HERNIA

PRESENTED BY- DR. KUMAR SAURAV SUMAN

MODERATOR- PROF. DR. N. K. SINGH
 HERNIA

 The word “hernia” is derived from a Latin term meaning “a rupture”

 Hernia is defined as an area of weakness or complete disruption of the

fibromuscular tissues of the body wall.

 Hernia refers to the actual anatomic weakness or defect, and hernia contents
describe those structures that pass through the defect.
 Epidemiology

 75% of all abdominal wall hernias are found in the groin, making it the most common
location for an abdominal wall hernia.

 Of all groin hernias, 95% are inguinal with remainder being femoral hernia defects.

 Inguinal hernias are 9 times more common in men than in women.

 Although femoral hernias are found more often in women, the inguinal hernia is still
the most common hernia in women.
 Epidemiology

 Lifetime risk of developing a groin hernia: ~15% in males and <5% in females.

 There is a clear association between age and hernia diagnosis.

 After an initial peak in the infant, groin hernias become more prevalent with
advancing age.

 In the same way, the complications of hernias (incarceration, strangulation, and

bowel obstruction) are found more commonly at the extremes of age.
 Anatomic Classification

 All hernias can be broadly classified as congenital or acquired

 Vast majority of inguinal hernias are congenital in nature.

 Division of inguinal hernia by anatomical location into direct and indirect types. (based on the
location of the actual hernia defect in relation to the inferior epigastric vessels)

 Hernias lateral to the inferior epigastric vessels are indirect while medial to the vessels are
direct inguinal hernias
 Femoral hernia are located inferior to the inguinal ligament in a medial position.
Anatomic Classification
 Anatomic Classification

 Indirect inguinal hernias are thought to be congenital (although it may

present at any age).

 Arises from the incomplete obliteration of the processus vaginalis.

(Canal of Nuck in female is analogus to a patent processus vaginalis in
male)

 The processus is the peritoneal layer that covers the testicle or ovary as it
passes through the inguinal canal and into the scrotum in men or the
broad ligament in women during the 28th week of gestation
 Between 36 and 40 weeks AOG, the processus vaginalis becomes
obliterated following the migration of the testicle into the inguinal canal and
eliminates the peritoneal opening at the internal inguinal ring
 Anatomic Classification

 The failure of this closure provides an environment for the

indirect inguinal hernia to develop.

 The remnant layer of peritoneum forms a sac at the

internal ring through which intra-abdominal contents may
herniate, thereby resulting in a clinically detectable
inguinal hernia.

 It is noteworthy that indirect inguinal hernia develops

more frequently on the right, where descent of the
gonads occurs later during fetal development.
 Anatomic Classification

 Direct inguinal hernias are found medial to the inferior

epigastric vessels and within Hesselbach’s triangle.

 These hernias are acquired and only rarely found in the

youngest age groups.

 Hesselbach’s triangle:
 lateral border of the rectus sheath as its medial border
 inferior epigastric vessels as its lateral border
 inguinal (Poupart’s) ligament itself as the inferior border.
(RIP)
 indirect v/s direct inguinal hernia

indirect direct

can occur in any age from childhood to adult common in elderly

occurs in a pre existing sac always acquired

protrusion through the deep ring; herniation occurs later herniation through posterior wall of inguin canal

pyriform/oval in shape globular/round in shape

descends obliquely and downward descends directly and forward

can become complete by descending down in scrotum descent in to scrotum is rare

neck of sac is narrow & lateral to inferior epigastric wide neck of the sac & medial to inferior epigastric
artery artery
 indirect v/s direct inguinal hernia

sac is anterolateral to the cord sac is posterior to the cord

DROT doesnt show any impulse after occluding the test shows impulse even after occluding the deep ring
deep ring

invagination test shows impulse on the tip of the little impulse is felt over the pulp of the little finger
finger

Ziemans test shows impulse on the index finger impulse on the middle finger

commomly U/L can be B/L commonly B/L

Obstruction/ strangulation are common rare but can occur

sac should be opened during surgery sac is not necessarily opened unless obstruction is
present
 Anatomic Classification

 Femoral hernias: <10% of all groin hernias.

 Presentation: can be more acute in nature. Up to 40%

of femoral hernias present as emergencies with hernia
incarceration or strangulation

 Femoral hernias protrude through the small and

inflexible femoral ring.

