This document provides information on the management of inguinal hernias. It begins with an introduction to inguinal hernia including definitions, anatomy of the inguinal region, epidemiology, causes, types, classifications, clinical presentation, diagnosis, hernia repair techniques, complications and recent advances. The majority of the document then focuses on providing detailed descriptions and illustrations of the anatomy of the inguinal region and inguinal canal, classifications of hernias, clinical presentation, investigations for diagnosis and the open tension free Lichtenstein hernia repair technique.

1. 1

2. Dr. Shabir Ahmad
PG4 Trainee ,Surgical B Unit
Lady Reading Hospital, Peshawar
Supervisor:
Prof: Dr. Nadim Khan
HOD Surgical B Unit
Lady Reading Hospital, Peshawar
2

3. Inguinal Hernia
Management
3

4. 4

5.  Introduction
 Anatomy of Inguinal Region
 Epidemiology
 Causes of Inguinal Hernia
 Types of Inguinal Hernia
 Classification
 Clinical Presentation
 Diagnosis
 Inguinal Hernia repair
 Conservative Mx
 Complication
 Recent Advances
 References
 Conclusions
5

6. 6
The term “hernia” is derived from the Greek word hernios, which means
“budding.”
A hernia is a protrusion of a viscus or part of a viscus through an
abnormal or normal opening in the walls of its containing cavity
Parts of Hernia
Covering
Sac
Content
Coverings of the sac are the layers of the abdominal wall through which
the sac passes

7. An inguinal hernia is a
protrusion of abdominal cavity
contents through the inguinal
canal.
Inguinal hernia is the commonest
hernia (73%) because the muscular
anatomy in the inguinal region is weak
and also due to the presence of natural
weakness like deep ring and cord
structures
7

8. 8

9.  The inguinal region of the body is
located on the lower portion of the
anterior abdominal wall, with the
thigh inferiorly, the pubic tubercle
medially and the anterior superior
iliac spine superolaterally
9

10.  This is an oblique passage in the lower part of
the anterior abdominal wall , Situated just
above the medial half of the inguinal ligament
 It is about 4cm (1.5 inches) long, and is
directed downwards, forwards and medially
 The inguinal canal extends from the deep
inguinal ring to the superficial inguinal ring
 Deep inguinal ring is an oval opening in the
fascia transversalis situated 1.2 cm above the
midinguinal point, and immediately lateral to
the inferior epigastric artery
 Superficial inguinal ring is a triangular gap
in the external oblique aponeurosis
 The inguinal canal is larger in males than in
females
10

11. Anterior wall: external oblique
aponeurosis throughout the length of
the canal and internal oblique muscle
laterally
Posterior wall: transversalis fascia
laterally; conjoint tendon medially
Superior wall (Roof): Internal
oblique and transversus abdominis
muscles
Inferior wall (Floor): inguinal
ligament, and medially by the lacunar
ligament.
11

12. Ilioinguinal Nerve is a direct branch of
L1….. Provides sensation to the upper
and medial thigh , perineum
Genital Branch of the genitofemoral
nerve is derived from L1/L2 nerve
roots…..provides motor function to
cremaster muscle.
Special care must be taken to protect
this nerve
12

13.  Weak spot in anterior abdominal
wall through which direct hernia
appears
Lateral : inferior epigastric vessels
Medial: lateral border of rectus
abdominis
Inferior: Medial part of inguinal
ligament
Floor : Fascia Tranversalis
13

14. Mid-inguinal point
Halfway between the pubic
symphysis and the anterior superior
iliac spine.
The femoral pulse can be palpated
here
Midpoint of the inguinal ligament
halfway between the pubic tubercle
and the anterior superior iliac spine
The opening to the inguinal canal is
located just above this point.
14

15. 1.The spermatic cord in males, or the
round ligament of the uterus in
females, enters the inguinal canal
through the deep inguinal ring and
passes out through the superficial
inguinal ring.
2.The ilioinguinal nerve enters the
canal through the interval between the
external and internal oblique muscles
and passes out through the superficial
inguinal ring
15

