INGUINAL HERNIA- SURGICAL ANATOMY

1. GROIN HERNIA
DR.BENOSAMA
DEPARTMENTOFSURGERY
SURGICALANATOMY
06/05/2021

2. OUTLINE
• Definition
• General Considerations
• Surgical anatomy
• Epidemiology
• Etiology
• Classification
• Pathophysiology
• Clinical presentation
• Diagnosis
• Treatment
• Laparascopy and Future
Considerations

3. GENERAL CONSIDERATIONS
• Are the most common conditions s requiring major
surgery
• Have a significant rate of surgical failure
• Requires accurate anatomical knowledge with surgical
skills
• In the US, 96% of hernias are inguinal, 4% femoral,
20% bilateral Indirect hernias are most common in both
sexes
• Male to female ratio is 9:1 for inguinal hernias, 1:3 for

4. DEFINITION
• Abnormal protrusion of a peritoneal lined sac through
the musculoaponeurotic covering of the abdomen

5. INGUINAL HERNIA

6. GENERAL FEATURES
• External- when the sac protrudes completely through
the abdominal wall
• Inter-parietal- the sac is contained in the abdominal
wall
• Internal- the sac is within the visceral cavity
• Reducible vs irreducible

7. SURGICAL ANATOMY

8. POSITION
• The inguinal region (groin) is the
lower part of the anterior
abdominal wall extending between
the ASIS and pubic tubercle

9. SURGICAL IMPORTANCE
• Inguinal region is an important area anatomically and clinically
• Anatomically
• because it is a region where structures exit and enter the abdominal cavity
• Clinically
• because the pathways of exit and entrance are potential sites of herniation

10. WHAT ARE THE POTENTIAL WEAK
AREAS IN THE INGUINAL REGION
• The inguinal region is the weak part of the abdominal wall by the
presence of the:-
• Superficial inguinal ring
• Deep inguinal ring
• Inguinal canal
• Hesselbach’s triangle

12. SUPERFICIAL INGUINALRING
• Triangular opening in the
aponeurosis of the external oblique
muscle
• Lies immediately (1.25cm) above
and medial to the pubic tubercle

13. DEEP INGUINALRING
• U-shaped condensation of the
transversalis fascia
• Lies 1.25cm above the mid-inguinal
point (ASIS  symphisis pubis)
• Lateral to the inferior epigastric
vessels

14. INGUINALCANAL
• Inguinal canal is a tunnel in the
lower abdominal muscles

16. POSITION
• It extends downwards and medially from the deep inguinal ring to the superficial inguinal ring
• It is 3.75-4.0 cm long

17. BOUNDARIES
• Anteriorly
• External oblique aponeurosis
• Posteriorly
• Fascia transversalis+conjoint tendon+
inferior epigastric vessels
• Superiorly
• conjoint muscles (internal oblique
+transversalis )
• Inferiorly
• inguinal ligament

18. CONTENTS
• 3 coverings
• Internal spermatic fascia (derived from transversalis fascia)
• Cremasteric fascia (derived from internal oblique)
• External spermatic fascia (derived from external oblique aponeurosis)
• 3 nerves
• Ilioinguinal nerve
• Genital branch of Genitofemoral nerve
• Sympathetic fibres from T10-11 spinal segments

19. CONTENTS…….
• 3 arteries
• Testicular artery
• Artery of the vas
• Cremasteric artery
• 3 veins
• Pampiniform plexus of veins
• Cremasteric vein
• Vein of the vas
• 3 others
• Vas deferens
• Lymphatic vessels of the testis
• A patent processus vaginalis in patients with indirect hernia

21. HESSELBACH’S TRIANGLE
• Boundaries
• Supero-lateral border
• Inferior epigastric vessels
• Medial border
• The lateral border of the rectus
sheath
• Inferior border
• Inguinal ligament
• Direct hernias occur within the
Hesselbach’s triangle, whereas
indirect inguinal hernias arise
lateral to the triangle

