Approximately 75% of abdominal wall hernias occur in the groin. The lifetime risk of inguinal hernia is 27% in men and 3% in women. And hence Of inguinal hernia repairs, 90% are performed in men, and 10% are performed in women. The incidence of inguinal hernia in men has a distribution, with peaks before the first year of life and after age 40. Indirect inguinal and femoral hernias occur more commonly on the right side. This is attributed to a delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development. The predominance of right-sided femoral hernias is thought to be caused by the tamponading effect of the sigmoid colon on the left femoral canal The prevalence of hernias increases and the likelihood of strangulation and need for hospitalization increase with aging.

1. INGUINAL HERNIA
DR SETH JOTHAM (GS,PG-2)
CUHAS

2. OUTLINE
• Introduction
• Applied Anatomy
• Aetiology and risk factors
• Diagnosis formulation
• Management modalities &
complications

3. Introduction
• Approximately 75% of abdominal wall hernias occur in the groin.
• The lifetime risk of inguinal hernia is 27% in men and 3% in women.
• And hence Of inguinal hernia repairs, 90% are performed in men, and
10% are performed in women.
• The incidence of inguinal hernia in men has a distribution, with peaks
before the first year of life and after age 40.

4. cont …
• Indirect inguinal and femoral hernias occur more commonly on the right
side.
• This is attributed to a delay in atrophy of the processus vaginalis after the
normal slower descent of the right testis to the scrotum during fetal
development.
• The predominance of right-sided femoral hernias is thought to be caused
by the tamponading effect of the sigmoid colon on the left femoral canal
• The prevalence of hernias increases and the likelihood of strangulation and
need for hospitalization increase with aging.

5. Applied anatomy
• The inguinal canal is an
approximately 4- to 6-cm long cone
shaped region situated in the
anterior portion of the pelvic basin
• The canal extends between the
internal (deep) inguinal and
external (superficial) inguinal rings
• Note the ASIS and the Pubic
turbacle

6. Boundaries
• The external oblique aponeurosis anteriorly.
• Internal oblique muscle laterally
• The transversalis fascia and transversus abdominis muscle posteriorly,
• The internal oblique and transversus abdominis muscle superiorly
• The inguinal (Poupart’s) ligament inferioirly

7. • The inguinal canal contains the spermatic cord in men and the round
ligament of the uterus in women
The contents
3 coverings
• Internal spermatic fascia (derived from transversalis fascia)
• Cremasteric fascia (derived from internal oblique)
• External spermatic fascia (derived from external oblique aponeurosis)

8. Cont…
3 arteries
• Testicular artery
• Artery of the vas
• Cremasteric artery
3 veins
• Pampiniform plexus of veins
• Cremasteric vein
• Vein of the vas

9. Cont…
3 nerves
• Ilioinguinal nerve
• Genital branch of Genitofemoral
nerve
• Sympathetic fibres from T10-11
spinal segments
3 other structures
• Vas deferens
• Lymphatic vessels of the testis
• A patent processus vaginalis in
patients with indirect hernia

10. Hesselbach’s
triangle

11. Femoral triangle
•

12. Nyhus Classification of Groin Hernia

13. .

14. Aetiology : Congenital causes
• Results from preformed hernial sac as a result of persistent processus
vaginalis
• Failure of the peritoneum to close results in a patent processus
vaginalis (PPV).
• In preterm babies, indirect inguinal hernias as a result of PPV is very
high
• However, overall, the risk of developing a symptomatic hernia during
childhood in the presence of a known PPV is relatively low.

