This document discusses groin hernias, including their definition, anatomy, types, and treatment methods. It notes that inguinal hernias are most common, occurring in 96% of cases, and are more frequent in males. The two main types are indirect hernias, which pass through the internal ring, and direct hernias, which occur through Hesselbach's triangle. Treatment has evolved from early cauterization and debridement to modern tension-free repairs using synthetic mesh, which have significantly lower recurrence rates than open suture repairs. Laparoscopic techniques are increasingly utilized but remain more complex and costly.

1. Groin Hernias
Sameh Shehata

2. Definition
 Abnormal protrusion of a peritoneal lined
sac thru the musculoaponeurotic covering
of the abdomen

3. Introduction
 In US 96% are inguinal, 4% femoral
 20% bilateral
 Most common in both sexes indirect.
 Femoral hernias more common in elderly
females
 Male to female ratio in 9:1 for inguinal
hernias, 1:3 for femoral hernias

4. Myopectineal Orifice of Fruchaud
The MPO is bordered:
 Above by the arching fibers of the internal
oblique and transversus abdominus Muscles,
 Medially (towards the center or to the right) 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

5. Myopectineal Orifice of Fruchaud

6. Anatomy
 4cm in length
 2-4 cm cephalad to inguinal ligament
 Extends between superficial and deep
rings
 Contains spermatic cord or round
ligament

7. Anatomy
 Bounded superficially by external oblique
 Cephalad by conjoint tendon
 Inferior border is inguinal ligament
 Floor is transversalis fascia

8. Layers
 Skin, subcutaneous, campers, scarpa,
external spermatic fascia, cremaster,, int
spermatic fascia , preperitoneal tissues,
peritoneum

9. Anatomy
 Broadly classified as indirect and direct
depending on relationship to epigastric
vessels.
 Hesselbach’s triangle is inferior epigastric
artery laterally, lateral border of rectus
medially, inguinal ligament inferiorly.

10. Anatomy
 An indirect hernia passes lateral to
Hesselbach’s triangle.
 A direct hernia passes thru Hesselbach’s
triangle.
 Indirect hernia has a congenital
component, from processus vaginalis.
 The processus is supposed to obliterate
after descent of testes.

11. Hesselbach’s Triangle

12. Indirect Inguinal hernia
 Abdominal contents protrude through internal inguinal
ring

13. Indirect Hernia

14. Indirect Inguinal Hernia
 Accepted hypothesis:
incomplete or defective
obliteration of the
processus vaginalis during
the fetal period
 remnant layer of
peritoneum forms a sac
at the internal ring
 more frequently on the
right

15. 15

16. Direct Hernia

17. Direct Inguinal Hernia

18. Direct Inguinal Hernia
 Medial to the inferior
epigastric artery and vein,
and within Hesselbach's
triangle
 acquired weakness in the
inguinal floor

19. Anatomy
 Direct hernias are usually not congenital.
 Acquired by the development of tissue
deficiencies of the transversalis fascia.
 Development of femoral hernia less
understood. Can result from increased
intraabdominal pressure. The sac then
migrates down the femoral vessels into
thigh.

20. Anatomy Inguinal ligament
(Poupart’s) – inferior edge
of external oblique
 Lacunar ligament –
triangular extension of the
inguinal ligament before
its insertion upon the pubic
tubercle
 conjoined tendon (5-10%)-
Internal oblique fuses with
transversus abdominis
aponeurosis
 Cooper’s Ligament -
formed by the periosteum
and fascia along the
superior ramus of the pubis.

21. Inguinal hernia
Male inguinal hernia Female inguinal hernia

22. Nyhus Classification
 I indirect, internal ring normal (kids)
 II indirect, dilated internal ring
 III posterior wall defects, direct inguinal
hernia, dilated internal ring, massive
scrotal, sliding, femoral hernia
 IV recurrent hernia

23. Terminology
 Reducible – can be replaced within
surrounding musculature
 Incarcerated – cannot be reduced
 Strangulated – compromised blood supply to
its contents

24. 24
Hernia complications
Bowel obstruction: usually not partial,
look at groin
Irreducibility .
Strangulation: serious, life-threatening
 Inflammation.