22. EPIDEMIOLOGY
• Incidence
• Morbidity/mortality
• Age
• Sex

23. INCIDENCE
• Worldwide, inguinal Hernias account for up to 75% of all anterior
abdominal hernias
• 2/3 of these are indirect, and the remaining 1/3 are direct inguinal hernias

24. AGE
• Generally, the prevalence of inguinal hernias increases with age
• Indirect hernia is more common in children and young adult while direct hernia is common in elderly
individuals
• Most serious complication of inguinal hernia- 1-3% develop strangulation
• Femoral hernia have the highest rate of complication- 15-20%, repair recommended at the earliest time of
discovery

25. SEX
• Men are 25 times more likely to have a groin hernia than women
• An indirect inguinal hernia is the most common hernia, regardless of gender
• In men, indirect hernias predominate over direct hernias at a ratio of 2:1
• Direct hernias are very uncommon in women

26. ETIOLOGY
• Congenital causes
• Acquired causes

27. CONGENITAL CAUSES
• Developed from preformed hernial sac as a result of persistent processus vaginalis
• All indirect inguinal hernia belongs to this type

28. ACQUIRED CAUSES
•  intra-abdominal pressure
• Chronic cough
• Straining
• Obstructive uropathy
• Chronic constipation
• Lifting heavy objects
• Weakness of abdominal wall due:-
• Acquired deficiency of collagens
• Damage to the ilioingiunal nerve
• Recurrent inguinal hernia

29. CLASSIFICATION
• Etiological classification
• Anatomical classification
• Clinical classification

30. ETIOLOGICAL CLASSIFICATION
• Congenital inguinal hernia
• It is due to persistence of processus vaginalis
• Developed from a pre-formed sac
• Reaches the scrotum very quickly
• All indirect inguinal hernia belongs to this type
• Acquired inguinal hernia
• Occurring later in life as a result of underlying weakness of the abdominal muscles
• Most of direct inguinal hernias are of acquired type

31. ANATOMICAL CLASSIFICATION
• According to its site of exit
• According to the extent of the hernia
• According to the contents

32. ACCORDING TO ITS SITE OF EXIT
• Indirect
• Comes through deep inguinal ring lateral to the inferior
epigastric artery
• Direct
• Comes out through the Hesselbach’s triangle
• The neck of the sac lies medial to the inferior epigastric artery

33. MYOPECTINEAL ORIFICE OF
FRUCHAUD
• According to (Bittner , 2018, p. 31), the boundaries are:
• Superiorly- Arching fibers of the internal oblique and
tranversus abdominus muscles
• Medially- Rectus abdominus muscles and the rectus
sheath
• Inferiorly- Coopers ligament
• Laterally- Iliopsoas muscles
• Th inguinal ligament runs diagonally through the
myopectineal orifice

35. FEATURES OF THE MYOEPITHELIAL
ORIFICE
• 4 cm in length
• 2-4cm cephalad to the inguinal ligament
• Extends between the superficial and deep rings
• Contains the spermatic cord or round ligament

36. ANATOMY OF THE MPO
• Superficially- External oblique
• Superiorly- Conjoint tendon
• Inferiorly-Inguinal ligament
• Floor- Transversalis fascia

37. THE MYOPECTINEAL ORIFICE

38. LAYERS OF MPO
• The skin, subcutaneous, campers, Scarpa, external
spermatic fascia, cremaster, internal spermatic fascia,
preperitoneal tissues, peritoneum

39. HERNIAS BASED ON ANATOMICAL
SITE
• Broadly classified as indirect and direct depending on
relationship to the epigastric vessels
• Hesselbach’s triangle is:
• Lateral- Inferior Epigastric Artery
• Medially-Lateral border of Rectus
• Inferiorly- Inguinal Ligament

