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1. Management of Groin and
Abdominal Wall Hernias
Natnael Gebeyehu GSR III
Moderator- Dr. Abebe Alemayehu (MD, Ass. Professor of General and
HPB surgery)

2. Outline
1.Introduction
2.Anatomy Overview
3.Types of Hernias
4.Symptoms and Diagnosis
5.Surgical Management Overview
6.Preoperative Care
7.Surgical Techniques
8.Recent Advances
9.Conclusion
10.References

3. History
1500 BC - 400 BC: The Egyptians, Phoenicians, and
Ancient Greeks describe the diagnosis of hernia and
various methods of treatment.
Mid-1700s: The Age of Dissection begins, when surgical
anatomists began to appreciate and understand the
complexity of inguinal (groin) anatomy.
1846: The first demonstration of effective anesthesia
occurred at Massachusetts General Hospital.
1887: Eduardo Bassini introduces the first true
anatomical repair of a groin hernia.
1940s: Various forms of synthetic polymers were used in
inguinal hernia repair.
1960s: Dr Richard Newman had performed over 1600
inguinal hernia repairs using polypropylene.
1979: The first laparoscopic inguinal hernia surgery was
described.
1989: The first use of a prosthetic mesh during
laparoscopic hernia repair was described.

4. Introduction
Derived from the Greek words meaning ‘to bud’ or ‘to protrude’
and the Latin word for ‘rupture’.
A hernia is defined as an abnormal protrusion of a viscous or
part of a viscous through an opening, either artificial or natural.
 This condition often occurs due to an area of weakness or
disruption in the fibromuscular tissues of the body wall.

5. Groin hernias, which include inguinal and femoral hernias,
account for 75-85% of all abdominal wall hernias. They are more
common in males, with 27% of males and 3% of females likely to
develop a groin hernia in their lifetime.
They occur due to weaknesses in the muscular anatomy of the
inguinal region, including natural weak points like the deep ring
and cord structures. Among inguinal hernias, indirect ones are
more common than direct.

6. Other types of hernias include femoral (7%), umbilical (8.5%),
and others excluding incisional hernias (1.5%). Incisional hernias,
which occur post-surgery, are the second most common type
after inguinal hernias, accounting for 15% of cases.
Groin hernias are 25 times more common in men than women.
However, certain types of hernias such as femoral, umbilical, and
incisional hernias are more common in females.

9. Anatomy Overview:

10. Types of Hernias
Classification I (Clinical)
Reducible Hernia
Irreducible Hernia
Obstructed Hernia
Inflamed Hernia
Strangulated Hernia
Occult (Inguinal) Hernia
Classification II
 congenital-Common
 Acquired
 Classification Ill: According
to the Contents
 Omentocele-omentum.
 Enterocele-intestine.
 Cystocele- urinary bladder.
 Littre's hernia-Meckel's diverticulum.
 Maydl's hernia.
 Sliding hernia.
 Richter's hernia-part of the bowel
wall
Classification IV: Based on Sites
 Inguinal hernia
 Femoral hernia
 Obturator hernia
 Diaphragmatic hernia
 Lumbar hernia
 Spigelian hernia
 Umbilical hernia
 Epigastric hernia

11. Structure of a Hernia
The hernial orifice. This is formed by the layers of the abdominal wall, periosteum and bone
The hernial sac. a pouch of varying size that contains the hernia. neck, body, and fundus
The hernial contents. comprise any of the abdominal contents, though the omentum and small
bowel are most often involved.
The hernial coverings. layers of tissue surrounding the hernial sac.

12. Etiology :Theories for Hernia Formation
Russell’s theory—preformed sac.
Reid’s metastatic emphysema theory—do not smoking.
Cloquet’s lipoma theory—pile driver action of fat.
Fruchaud’s theory—big opening in the lower abdomen-between the pubic bone and conjoint
tendon. Divided into two by inguinal ligament. Through the upper part passes the inguinal hernia,
while through the lower part passes the femoral hernia.
Denervation theory—ilioinguinal nerve especially after appendectomy.
Oblique pelvis—high arch of the internal obliqueinefficient shutter mechanism–prone to inguinal
hernia.
Wide female pelvis—lower arch of internal obliquemore efficient shutter mechanism-indirect inguinal
hernias are uncommon in females. Results in wider femoral ring–femoral hernias most common in
females.
Uglavasky theory—chronic increased IAP.
Peacock’s theory—defective collagen synthesis.

