Ellery Ivan E. Apolinario
Zamboanga City Medical Center
DEPARTMENT OF SURGERY
To present a case of Indirect Inguinal Hernia
To present a clinical picture of a patient with IIH
To discuss the approach to a patient with IIH
To discuss the management options of a patient
EV, a 55 year old
2 years PTA, onset of inguino scrotal mass on
the right, reducible, with no other associated
signs and symptoms.
2 days PTA, inguinoscrotal mass noted but this
time associated with pain, dragging sensation
and a pain scale of 6/10 non-radiating and
A few hours PTA, prompted consult at the ER for
persistence of symptoms hence admission.
No previous surgery and no known allergy to
food and drugs
Urinary: (-) oliguria, (-) flank pain
PeripheralVascular: (-) varicose veins, (-) leg cramps
Musculoskeletal system: (-) bone or joint pains and
muscle cramps (-) bipedal edema, (-) tremors or
Neurologic system: memory good, (-) fainting, (-)
numbness and tingling, (-) weakness, paralysis
and loss of sensation,(-) involuntary
Hematologic: (-) anemia, (-) easy bruising or bleeding
Endocrine system: (-) excessive sweating, hunger or
thirst, (-) polyuria, (-) heat or cold intolerance
Conscious, coherent, cooperative , NIRD
Temperature - 36.2 C, Respiration - 22 bpm, Blood pressure - 100/ 60
mmHg and a Pulse Rate - 71 bpm.
No jaundice noted. No pallor.
Eyes: Anicteric sclerae. Conjunctivae is pink, , reactive to light.
Ears: (-) discharges,With good acuity to whispered voice.
Nose: No alar flaring. (-) discharges
Throat: Oral mucosa is pink, tongue midline.Tonsils (-) infection /
inflamed. Pharynx: (-) exudates
Trachea midline. No palpable lymph nodes.
THORAX AND LUNGS
Thorax are symmetrical. Clear breath sounds. No rales or wheezes
AP, NRRR, distinct sounds with no heart murmurs.
flat, soft, normoactive bowel sound, percussed and revealed a dull
sound, palpated with tenderness on hypogastric area, 6 x9 cm.
RECTAL AND GENITALIA
No discharges/ulcers noted on genitalia, inguino-scrotal mass on
the right, no cyanosis noted, (-) transillumination, 6x7cm.
EXTREMITIES Warm to touch, no edema, CRT < 2 secs.
No deformities and with good range of motion.
Oriented to time and place, is conscious and has a stable gait.
Indirect Inguinal Hernia Right, Incarcerated
Hx of scrotal mass that was formerly
Irreducible scrotal mass with inguinal
component, no cyanosis noted. No
Rule in Rule out
1. Hydrocele -scrotal mass (-) soft fullness within the
Usually presents with painless
2. Testicular tumor - scrotal mass
- age of the patient
(-) Painless swelling or nodule
of one testicle
(-) mass/nodule exclusively
within the testis
(-) Unilateral or bilateral lower
extremity swelling may be
(-) weight loss
Rule in Rule out
3.Epidydimitis - scrotal mass (-) acute scrotal pain
(-) epididymal pain and inflammation
(-) Dysuria, frequency and/or urgency
(-) Fever and chills
(-) preceded by Urethral discharge
(-)Tenderness and induration in the
4. Orchitis - scrotal mass (-) testicular pain and swelling
(-) Associated systemic symptoms:
(Fatigue, Malaise, Myalgias
Fever and chills, Nausea, Headache)
(-) Testicular enlargement
(-) edematous scrotal skin
Rule in Rule out
5. Testicular Torsion - scrotal mass (-) Peak incidence occurs in
adolescents aged 13 years
(-) acute-onset scrotal
discomfort which may occur
at rest or may relate to
sports or physical activities
IVF D5lr 1 L at 40 gtts/ min
Labs: cbc, platelet, blood typing
Chest xray and 12 lead ECG for CP evaluation
Meds: Cefoxitin 2 gm IVTT ANST 1 hour before
For emergency Hernioplasty right mesh inguinal
Notify OR/ Anesthesiologist
Insert FBC and attach to urine bag collector
Subjective Objective Assessment Plan
Pain at surgical site Vital Signs:
O2 Sat- 97%
PR – 68
(-) discharges on
(-) hx of febriles
episodes for the
past 24 hours
right with mesh
inguinal; iih right
MGH with home meds of:
1. Cefuroxime 500mg BID x 7 days
2. Celecoxib 200mg BID PRN pain
3. MV tab OD
Indirect Inguinal Hernia Right with incarcerated
Hernioplasty Right with Inguinal Mesh
Hernia- is the protrusion of an organ or the
fascia of an organ through the wall of the
cavity that normally contains it.