 The borders of the femoral ring include the inguinal

ligament anteriorly, Cooper’s ligament posteriorly, the
lacunar ligament medially, and the femoral vein laterally.
femoral triangle
femoral triangle
 Anatomic Classification

 However, while the femoral ring is inferior to the ligament, the herniated contents may present
superior to the ligament, making an accurate diagnosis difficult.

 Femoral hernias are much more common in females.

 The predilection in women may be secondary to less bulky groin musculature or weakness in the
pelvic floor tissues from previous childbirth.

 Previous inguinal hernia repair may be a risk factor for the subsequent development of a femoral
hernia.
 classification according to the extent

 INCOMPLETE:
a) Bubonocele- sac is confined to
the inguinal canal
b) Funicular- sac crosses
superficial inguinal ring but
does not reach the bottomn of
scrotum

 COMPLETE: sac descends to

the bottomn of the scrotum
 classification on the basis of content

ENTEROCELE OMENTOCELE

First part is difficult to reduce but last part is easier First part is easier to reduce but last part is difficult

Gurgling sound on reduction doughy feeling

resonant on percussion dull on percussion

peristalsis is seen no peristalsis seen

bowel sound may be heard bowel sound not heard

enterocele
 NAMED HERNIA

 Richter's hernia: hernial sac contains a portion of the circumference of the bowel
 Sliding hernia: wall of the hernial sac (usually the posterior wall) is formed by a
viscus. On right side cecum or urinary bladder may form the posterior wall of the sac
and on the left side sigmoid or urinary bladder may form the posterior wall of the
hernial sac.
 Litters hernia: hernial sac containing meckel's diverticulum as the content
 Pantaloons (saddle bag hernia): hernia having both direct and indirect inguinal
hernial sac lying on either side of inferior epigastric vessels. its also known as dual
hernia.
 Amyand's hernia: appendix as hernial contents
NAMED HERNIA

Amyand hernia

Litters hernia
 NAMED HERNIA

 Maydl's hernia (hernia-in-W): hernial sac contains two loops of bowel with another
loop of bowel being intra abdominal.
 Gibbon's hernia: hernia with hydrocele
 Berger's hernia: hernia in to pouch of Douglas
 Beclard's hernia: femoral hernia through opening of saphenous vein
 Ogilive's hernia: hernia through defect in conjoint tendon just lateral to where it inserts
with the rectus sheath
 Stammer's hernia: internal hernia occuring through window in the transverse
mesocolon after retrocolic gastrojejunostomy
 Anatomy of the Groin

 The inguinal canal is an approximately 4 to 6 cm long,

cone shaped region situated in the anterior portion of the
pelvic basin.

 The canal begins on the posterior abdominal wall, where

the spermatic cord passes through the deep (internal)
inguinal ring (a hiatus in the transversalis fascia).

 The canal concludes medially at the superficial (external)

inguinal ring (the point at which the spermatic cord
crosses a defect in the external oblique aponeurosis).
 Anatomy of the Groin

 The boundaries of the inguinal canal:

 Anteriorly- external oblique aponeurosis along its whole length &
reinforced laterally by the fibers of internal oblique
 Posteriorly- fascia transversalis throughout and reinforced
medially by the conjoint tendon
 Medially- lateral border of rectus sheath
 Roof- by conjoint tendon and arch fibers of internal oblique and
transverse abdominis
 Floor- formed by lacunar ligament medially and inguinal ligament
laterally
 Anatomy of the Groin

 The spermatic cord traverses the inguinal canal, and it contains-

 3 artries: Artery to vas, testicular artery, cremasteric artery

 3 veins: cremasteric vein, pampiniform plexus and testicular vein
 3 nerves: ilioinguinal nerve, genital branch of genitofemoral nere,
sympathetic nerves
 vas deferens
 oblterated processus vaginalis
 lymphatics
 spermatic cord coveings

 Spermatic cord is enveloped in 3 layers of spermatic fascia i.e.,

I. External spermatic fascia- from external oblique aponeurosis

II. Cremasteric fascia- formed from the internal oblique
III. Internal spermatic fascia- from fascia transversalis
 Anatomy of the Groin

 Fruchaud's myopectineal orifice:

 its an osseo-myo-aponeurotic tunnel
 all groin hernia occur through this tunnel
 bounded:

 medially by lateral border of rectus sheath

 above by arched fibers of internal oblique &
transversus abdominis muscle
 laterally by iliopsoas muscle
 below by the pectin pubis and fascia covering it
 Ligaments that contribute to the inguinal canal

 The iliopubic tract is an aponeurotic band that

begins at the ASIS and inserts into Cooper’s
ligament from above.