40. …
• An indirect hernia passes lateral to the Hesselbach’s
triangle
• A direct hernia passes through the Hesselbach’s
trainagle
• Indirect hernia has a congenial component- from the
processus vaginalis
• The processus is supposed to obliterate after descent
of testes

41. INDIRECT INGUINAL HERNIA

47. DIRECT INGUINAL HERNIA

48. DIRECT INGUINAL HERNIA
• Medial to the inferior epigastric artery and vein, and
within the Hesselbach’s triangle
• Acquired weakness in the inguinal floor
• Usually not congenital
• Acquired by development of tissue deficiencies of the
transversalis facia

49. …
• Development of femoral hernias less understood
• Increased intrabdominal pressures
• The sac then migrates down the femoral vessels into
the thigh

52. NYLUS CLASSIFICATION
• I- indirect, internal ring normal (Kids)
• II- indirect, dilated internal ring
• III- Posterior wall defects, direct inguinal hernia,
dilated inguinal ring, massive scrotal, sliding, femoral
hernia
• IV-Recurrent hernia

53. ACCORDING TO THE EXTENT OF THE HERNIA
• Bubonocele inguinal hernia
• Hernia does not come out the superficial inguinal ring
• Funicular inguinal hernia
• Comes out through the SIR but does not reach the
bottom of the scrotum
• Complete inguinal hernia
• Reaches the bottom of the scrotum

54. ACCORDING TO THE CONTENTS
• Enterocoele (intestines)
• Omentocoele (omentum)
• Cystocoele (urinary bladder)
• Littre’s hernia (Meckel’s diverticulum)
• Richter’s hernia (part of the circumference of the bowel)

55. CLINICAL CLASSIFICATION
• Reducible inguinal hernia
• irreducible inguinal hernia
• Obstructed inguinal hernia
• Strangulated inguinal hernia
• Inflamed inguinal hernia

56. REDUCIBLE INGUINAL HERNIA
• Contents can be easily returned into the abdominal cavity leaving the hernial sac in its position

57. IRREDUCIBLE INGUINAL HERNIA
• Contents cannot be returned to the abdomen
• It is due to :-
• Adhesions of its contents to each other
• Adhesions of its contents with the sac
• Adhesions of one part of the sac to the other part
• Sliding hernia
• Very large scrotal hernia

58. OBSTRUCTED INGUINAL HERNIA
• Irreducible hernia + intestinal obstruction
• No interference with blood supply to the intestine

59. STRANGULATED INGUINAL HERNIA
• Irreducible hernia + interference with blood supply± intestinal obstruction

60. INFLAMED INGUINAL HERNIA
• Rare type
• Occurs when the contents of the hernia become inflamed and present with constitutional symptoms
associated with inflammation e.g. overlying skin become red, edematous, tenderness
• Differs from strangulated hernia not tense and not associated with intestinal obstruction

61. PATHOPHYSIOLOGY
• A hernia consists of 3 parts:-
• The sac
• Coverings
• Contents

62. THE SAC
• This is the diverticulum of peritoneum consisting of a mouth, neck, the body and the fundus
• The mouth
• The neck
• The body
• The fundus

63. COVERINGS
• Derived from the layers of the abdominal wall through which the sac passes

64. CONTENTS
• Omentum (omentocoele)
• Intestine (enterocoele)
• Part of the urinary bladder ( cystocoele)
• Ovaries
• Meckel’s diverticulum (Littre’s hernia)
• Part of the circumference of the intestine (Richter’s hernia)
• Fluids

65. MECHANISMSWHICH PREVENTINGUINALHERNIAFORMATION
• Obliquity of the inguinal canal opposes an intra-abdominal pressure [IAP]
• Shutter mechanisms of the arched fibres of the conjoined muscles opposes an 
IAP as they contact
• Strong fibres of internal oblique in front of the deep inguinal ring prevent herniation
through it
• Strong conjoined tendon in front of Hesselbach’s triangle prevents direct hernia
• Action of the cremaster muscle pulls up the spermatic cord into the canal and plug it
during  IAP