follows the tract through the inguinal canal.This
results from a persistent process vaginalis.
The inguinal canal begins in the intra-abdominal
cavity at the internal inguinal ring, located
approximately midway between the pubic symphysis
and the anterior iliac spine.The canal courses down
along the inguinal ligament to the external
ring, located medial to the inferior epigastric
arteries, subcutaneously and slightly above the pubic
tubercle. Contents of this hernia then follow the tract
of the testicle down into the scrotal sac.[
A direct inguinal hernia usually occurs due to
a defect or weakness in the transversalis
fascia area of the Hesselbach triangle.The
triangle is defined inferiorly by the inguinal
ligament, laterally by the inferior epigastric
arteries, and medially by the conjoined
follows the tract below the inguinal ligament
through the femoral canal.The canal lies
medial to the femoral vein and lateral to the
lacunar (Gimbernat) ligament. Because
femoral hernias protrude through such a
small defined space, they frequently become
incarcerated or strangulated.
Reducible hernia:This term refers to the ability to return
the contents of the hernia into the abdominal cavity,
either spontaneously or manually.
Incarcerated hernia:An incarcerated hernia is no longer
reducible.The vascular supply of the bowel is not
compromised; however, bowel obstruction is common.
Strangulated hernia:A strangulated hernia occurs when
the vascular supply of the bowel is compromised
secondary to incarceration of hernia contents.
Approximately 75% of all hernias occur in the
groin; two thirds of these hernias are indirect
and one third direct.
Indirect inguinal hernias are the most
common hernias in both men and women; a
right-sided predominance exists.
Femoral hernias (although rare) occur almost
exclusively in women because of the
differences in the pelvic anatomy.
Any condition that increases the pressure in the
intra- abdominal cavity may contribute to the
formation of a hernia, including the following:
Straining with defecation or urination
Chronic obstructive pulmonary disease (COPD)
Family history of hernias
Borders of the triangle:
1. Inguinal ligament - forms the inferior margin
2. Edge of rectus abdominis - medial border
3. Inferior epigastric vessels - superior or lateral border
Approx. 4 to 6 cm long
situated in the anteroinferior portion of the
Shaped like a cone
begins intra-abdominally on the deep aspect of
the abdominal wall, where the spermatic cord
passes through a hiatus in the transversalis
fascia (in females, this is the round ligament)
This hiatus is termed the deep or internal inguinal
consists of three arteries, three veins, and
it contains the pampiniform venous plexus
anteriorly and the vas deferens
posteriorly, with connective tissue and
remnant of the processus vaginalis
Arteries: testicular artery, deferential
artery, cremasteric artery
Nerves: nerve to cremaster (genital branch of
the genitofemoral nerve), testicular nerves
Vas deferens (ductus deferens)
Tunica vaginalis (remains of the processus
Inguinal ligament - spans the anterior superior iliac spine to the pubic bone
Cooper's ligament - seen as the lateral extension of the lacunar ligament, which is the
fanning out of the inguinal ligament as it joins the pubic tubercle
Iliopubic tract - originates and inserts in a similar fashion to the inguinal ligament
Inguinal ligament (Poupart's ligament)
is comprised of the inferior fibers of the external oblique
stretches from the anterior superior iliac spine to the
serves an important purpose as a readily identifiable
boundary of the inguinal canal, as well as a sturdy
structure used in various hernia repairs.
