An inguinal hernia occurs when abdominal contents bulge through the inguinal canal. There are two main types - indirect which are congenital and direct which are acquired. Diagnosis is made through history and physical exam assessing for reducibility and impulse on coughing. Treatment options include watchful waiting for small reducible hernias or surgical repair through open or laparoscopic techniques. The Lichtenstein tension-free repair using mesh placement is commonly performed.

1. INGUINAL HERNIA
Dr Faisal Ali
PGR SU2

2. WHAT IS AN
INGUINAL HERNIA?
Protrusion of a peritoneal sac through a
musculoaponeurotic barrier in inguinal
area

3. ANATOMY
Inguinal Hernia

4. ABDOMINALWALL
 Skin
 Subcutaneous fat
 Scarpa’s fascia
 External oblique muscle
 Internal oblique muscle
 Transversus abdominis
 Transveralis fascia
 Preperitoneal fat
 Peritoneum

5. INGUINALCANAL
4-6 cm long
Anteroinferior of
pelvic basin
Cone-shaped
Base
 superolateral margin
Apex
 Inferomedially

6. BOUNDARIES
 Anterior
 external oblique aponeurosis
 Posterior
 fusion of the transversalis fascia
and transversus abdominus
muscle,
 Superior
 arch formed by the fibers of the
internal oblique muscle.
 Inferior
 inguinal ligament

7. DEFENCE MECHANISM OF INGUINAL
CANAL
 Obliquity of inguinal canal
 Arching of conjoint tendon
 Shutter mechanism of internal oblique
 ‘Ball valve mechanism’ due to contraction of cremaster muscle which plugs
to superficial ring
 When External oblique muscle contracts intercrural fibers of superficial ring
appose causing ‘Slit valve mechanism’
 Hormones

8. SPERMATICCORD
 Cremasteric muscle
fibers
 Vas deferens
 Testicular artery
 Testicular
pampiniform
venous plexus
 Genital branch of
the genitofemoral

9. HESSELBACH’S
TRIANGLE
 Medial aspect of Rectus
abdominis muscle
 Inferior epigastric
vessels
 Inguinal ligament

10. POSTERIOR

11. MYOPECTINEALORIFICE
OF FRUCHAUD Superior
 Arch of IO Muscle and
TAbdominis.
 Lateral
 Iliopsoas muscle
 Medial
 Lateral edge of RA and
Pubic pectin
 Iliopubic tract
 Spermatic cord
 Iliac vessels

12. TRIANGLE OF DOOM
 External iliac vessels
 Deep circumflex iliac vein
 Femoral nerve
 Genital branch ofGFnerve

13. TRIANGLE OF PAIN
Nerves
 Lateral femoral cutaneous
 Femoral branch of GF nerve
 Femoral nerve

14. CLASSIFICATION
Inguinal Hernia

15. A.ANATOMICAL CLASSIFICATION
DIRECT INGUINAL HERNIA
Within the floor of
Hesselbach’s triangle
Acquired defectfrom
mechanical
breakdown over the
years
~1% Lifetime risk

16. INDIRECT INGUINAL HERNIA
Through the internal ring
of inguinal canal
Congenital
Patent processus
vaginalis
~5% Lifetime risk
Higher risk of
strangulation than direct

17. INDIRECT INGUINAL HERNIA

18. ACCORDING TO EXTENT
INDIRECT INGUINAL HERNIA
 INCOMPLETE
BUBONOCELE: Here sac is confined to the inguinal canal
FUNICULAR: Here sac crosses the superficial ring but does not
reach the bottom of the scrotum.
 Complete : Here sac descends to the bottom of scrotum

19. INDIRECT
 Can occur at any age from childhood
to adults
 Occurs in pre-existing sac
 Protrusion through deep ring
 Pyriform/oval in shape, descends
obliquely
 Can become complete
 Neck of sac is narrow and lateral to
inferior epi- artery
 Sac is anterolateral to cord
 Ring occlusion is positive
 Commonly unilateral but can be
bilateral
 Obstruction/strangulation is common
 Sac should be opened during surgery
DIRECT
 Common in elderly
 Always acquired
 Herniation through posterior wall
 Globular/round in shape, descends
directly forward
 Descent down in the scrotum is rare
 Wide neck and medial to inf epigastric
artery
 Ring occlusion test is negative
 Commonly bilateral
 Obstruction/strangulation is rare
 Sac is not necessarily opened unless
obstruction is present

20. PENTALOON HERNIA
(DOUBLE,SADDLE,ROMBERG)
Here both direct and indirect inguinal sacs
are present and clinically present as direct
hernia
During surgery , indirect sac may be
missed and so leads to recurrent hernia
through retained or unidentified indirect
sac
Here both medial and lateral sacs
straddle the inferior epigastric artery

21. Sliding hernia
Here posterior wall of the
sac is not only formed by
parietal peritoneum but
also by sigmoid colon with
its mesentery on left side;
cecum on right side and
often with a portion of
bladder.
It occurs exclusively in
males and mainly on left
side.

