An inguinal hernia occurs when an organ or tissue protrudes through a weak spot in the abdominal wall. There are two main types - indirect (lateral) hernias which occur through the deep inguinal ring and direct (medial) hernias which occur through Hesselbach's triangle. Surgical repair is the standard treatment and involves identifying and reducing the hernia sac, ligating the neck if present, and reconstructing the posterior wall with sutures or a mesh. Complications can include incarceration, strangulation or infection if left untreated.

1. Inguinal hernia
Dr.MOHAMED RUVAIS

2.  A hernia is defined as an abnormal protrusion of
an organ or tissue through a defect in its
surrounding walls.
 more common in men and women but
much more common in men.

3. Comprises of :
 Covering
 Sac
 Content
 The sac is a diverticulum of the peritoneum
with mouth, neck,body and fundus.

4.  Hernias without neck and large mouth-
incisional hernia and direct hernia.
 Hernias without sac – epigastric
hernia(protrusion extra peritoneal fat).

5.  Anatomy
 Types
 Origin
 Classification
 Diagnosis
 Surgery
Index

6.  A canal 4cm long
 located in the lower part of the anterior
abdominal wall above the groin,directed
downwards, medially and forward.
EXTENT
 Deep inguinal ring to the superficial inguinal
ring.
Basic anatomy of the inguinal canal

7. Deep inguinal ring
 U-shaped opening on the transversalis fascia 1.25cm
above and perpendicular to the mid inguinal
point(midway between the anterior superior iliac
spine and the pubic tubercle)
 approximately 2–3 cm above the femoral artery pulse
in the groin
Superficial inguinal ring
 V-shaped defect
 opening on the `external oblique aponeurosis

8. Formed by-
 herniation of the gubernaculum testis and the
processus vaginalis which makes it possible
for the testis and spermatic cord to pass from
the abdomen to the scrotum in males and the
round ligament in female.
Embryology

9. Anterior wall-
 aponeurosis of the external oblique, and
reinforced by the internal oblique muscle
laterally.
Posterior wall-
 transversalis fascia and conjoint tendon
medial half.
BOUNDRIES

10. Roof-
 by the internal oblique, transversus abdominis
and transversalis fascia.
Floor-
 inguinal ligament (a ‘rolled up’ portion of the
external oblique aponeurosis) and thickened
medially by the lacunar ligament.

12.  Spermatic cord (men)
 Round ligament (women)
 Ilioinguinal nerve
CONTENT

13.  The classic and memorable description of the
contents of
 spermatic cord in the male are:
 3 arteries: cremasteric, differential and testicular art.
 3 nerves: ilioinguinal, the iliohypogastric
 and the genital branch of the genitofemoral nerve
 3 fascial layers: external spermatic, cremasteric,
 and internal spermatic fascia.
 3 other structures: pampiniform plexus, vas
 deferens (ductus deferens), testicular lymphatics
Spermatic cord

14.  Indirect(lateral ,oblique)
 Direct(medial)
 Slidinghernia
TYPES

15. Three types of classification
1.According to the extent of the hernia
 a) bubonocele — when the hernia does not come out
of the superficial inguinal ring
 (b) incomplete hernia— when it comes out through
the superficial inguinal ring but fails to reach the
bottom of the scrotum
 (c) complete hernia — when it reaches the bottom of
the scrotum
A. ANATOMICAL TYPES

16. 2.According to its site of exit-
(a)oblique (indirect) hernia
(b)direct hernia

17. 3.According to the contents of the hernia-
 Omentum – omentocele-
 Intestine – enterocele
 urinary bladder-cystocele
 Two loops of intestine in a manner of W -Maydl’s
hernia
 Appendix – Amayand hernia
 Meckel’s diverticulum – litter’s hernia

18.  lateral because its origin is lateral to the
inferior epigastric vessels.
 oblique as the hernia passes obliquely from
lateral to medial through the abdominal
muscle layers.
1.Indirect(lateral ,oblique)