25. Epidemiology
 Prevelance of hernias increases with age
 Most serious complication – strangulation
 1 to 3% of groin hernias
 Femoral – highest rate of complications 15% to
20%
 recommended all be repaired at time of discovery

26. Treatment

27. 27

28. 28
History
 1st
century: Surgical treatment
 15th
century: Castration with wound cauterization or
hernia sac debridement with secondary healing
 Early 18th
century: Sir Astley Cooper:
recommended truss > surgery, only in
strangulation

29. History
 1881: French surgeon, Lucas-
Championni re: high ligation of indirectѐ
inguinal hernia
 1844-1924: Edoardo Bassini (father of
modern inguinal hernia surgery): high
ligation and reconstruction of inguinal floor

30. Father of Modern Inguinal Hernia Repair
EDUARDO BASSINI

31. Surgical Techniques
 Open anterior repair (Bassini, McVay,
Shouldice).
 Tension-free repair with
mesh(Liechtenstein, Rutkow)

32.  Posterior repair
 Open : Nyhus
 Laparoscopic

33. Open anterior repair
 Herniotomy
 Herniorrhaphy (repair)
 Hernioplasty .

34. 34
Herniotomy
 Patent processus vaginalis ligated at
origin at internal ring (high ligation)
 Nyhus type I
 Children

35. 35
Herniorrhaphy
 Nyhus type II and III
 High ligation + reinforced area of
weakness with patient’s own tissue
 Bassini, Shouldice, McVay

36. 36
Bassini repair
 Transversus abdominis aponeurosis +
transversalis fascia  inguinal
ligament with nonabsorbable
interrupted sutures

37. 37
Shouldice repair
 4 rows of suture

38. 38
McVay repair
 Inguinal and femoral hernias,
Transversus abdominis aponeurosis +
transversalis fascia  Cooper’s
ligament + iliopubic tract

39. 39
Hernioplasty
 High ligation, inverted sac + reinforce
defect with synthetic material
 Tension-free
 Lichtenstein
 Recurrent rate 0.1%

40. Tension-Free Repair
 Same initial approach as anterior repair
 Instead of sewing fascial layers together
to repair defect, a prosthetic mesh onlay
used
 Simple to learn, easy to perform, suited for
local anesthesia, excellent results with
recurrence less than 4%.

43. Techniques
 Coined by Liechtenstein in 1989
 Central feature is polypropylene mesh
over unrepaired floor.
 Gilbert repair uses a cone shaped plug
placed thru deep ring.
 Slit placed in mesh for cord structures

44. Techniques
 Suturing the mesh to the inguinal ligament
is not important.
 Fixing the mesh to the rectus sheath 1-
1.5cm medial and superior to the pubic
tubercle is very important.
 Should have a surplus of mesh over
inguinal ligament, the medial suture
ensures surplus mesh inferiorly

45. Open Posterior Repair
 Divide the layers of the abdominal wall
superior to the internal ring, enter
preperitoneal space. Dissection continues
behind and deep to the entire inguinal
region.
 Suture tension problems.

46. Laparoscopic Procedures
 Increasingly popular, controversial
 Early in the development, hernias were
repaired by placing very large mesh over
entire inguinal region on top of the
peritoneum. Was abandoned because of
contact with bowel.
 Today, most performed TEP or TAPP

48. 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.

49. Laparoscopic Procedures
 The argued advantage of these
procedures was less pain and disability,
faster return to work.
 Great for bilateral hernia, with no increase
in morbidity.
 For recurrent hernia
 Disadvantages are cost, time.

50. Recurrence
Type of repair Recurrence
McVay 9%
Shouldice 7-11%
Liechtenstein 0-4%
Laparoscopic 0-1%