22. CLINICAL CLASSIFICATION
 REDUCIBLE
Can be reduced by the patient,surgeon or by it self when pt. lies
supine. Has expansile impulse on coughing.
 IRREDUCIBLE
Cant be returned to the abdomen, usually due to adhesion b/w
sac and its contents or over crowding of the contents.
 OBSTRUCTED
Bowel is obstructed but there in no interference to the blood
supply.

23. STRANGULATION
 When blood supply of contents of hernia is seriously impaired leading to
formation of gangrene.
Obstruction impaired venous return Congestion Further
dilatation of bowel which becomes purple colored Fluid collects in the
sac Eventually arterial supply is compromised Bowel becomes dark
brownish with friable wall Bacteria migrate to fluid of sac
Perforation occurs at site of constriction ring Peritonitis

24. CAUSES OF STRANGULATION
 Narrow neck
 Adhesions
 Irreducibility
 Long time large hernia with adhesions

25. RICHTERS HERNIA
 This is the partial enterocele when only the anti-mesenteric margin of the
gut is strangulated in the sac.

26. MAYDLS HERNIA
 When a W-shaped loop of gut lies in the hernia sac and the intervening
loop is strangulated within the main abdominal cavity
 Hernial sac containing a strangulated MECKELS diverticulum. It can
progress to gangrene .
LITTRES HERNIA

27. NEWER CLASSIFICATION
 Gilbert classification
 NYHUS classification
 BENDAVID classification
 Halverson and McVay classification
 Ponka classification

28. NYHUS CLASSIFICATIONSYSTEM
Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, smalladults
Type II
INDIRECT HERNIA; internal ring enlarged without impingement on the floor of theinguinal
canal; does not extend to the scrotum
Type IIIA DIRECT HERNIA; size is not taken intoaccount
Type IIIB
INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinalwall;
INDIRECT SLIDINGOR SCROTAL HERNIAS are usually placed in this category because theyare
commonly associated with EXTENSIONTOTHE DIRECT SPACE; also includes PANTALOON
HERNIAS
Type IIIC FEMORAL HERNIA
Type IV
RECURRENT HERNIA; modifiers A–D are sometimes added, which correspondTOINDIRECT,
DIRECT, FEMORAL,AND MIXED,RESPECTIVELY

29. EPIDEMIOLOGY
One of the most common surgical procedures
Incidence:
~5-10% lifetime
75% of abdominal wall hernias
Male > Female
Indirect > Direct
Right > Left
1/3 may develop a contralateral inguinalhernia

30. ETIOLOGY
 Multifactorial
 Weakness in abdominal wall musculature
PRESUMEDCAUSESOF GROIN HERNIATION
Coughing Valsalva's maneuvers
Chronic obstructive pulmonary disease Ascites
Obesity Upright position
Straining Congenital connective tissue disorders
Constipation Defective collagen synthesis
Prostatism Previous right lower quadrant incision
Pregnancy Arterial aneurysms
Birthweight <1500 g Cigarette smoking
Family history of a hernia Heavy lifting
Physical exertion (?)

31. DIAGNOSIS

32. HISTORY
 More common in males(20:1)
 Dragging pain and swelling in
the groin which is better seen
while coughing and standing.
 History of
Constipation
Cough and Smoking
Urological symptoms
 Duration
 Progressiveness
 Any h/o surgery
(appendectomy)
 Reccurent hernia or
contralateral

33. PHYSICAL EXAMINATION
 Proper exposure from umbilicus to
mid thigh
 Inspection
 Standing
 lying
 Palpation
 Can you get above the swelling
 Reducibility
 Cough impulse
 Head or leg raise to look for
abdominal muscle tone
 Internal Ring Occlusiontest

34. EXAMINATION
 Zieman’s test
index finger on deep ring
middle finger on superficial ring
ring finger on femoral opening
 Ring invagination test
little/index finger is invaginated from
Bottom of scrotum gradually pushed to enter
In superficial inguinal ring, impulse on coughing is felt
At tip of invaginated finger.

35. EXAMINATION
 Always abdominal, urological and respiratory examination is done to rule
out any precipitating factor like Chronic Bronchitis , Ascites, Stricture
urethra and BPH.

36. DIFFERENTIAL DIAGNOSIS
 Malignancy
 Lymphoma
 Retroperitoneal sarcoma
 Metastasis
 Testicular tumor
 Primary testicular
 Varicocele
 Epididymitis
 Testicular torsion
 Hydrocele
 Ectopic testicle
 Undescended testicle
 Femoral artery aneurysm or
pseudoaneurysm
 Lymph node
 Sebaceous cyst
 Hidradenitis
 Cyst of the canal of Nuck (female)
 Saphenous varix
 Psoas abscess
 Hematoma
 Ascites

37. IMAGING
Inguinal Hernia

38. CXR
Ultrasound
CTScan
MRI

39. MANAGEMENT

40. MANAGEMENT PRINCIPLES
 Not all hernias require surgical repair
 Small hernias can be more dangerous than large
 Pain, tenderness and skin colour changes imply high risk of strangulation
 Femoral hernia should always be repaired

42. CONSERVATIVE MANAGEMENT
Aimed at alleviating symptoms such as
pain, pressure, and protrusion of abdominal
contents
Assuming a recumbent position
Truss, an elastic belt or brief

43. EMERGENT REPAIR
Incarcerated hernias
Strangulated hernias
Sliding hernias

44. TAXIS
 The patient is sedated and placed in aTrendelenburg position.
 The hernia sac is grasped with both hands, elongated, and then
milked back through the hernia defect.
 Pressure applied to the most distal portion of the sac will cause the
contents to mushroom and prevent reduction.