Cooper's ligament (Pectineal ligament)
lateral portion of the lacunar ligament that is fused to the
periosteum of the pubic tubercle
may include fibers from the transversus
abdominus, iliopubic tract, internal oblique, and rectus
often is confused with the inguinal ligament secondary
to common origin and insertion points.
forms on the deep side of the inferior margin of the
transversus abdominus and transversalis fascia.
is on the superficial side of the musculoaponeurotic
The shelving edge of the inguinal ligament is a structure
that more or less connects the iliopubic tract to the
Nyhus Classification System
Type I Indirect hernia; internal abdominal ring normal; typically in infants, children,
Type II Indirect hernia; internal ring enlarged without impingement on the floor of
the inguinal canal; does not extend to the scrotum
Type IIIA Direct hernia; size is not taken into account
Type IIIB Indirect hernia that has enlarged enough to encroach upon the posterior
inguinal wall; indirect sliding or scrotal hernias are usually placed in this
category because they are commonly associated with extension to the
direct space; also includes pantaloon hernias
Type IIIC Femoral hernia
Type IV Recurrent hernia; modifiersA–D are sometimes added, which correspond to
indirect, direct, femoral, and mixed, respectively
• assesses not only the location and size of the defect, but also the integrity of the inguinal
ring and inguinal floor
• most widely used classifications
• is limited by its subjectivity in assessment of distortion of the inguinal ring and posterior
floor, especially laparoscopically.
Gilbert Classification System
Type 1 Small, indirect
Type 2 Medium, indirect
Type 3 Large, indirect
Type 4 Entire floor, direct
Type 5 Diverticular, direct
Type 6 Combined (Pantaloon)
Type 7 Femoral
• requires intraoperative assessment
Type 1 - have a small internal ring
Type 2 - have a moderately dilated internal ring, < 4 cm
Type 3 - have a ring that is greater than 4 cm
Type 4 - involved complete disruption of the inguinal floor
Type 5 – no more than 2 cm, without complete weakness
ANTERIOR REPAIRS, NONPROSTHETIC
• Recurrence rate - 8.6 %
• importance of the Bassini repair lies in the paradigm shift it
promoted, which included dissection of the spermatic
cord, dissection of the hernia sac with high ligation, and
extensive reconstruction of the floor of the inguinal canal
• A triple-layer repair is then performed to restore integrity to the
A. The transversalis fascia is opened from the internal inguinal ring to the pubic tubercle
exposing the preperitoneal fat.
B. Reconstruction of the posterior wall by suturing the transversalis fascia (TF), the
transversus abdominis muscle (TA), and the internal oblique muscle (IO) (Bassini's famous
"triple layer") medially to the inguinal ligament (IL) laterally.
• principles of the Bassini repair were revitalized, resulting in superior
recurrence rates (6%)
• its success rates are equivalent to that of tension-free repairs in
many studies comparing the two approaches
• involve extensive dissection and reconstruction of inguinal canal
• The use of a continuous suture in multiple layers resulted in the dual
advantage of distributing tension over several layers and preventing
subsequent herniation between interrupted sutures
• Original descriptions of the Shouldice technique involved the use of a
stainless steel wire
• modern modifications have resulted in the use of a synthetic
• Care is taken to avoid injury to any preperitoneal structures, and
these are bluntly dissected to mobilize the upper and lower fascial
THE SHOULDICE REPAIR
A. The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia
and the internal oblique and transverse abdominis muscles.
B. This is the second of the four suture lines. After the stump of the cremaster muscle is picked
up, the suture is reversed back toward the pubic tubercle approximating the internal
oblique and transversus muscles to the inguinal ligament.Two more suture lines will
eventually be created suturing the internal oblique and transversus muscles medially to an
artificially created "pseudo" inguinal ligament developed from superficial fibers of the
inferior flap of the external oblique aponeurosis parallel to the true ligament.