 It forms on the deep inferior margin of the

transversus abdominis and transversalis fascia.
(The iliopubic tract originates and inserts in
a similar fashion to the inguinal ligament, but in
a deeper position)
 The iliopubic tract helps form the inferior margin
of the internal inguinal ring as it courses
medially, where it continues as the anteromedial
border of the femoral canal.
 Ligaments that contribute to the inguinal canal

 The lacunar ligament (ligament of Gimbernat) is the

triangular fanning of the inguinal ligament as it joins
the pubic tubercle.

 The shelving edge of the inguinal ligament is a

structure that connects the iliopubic tract to the
inguinal ligament.
 Cooper’s (pectineal) ligament is the lateral portion of
the lacunar ligament that is fused to the periosteum of
the pubic tubercle.

 The conjoined tendon is commonly described as the

fusion of the inferior fibers of the internal oblique and
transversus abdominis aponeurosis at the point where
they insert on the pubic tubercle.
 Anatomy of the Groin

 From superficial to deep, the surgeon first encounters Scarpa’s

fascia after incising the skin and subcutaneous tissue.

 Deep to Scarpa’s layer is the external oblique aponeurosis, which

must be incised and spread to identify the cord structures.

 The inguinal ligament represents the inferior extension of the

external oblique aponeurosis, and extends from the ASIS to PT

 The medial extension of the external oblique aponeurosis forms

the anterior rectus sheath.
 Anatomy of the Groin

 The iliohypogastric and ilioinguinal nerves, which provide sensation to the skin, penis,
and the upper medial thigh, lie deep to the external oblique aponeurosis in the groin
region.

 The internal oblique aponeurosis is more prominent cephalad in the inguinal canal, and its
fibers form the superior border of the canal itself.

 The cremaster muscle, which envelops the cord structures, originates from the internal
oblique musculature.

 The transversus abdominis muscle and its fascia represent the true floor of the inguinal
canal.

 Deep to the floor is the preperitoneal space, which houses the inferior epigastric artery
and vein, the genitofemoral and lateral femoral cutaneous nerves, and the vas deferens,
which traverses this space to join the remaining cord structures at the internal inguinal
ring.
classification of hernia
 ETIOLOGY

 congenital in etiology

 repeated increases in intra-abdominal pressure e.g., pregnancy, COPD, ascites, patients who undergo peritoneal
dialysis, laborers who repeatedly flex the abdominal wall musculature, and individuals who strain from
constipation.

 Collagen formation and structure deteriorates with age, and thus hernia is more common in the older individual.

 Several connective tissue disorders can lead to hernia formation e.g., Ehlers–Danlos syndrome, Marfan’s
syndrome, Hunter’s syndrome, and Hurler’s syndrome can predispose to defects in collagen formation.

 There is evidence that cigarette smoking is associated with connective tissue disruption, and hernia formation is
more common in the chronic smoker.
 Clinical Manifestations

 can present in a variety of ways, from the asymptomatic hernia to frank peritonitis in a strangulated hernia

 most common presenting symptom for a groin hernia is a dull feeling of discomfort or heaviness in the
groin region which exacerbates by straining the abdominal musculature, lifting heavy objects, or
defecating.

 With a reducible hernia, the feeling of discomfort resolves as the pressure is released when the patient
stops straining the abdominal muscles.

 Overwhelming or focal pain from a groin hernia is unusual and should raise the suspicion of hernia
incarceration or strangulation.
 Clinical Manifestations

 All types of groin hernias are at risk for incarceration and strangulation (femoral hernia seems to be
predisposed)

 Incarceration and strangulation of a groin hernia may present as a bowel obstruction when the tight hernia
defect constricts the lumen of the viscus.

 Hence, all patients presenting with bowel obstruction require a thorough physical examination of the groin
region for inguinal and femoral hernias.