16. The Spermatic cord is a
bundle of structures that
pass through the
inguinal canal to and
from the testis.
 It begins at the deep
ring lateral to the
inferior epigastric artery
and ends at the testis
16

17.  The spermatic cord is covered
with 3 layers
 The outermost layer is external
spermatic fascia which is
derived from the deep fascia of
the external oblique
 The middle layer is cremasteric
fascia which is derived from the
internal oblique muscle
 The innermost layer is internal
spermatic fascia which is
derived from the transversalis
fascia
17

18.  3 Arteries
 1) Testicular artery
 2)Artery to Vas Deferens
 3) Cremasteric Artery
 Pampiniform Plexus
 Lymphatics of testis
 Genital Branch of the genitofemoral
nerve
 Testicular plexus of sympathetic
nerve
 Vas Deferens
18

19. 19
 About 75% of all hernias occures in the inguinal region.
 90% of them are in men and 10% in women..
 The most common inguinal hernia in women and in men is the indirect inguinal hernia.
 The prevalence of hernia in men has two peak ages:
Under one and above 40.
 About 1/3 of the patients who present with hernia, also develop a contralateral hernia.
 Hernia in the right side is more common
 The prevalence of inguinal hernia increases with age (especially in men

20. Direct Hernia:
It occurs through the Hasselbach’s
triangle.
Hernia Sac is medial to the inferior
epigastric artery
Indirect hernias:
It occurs through the internal ring
along with the cord in male and round
ligament in female .
Hernia Sac is lateral to the inferior
epigastric artery.
20

21. 21

22. 22

23. 23
 i) Reducible
 ii) Irreducible
 iii) Obstructed or Incarcerated (irreducibility + obstruction)
 iv) Strangulated
 v) Inflammed

24.  Bubonocele: Hernial sac stops
within inguinal canal after
entering internal ring
 Funicular: Hernial sac after
emerging out of external ring
stops just above the testis
 Complete Scrotal: Processus
vaginalis is patent throughout
being continuous with tunica
vaginalis of the testis. It is a
congenital hernia, commonly
seen in children but it may
appear in adult or adolescent
life.
24

25. 25
Sliding hernia: A sliding hernia is formed when a retroperitoneal organ
protrudes (herniates) outside the abdominal cavity in such a manner that the
organ itself and the overlying peritoneal surface constitute a side of the hernia
sac
wall of the sac is not only formed by the parietal peritoneum, but also by sigmoid
colon with its mesentery on left side; caecum on right side and often with
portion of the bladder.
Richter Hernia: Richter’s hernia is a hernia in which the sac contains only a
portion of the circumference of the intestine (usually small intestine).
Littre Hernia: which contains Meckel Diverticulum

26. 26
.
Amyand Hernia: An inguinal hernia that contains the appendix
Gibbon,s Hernia: Hernia with hydrocele
Pantaloons hernia: when both direct and indirect hernias co-exist
Maydl’s Hernia (Hernia-in-W) a loop of bowel in the form of ‘W’ lies in the
hernial sac and the centre portion of the ‘W’ loop is strangulated and lies within
The abdominal cavity
Omentocele..……Omentum
Enterocele ……. Intestine
Cystocele…….Urinary bladder

27. 27
 European Hernia Society (EHS) Classification
 Nyhus Classification
 Gilbert classification
 Bendavid classification
 Halverson and McVay Classification
 Ponka’s Classification
Many classification systems have been devised for inguinal hernias, but
European Hernia Society, EHS has recently suggested a simplified system of
inguinal hernia classification

28.  EHS is a very simple
classification in which the type
of hernia and defect size can be
marked in respective columns in
the box .
 The defect size is measured in
finger breath which is assumed
to 1.5 cm
28