MCVAY (COOPER'S LIGAMENT) REPAIR
• advantage is the ability to address both inguinal and femoral canal defects
• Recurrence rate 11.2%
• Femoral hernias that are approached via a suprainguinal ligament approach, or
situations where the use of prosthetic material is contraindicated, are amenable to this
type of repair.
• Once the cord has been isolated, a transverse incision is performed through the
transversalis fascia, thereby entering the preperitoneal space.
• A small amount of dissection of the posterior aspect of the fascia is performed to allow
mobilization of the upper margin of the transversalis fascia.
• The floor of the inguinal canal is then reconstructed to restore its strength. Cooper's
ligament is identified medially, and it is bluntly dissected to expose its surface.The
upper margin of the transversalis fascia is then sutured to Cooper's ligament.The repair
is continued laterally along Cooper's ligament, occluding the femoral canal.
• An essential component of the procedure is the relaxing incision, which helps
reduce the considerable amount of tension that normally results.
• Before suturing the transversalis fascia to Cooper's and the inguinal ligament, an
incision in the anterior rectus sheath is made.
• The incision begins at the pubic tubercle and is extended superiorly for
approximately 2 to 4 cm.
• Potential consequences of the relaxing incision include increased postoperative
pain and less likely herniation at the anterior abdominal wall.
• Disadvantages of routinely performing the McVay Cooper's ligament repair include
elevated recurrence rates due to the tissue-based nature of the operation.
• Furthermore, the procedure requires extensive dissection and may result in injury
to the underlying femoral vessels.
ANTERIOR REPAIRS, PROSTHETIC
• mesh herniorrhaphies were developed to circumvent the high
recurrence rates of tissue-based repairs and adhere to no-tension
principles of effective surgical repair.
• The addition of a mesh prosthesis effected a reconstruction of the
posterior inguinal canal, without placing tension on the floor
itself, hence a tension-free repair, as championed by Lichtenstein.
Medially, the prosthesis is sutured to the anterior rectus sheath 2 cm medial to the pubic
Laterally, a continuous suture is used to fix the prosthesis to the shelving edge of the inguinal
The tails of the mesh are placed around the cord and secured with an interrupted suture.
PLUG AND PATCHTECHNIQUE
• modification of the Lichtenstein repair
• In addition to placement of the prosthesis in a similar fashion to the
Lichtenstein repair (i.e., the patch), the technique includes
placement of a prosthesis (i.e., the plug) through the internal ring
• Further modifications have involved shaping the plug into a flower
or umbrella configuration, with the apex pointed intra-abdominally,
in effect serving as a preperitoneal prosthesis.
• In this case, the plug is fixed to Cooper's and the inguinal ligament
inferiorly and the internal oblique aponeurosis superiorly.
A. Plug may be created from a flat piece of mesh, or a preformed, commercially available plug
is placed in the internal ring.
B. Final view of the repair following placement of the plug and patch.
A common modification is to use the flat mesh to overlap the plug, after it
PLUG AND PATCHTECHNIQUE
The definitive treatment of all hernias is surgical repair.
is aimed at alleviating symptoms related to the inguinal
hernia, such as pain, pressure, and protrusion of abdominal
Simple maneuvers include assuming a recumbent
position, which aids in self-reduction of the hernia.
A truss, an elastic belt or brief that aims to keep the hernia
reduced, may also be worn; however, its use does not prevent
hernia progression or incarceration.
A truss may provide relief in up to 65% of patients;
however, many will use it only intermittently as it does not
provide continuous control of the hernia and may actually lead
to an increased rate of hernia incarceration.
conservative management is applied to asymptomatic or
minimally symptomatic inguinal hernias.
One study has calculated the cumulative probability of developing
a strangulated hernia to be 2.8% at 3 months for an inguinal
hernia, and rising to 4.5% after 2 years.
The figures were much higher for development of a strangulated
femoral hernia at 3 months and 2 years, 22 and 45%.