 If there is no bowel in the hernia sac, an incarcerated groin hernia may alternatively present as a hard, painful
mass that is tender to palpation.

 The physical examination differs between an incarcerated hernia and a strangulated hernia.
 incarcerated hernia and strangulated hernia

 The incarcerated hernia- mildly tender due to venous congestion from the tight defect.

 The strangulated hernia- tender and warm and may have surrounding skin erythema secondary to the
inflammatory reaction from the ischemic bowel.

 The patient with the strangulated hernia may have a fever, hypotension from early bacteremia, and a
leukocytosis.

 The incarcerated hernia requires operation on an urgent basis within 6–12 hours of presentation.

 The strangulated hernia clearly requires emergent operation immediately following diagnosis.
 Physical Examination

 Asymptomatic hernias are frequently diagnosed incidentally on physical examination or may be brought
to the patient’s attention as an abnormal bulge.

 Ideally, the patient should be examined in a standing position to increase intra-abdominal pressure, with
the groin and scrotum fully exposed.

 Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the
scrotum.

 If an obvious bulge is not detected, palpation is performed to confirm the presence of the hernia.
 Physical Examination

 To get above the swelling:

 Physical Examination

 Palpation is performed by advancing the index/ little finger

through the scrotum toward the external inguinal ring.

 This allows the inguinal canal to be explored. The patient is

then asked to perform Valsalva’s maneuver to protrude the
hernia contents.

 This maneuver will reveal an abnormal bulge and allow the

clinician to determine whether the hernia is reducible or not.

 Examination of the contralateral side provides opportunity to

compare the presence and extent of herniation between
 Physical Examination

 Certain techniques are classically used to differentiate between direct

and indirect hernias.

 The deep ring occlusion test: blocking the internal inguinal ring
with a finger as the patient is instructed to cough. A controlled
impulse suggests an indirect hernia, while persistent herniation
suggests a direct hernia.

 The cough impulse: transmission of the cough impulse to the tip of

the finger implies an indirect hernia, while an impulse palpated on the
dorsum of the finger implies a direct hernia.
 Physical Examination

 Zieman's 3 finger test:

 Physical Examination

 The examination for the femoral hernia in both genders involves palpation of the femoral canal just
below the inguinal ligament in the upper thigh.

 Most easily palpable landmark is the femoral artery, which is located lateral in the canal. Medial to the
femoral artery is the femoral vein, and the femoral empty space is just medial to the vein.

 This area can be located easily, palpated with two fingers, and then examined closely while the patient
coughs or strains.

 In general, a focused groin hernia examination should involve the investigation for both inguinal and
femoral hernias in both genders.
Physical Examination
PARTS OF HERNIA
Diffrential diagnosis of inguinal swelling
 Treatment

 ALWAYS SURGERY
 In infants- whether it is hernia or hydrocele , only herniotomy is done through inguinal
approach (Michaelis plank operation)

 In adults- it includes herniotomy i.e., excision of hernial sac and herniorraphy or

hernioplasty i.e., strengthening of the posterior wall of inguinal canal either by repair
or mesh

 Hernioplasty is the ideal treatment for all inguinal and groin hernia.
 Polypropylene mesh is used. Herniotomy is done prior to mesh placement.
 Treatment

 Operative Repair:

 Anterior Repairs
 Most common operative approach for inguinal hernias.
 Tension-free repairs are now standard, and there are a variety of different types.
 Tissue repair are rarely indicated except for cases with simultaneous contamination
or concomitant bowel resections when placement of a mesh prosthesis may be
contraindicated.
 Treatment

 Some technical aspects of operation are common to all anterior repairs.