19.  Two forms of indirect inguinal hernia
 (i) Congenital hernia
 (ii) Acquired hernia

20. In neonates and young children
 As the testis descends, a tube of peritoneum(funicular
process of peritoneum) is pulled with the testis and wraps
around it ultimately to form tunica vaginalis.
 This peritoneal tube should obliterate, possibly under
hormonal control, but it commonly fails to fuse either in
part or totally. As a result, bowel within the peritoneal
cavity is able to pass inside the tube down towards the
scrotum.
1.Congenital hernia

21.  In case of congenital hernia the whole process remains patent.
 Thus a congenital hernia reaches the bottom of the scrotum
very quickly.
 It may so happen that the funicular process remains patent up
to the top of the testis. So the hernia stops at the top of the
testis and is known as a congenital funicular hernia.

22.  As the name suggests it does not protrude into a pre-
formed sac.
 Clinically it can be differentiated from a congenital
hernia by the fact that it does not become complete
at once.
 Acquired hernia progresses gradually.
2.Acquired hernia

23.  Is acquired
 more common above the age of 40.
 It is a result of stretching and weakening of the
abdominal wall just medial to the inferior epigastric
(IE) vessels.
There is a triangle referred to as Hasselbach’s triangle
 laterally- the IE vessels
 medially -lateral edge of rectus abdominis
 below -pubic bone (the iliopubic tract)
2.Direct(medial)

24. Hesselbach’s Triangle(inguinal
triangle)

25.  This area is weak
 Abdominal wall here consists of only transversalis fascia
covered by the external oblique aponeurosis.
 A direct, medial hernia is more likely in elderly patients.
 It is broadly based and therefore unlikely to strangulate.
 The medially placed bladder can be pulled into a direct
hernia.

26. This cystogram shows the urinary bladder, part of
which has descended into a left direct inguinal hernia
(arrows).

27.  Acquired hernia
 Due to weakening of the abdominal wall
 lateral to the IE vessels.
 Retroperitoneal fatty tissue is pushed downwards .
 As more tissue enters the hernia- peritoneum is
pulled-creating a sac.
 Sac has formed secondarily, distinguishing it from a
classic indirect hernia.
3.Sliding hernia

28. Pantaloon hernia
Occasionally, both lateral and medial hernias are present in
the same patient.
Richter hernia
small portion of the antimesenteric wall of the intestine is
content.
Ogilvie hernia
 Congenital direct hernia
 through a rigid circular orifice in the conjoined tendon

29. Clinically hernia may be of five types-
1. Reducible hernia—contents can be returned
into the abdominal cavity, but the sac remains
in its position.
2. Irreducible hernia contents cannot be
returned to the abdomen.
 not suggest any other complication.
B. CLINICAL TYPES

30. causes of irreducibility are
 (i) adhesion of its contents to each other
 (ii) adhesion of its contents with the sac
 (iii) adhesion of one part of the sac to the other part
 (iv) sliding hernia
 (v) very large scrotal hernia (scrotal abdomen)

31.  Often confused with strangulated hernia by the
beginners.
 Clinically a strangulated hernia is also irreducible,
but it is extremely tender and tense and the
overlying skin may be red.
 These signs are absent in a pure irreducible hernia.

32. 3. Obstructed or incarcerated hernia
 irreducibility+Intestinal obstruction
 Due to occlusion of the lumen of the bowel.
 No interference with the blood supply

33. 4. Strangulated hernia
 irreducibility+obstruction+arrest of blood supply to
the contents
Diagnosis
 Irreducible
 No impulse on coughing
 Tense and tender
 Features of acute intestinal obstruction.

34. 5. Inflamed hernia
 very rare condition
 Mimic a strangulated hernia.
 when its content such as an appendix, a salpinx or a
Meckel's diverticulum becomes inflamed.