13. Walk’s theory—weakness of abdominal wall at exit of neurovascular bundle.
Keith’s theory—stress related degeneration of connective tissue, especially in the fascia transversalis.
Deficient insertion of the conjoint tendon seen in males–especially white males—predisposes to direct
inguinal hernia–less support to posterior inguinal canal wall. Attachment quite wide in females–direct
hernia almost never occurs in females.
Dr Desarda’s theory adynamic and weak posterior wall due to absent or deficient aponeurotic
extensions is the main cause of hernia formation. Loss of shielding action of the muscles and binding
action of the interparietal connective tissue are also important factors.

14. Straining.
Lifting of heavy weight.
Chronic cough (tuberculosis, chronic bronchitis, bronchial
asthma, emphysema).
Chronic constipation (habitual, rectal stricture).
Urinary causes
 Old age-BPH, carcinoma prostate.
 Young age-stricture urethra.
 Very young age-phimosis, meatal stenosis.
Obesity.
Pregnancy and pelvic anatomy (especially in femoral hernia in females).
Smoking.
Ascites.
Appendicectomy through McBurney's incision may injure the ilioinguinal nerve causing right sided
direct inguinal hernia.

15. Symptoms and Diagnosis
swelling and a bulge in the groin that often
resolves spontaneously.
When incarceration is present, the swelling
persists and is associated with pain
local examination
patient standing , lying and with and without a
Valsalva maneuver.
Inspection.
Palpation.
 Complete hernia
 Incipient hernia
 Soft groin

16. Investigations
Plain X-Ray of the Abdomen
Gastrointestinal or Colon Imaging with Water-Soluble Contrast Agent
Herniography (Peritoneography)
Computed Tomography, Magnetic Resonance Imaging
Ultrasonography/se86% vs Sp77%
 Evidence of a gap in the fascia.
 Imaging of hernia contents.
 Increase in the volume of the hernia contents or
 in the size of the hernial orifice with the Valsalva maneuver
 Incarceration -thickening of the bowel wall

17. Surgical Management Overview:
Choice of Procedure
Permanently closed with low risk
 Avoidance of recurrence,
 Low pain levels, and a
 Low infection rate.
Adequate personal experience
Patients and types of hernia
The Patient
The following are the risk factors:
 For recurrence:
 Familial predisposition.
 Multiloculated hernia.
 Recurrent hernia.
 Connective tissue disorders.
 For infection:
 Contaminated wound.
 Hypotrophic or infected skin condition.
 High BMI.
 Shock.
 Incarceration.
 For chronic pain:
 Preoperative pain.
 Low BMI.
 Young patient.
 Re-operation
Repair Principles and Materials

18. Hernia Type
 Anatomical location
 Hernia size

19. Adult Inguinal Hernia
• Prevalence of inguinal hernia is 25% in
males; 2% in females.
• It is more common in males (20:1
Male:Female)
• Contents are either small bowel, large bowel,
omentum or combination of all these.
• In females, sometimes ovary and tubes may
be the content.
• In infants, swelling appears when the child
cries and is often translucent.

20. Indications
Absolute indications
 Incarcerated, nonreducible hernia.
 Incarcerated hernia with peritonitis or suspected bowel Necrosis.
 Recurrent incarceration.
Relative indication
 Impaired general operability in elderly or severely ill patients.
Contraindications
 Incurable intra-abdominal conditions (e.g., peritoneal carcinomatosis).
 General and local inoperability (maximum 1% of all inguinal hernias).

21. Preoperative Care
Preparation
 Shaving or chemical depilation of the operation area on the day of surgery.
 Transurethral catheter if necessary (e.g., in the case of prostatic hyperplasia).
 Medications can be given safely during inguinal hernia surgery, with the exception of anticoagulant drugs.
 warfarin switched to heparin.
 Aspirin up to 100 mg per day but > 100 mg D/C for 1 week -switched to heparin.
 Local anesthesia is preferable in cooperative patients; otherwise, spinal/epidural anesthesia or general anesthesia
is used.
Special Risks, Informed Consent
 Spermatic cord injury (1%).
 Wound infection (2%).
 Chronic groin pain (< 5%).
 Recurrence (1–10%).
 Mortality (< 0.2%).