29. 29
 Type I : Indirect hernia; internal ring normal
 Type II: Indirect hernia; internal ring enlarged
 Type III: 3 subtypes
 Type IIIA: Direct hernia
 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
 Type IIIC : Femoral hernia
 Type IV : Recurrent hernia
 Type IV A : Recurrent Direct Hernia
 Type IV B : Recurrent Indirect Hernia
 Type IV C : Recurrent Femoral Hernia
 Type IV D : Combination

30. 30

31.  Coughing
 COPD
 Obesity
 Straining
 Constipation
 Enlarged Prostate
 Pregnancy
 Family history of hernia
31
 Congenital connective tissue
disorders
 Defective collagen synthesis
 Previous RLQ incision
 Arterial aneurysum
 Cigarette smoking
 Heavy weight lifting
 Ascities
Mutifactorial i.e genetic, environmental, metabolic or hormonal • Weakness in abdominal wall musculature • Presumed causes of groin hernias are:
•

32. 32
 The symptoms are variable from a hernia with no symptoms to one with
stangulation.
 Asymptomatic hernia is either found in physical exam, or the patient himself
realizes the bulging, or it is found during laparascopy.
 Symptomatic patients mostly present with inguinal pain.
 Sometimes patients present with symptoms outside the inguinal region such
as a change in bowel habits, and/or urinary symptoms (in the form of sliding
hernia).

33. 33
 With pressure on the nearby nerves, hernia can cause different symptoms
such as a general feeling of pressure, localized pain, and referred pain.
 The feeling of pressure and weight on the inguinal region especially after a
daily activity is common

34. 34
 Malignancy:
Lymphoma, metastasis, testicular tumor, Retroperitoneal sarcoma
 Testeicular primary conditions :
Varicocele, Testicular torsion, Hydrocele, Ectopic and undescended testes
 Aneurism or pseudoaneurism of the femoral artery
 Enlarged lymph nodes
 Sebacious cyst
 Nuck canal cyst (in women)
 Psoas Abcess
 Hematoma
 Ascites

35. 35
 The diagnosis is based on history, physical exam and sometimes imaging.
 In some conditions physical exam cannot diagnose the hernia:
1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam
 In these conditions imaging is important

36. 36
Diagnosis of ingunial hernia is clinical but following investigations may be done
Ultrasound abdomen and pelvis: It defines defect and its contents. In old age, to
look for BPH, its size and to calculate post-voidal volume And to find any mass.
•
CT scan: Its helpful in complex incisional hernia determining the number and
size of muscle defects, identifiying the contents as well as intraabdominal
pathology.
MRI: It is helpful in diagnosing sportsman’s groin where pain is the presenting
feature and to distinguish occult hernia from orthopedic injury.
Herniography: It can be performed in suspected hernia when clinical diagnosis is
unclear. This procedure is done under floruoscopy following injection of contrast
medium in peritoneum. Frontal and oblique radiographs are taken with and
without increased intra-abdominal pressure.

37. 37
Inguinal Hernia Repair

38. 38
 1) Reduction of hernia content into the abdominal cavity with removal of any
non-viable tissue and bowel repair if necessary.
 2) Excision and closure of a peritoneal sac if present or replacing it deep to the
muscle.
 3) Reapproximation of the walls of the neck of the hernia if possible
 4) Permanent reinforcement of the abdominal wall defect with sutures or
mesh.

