Inguinal HerniasDorothy Sparks, PGY-1c

Historical HerniasHernias have been documented throughout history with varying success at either reduction or repair.

Trusses & Techniques

Anatomic ConsiderationsThe inguinal region must be understood with regard to its three-dimensional configurationA knowledge of the convergence of tissue planes is essentialIf 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:Size and location of the herniaDegree of adipose tissue

Anatomic ConsiderationsThe surgeon must also be aware of the precise location of the:Femoral nerveGenitofemoral nerveLateral femoral cutaneous nerves

Pelvic & Inguinal AnatomyBoth 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.

Myopectineal Orifice of FruchaudThe MPO is bordered: Above by the arching fibers of the internal oblique and transversus abdominus Muscles, Medially (towards the center or to the right) by the Rectus Abdominus Muscle and its fascial Rectus SheathInferiorly by Coopers Ligament, and Laterally by the Ileopsoas MuscleRunning diagonally thru the MPO is the inguinal ligament

Myopectineal Orifice of Fruchaud

Hesselbach's triangleBoundaries:

Medial:Rectus abdominis muscle medially,

Inferiorly:Inguinal ligament

Laterally:Inf. Epigastrics

DiagnosisThe patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal regionThey may describe minor pain or vague discomfort associated with the bulgeExtreme pain usually represents incarceration with intestinal vascular compromiseParesthesias may be present if inguinal nerves are compressed

DiagnosisPhysical examThe patient should be standing and facing the examinerVisual inspection may reveal a loss of symmetry in the inguinal area or bulgeHaving the patient perform valsalvas maneuver or cough may accentuate the bulgeA fingertip is then placed in the inguinal canal; Valsalva maneuver is repeatedDifferentiation between indirect and direct hernias at the time of examination is not essential

Hernia Exam

DiagnosisPhysical examIncarcerated hernias sometimes can be reduced manuallyGentle continuous pressure on the hernial mass towards the inguinal ring is generally effective (Trendelenburg)

Nyhus ClassificationType 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)

Nyhus ClassificationType III: Posterior wall defectA. Direct inguinal herniaB. Indirect inguinal hernia- internal inguinal ring dilated (massive scrotal or sliding hernia)C. Femoral herniaType IV: Recurrent herniaA. DirectB. IndirectC. FemoralD. Combined

Inguinal HerniaIndirect inguinal herniaIs a congenital lesionOccurs when bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalisIf the processus vaginalis does not remain patent an indirect hernia cannot developMost common type of hernia

Indirect Hernia RouteNote: The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.

Inguinal HerniaDirect inguinal herniaProceeds directly through the posterior inguinal wallDirect hernias protrude medial to the inferior epigastric vessels and are not associated with the processus vaginalisThey are generally believed to be acquired lesionsUsually occur in older males as a result of pressure and tension on the muscles and fascia

Direct Hernia RouteNote: The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.

IncidenceApproximately 700,000 hernia repairs are performed as an outpatient procedure each yearApproximately 75% of all hernias occur in the inguinal regionApproximately 50% of hernias are indirect inguinal herniasA vast majority occur in malesHernias more commonly occur on the right side

Causes of Groin HerniasDivided into two categories: congenital & acquired defectsCongenital factors are responsible for the majority of groin herniasPrematurity and low birth weight are significant risk factorsDirect hernias are attributed to the wear and tear stresses of lifeGroin hernias have been demonstrated to occur more frequently in smokers than nonsmokers especially women

Specific Surgical ProceduresLichenstein (Tension Free) Repair

McVay (Coopers Ligament) Repair

Shouldice (Canadian) Repair

Laproscopic Hernia Repair

Bassini Repair

Bassini RepairIs frequently used for indirect inguinal hernias and small direct herniasThe conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

Bassini Repair

McVay RepairAKA: Coopers ligament RepairIs for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral herniasThe conjoined tendon is sutured to Coopers ligament from the pubic cubicle laterally

McVay RepairNote: This repair reconstructs the inguinal canal without using a mesh prosthesis.

Shouldice Repair AKA: Canadian RepairA primary repair of the hernia defect with 4 overlapping layers of tissue.Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.

Shouldice Repair

Lichtenstein RepairAKA: Tension-Free RepairOne of the most commonly performed proceduresA mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord

Lichtenstein Repair Note: Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

Laparoscopic Hernia RepairEarly attempts resulted in exceptionally high reoccurrence ratesCurrent techniques includeTransabdominal preperitoneal repair (TAPP)Totally extraperitoneal approach (TEPA)

Laparoscopic Mesh RepairNote: 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.