22. Surgical Techniques-Open Suture Techniques
Common Steps for all
techniques
Access

23. Splitting the External Oblique
Aponeurosis I/Protecting the Nerves

24. Splitting the Cremaster

25. Resection of the Cremaster
Muscle

26. Dissection of the Hernial Sac
/Neck Sac

27. Management of the Hernial
Sac

28. Inspection of the Transversalis Fascia
The hernia type is then
classified, distinguishing
between
 lateral (L) = indirect and
 Medial (M) = direct hernias
Size
 I (< 1.5 cm),
 II (< 3 cm) and
 III (> 3 cm)
 Small indirect hernias –
Zimmerman method /direct-
sutured directly
 Procedure of choice- Shouldice
method
 Larger hernias -polypropylene
mesh.

29. Bassini Repair-three layer
method

30. Interrupted sutures -0.6 cm as far
as the deep inguinal ring
The newly constituted deep ring
must admit the tip of the little finger
or forceps to ensure that the
spermatic cord has enough room
 “Modified” or “North American” Bassini
 Girard Variation
 Kirschner Variation
 The Hackenbruch Variation

31. Shouldice Repair-
four layer repair

32. Lotheissen/
McVay Repair
 It is technically complex,
 Painful
 Often unsafe
 As the elastic muscles may tear out
of the cooper ligament, in the long-
term
 TEP is a better alternative today.

33. Open Mesh Techniques/
Lichtenstein Repair  1970s by I.L. Lichtenstein (los angeles, CA,
united states of america)
 6 × 14 cm mesh
 Simple
 Direct and indirect hernias that require mesh
repair
 Femoral hernias through an inguinal approach.

34. External cremasteric vessels and genital
branch that runs in the floor of the inguinal
canal ligated and divided together with the
nerve laterally where they join the deep
epigastric vessels.
large-pore, lightweight mesh
Mesh fixation starts over the pubic
bone with a U-shaped suture- overlap by
1 cm medially.
lateral side, the mesh is incised 2 cm above
the lower edge of mesh as far as the medial
boundary of the deep inguinal ring.

35. Transinguinal preperitoneal patch(TIPP)
 Rives preperitoneal repair
 Kugel preperitoneal repair
 Pélissier preperitoneal repair
 Ugahary preperitoneal repair
 Transrectus sheath preperitoneal patch repair technique(TREPP)
Nyhus repair with mesh
The stoppa/wantz procedure
Three-dimensional mesh procedures
Plug and patch

36. Mesh free inguinal hernia repair by
DESARDA technique

37. Laparoscopic Techniques/Anatomy review
Point of reference
• 5 peritoneal folds
• Bladder
• Inferior epigastric vessels
• Psoas muscle

38. Triangle of doom
Triangle of Pain
Space of Bogro’s
Space of Retzius

39. Laparoscopic Techniques/Transabdominal Preperitoneal Mesh
All hernia except - large
chronic irreducible hernias
 In patients in whom
laparoscopy is contraindicated
on anesthesiologic grounds
Recurrence after previous
preperitoneal mesh
implantation.
Discovering a hernia on the
opposite side, which is the
case in 10 to 25% of patients
30% of these patients become
symptomatic within a year

40. Conclusions
Shouldice hernia repair provides the patient with
the best chances of nonrecurrence regardless of
the anatomical type of hernia The Shouldice
hernia repair should be the gold
standard for inguinal hernia repair in men and
serves as the basis for comparison with all other
techniques, be they prosthetic or laparoscopic.

42. • 6 RCT/2159
• Meta analysis
 Both DT and LT provided satisfactory treatment for primary
inguinal hernia in adults with low recurrence rates (less
than1%).
 Acceptable rates of complications that were significantly less
after DT.
 DT can become a valid alternative to LT especially in resource-
limited communities, and in cases of gross contamination.