39.  For any hernia the surgical option comprises of 2 componenets
 Herniotomy
 Herniorrhapy or hernioplasty
 It is either
 Open repair
Tissue Repair
Mesh Repair
 Laparoscopic repair
1. Transabdominal preperitoneal “TAPP”
2. Totally extraperitoneally “TEP
3. Intraperitonial onlay Mesh “IPOM
39

40. 40

41. 41
Open Mesh Repair
Lichtenstein’s Tension Free Mesh Hernioplasty
Gilbert’s Plug ( Patch & Plug )
Stoppa’s Repair
Laparoscopic Mesh Repair
1. Transabdominal preperitoneal “TAPP”
2. Totally extraperitoneally “TEP
3. Intraperitonial onlay Mesh “IPOM”

42. 42
Lichtenstein’s Tension
Free Mesh Repair

43. Skin Incision
start skin incision 2cm to 3cm above
the pubic tubercle within the skin
crease and extend it 5 to 6cm laterally
parallel to the inguinal ligament up to
the mid inguinal point
Incise the subcutaneous fats,
camper,s and scarpa,s fascia to expose
the external oblique aponeurosis and
then identify the external ring which
confirms the line of inguinal canal
43

44. Exposure of the inguinal canal
The external oblique aponeurosis is
then opened along the line of incision,
starting from the external ring and
extending laterally for up to 5cm
The superior and inferior flaps of the
external oblique aponeurosis are
gently freed from the underlying
contents of the inguinal canal
Wide separation of the two flaps
provides ample space for placement
and fixation of mesh under vision
while protecting the nerves
44

45. Dissection of spermatic cord
The spermatic cord, along with the
cremaster, is then lifted up and
separated from the pubic bone for
about 2 cm beyond the pubic tubercle
to create space for extending the mesh
well beyond the pubic tubercle
When lifting the cord, the surgeon
must be sure to include the
ilioinguinal nerve, the genitofemoral
nerve, and the spermatic vessels along
with it.
All of these structures may then be
encircled in a tape for ease of
handling.
45

46. The patient is asked to cough, and the
groin region is examined for the
presence of an indirect hernia, a direct
hernia, a femoral hernia, a combined
hernia
A hernia sac can be managed by means
of inversion, division, resection, or
ligation
Indirect sac is anterolateral and direct
hernia sac is posteromedial to to the
vas deferens and spermatic vessels
Indirect sac can be ligated at the neck
and remaining portion excised or
directly pushed back into the
peritoneal cavity
Direct hernia sac simply pushed back
into the peritoneal cavity 46

47. Prolene mesh is commonly used for a
Lichtenstein hernioplasty.
Lower border of the mesh is sutured to
the in-turned portion of the inguinal
ligament by continue 2/0 prolene
sutures till the level of the deep ring
A slit is made at the lateral end of the
mesh creating two tails , upper wide
2/3rd
and lower narrow 1/3rd
. Crossing
of the two tail creates new internal
ring
47

48. Upper margin of mesh is fixed to
internal oblique with 2/0 interrupted
sutures
Mesh should be lax, slightly wrinkled
rather than lying flat to avoid tension
on mesh when patient stands
External oblique aponeurosis is stiched
by contionous prolene 1/0 suture
Scrotal Support is routinely prescribed
to all patient to avoid scrotal edema or
hematoma
48

49. 49
 With the advent and gaining popularity of tension free mesh hernioplasty,
tissue repair have been largely replaced because of their high recurrence rate
 In the modern surgical practice tissue repair indicated in the following
condition
 1) Strangulated inguinal hernia …….. Mesh hernioplast is contraindicated
 2) Known Allergy to Mesh
 3) Not affording Mesh ….. Poor developed countries
 4) Patient refuse to have foreign material

50.  Shouldice Repair
 Bassini’s Repair
 Modified Bassini,s Repair
 Halstead’s
 Lytle’s Method
 Ferguson’s Repair
 McVay’s Repair
 Darning Repair
 Desarda Repair
50

51. Shouldice Repair
51

52. The Shouldice repair is the gold standard
for the prosthesis (mesh) free treatment of
inguinal hernias.
> Canadian repair
In good Surgeon Hands,
Shouldice repair is safe and effective
Recurrence rate is less than 1%
Complication rate is less than 0.5%
After handling the hernia sac, fascia
transversalis is opened in its middle from
internal ring to pubic tubercle so that it
forms a superior and inferior flap
The repair involves placing four lines of
sutures.
52