66. PATHOPHYSIOLOGICALCONSEQUENCES OF HERNIA
• Reduced inguinal hernia

• Irreducible inguinal hernia

• Obstructed inguinal hernia

• Strangulated inguinal hernia

67. CLINICAL PRESENTATION
• History
• Physical Examination

68. HISTORY
• Patient characteristics
• Main symptoms

69. PATIENT CHARACTERISTICS
• Age
• Indirect inguinal hernia is common in young individual while direct inguinal hernia is common in the older
• Occupation
• Strenuous work is often responsible for development of hernia

70. MAIN SYMPTOMS
• Inguinal or inguinal swelling; note:-
• How long has the swelling been there?
• How did it start?
• Where did it 1st appear?
• What were the size + extent when it was first
seen?
• Congenital type: reaches the bottom of the
scrotum at its first appearance
• Acquired type: small to start and gradually
descend to reach the bottom of the
scrotum
• Does it disappear automatically on lying
down?

71. PHYSICAL EXAMINATION
• General examination
• Local examination
• Systemic examination

72. GENERAL EXAMINATION
• Commonly normal in uncomplicated hernia
• In pain
• Dehydrated
• Shock
• Etc

73. LOCAL EXAMINATION
• Position and extent
• To get above the swelling
• Consistency
• Impulse on coughing
• Reducibility
• Invagination test
• Ring occlusion test

74. POSITION AND EXTENT
• If the swelling reaches the scrotum or labia
majora it is an obviously inguinal hernia
• When confined to the groin, the hernia needs
to be differentiated from femoral hernia
• Two anatomical landmarks to be considered:
pubic tubercle +inguinalligament
• Inguinal hernia lies above the inguinal
ligament and medial to pubic tubercle
• Femoral hernia lies below the inguinal
ligament and lateral to the pubic tubercle

76. TO GET ABOVE THE SWELLING
• To differentiate scrotal swelling from inguino-scrotal swelling
• The root of the scrotum is held between the thumb in front and other fingers behind in an attempt to reach
above the swelling
• One cannot get above the swelling in case of inguinal hernia, whereas in case of pure scrotal swelling e.g.
Hydrocoele one can get above the swelling

77. CONSISTENCY
• Omentocoele  doughy and granular
• Enterocoele  elastic
• Strangulated hernia  tense and tender

78. IMPULSE ON COUGHING
• When a finger is placed over the SIR or when the root of the scrotum is held
between the index finger and the thumb and the patient asked to cough
an expansile impulse on coughing can be felt as the hernial contents will be
forced out through the SIR in case of reducible hernia
• Impulse on coughing is negative in case of:-
• Irreducible hernia
• Obstructed hernia
• Strangulated hernia

79. REDUCIBILITY
• The hernial contents is squeezed in the abdomen by holding the fundus of the sac gently using one
hand while the other hand is guiding the contents into the superficial inguinal ring

80. INVAGINATION TEST
• After reduction of the hernia one
can perform this test to know the
gap in the superficial inguinal
ring
• A little or the index finger is pushed
up gradually from the bottom of
scrotum to enter the superficial
inguinal ring

81. RING OCCLUSION TEST
• The hernia must be reduced first
• A thumb is placed on the deep inguinal ring i.e. 1.3cm above the mid-inguinal point
• The patient is asked to cough
• A direct hernia will show a budge medial to the occluding finger but an indirect hernia will not find access, so
no budge

82. SYSTEMIC EXAMINATION
• Abdominal examination
• CVS
• RS
• CNS

83. TREATMENT
• Conservative treatment
• Surgical (operation) treatment

84. FEMORAL HERNIA

85. INTRODUCTION
• Third most common (5%) after inguinal (80%),
incisional (10%)
• Highest risk of obstruction due to the narrow femoral
ring