43. Femoral Hernia
“Radical operation of femoral hernias is far less popular
with the public than that of inguinal hernias.” (G. Lotheissen, 1898)
• Often overlooked entity
• Primary vs secondary
• 60%of femoral hernias are on the right side, and they are bilateral in 20% of
cases.
• Roughly 40% of femoral hernias are already incarcerated when they are
diagnosed
• 53% of men with a femoral hernia also have an ipsilateral inguinal hernia, usually
direct
• Only 12% of women have an ipsilateral inguinal hernia, predominantly indirect.
• Crural access usually suffices in women/ inguinal repair for men.
• Emergency /recurrent – joint crural and inguinal
• Laparoscopic TAPP and TEP

44. Four methods of surgical femoral hernia repair
Crural access, without opening the external oblique aponeurosis (most
frequent procedure in women).
Crural access, opening of the inguinal canal and inspection of the
posterior wall without the need for repair (primary procedure in men).
Crural access, opening of the external oblique aponeurosis, repair of the
posterior wall of the inguinal canal if there is an inguinal hernia (procedure
for small combined hernias).
Crural and inguinal access, opening of the external oblique aponeurosis
and posterior wall of the inguinal canal, closure of the femoral hernial
orifice from above and below, then closure of the posterior wall of the
inguinal canal (procedure for large combined hernias,recurrence, and
incarceration).

45. Crural Access
Fabricius Closure
Kummer Repair

46. Inguinal Access
Lotheissen/McVay
Repair

47. Umbilical Hernia
5% of all hernias
Risk factors (adults)
 Pregnancy
 Obesity
 Disorders of connective tissue metabolism due to
 Endogenous factors(genetic) and
 Exogenous factors (smoking, corticosteroids)
Hepatic cirrhosis, and malignant disease.
Spontaneous healing cannot be assumed
(pregnant women)
The incarceration rate is up to 30% with mortality
of 10 to 15%
Classification follows EHS criteria
(European hernia Society).
Small </= 2 cm,-minimal
defects < 0.5 cm.
Medium 2 to 4 cm, and
Large > 4 cm.

48. Indications
Absolute -incarceration and
persistent symptoms
Relative indication->6yrs
mild symptom
Asymptomatic umbilical
hernias < 0.5 cm- no surgery
< 2 cm- spitzy
> 4 cm mesh repair
Operation Technique
Spitzy Repair
Mayo
“vest over-
pants”

49. Preperitoneal Umbilical Mesh Plasty
Peritoneum is dissected bluntly from the edges of
the defect
in all directions for a distance of 3 cm
A circular or oval implant at least 6 cm in diameter is
cut from a lightweight large-pored mesh and two to
three fixing sutures

50. Complications
Impaired wound healing
 Infection
 Disturbed blood supply
Bowel injuries
Cirrhotic and ascitic patients- skin ulceration and postoperative ascites leaks
 Abdominal drain is recommended for 10 to 14 days until the wound heals
 Reduce ascites

51. Incisional Hernias
Incisional hernias arise at the site of
a previous laparotomy incision.
 They consist of a hernial orifice and
peritoneal sac.
The width of the defect is the most
important aspect.

52. Indications
Absolut indications. Incarcération, intestinal strangulation,or perforation of the bowel in the sac.
Relative indications. Persistent symptômes, sustained
incapacity for work, social deprivation, increase in size.
The interval since the last operation should be more than 6 months to allow adequate fascial
strength to be regained.
 Contraindications. Peritoneal carcinomatosis, general inoperability, especially respiratory
impairment, absent consent.

53. Operation
With mesh augmentation, the
abdominal wall is reinforced
With mesh bridging, the
abdominal wall is partially
replaced

54. Open Sublay (Retro muscular
Augmentation)
mesh behind the rectus muscle
medially / between the external
and internal oblique muscles
The aim ----- augmentation of
the abdominal wall(i.e., fascial
closure should be achieved)
When placing the mesh, it must
lie flat without creases and
overlap the closed defect by at
least 5 to 6 cm in all directions

55. Recent Advances
• GPS (Gentle, Prepared and Safe) Taxis
• Increased use of robotics
• Nonpermanent mesh
• Shared video learning:
• Machine learning applications
• Holistic approach to hernia care

56. Conclusion
Age
Non Operative Vs Operative
Symptomatic /asymptomatic
Laparoscopic Vs Open
TAPP-TEP
Tissue vs Mesh
Lichtenstein – Desarda-
Shouldice
LA/GA
ASA/Laparoscopy/ Setup
Local anesthesia

57. References