53.  The first suture line is started
medially at the pubic tubercle
using continuous prolein
suture, and approximating the
lower cut edge of tarnsversalis
fascia to the deep surface of the
fascia of the upper flap.
53

54. The 2nd suture line : At the internal
ring the suture is tied and then
continued towards medially by
approximating the free edge of the
superior flap of transversalis fascia to
the shelving portion or reflected
border of inguinal ligament. When
the pubic tubercle is reached, the
suture is tied and divided.
The periosteum should not be
included in any bite as this can result
in a painful osteitis.
54

55.  The third suture line is started at
the level of the internal ring where
the conjoined tendon is
approximated to the inner aspect
deep surface of the lower flap of
external oblique, close to the
inguinal ligament and suture is tied
when the pubic tubercle is reached
55

56.  After reaching the pubic tubercle
the suture is then reversed and
continued as the fourth suture
line laterally towards the deep
ring, again the conjoined tendon is
approximated to the inner aspect
deep surface of the lower flap of
external oblique in a more
superficial plane
 The fourth line duplicates the third
in reverse.
 The cord is replaced within the
inguinal canal, and the external
oblique aponeurosis is
approximated with continuous 2-0
absorbable sutures
56

57. 57
.
Bassini’s Repair

58. Exdwards Bassini > Father of hernia
surgery
Remained gold standard for hernia
repair > 20th
century
After handling the hernia sac,
fascia transversalis is opened from
internal ring to pubic tubercle thus
creating upper flap comprising of
fascia transversalis, transversus
abdominus and internal oblique
.
58

59.  Repair is started medially from
pubic tubercle and is continued
laterally and triple layer upper flap
is approximated to the reflected
inturned portion of the inguinal
ligament and lower flap of
transversalis fascia by means of
interrupted sutures.
 Suture line extends from the pubic
tubercle to the medial border of the
internal ring
 Not done nowadays
59

60.  Original Bassini,s repair has been
modified in North America in which
fascia transversalis in not incised
and only conjoind tendon (internal
oblique and transversus
abdominus) are approximated to
the inguinal ligament
 Getting absolete slowly
60

61. 61
 Lytle,s repair is narrowing of internal ring by placing interrupted sutures over
the medial side of the ring to the transversalis fascia

62.  In this repair, external oblique
aponeurosis is used to strengthen
the postrior wall. • The spermatic
cord, placed beneath the layers of
abdominal wall fascia. •
 This technique is not appreciated
because of the high incidence of
hydrocoels and testicular atrophy as
well as recurrence postoperatively.
62

63.  In this procedure, interrupted
suture is applied between
transversalis fascia to copper’s
ligament starting from public
tubercle medially towards femoral
sheath and later continued as
suture repair between transversalis
fascia and iliopublic tract laterally
upto enterence of cord. •
 It covers all three groin defects-
indirect, direct and femoral.
63

64. 64
Laparoscopic Mesh Repair

65. 65
 Laparoscopic repair of inguinal hernia is increasingly popular because
of less postoperative pain and quick return to normal activity
 First repair was done in 1992
 There is a steep learning curve for laparoscopic inguinal hernia repair
and should only be performed by experienced surgeons
 All currently performed laparoscopic hernia involve placing a mesh in
the preperitoneal space and its anatomical approaches is crucial for
successful laparoscopic hernia repair

66.  Primary challenges in learning
laparoscopic hernia repair is the
unfamiliarity of anterior
abdominal wall anatomy for
most surgeons
 The two dangerous areas•
 1) Triangle of Doom
 2) Triangle of pain
66

67.  The Triangle of Doom is an anatomical
triangle bounded by
 The vas deferens medially,
 Spermatic vessels laterally
 and Peritoneal fold inferiorly.
 This triangle contains
 External iliac artery and vein,
 The deep circumflex iliac vein,
 The genital branch of genitofemoral.
 Significance: During laparoscopic repair
Surgical staples are avoided because
fixation of the mesh inside these
boundaries causes haemorrhaging
67