15. Acquired causes
• Increase 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

16. CLASSIFICATION
• Etiological classification ( congenital or acquired)
• Anatomical classification
• Clinical classification

17. Anatomical classification
• According to its site of exit
• According to the extent of the hernia
• According to the contents

18. 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

19. According to the extent of the hernia

20. 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)

21. Clinical classification
• Reducible inguinal hernia
• irreducible inguinal hernia
• Obstructed inguinal hernia
• Strangulated inguinal hernia

22. Dx
• Hx
• Clinical examination
• Auxiliary investigations

23. Clinical examination (local)
• Position and extent
• To get above the swelling
• Consistency
• Impulse on coughing
• Reducibility
• Invagination test
• Ring occlusion test
• Zieman’s (three finger test)

24. Systemic examinations
• PA
• CVS
• RS
• CNS

25. Imaging investigations
• In the case of an ambiguous diagnosis, radiologic investigations may
be used as an adjunct to history and physical examination.
• Imaging in obvious cases is unnecessary.
1. USS
• least invasive technique and does not impart any radiation to the
patient.
• Anatomic structures can be more easily identified by the presence of
bony landmarks;
• Sensitivity of 86%, specificity of 77%.

26. 2. CT-SCAN
• Meta-analysis determined standard CT detects inguinal hernia with a
sensitivity of 80%, specificity of 65%.
• limited availability restrict its routine use.
3. MRI
• With a sensitivity of 95%, specificity of 96%.
• The expense of MRI precludes its routine use to diagnose inguinal
hernias.
Sensitivity & specificity : MRI > USS> CT

27. TREATMENT
• NON SURGICAL MX
• SURGICAL MX

28. NON SURGICAL MX
I. Watchful waiting
• Recommended in asymptomatic patients especially in adults if the
hernia size is small, reducible and does not cause anxiety to the
patient
• Patient should be counseled of the danger signs so that they can
present early to the facility for prompt actions.

29. II. Truss
• Confine hernias to a reduced state and intermittently relieve
symptoms in up to 65% of patients; however, they do not prevent
complications, and they may be associated with an increased rate of
incarceration
• The requirement : reducible hernia and patient
Indications
- Very old or frail patients
- Patients who refuses surgery
- Can sometimes be used in children

30. .

31. III. Taxis method
• Taxis from Greek – meaning “Arrangement”
• It is the manual reduction of hernia under minimal anaesthesia
• Taxis should be attempted for incarcerated hernias without sequelae
of strangulation, and the option of surgical repair should be discussed
prior to the maneuver.
• Analgesics and light sedatives are administered, and the patient is
placed in the Trendelenburg position.

32. …
• The hernia sac is elongated with both hands, and while slight counter
traction is maintained,
• Reduction of the contents is attempted circumferentially in a small
stepwise fashion to ease their reduction into the abdomen.
• Should not be performed when strangulation is suspected, as
reduction of potentially gangrenous tissue into the abdomen may
result in an intra-abdominal catastrophe

33. SURGICAL MX
1. OPEN APPROACH
2. LAPARASCOPIC APPROACH
3. ROBOTIC ASSISTED APPROACH

34. 1. OPEN APROACH
A. HERNIOTOMY
• Higher sac ligation with no repair of posterior abdominal wall
• Children < 10yrs of age
B. HERNIORAPHY
• Herniotomy plus tissue repair of posterior abdominal wall
C. HERNIOPLASTY
• Herniotomy plus posterior wall re-enforcement using a prosthetic
mesh

35. I. Modified Bassini repair
• The conjoined tendon is
approximated to the shelving
portion of the inguinal ligament
with interrupted non absorbable
sutures
• RECURRENCE 9-10%
• .

36. II. Shouldice repair
• The iliopubic tract is sutured to the medial flap of the transversalis
fascia and the internal oblique and transverse abdominis muscles.
• The second of the four suture lines, reversing toward the pubic
tubercle approximating the internal oblique and transversus muscles
to the inguinal ligament.
• It is a continuous running suture technique

37. Cont…
• It is associated with
a very low
recurrence rate
and a high degree
of patient
satisfaction rate
• RECURENCE 1%

38. III. Desarda hernia repair
• The medial leaf of the external oblique aponeurosis is sutured to the
inguinal ligament from the pubic tubercle to the abdominal ring using
1–0 Ethilon or Prolene interrupted sutures.
• A splitting incision is then taken in the EOA, partially separating a
strip. This splitting incision is extended medially up to the pubic
symphysis and laterally 1 to 2 cm beyond the reconstructed
abdominal ring.
• The free border of the strip of the EOA is now sutured to the internal
oblique or conjoined tendon lying close to it with 1–0 Ethilon or
Prolene interrupted sutures.