35. Diagnosis
 constitutional disturbances
 local signs of inflammation-skin becomes red and
oedematous and the swelling becomes painful,
tender and swollen.
 The only differentiating feature from a strangulated
hernia is that this hernia is not tense and is not
associated with intestinal obstruction.

36.  Casten,Halverson and McVay, Zollinger, Ponka, Gilbert
and Nyhus.
 The European Hernia Society has recently suggested a
simplified system
 primary or recurrent (P or R);
 lateral, medial or femoral (L, M or F);
 defect size in fingerbreadths assumed to be 1.5 cm
 A primary, indirect, inguinal hernia with a 3-cm defect
 size would be PL2.
Classification

38.  presenting as intermittent swellings,
 lying above and lateral to the pubic tubercle
 associated cough impulse.
 Often the hernia will reduce on lying and reappear on
standing.
Diagnosis of an inguinal hernia

39.  Irreducibility
 Obstruction
 incarceration
 Strangulation
 Rupture of sac – trauma, pressure necrosis
ofoverlying skin
 Fistula formation – Richter's hernia
 Hemorrhage
 Hydrocele of sac
 Extension of intra abdominal inflammation
 Extension of intra abdominal tumour.
 Torsion of omentum
Complications

40. Investigation
Treatment
MANAGEMENT OF INGUINAL
HERNIA

41.  Ultrasound
 High Test Sensitivity (>90%)
 High Test Specificity
 CT&MRIof the abdomen and pelvis may be useful
 laparoscopy can be diagnostic and therapeutic for
particularly challenging cases.
 A herniogram involves the injection of contrast into the
peritoneal cavity followed by screening which shows the
presence of a sac or asymmetrical bulging of the inguinal
anatomy.
Investigations

43. Incarcerated hernias
Strangulated hernias
Sliding hernias
EMERGENCY REPAIR

44. Non operative Treatment-with the use of a truss
 Truss is a mechanical appliance ,belt with a pad
applied to groin after spontaneous or manual
reduction of hernia.
 purpose is to maintain reduction and to prevent
enlargement.
TREATMENT

45. INDIRECT INGUINAL HERNIA
 Herniotomy
 Lytle’s repair
 herniorrhaphy

46. HERNIOTOMY-
 Separation of sac from cord srtuctures
 Reducing the content
 Transfixation and ligation of sac
 Excise the redundant sac

47. LYTLE’S REPAIR-
 Tightening of the internal inguinal ring around the
spermatic cord.
 Use prolene 2.o

48. HERNIORRHAPHY
 Heniotomy +reconstruction of the posterior wall of
the inguinal canal.

49.  Anterior repairs are the most common operative
approach-Tension-free repairs are now standard.
 Older tissue types of repair are rarely indicated
except
 for patients with simultaneous contamination or
concomitant bowel resection, when placement of a
mesh prosthesis may be contraindicated
Operative Repair

50.  make a transversely oriented linear or slightly
curvilinear incision above the inguinal ligament and a
fingerbreadth below the internal inguinal ring.
 Dissection is continued through the subcutaneous
tissues and Scarpa fascia.
 The external oblique fascia and external inguinal ring
are identified. The external oblique fascia is incised
through the superficial inguinal ring to expose the
inguinal canal.
`

51.  The genital branch of the genitofemoral nerve
and the ilioinguinal and iliohypogastric nerves
are identified and avoided or mobilized to
prevent transection and entrapment.

52.  The cremaster muscle of the mobilized spermatic
cord is separated parallel to its fibers from the
underlying cord structures.
 The cremaster artery and vein, which join the
cremaster muscle near the inguinal ring, can usually
be avoided but may need to be cauterized or ligated
and divided.
 When an indirect hernia is present, the hernia sac is
located deep to the cremaster muscle and anterior
and superior to the spermatic cord structures.