86. FEMORAL CANAL BOUNDARIES
• Anterosuperiorly- Inguinal ligament
• Posteriorly- Pectineal ligament
• Medially- Lacunar ligament
• Lateral- Femoral vein

90. CONSERVATIVE TREATMENT
• No treatment
• Truss

91. NO TREATMENT
• This is indicated in a patient:-
• With severe general ill-health not suitable for anaesthesia
• With chronic bronchitis not cured by medicinal treatment
• With obstructive uropathy
• Who refuses surgery

92. TRUSS
• A truss does not cure a hernia, it is used to prevent the hernia to come out of the
superficial inguinal ring
• The requirements are:-
• The hernia should be easily reducible
• The patient should be reasonably intelligent
• Indications:-
• Very old patients suffering from diseases like chronic bronchitis, obstructive uropathy etc
• Patients who refuses surgery
• In children

93. OPERATIVE TREATMENT
Preoperative care
Type of operations
Postoperative care

94. TYPE OF OPERATIONS
• Open hernial repair
• Laparoscopic hernial repair

95. SURGICAL TECHNIQUES
• Open anterior repair- Bassini, McVay, Shouldice
• Tension-free repair with mesh- Rutkow, Liechtenstein
• Posterior– Laparoscopic, , Open-Nyhus

96. OPEN HERNIAL REPAIR
• Herniotomy
• Herniorrhaphy
• Hernioplasty

97. HERNIOTOMY
• Commonly done in children < 10 years
• No repair of the posterior wall of the inguinal canal
• Patent processus vaginalis ligated at the origin at the internal ring (high ligation)
• Nyhus type I

98. HERNIORRHAPHY
• Herniotomy + repair of the posterior wall
• Nyhus type II and III
• High ligation and reinforcement of the weakness with patient’s own tissue
• Technique include
• Modified Bassini repair
• Shouldice repair
• Lichtenstein mesh repair
• Desarda hernial repair
• Darning hernial repair

100. MODIFIED BASSINI REPAIR
• Suturing the conjoined tendon to the inguinal
ligament

101. SHOULDICE REPAIR
• Multilayer imbricated repair of the
posterior wall of the inguinal canal with a
continuous running suture technique:
• 1st suture line - transversus abdominis
aponeurotic arch to the iliopubic tract
• 2nd line - internal oblique and transversus
abdominis muscles and aponeuroses
(Conjoint) to the inguinal ligament
• 3rd line - Conjoint to Ext. oblique
• 4th line - Conjoint to Ext. oblique

103. 1ST POSTERIOR SUTURE
• 1st posterior suture – Transversus
abdominis to Iliopubic tract

104. 2ND POSTERIOR SUTURE
• 2nd posterior suture –
Int. oblique and
transversus abdominis
to inguinal ligament

105. 3RD POSTERIOR SUTURE
• 3rd posterior suture - Conjoint to
Ext. oblique

106. 4TH POSTERIOR SUTURE
• 4th posterior suture - Conjoint to
Ext. oblique

107. LICHTENSTEIN MESH REPAIR

108. DESARDA HERNIAL REPAIR
The medial leaf of the external oblique
aponeurosis is sutured to the Inguinal
ligament.
1) Medial leaf
2) Interrupted sutures taken to suture the
medial leaf to the inguinal ligament
3) Pubic tubercle
4)Abdominal ring
5) Spermatic cord
6) inguinal ligament

110. HERNIOPLASTY

111. HERNIOPLASTY
• High ligation, inverted sac, and reinforcement of the
defect with synthetic material
• Tension-free
• Lichtenstein

112. TENSION-FREE REPAIR
• Similar approach as anterior repair
• Instead of sewing fascial layers together to repair the
defect, a prosthetic mesh onlay is used
• Suited for local anesthesia with excellent results in
terms of recurrence rate below 4%