68.  The "triangle of pain" is an inverted
"V" shaped area with its apex at the
internal (deep) inguinal ring.
 It is bound anteriorly by the
iliopubic tract / inguinal ligament
and by the Gonadal vessels
posteromedially
 During laparoscopic repair staples
and suturs are avoided in this area
because it cause pain.
68

69. 69
 A number of studies have shown laparoscopic repair of inguinal hernias to have
advantages over conventional repair, including the following .
 Reduced postoperative pain
 Diminished requirement for narcotics
 Earlier return to work
 lower incidence of chronic groin pain
 Less wound complication
 Laparoscopic repair has some disadvantages as well, including the following:
 Need of gereral anesthesia in every case
 Increased cost
 Increase duration of operation
 Steeper learning curve
 Higher recurrence and complication rates early in a surgeon’s experience

70. 70
The laparoscopic approach to inguinal hernia is theoretically possible in nearly
all inguinal hernia but it is ideal for:
 Bilateral inguinal hernia
 Recurrent inguinal hernia
 When the diagnosis of inguinal hernia is uncertain
 When the patient want to return to normal physical life

71. 71
The patient unfit for general anesthesia
Patient who have planned pelvic or extraperitoneal operations (eg, radical
prostatectomy)
Patient who have had a recurrence from a prior laparoscopic repair
Patient presented with strangulated hernia.
Past Hx of pelvic irradiation
Incarcerated hernia is a relative contraindication
Presence of local or systemic infection
Previous lower abdominal midline scar

72. 72
Laparoscopic repair is done by following approaches :
1. Transabdominal preperitoneal “TAPP”
2. Totally extraperitoneally “TEP
3. Intraperitonial onlay Mesh

73. 73
 Transabdominal preperitoneal technique: A laparoscopic repair procedure in
which the surgeon enters the peritoneal cavity, incises the peritoneum, then
enters the preperitoneal space, and places the mesh over the hernia; the
peritoneum is then sutured

74. The patient is placed supine with both
arms tucked and general anesthesia
induced.
After pneumoperitoneum is
established and the trocars are
inserted, the patient is placed head-
down position during the operation
and slightly (approximately 15°) turned
toward the surgeon.
The monitor is placed at the foot of
the bed
The operating surgeon & the camera
assistant stay on opposite sides of the
hernia.
74

75.  First Establish the carbon dioxide
pneumoperitoneum using the Veress
needle.
 Three ports are used for a TAPP repair
 One 10 mm optical port– supraumbilical
or Infraumbilical is placed
 Under laparoscopic view - Two 5 mm
operating ports placed on the
midclavicular line 2 cm below the level
of the horizontal line from the
umbilicus.
75

76. The following key structures should be
identified
Median and medial umbilical folds
Lateral umbilical folds and epigastric vessels
(see the first image )
Vas deferens and spermatic vessels ,Iliac vessels
Hernia defect (direct or indirect) (see the
second image below)
The two dangerous “triangles”
1) Triangle of Doom
2) Triangle of Pain
76

77.  After the anatomy is identified,
laparoscopic scissors are used to
make a small incision in the
peritoneum at (or just lateral to) the
medial umbilical ligament, just
below the umbilicus
 This incision is then extended
laterally to the ASIS
 The peritoneum is bluntly dissected
away from the abdominal wall with
blunt laparoscopic graspers
 The peritoneal flap must be
extended far enough so that it can
cover the mesh and completely
exclude it from the peritoneal
cavity.
77

78. Reduction of hernia sac and lipoma with
upward traction.
78

79.  Direct hernia sacs are easily
dissected. Care should be taken not
to dissect lateral and inferior to
Cooper's ligament, as the Iliac Artery
and Vein will enter the femoral canal
at this site
 The hernia sac dissection is
performed using traction contra-
traction maneuvers and fine
coagulation. To avoid the injuries of
the ductus deferens and spermatic
vessels the sac dissection always
starts anteriorly
 When performing inguinal hernia
repair in women, extra effort should
be undertaken to reveal and treat
occult synchronous femoral hernia
79
 Reduction of hernia, showing
hernia defect.

