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Inguinal hernia


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Brief description of inguinal hernia anatomy, pathophysiology and surgery options

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Inguinal hernia

  1. 1. Inguinal Hernia: Options for Surgery Syed Fahad Ali Zaidi PGR SU II BBH
  2. 2. Incidence • Approximately 700,000 hernia repairs are performed as an outpatient procedure each year • Approximately 75% of all hernias occur in the inguinal region • Approximately 50% of hernias are indirect inguinal hernias • A vast majority occur in males • Hernias more commonly occur on the right side
  3. 3. The Anatomy
  4. 4. Historical Hernias Hernias have been documented throughout history with varying success at either reduction or repair.
  5. 5. Trusses & Techniques
  6. 6. Anatomic Considerations • The inguinal region must be understood with regard to its three-dimensional configuration • A knowledge of the convergence of tissue planes is essential • If repairing the hernia laparoscopically, the anatomy must be well understood from the peritoneal surface outward • There is a considerable amount of anatomic variability with regard to: o Size and location of the hernia o Degree of adipose tissue
  7. 7. Pelvic & Inguinal Anatomy • Both the ilioinguinal nerve and the genitofemoral nerve traverse the usual hernia-repair operative field. The femoral vein also runs just deep to the inguinal floor laterally.
  8. 8. Myopectineal Orifice of Fruchaud The MPO is bordered: • Above by the arching fibers of the internal oblique and transversus abdominus Muscles, • Medially by the Rectus Abdominus Muscle and its fascial Rectus Sheath • Inferiorly by Coopers Ligament, and • Laterally by the Ileopsoas Muscle • Running diagonally thru the MPO is the inguinal ligament
  9. 9. Myopectineal Orifice of Fruchaud
  10. 10. Hesselbach's triangle Boundaries: Medial: Rectus abdominis muscle medially, Inferiorly: Inguinal ligament Laterally: Inf. Epigastrics
  11. 11. Diagnosis • The patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal region • They may describe minor pain or vague discomfort associated with the bulge • Extreme pain usually represents incarceration with intestinal vascular compromise • Paresthesias may be present if inguinal nerves are compressed
  12. 12. Diagnosis • Physical exam o The patient should be standing and facing the examiner o Visual inspection may reveal a loss of symmetry in the inguinal area or bulge o Having the patient perform valsalva’s maneuver or cough may accentuate the bulge o A fingertip is then placed in the inguinal canal; Valsalva maneuver is repeated o Differentiation between indirect and direct hernias at the time of examination is not essential
  13. 13. Nyhus Classification • Type I: Indirect inguinal hernia Internal inguinal ring normal (simple pediatric hernia) • Type II: Indirect inguinal hernia Internal inguinal ring dilated but posterior inguinal wall intact (inferior deep epigastric vessels not displaced)
  14. 14. Nyhus Classification • Type III: Posterior wall defect o A. Direct inguinal hernia o B. Indirect inguinal hernia- internal inguinal ring dilated (massive scrotal or sliding hernia) o C. Femoral hernia • Type IV: Recurrent hernia o o o o A. Direct B. Indirect C. Femoral D. Combined
  15. 15. Inguinal Hernia • Indirect inguinal hernia o Is a congenital lesion o Occurs when bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalis o If the processus vaginalis does not remain patent an indirect hernia cannot develop o Most common type of hernia
  16. 16. Indirect Hernia Route Note: The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.
  17. 17. Inguinal Hernia • Direct inguinal hernia o Proceeds directly through the posterior inguinal wall o Direct hernias protrude medial to the inferior epigastric vessels and are not associated with the processus vaginalis o They are generally believed to be acquired lesions o Usually occur in older males as a result of pressure and tension on the muscles and fascia
  18. 18. Direct Hernia Route Note: The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.
  19. 19. Specific Surgical Procedures • Lichenstein (Tension Free) Repair • McVay (Cooper’s Ligament) Repair • Halstead’s Repair • Shouldice (Canadian) Repair • Laproscopic Hernia Repair • Bassini Repair
  20. 20. Bassini Repair o Is frequently used for indirect inguinal hernias and small direct hernias o The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
  21. 21. McVay Repair • AKA: Cooper’s ligament Repair o Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias o The conjoined tendon is sutured to Cooper’s ligament from the pubic tubercle laterally to femoral vein, and to inguinal ligament laterally from here
  22. 22. McVay Repair This repair reconstructs the inguinal canal without using a mesh prosthesis. • It requires a relaxing incision •
  23. 23. Halstead’s Repair • In this repair, (which otherwise resembles Bassini) external oblique aponeurosis is used to strengthen the posterior wall. • This exteriorizes the spermatic cord, placing it beneath the layers of abdominal wall facia
  24. 24. Halstead’s Repair • Technique not appreciated because of high incidence of hydrocoels, and testicular atrophy as well as recurrence post-operatively.
  25. 25. Shouldice Repair • AKA: Canadian Repair o A primary repair of the hernia defect with 4 overlapping layers of tissue. o Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.
  26. 26. Shouldice Repair
  27. 27. Shouldice Repair • At the shouldice hospital, steel wires are used for the closure of all layers upto subcutaneous fat, and recurrence rates of less than one percent are reported • Other centers which practiced this technique do not report similar success rates
  28. 28. Lichtenstein Repair AKA: Tension-Free Repair • One of the most commonly performed procedures • A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord
  29. 29. Lichtenstein Repair Note: Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.
  30. 30. Other repairs using Mesh • Patch & plug technique involvs placementof a preformed mesh plug in the hernia defect that is sutured to the facial margins of defect. • Stoppa ‘s Repair uses posterior approach for implanting a mesh in the preperitoneal plane without closing peritoneal defect per se • Kugel’s repair is a preperitoneal repair in which a preformed mesh with a stiff ring around the edges is placed in the preperitoneal space.
  31. 31. Laparoscopic Hernia Repair o Early attempts resulted in exceptionally high reoccurrence rates o Current techniques include • Transabdominal preperitoneal repair (TAPP) • Totally extraperitoneal approach (TEPA)
  32. 32. Laparoscopic Mesh Repair Note: Viewed from inside the pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.
  33. 33. Laparoscopic Mesh Repair
  34. 34. TAPP Repair
  35. 35. TEP Repair
  36. 36. • Contraindication to laparoscopic repair is : o Patients with large inguinoscrotal hernias o Patients with previous abdominal surgeries