53.  Incising the cremaster muscle in a longitudinal
direction and dividing it circumferentially near the
internal inguinal ring help expose the indirect hernia
sac.
 The hernia sac is carefully separated from adjacent
cord structures and dissected to the level of the
internal inguinal ring.
 The sac is opened and examined for visceral contents
if it is large; however, this step is unnecessary in small
hernias.

54.  The sac can be mobilized and placed within the
preperitoneal space, or the neck of the sac can be
ligated at the level of the internal ring and any excess
sac excised.
 If a large hernia sac is present, it can be divided with
use of electrocautery to facilitate ligation.
 It is not necessary to excise the distal portion of the
sac.

55.  If the sac is broad based, it may be easier to displace it
into the peritoneal cavity rather than to ligate it.
 Direct hernia sacs protrude through the floor of the
inguinal canal and can be reduced below the
transversalis fascia before repair.
 A “lipoma” of the cord actually represents
retroperitoneal fat that has herniated through the
deep inguinal ring; this should be suture ligated and
removed.

56.  Not done nowadays- because of high recurrence
rates.
Tissue repairs

57.  Iliopubic tract
 Shouldice
 Bassini
 McVay repairs
Available options for tissue repair

58.  Approximates the transversus abdominis aponeurotic
arch to the iliopubic tract with the use of interrupted
sutures.
 The repair begins at the pubic tubercle and extends
laterally past the internal inguinal ring.
Iliopubic tract repair

60. A multilayer imbricated repair of the posterior
wall of the inguinal canal with a continuous
running suture technique.
The initial suture line secures the transversus
abdominis aponeurotic arch to the iliopubic
tract.
Shouldice repair

61.  The internal oblique and transversus abdominis
muscles and aponeuroses are sutured to the inguinal
ligament.
 The Shouldice repair is associated with a very low
recurrence rate and a high degree of patient
satisfaction in highly selected patients.

62.  By suturing the transversus abdominis and internal
oblique musculoaponeurotic arches or conjoined
tendon (when present) to the inguinal ligament.
 This once popular technique is the basic approach to
nonanatomic hernia repairs .
 most popular type of repair done before the advent
of tension-free repairs.
Bassini repair

63. Also known as Cooper ligament repair.
has traditionally been popular for the correction of
direct inguinal hernias, large indirect hernias, recurrent
hernias, and femoral hernias.
Interrupted nonabsorbable sutures are used to
approximate the edge of the transversus abdominis
aponeurosis to Cooper ligament(extension of lacunar
ligament).
McVay repair

64. The McVay repair
 suited for strangulated femoral hernias because it
provides obliteration of the femoral space without
the use of mesh.

65.  Dominant method of inguinal hernia repair
 Tension in a repair is the principal cause of
recurrence.
 Current practices in hernia management-synthetic
mesh to bridge the defect a concept-by
Lichtenstein.
Tension-free anterior repair

66. Anterior inguinal herniorrhaphy
includes
 Lichtenstein approach
 plug and patch technique
 sandwich technique, with both an anterior and
preperitoneal piece of mesh.
Tension-free anterior repair

67.  nonabsorbable mesh is fashioned to fit the
canal.
 A slit is cut into the distal lateral edge of the
mesh to accommodate the spermatic cord.
Lichtenstein repair

68.  nonabsorbable suture - to secure the mesh
 beginning at the pubic tubercle and running a length
of suture in both directions toward the superior
aspect above the internal inguinal ring to the level of
the tails of the mesh.
 The mesh is sutured to the aponeurotic tissue
overlying the pubic tubercle medially, continuing
superiorly along the transversus abdominis or
conjoined tendon.

69.  The inferolateral edge of the mesh is sutured to the iliopubic
tract or inguinal ligament
 Tails created by the slit are sutured together around the
spermatic cord-forming a new internal inguinal ring.
 It is important to protect the nerves from as they are passed
through this newly fashioned internal inguinal ring.