45. STRANGULATED HERNIA
 Femoral > Indirect > Direct
 Fever, leukocytosis, and hemodynamic instability.
 The hernia bulge usually is very tender, warm, and may exhibit
red discoloration.
 Taxis should not be applied to strangulated hernias as a
potentially gangrenous portion of bowel may be reduced into the
abdomen without being addressed

46. OPERATIVETECHNIQUES
Inguinal hernia

47. PRINCIPLES OF SURGICAL REPAIR
 Reduction of the hernia content into the abdominal cavity
 Excision and closure of peritoneal sac
 Reapproximation of the walls of the neck of the hernia
 Permanent reinforcement of the abdominal wall defect with sutures or
mesh

48. SURGICAL OPTIONS
 Herniotomy : excision of hernia sac
in children
 Hernirraphy : strengthening of posterior wall of inguinal canal
 Hernioplasty : placement of mesh

49. ANTERIOR REPAIR
NON PROSTHETIC

50. OPENAPPROACH

51. OPENAPPROACH

52. BASSINI REPAIR
 Is frequently used for
indirect inguinal
hernias and small direct
hernias
 The conjoined tendon of
the transversus abdominis
and the internal oblique
muscles is sutured to the
inguinal ligament

53. LYTLE’S REPAIR
Only internal ring is narrowed
by placing interrupted sutures
over the medial side of the
ring to the fascia transversalis

54. MCVAY REPAIR
 inguinal and femoral
canal defects
 The conjoined tendon is
sutured to Cooper’s
ligament from the pubic
cubicle laterally

55. SHOULDICE
REPAIR
Multilayered
Transversalis fascia is incised,
lower flap is sutured to
posterior part of upper flap
Upper flap is sutured to
inguinal ligament.
Then conjoint tendon and
inguinal ligament is further
approximated by two layers in
front of cord .
Then Ext Oblique apo is sutured
in two layers.

56. MALONY DARN REPAIR
Posterior wall is re-inforced
with monofilament nylon
darn. The Darn is made in
crisscross fashion between
the conjoint tendon and
inguinal ligament
Excellent results.
Most commonly performed
in countries where mesh is
too expensive

57. MESH
 Gross structure
Net meshes or flat sheets
 Synthetic mesh
Polypropylene, polyester and polytetrafloroethylen PTFE
 Weight and porosity
Dense or heavy weight and Light weight, Large pore meshes
 Biological mesh
Sheets of sterilized, decellularised, non immunogenic connective tiisue

58. LICHTENSTEIN TENSION- FREE
REPAIR

59. LICHTENSTEINTENSION- FREE
REPAIR
 Initial part of surgery is same as Bassini repair.
 Once hernia has been removed and any medial defect closed, a piece of
mesh measuring 8-15cm is placed over posterior wall, behind the
spermatic cord and is split to wrap around the spermatic cord at deep
inguinal ring.
 Loose sutures with Prolone hold mesh to inguinal ligament and conjoint
tendon
 ADVANTAGES
Lowered recurrence rates
Accelerated postoperative delivery

60. Open plug/device/complex
mesh repair.
Gillbert mesh repair ;
plug and
patch, internal ring is
plugged by a cone shaped
piece of prolene mesh
PHS (Prolene hernia
system)
onlay and
sublay sandwich technique

61. LAPAROSCOPIC HERNIA
REPAIRTransabdominal Preperitoneal Procedure(TAPP)
Totally Extraperitoneal (TEP) Repair
Indications include
bilateral inguinal hernia,
recurrent hernia,
need for early recovery

62. Transabdominal Preperitoneal
Procedure (TAPP)
 Surgeon enters the peritoneal cavity incises the peritoneum above the
hernia defects and reflects it away from the muscles entering Pre-
peritonealy
 Hernia is reduced and a 10*15 cm mesh is placed just deep to the
abdominal wall extending across midline into retropubic space and 5cm
lateral to the deep inguinal ring.

63. Totally Extraperitoneal (TEP) Repair
 Space is created just deep to the
abdominal msucles without entering
the peritoneal cavity
 Hernia is reduced and mesh is
inserted preperitonealy.

64. RECURRENCE
Bassini repair 10%
Around 1% for Shouldice repair
Hernioplasty 1-3%
Most recurrences are of the same type as the original
hernia
Recurrence Factors
 Patient
 Technical
 Tissue

65. RECURRENCE
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

66. COMPLICATIONS
The overall risk of complications of inguinal
hernia repair is low.
CommonComplications
 EARLY: pain, bleeding, urinary retention, anaesthesia
related
 Medium : seroma, wound infection
 Late: chronic pain, testicular atrophy, recurrance

67. THANK
YOU