39. ..
Advantages
• Tension free
• O.2% recurrence rate

40. iv. Darning repair (Darn Moloney)
• A pure tension free repair by
continuously placing the suture
btn the conjoined tendon and
the inguinal ligament without
approximating them
Advantages
• Tension free
• Recurence 1.5%

41. V. Lichtenstein mesh repair
• Re enforcement of the posterior
abdominal wall wit a prosthetic
mesh
Advantages
• Tension free
• Recurence < 1%

42. OPEN FEMORAL HERNIA REPAIR
.

43. .

44. 1. Femora/low Lockwood’s approach
• A transverse groin incision made below the inguinal ligament
• The contents mostly omentum assessed for viability and reduced
• Neck pulled down and ligated as high as possible
• Canal is closed by suturing the illiopectinal line to the inguinal ligament
by non absorbable eg prolene 0
• A mesh plug can also be used to close the defect

45. 2. Inguinal/Lotheissen’s approach
• Most of the steps similar to that of open inguinal hernia repair
• Should be preferred approach interms of open methods as it facilitate
adequate exposure
• Cord mobilized and retracted upward
• Dissection made to reach the transversus fascia which is opened
medially to inferior epigastric vessel
• Femoral hernia found and reduced
• The defect closed by suturing the conjoined tendon to the illio-
pectinal line so as to form a shutter
The classical McVay (coopers suture to inguinal ligament ) is strong
but with tension culminating to recurrence

46. 3. Pre peritoneal/High McEvedy’s approach
• Best approach to deal with bowel strangulation as it allow generous
incision in peritoneum to give proper exposure for bowel resection
• Incision is made in lower abdomen at the lateral edge of the rectus
muscle
• Anterior rectus sheath is incised and rectus muscle retracted medially
and dissection done down to pre-peritoneal space
• Femoral hernia is delivered and contents assessed for viability and
dealt accordingly
• Sac closed and the defect with placement of a mesh/plug.
• The mesh-plug repair is tension free, easy, low post op pain with low
recurrences

47. LAPARASCOPIC METHODS
Principal endoscopic methods include:
1. The transabdominal preperitoneal (TAPP) repair
2. The totally extraperitoneal (TEP) repair

48. Indications
The indications for laparoscopic inguinal hernia repair are similar to
those for open repair.
• Most surgeons would agree that the endoscopic approach to bilateral
or recurrent inguinal hernias is superior to the open approach.
• Concurrent inguinal hernia repair can be considered if a hernia
patient is scheduled to undergo another laparoscopic procedure
without gross contamination, such as prostatectomy
• Preferred to Lichtenstein repair for recurrent hernias after open
anterior repair

49. ROBOTIC ASSISTED METHODS
Similar to laparoscopy, robot-assisted repair is ideal for:
• Recurrent inguinal hernia patients who had previous anterior repair and
• Bilateral inguinal hernias.
Contraindications to robotic hernia repair are the same as for laparoscopic
repair and include
• coagulopathy and/or severe cardiopulmonary disease precluding induction
of general anesthesia and pneumoperitoneum.
• Previous preperitoneal repair is a relative contraindication along with the
presence of a large incarcerated inguinal hernia.
• Patient evaluation should proceed similarly to workup for laparoscopic
inguinal hernia repair.

50. . From Neumayer L,
Giobbie-Hurder A,
Jonassen O, et al: Open
mesh versus
laparoscopic mesh
repair of inguinal
hernias. N Engl J Med
350:1819–1827, 2004.
Sabiston 20th ed,pg
1129

51. REFERENCES
I. Shwartz’s principle of surgery 11thEd
II. Sabiston textbook of surgery 15th and 20thEd
III. Shamim,M,.2021,’Femorl hernia; Open laparascopic Surgery
Approaches’, in M.Shamim (ed.),The art of science of Abdominal
Hernia, Intech open, London.10.5772/intechopen.98954

52. THANK
YOU