of hernia
  • 16. Indirect Hernia Route Note: The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.
  • 17. Inguinal Hernia • Direct inguinal hernia o Proceeds directly through the posterior inguinal wall o Direct hernias protrude medial to the inferior epigastric vessels and are not associated with the processus vaginalis o They are generally believed to be acquired lesions o Usually occur in older males as a result of pressure and tension on the muscles and fascia
  • 18. Direct Hernia Route Note: The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.
  • 19. Specific Surgical Procedures • Lichenstein (Tension Free) Repair • McVay (Cooper’s Ligament) Repair • Halstead’s Repair • Shouldice (Canadian) Repair • Laproscopic Hernia Repair • Bassini Repair
  • 20. Bassini Repair o Is frequently used for indirect inguinal hernias and small direct hernias o The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
  • 21. McVay Repair • AKA: Cooper’s ligament Repair o Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias o The conjoined tendon is sutured to Cooper’s ligament from the pubic tubercle laterally to femoral vein, and to inguinal ligament laterally from here
  • 22. McVay Repair This repair reconstructs the inguinal canal without using a mesh prosthesis. • It requires a relaxing incision •
  • 23. Halstead’s Repair • In this repair, (which otherwise resembles Bassini) external oblique aponeurosis is used to strengthen the posterior wall. • This exteriorizes the spermatic cord, placing it beneath the layers of abdominal wall facia
  • 24. Halstead’s Repair • Technique not appreciated because of high incidence of hydrocoels, and testicular atrophy as well as recurrence post-operatively.
  • 25. Shouldice Repair • AKA: Canadian Repair o A primary repair of the hernia defect with 4 overlapping layers of tissue. o Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.
  • 26. Shouldice Repair
  • 27. Shouldice Repair • At the shouldice hospital, steel wires are used for the closure of all layers upto subcutaneous fat, and recurrence rates of less than one percent are reported • Other centers which practiced this technique do not report similar success rates
  • 28. Lichtenstein Repair AKA: Tension-Free Repair • One of the most commonly performed procedures • A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord
  • 29. Lichtenstein Repair Note: Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.
  • 30. Other repairs using Mesh • Patch & plug technique involvs placementof a preformed mesh plug in the hernia defect that is sutured to the facial margins of defect. • Stoppa ‘s Repair uses posterior approach for implanting a mesh in the preperitoneal plane without closing peritoneal defect per se • Kugel’s repair is a preperitoneal repair in which a preformed mesh with a stiff ring around the edges is placed in the preperitoneal space.
  • 31. Laparoscopic Hernia Repair o Early attempts resulted in exceptionally high reoccurrence rates o Current techniques include • Transabdominal preperitoneal repair (TAPP) • Totally extraperitoneal approach (TEPA)
  • 32. 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.
  • 33. Laparoscopic Mesh Repair
  • 34. TAPP Repair
  • 35. TEP Repair
  • 36. • Contraindication to laparoscopic repair is : o Patients with large inguinoscrotal hernias o Patients with previous abdominal surgeries