-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 – first operation in 1884
Groin hernia 4th year
Groin HerniasSameh Shehata
Definition Abnormal protrusion of a peritoneal linedsac thru the musculoaponeurotic coveringof the abdomen
Introduction In US 96% are inguinal, 4% femoral 20% bilateral Most common in both sexes indirect. Femoral hernias more common in elderlyfemales Male to female ratio in 9:1 for inguinalhernias, 1:3 for femoral hernias
Myopectineal Orifice of FruchaudThe MPO is bordered: Above by the arching fibers of the internaloblique and transversus abdominus Muscles, Medially (towards the center or to the right) bythe Rectus Abdominus Muscle and its fascialRectus Sheath Inferiorly by Coopers Ligament, and Laterally by the Ileopsoas Muscle Running diagonally thru the MPO is theinguinal ligament
Anatomy Broadly classified as indirect and directdepending on relationship to epigastricvessels. Hesselbach’s triangle is inferior epigastricartery laterally, lateral border of rectusmedially, inguinal ligament inferiorly.
Anatomy An indirect hernia passes lateral toHesselbach’s triangle. A direct hernia passes thru Hesselbach’striangle. Indirect hernia has a congenitalcomponent, from processus vaginalis. The processus is supposed to obliterateafter descent of testes.
Indirect Inguinal Hernia Accepted hypothesis:incomplete or defectiveobliteration of theprocessus vaginalis duringthe fetal period remnant layer ofperitoneum forms a sacat the internal ring more frequently on theright
Direct Inguinal Hernia Medial to the inferiorepigastric artery and vein,and within Hesselbachstriangle acquired weakness in theinguinal floor
Anatomy Direct hernias are usually not congenital. Acquired by the development of tissuedeficiencies of the transversalis fascia. Development of femoral hernia lessunderstood. Can result from increasedintraabdominal pressure. The sac thenmigrates down the femoral vessels intothigh.
Anatomy Inguinal ligament(Poupart’s) – inferior edgeof external oblique Lacunar ligament –triangular extension of theinguinal ligament beforeits insertion upon the pubictubercle conjoined tendon (5-10%)-Internal oblique fuses withtransversus abdominisaponeurosis Cooper’s Ligament -formed by the periosteumand fascia along thesuperior ramus of the pubis.
Nyhus Classification I indirect, internal ring normal (kids) II indirect, dilated internal ring III posterior wall defects, direct inguinalhernia, dilated internal ring, massivescrotal, sliding, femoral hernia IV recurrent hernia
Terminology Reducible – can be replaced withinsurrounding musculature Incarcerated – cannot be reduced Strangulated – compromised blood supply toits contents
24Hernia complicationsBowel obstruction: usually not partial,look at groinIrreducibility .Strangulation: serious, life-threatening Inflammation.
Epidemiology Prevelance of hernias increases with age Most serious complication – strangulation 1 to 3% of groin hernias Femoral – highest rate of complications 15% to20% recommended all be repaired at time of discovery
38McVay repair Inguinal and femoral hernias,Transversus abdominis aponeurosis +transversalis fascia Cooper’sligament + iliopubic tract
39Hernioplasty High ligation, inverted sac + reinforcedefect with synthetic material Tension-free Lichtenstein Recurrent rate 0.1%
Tension-Free Repair Same initial approach as anterior repair Instead of sewing fascial layers togetherto repair defect, a prosthetic mesh onlayused Simple to learn, easy to perform, suited forlocal anesthesia, excellent results withrecurrence less than 4%.
Techniques Coined by Liechtenstein in 1989 Central feature is polypropylene meshover unrepaired floor. Gilbert repair uses a cone shaped plugplaced thru deep ring. Slit placed in mesh for cord structures
Techniques Suturing the mesh to the inguinal ligamentis not important. Fixing the mesh to the rectus sheath 1-1.5cm medial and superior to the pubictubercle is very important. Should have a surplus of mesh overinguinal ligament, the medial sutureensures surplus mesh inferiorly
Open Posterior Repair Divide the layers of the abdominal wallsuperior to the internal ring, enterpreperitoneal space. Dissection continuesbehind and deep to the entire inguinalregion. Suture tension problems.
Laparoscopic Procedures Increasingly popular, controversial Early in the development, hernias wererepaired by placing very large mesh overentire inguinal region on top of theperitoneum. Was abandoned because ofcontact with bowel. Today, most performed TEP or TAPP
Laparoscopic Mesh RepairNote:Viewed from inside thepelvis toward the directand indirect sites. Abroad portion of mesh isstapled to span bothhernia defects. Staplesare not used inproximity toneurovascularstructures.
Laparoscopic Procedures The argued advantage of theseprocedures was less pain and disability,faster return to work. Great for bilateral hernia, with no increasein morbidity. For recurrent hernia Disadvantages are cost, time.
RecurrenceType of repair RecurrenceMcVay 9%Shouldice 7-11%Liechtenstein 0-4%Laparoscopic 0-1%