80.  After dissection and hernia reduction, the mesh is placed in the
extraperitoneal space.
 A large (12x15 cm) prolene mesh is rolled longitudinally and introduced with a
grasper through Camera trocar. It is then spread in the peritoneal cavity
Then, the mesh is placed in the appropriate position and fixed by 1 Prolene
sutures or tacking staples or glue.
 The mesh shouldn’t be sutured/stapled at the level of dangerous triangles and
epigastric vessels
 The Mesh is secured to Cooper's Ligament and on the anterior abdominal
wall.
80

81.  The peritoneum is closed by a
running suture using a 2-0 vicryl.
 After peritoneal closure, the ports
are removed under direct vision,
and close the fascial defect of the
camera port
.
 Closure of peritoneum over inserted
mesh
81

82. 82

83.  It is more popular then TAPP but
having high steeping curve of
learning …….about 250 cases
 Through subumbilical incision
(10mm) extraperitoneal space is
reached.
 After CO2 insufflation, another
5mm port is created 4cm below the
1st port in the midline, 3rd port on
the same line or RIF.
83

84.  Dissection is carried downwards
carefully, then medially upto public
tubercle, iliopectneal line, laterally
to iliac vessels and inferior
epigastric vessels.
 Once adequate spce is dissected 15 x
15cm mesh is placed and spread. •
Mesh may be sutured to iliopectinal
ligament.
 Displacement of mesh is not seen.
 Another side can be done at the
same time
84

85. 85

86. 86
 Indications of conservative surgery:
1-Bad coexisting medical condition
2-A small asymptomatic hernia
3-An elderly person who is asymptomatic
4- Patient refuse inguinal hernia repair
 Important Point: Conservative treatment is not used in femoral hernia

87.  Truss:
A truss is a surgical appliance which
provides support for the herniated
area, using a pad and belt
arrangement to hold it in the
correct position
 –It is not curative
 –Hernia should be reducible
 –Contraindicated in case if
irreducible hernia, undesended
testies, associated huge hydrocele
87

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 Intra operative
 Injury to blood vessels ( inferior epigastric & femoral.
 Injury to bowel and bladder
 Injury to ilioinguinal & iliohypogastric nerves
 Injury to cord structues
Immediate Post Operative
 Urine retention
 Hematoma formation
 Infection
 Seroma
 Periosteitis of public tubercle
 Post herniorrhaphy hydrocele

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 Late
 Recurrence –Recurrence rate
Bassini’ repair – 10%
Shouldice repair – 1%
Hernioplasty – 1 t0 3%
Other methods – 1 to 5%
 Testicular atrophy if testicular artery is demaged
 Numbness over the local region if the nerve was cut during surgery

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 Laproscopic Hernia Repair Complication
 Vascular injury
 Visceral Injury
 Trocar site complications
 Bowel obstruction
 Hypercarbia syndrome
 Abdomen compartment syndormesr

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 Symptomatic groin hernias should be treated surgically.
 Asymptomatic or minimally symptomatic male IH patients may be managed
with "watchful waiting" since their risk of hernia related emergencies is low.
 Mesh repair is recommended as first choice, either by an open procedure or a
laparoscopic repair technique.
 One standard repair technique for all groin hernias does not exist
 Lichtenstein tension free mesh repair and laparoscopic repair are best hernia
repair procedure

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Books
Bailey and Loves
SRB’s Manual of Surgery
Atlas of General Surgery
Schwartzs Principle of Surgery
Kirk
Internet
Medscape
Upto Date @ 2015
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999770/
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1464-410X.2009.09155.x
https://www.shouldice.com/the-shouldice-hernia-repair-surgery/

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