115. • Coined by Liechtenstein in 1989
• Central feature is polypropylene mesh over the unrepaired floor
• Gilbert repair uses a cone shaped plug placed through the deep
ring
• Slit placed in mesh for cord structures
• Fixing the mesh to the rectus sheath 1-1.5 cm medial and
superior to pubic tubercle is very important
• A medial suture should be used to secure the surplus mesh
inferiorly

116. OPEN POSTERIOR REPAIR
• Divide the layers of the abdominal wall
superior o the internal ring, enter
preperitoneal space
• Dissection continues behind and deep to the
entire inguinal region
• There are challenges with tension suturing

117. LAPARASCOPIC APPROACHES
• Increasingly popular
• Most performed is TEP or TAPP

118. IMPORTANT TRIANGLES IN
LAPARASCOPY
• Triangle of Doom
• Triangle of Disaster
• Trapezoid of Disaster
• Triangle of Pain ((Bittner , 2018, p. 31)

123. LAPARASCOPIC ANATOMY OF THE
INGUINAL REGION
• Recognize that the parietal peritoneum covers certain structures
forming five ligaments
• These ligaments include the median umbilical ligament, the medial
umbilical ligaments, the lateral umbilical ligaments
• The spatial relationships of these ligaments allow recognition of the
various types of hernias
• A view of the femoral hernia space can be seen below the iliopubic tract
and medial to the femoral vessels exiting through the femoral canal.
During the laparoscopic repair, the direct, indirect, and femoral spaces
should all be covered with mesh (Bittner , 2018, p. 31)

124. ANATOMICAL PRINCIPLES IN
LAPAROSCOPY
• The second important concept concerns the spaces that occur beneath the
peritoneal covering
• The preperitoneal space is the space bounded by the peritoneum posteriorly
and the transversalis fascia anteriorly
• The space of Retzius is that space between the pubis and the bladder
• The lateral extent of this space is named Bogros’ space
• The transversalis fascia forms the floor of the inguinal canal and the
iliopectineal arch, iliopubic tract, and crura of the deep inguinal ring
• The iliopectineal arch divides the vascular compartment (iliac vessels) from
the neuromuscular compartment (iliopsoas muscle, femoral nerve, and the
lateral femoral cutaneous nerve)

125. ANATOMICAL PRINCIPLES IN
LAPARASCOPY
• The iliopubic tract is an aponeurotic band that begins near the anterior superior iliac
spine and inserts on the pubic tubercle medially
• In its medial extent, it contributes to the formation of Cooper’s ligament
• It forms the inferior margin of the deep musculoaponeurotic layer made up of the
transversus abdominis muscle and aponeurosis and the transversalis fascia. Laterally,
it extends to the iliacus and psoas fascia
• It forms with fibers of the transversalis fascia, the anterior margin of the femoral
sheath and the medial border of the femoral ring and canal
• Its lower margin is attached to the inguinal ligament
• The iliopubic tract is an important landmark. Dissection or tacking of preperitoneal
mesh should not take place inferior to the iliopubic tract except in the limited region
of Cooper’s ligament (Yang & Liu, 2016, p. 372)

126. ANATOMICAL PRINCIPLES IN
LAPAROSCOPIC SURGERY

128. ANATOMICAL LANDMARKS IN THE
EXTRAPERITONEAL SPACE

133. LAPARASCOPIC VIEW OF
INGUINAL ANATOMY

134. LAPARASCOPIC VIEW

135. LAPARSCOPCI PROCEDURES
• Great for bilateral hernia, with no increase in morbidity
• For recurrent hernia
• Disadvantages of cost

136. REFERENCES
• Bittner , R. (2018). Laparoscopic view of surgical
anatomy of the groin. International Journal of
Abdominal Wall and Hernia Surgery, 1(1), 24-31.
doi:10.4103/ijawhs.ijawhs_1_18
• Yang, X.-F., & Liu, J.-L. (2016). Anatomy essentials for
laparoscopic inguinal hernia repair. Annals of
Translational Medicine, 372.