Inguinal

Hernia

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Incidence

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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

The Anatomy

Historical Hernias

Herniashave been documented throughout history with varying successat either reduction or repair.

Trusses & Techniques

Anatomic Considerations

• The inguinal region must be understood with regard

to its three-dimensional configuration

• A knowledge of the convergence of tissue

planesisessential

• If repairing the hernia laparoscopica lly, theanatomy must be well understood from theperitoneal 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

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.

Myopectineal Orifice of Fruchaud

The MPO isbordered:• Above by the arching fibersof the internal

oblique and transversus abdominus Muscles,• Medially by the Rectus AbdominusMusc le

and its fascial RectusSheath• Inferiorly by Coopers Ligament, and• Laterally by the IleopsoasMuscle

• Running diagonally thru the MPO is the inguinal ligament

Myopectineal Orifice of Fruchaud

Hesselbach's triangle

Boundaries:

Medial:

Rectusabdominismuscle

medially,

Inferiorly:

Inguinal ligament

Laterally:

Inf. Epigastrics

Diagnosis

• The patient usually presents (forgroin hernia)with the complaint of a bulge in the inguinalregion

• They may describe minor pain or vague discomfort associated with the bulge

• Extreme pain usually represents incarceration with intestinal vascular compromise

• Paresthesiasmay be present if inguinal nervesare compressed

Diagnosis

Physical examo The patient should be standing and facing the

examiner

o Visual inspection may reveal a lossof symmetry in the inguinal area or bulge

o Having the patient perform valsalva’smaneuver 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

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 vesselsnot displaced)

Inguinal Hernia

• Indirect inguinal hernia

o Isa congenital lesion

o Occurswhen bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalis

o If the processusvaginalisdoes not remain patent an indirect hernia cannot develop

o Most common type of hernia

Indirect Hernia Route

Note:

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

Inguinal Hernia

• Direct inguinal hernia

o Proceedsdirectly through theposterior inguinal wall

o Direct hernias protrude medial to the inferior epigastric vessels andare not associated with theprocessusvaginalis

o They are generally believed tobe acquired lesions

o Usually occur in older males as a resultof pressure and tension on the musclesand fascia

Direct Hernia Route

Note:

The hernia sac passes directly through Hesselbach's triangle and may disrupt the floorof the inguinal canal.

Specific Surgical Procedures

• Lichenstein (Tension Free) Repair

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McVay (Cooper’s Ligament) Repair

Halstead’sRepair

• Shouldice (Canadian) Repair

• Laproscopic Hernia Repair

• Bassini Repair

Bassini Repair

o Is frequently used for indirect inguinal hernias and small direct hernias

o The conjoined tendon of the transversus abdominisand the internal oblique muscles issutured to the inguinal ligament

Laparoscopic Hernia Repair

o Early attempts resulted inexceptionally high reoccurrencerates

oCurrent techniques include

• Transabdominal preperitoneal repair(TAPP)

• Totally extraperitoneal approach(TEPA)

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.

Laparoscopic Mesh Repair

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