71.  Adapting the principles of tension-free repair.
 By Gilbert .
 A cone-shaped plug of polypropylene mesh into the
internal inguinal ring - act like an upside-down
umbrella and occlude the hernia.
 plug is fixed to the surrounding tissues and held in
place by an additional overlying mesh patch
Plug and patch repair

72.  This patch may not need to be secured by sutures.
 An extension of Lichtenstein’s original mesh repair,
has now become the most commonly performed
primary anterior inguinal hernia repair.
 Can be done without suture by some experienced
surgeons.
 Most secure plug and patch -nonabsorbable suture.

73.  A bilayered device, with three polypropylene
components.
 An underlay patch provides a posterior repair similar
to that of the laparoscopic approach
 An onlay patch covers the posterior inguinal floor.
Sandwich technique

74.  using a self-expanding polypropylene patch.
 A pocket is created in the preperitoneal space
 A preformed mesh patch is inserted into the hernia defect,
which expands to cover the direct, indirect, and femoral
spaces.
 The patch lies parallel to the inguinal ligament.
 can remain without suture fixation, or a tacking suture .
Preperitoneal repair

75.  A subumbilical midline incision.
 large mesh prosthesis into the preperitoneal space.
 space that extends into the prevesical space, beyond
the obturator foramen, and posterolateral to the
pelvic brim.
Stoppa-Rives repair

76.  distributing the natural intra-abdominal pressure
across a broad area to retain the mesh in a proper
location.
 Useful for large, recurrent, or bilateral hernias.

77. Open preperitoneal approach is useful for
 Recurrent inguinal hernias
 Sliding hernias
 Femoral hernias
 Some strangulated hernias.
Preperitoneal repair

78.  A transverse skin incision 2 cm above the internal
inguinal ring and is directed to the medial border of
the rectus sheath.
 The muscles of the anterior abdominal wall are
incised transversely.
 preperitoneal space is identified

79.  The transversalis fascia and transversus abdominis
aponeurosis are identified and sutured to the
iliopubic tract with permanent sutures.
 A mesh prosthesis is frequently used to obliterate
the defect.

80.  Method of tension-free mesh repair based on a
preperitoneal approach.
The most popular techniques are-
 Totally extraperitoneal (TEP)
 Transabdominal preperitoneal (TAPP)
Laparoscopic repair

81.  main difference between these two techniques is the
sequence of gaining access to the preperitoneal
space.
 TEP approach, the dissection begins in the
preperitoneal space using a balloon dissector.
 TAPP repair, the preperitoneal space is accessed after
initially entering the peritoneal cavity.

82. Merits of TEP
 preperitoneal dissection is quicker.
 potential risk for intraperitoneal visceral damage is minimized.
De-merits of TEP
 Use of dissection balloons is costly.
 May not be possible to create a working space if the patient
has had a prior preperitoneal operation.
 If a large tear in the peritoneum is created during a
TEP,potential working space can become obliterated,
necessitating conversion to a TAPP approach.

83. Laparoscopic mesh surgery, as compared to open mesh surgery
Advantages Disadvantages
•Quicker recovery •Needs surgeon highly
experienced
•Less pain during first days Longer operating time
•Fewer postoperative
complications
such as infections, bleeding
and seromas
Increased recurrence of
primary hernias if
surgeon not experienced
enough
•Less risk of chronic pain

84. Merits of TAPP
 The transabdominal approach allows identification of
the groin anatomy.
 larger working space of the peritoneal cavity .

85.  No absolute contraindications to laparoscopic
inguinal hernia repair , except
 Inability to tolerate GA.
 prior lower abdominal surgeries-adhesions.
 radical retropubic prostatectomy - preperitoneal
space previously dissected-

86.  Infraumbilical incision
 Anterior rectus sheath is incised
 Ipsilateral rectus abdominis muscle is retracted
laterally
 Create a space beneath the rectus.
 A dissecting balloon is inserted deep to the posterior
rectus sheath, advanced to the pubic symphysis, and
inflated under direct laparoscopic vision.
TEP approach

87.  30-degree laparoscope provides the best
visualization of the inguinal region.
 inferior epigastric vessels are identified along the
lower portion of the rectus muscle and serve as a
useful landmark.

88.  Care must be taken to avoid injury to
 femoral branch of the genitofemoral nerve and
lateral femoral cutaneous nerve- which are located
lateral to and below the iliopubic tract
 Lateral dissection is carried out to the anterior
superior iliac spine. Finally, the spermatic cord is
skeletonized.

90.  infraumbilical incision -gain access to the peritoneal
cavity
 Two 5-mm ports -lateral to the inferior epigastric
vessels at the level of the umbilicus.
 A peritoneal flap is created high on the anterior
abdominal wall, extending from the median umbilical
fold to the anterior superior iliac spine.
 Rest is similar to a TEP procedure
TAPP approach

91.  direct hernia- preperitoneal fat
 Reduced by traction if not already reduced by balloon
expansion of the peritoneal space.
 Small indirect hernia sac is mobilized from the cord
structures and reduced into the peritoneal cavity.

92.  large sac -difficult to reduce
 So, the sac is divided with cautery near the internal
inguinal ring, leaving the distal sac in situ.
 The proximal peritoneal sac is closed with a loop
ligature to prevent pneumoperitoneum.

93.  After reduction- piece of polypropylene mesh is
inserted through a trocar and unfolded.
 It covers the direct, indirect, and femoral spaces and
rests over the cord structures

94.  mesh is carefully secured with a tacking stapler to
Cooper ligament from the pubic tubercle to the
external iliac vein.
 Anteriorly to the posterior rectus musculature and
transversus abdominis aponeurotic arch at least 2 cm
above the hernia defect.
 laterally to the iliopubic tract.

95.  The mesh extends beyond the pubic symphysis and
below the spermatic cord and peritoneum.
 Tacks are not placed inferior to the iliopubic tract
beyond the external iliac artery.
 Staples placed in this area may injure the femoral
branch of the genitofemoral nerve or lateral femoral
cutaneous nerve.

97.  Staples are also avoided in - triangle of doom
 bounded by the ductus deferens medially
 spermatic vessels laterally,
 avoid injury to the external iliac vessels and femoral
nerve.

98. TRIANGLE OF DOOM
External iliac vessels
Deep circumflex iliac vein
Femoral nerve
Genital branch of GF nerve

99. Nerves
 Lateral femoral cutaneous
 Femoral branch of GF nerve
 Femoral nerve
TRIANGLE OF PAIN`

100. Intraoperative complications
 Injury to the Vas Deferens and Viscera
Postoperative complication
 Urinary retention
 Urinary tract infection
 Ischemic Orchitis
 Surgical site infection
 Neuralgia,
 pain
 Life-threatening complications
Complications After Open and Lap
Inguinal Hernia Repair

101. Long-term complications
 Seroma
 Infection
 Chronic pain
 Ischemic Orchitis and Testicular Atrophy
 Recurrence

102.  major quality indicators –
 Postoperative pain and return to work.
 Tension-free and laparoscopic mesh-based
approaches-less painful
 Lap-Least Pain
Quality of Life

103. Recurrence Factors
 Patient
 Technical
 Tissue
RECURRENCE

104. Patient factors
 malnutrition, immunosuppression, diabetes, steroid
use, and smoking.
Technical factors
 mesh size, prosthesis fixation, and technical
proficiency of the surgeon.
Tissue factors
 wound infection, tissue ischemia, and increased
tension within the surgical repair

105.  Bailey & Love's Short Practice of Surgery 27th Edition.
 S Das 9th Edition.
 Sabiston Text book of surgery 20thEdition.
REFERENCE

106. THANK YOU