1. Start open hernia repair by making a linear or slightly curvilinear incision 2 to 3 cm above and parallel
to the inguinal ligament.
2. Continue dissection through the subcutaneous tissues and Scarpa's fascia.
3. The external oblique fascia and external inguinal ring are identified.
4. The external oblique fascia is incised through the superficial inguinal ring to expose the inguinal canal.
5. The ilioinguinal and iliohypogastric nerves are identified and mobilized to avoid transection and
entrapment.
6. The spermatic cord is mobilized at the pubic tubercle by a combination of blunt and sharp dissection.
7. Improper mobilization of the spermatic cord too lateral to the pubic tubercle can cause confusion in
the identification of tissue planes and essential structures and may result in disruption of the floor of
the inguinal canal.
 Treatment

8. The cremasteric muscle separated parallel to its fibers from the underlying cord structures.
9. The cremasteric artery and vein, which join the cremaster muscle near the inguinal ring, are usually
cauterized or ligated and divided.
10. In an direct hernia,the hernia sac is located deep to the cremaster muscle and anterior and
superior to the spermatic cord structures while in direct hernia its located posteriorly.
11. Incising the cremaster muscle in a longitudinal direction and dividing it circumferentially near the
internal inguinal ring help expose the indirect hernia sac.
12. The hernia sac is carefully dissected from adjacent cord structures and dissected to the level of the
internal inguinal ring.
13. The sac is opened and examined for visceral contents if it is large; however, this step is
unnecessary in small hernias.
 Treatment

14. The sac can be mobilized and placed within the preperitoneal space, or the neck of the sac
can be ligated at the level of the internal ring, and any excess sac excised.
15. If a large hernia sac is present, it can be divided using the electrocautery to facilitate
ligation.
16. It is not necessary to excise the distal portion of the sac.
17. If the sac is broad based, it may be easier to displace it into the peritoneal cavity rather
than to ligate it.
18. Direct hernia sacs protrude through the floor of the inguinal canal and can be reduced
below the transversalis fascia before repair.
19. A lipoma of the cord represents retroperitoneal fat that has herniated through the deep
inguinal ring and needs to be suture ligated and removed.
 Treatment
 Tissue Repairs:
 Although abandoned due to high recurrence rates, they remain useful in certain situations. e.g.,
strangulated hernias where bowel resection is necessary, mesh prostheses are contraindicated.

 Available options for tissue repair include iliopubic tract, Bassini, Shouldice and McVay
repairs.

 The iliopubic tract repair approximates the transversus abdominis aponeurotic arch to the
iliopubic tract with the use of interrupted sutures.
 The repair begins at the pubic tubercle and extends laterally past the internal inguinal ring.
 This repair was initially described using a relaxing incision; however, many surgeons who use this
repair do not perform a relaxing incision.
iliopubic tract repair
 The Bassini repair

 The Bassini repair: performed by suturing the

transversus abdominis and internal oblique
musculoaponeurotic arches or conjoined tendon (when
present) to the inguinal ligament.

 This once popular technique is the basic approach to

nonanatomic hernia repairs and was the most popular
type of repair done before the advent of tension-free
repairs.
 The Shouldice repair

 The Shouldice repair- a multilayer imbricated repair of the posterior wall of the inguinal
canal with a continuous running suture technique.
 After completion of the dissection, the posterior wall of the inguinal canal is reconstructed by
superimposing running suture lines progressing from deep to more superficial layers.
 The initial suture line secures the transversus abdominis aponeurotic arch to the iliopubic
tract.
 Next, the internal oblique and transversus abdominis muscles and aponeuroses are sutured
to the inguinal ligament.
 The Shouldice repair is associated with a very low recurrence rate and a high degree of
patient satisfaction in highly selected patients.
The Shouldice repair
 McVay repair or Cooper's ligament repair

 McVay repair or Cooper's ligament repair: Popular for the correction of direct inguinal
hernias, large indirect hernias, recurrent hernias, and femoral hernias.
 Interrupted, nonabsorbable sutures are used to approximate the edge of the transversus
abdominis aponeurosis to Cooper's ligament.
 When the medial aspect of the femoral canal is reached, a transition suture is placed to
incorporate Cooper's ligament and the iliopubic tract.
 Lateral to this transition stitch, the transversus abdominis aponeurosis is secured to the
iliopubic tract.
 An important principle of this repair is the need for a relaxing incision.
 McVay repair or Cooper's ligament repair

 The relaxing incision is made by reflecting the external oblique aponeurosis cephalad and medial to
expose the anterior rectus sheath.

 An incision is then made in a curvilinear direction beginning 1 cm above the pubic tubercle throughout the
extent of the anterior sheath to near its lateral border.

 This relieves tension on suture line and results in decreased postoperative pain and hernia recurrence.

 The fascial defect is covered by the body of the rectus muscle, which prevents herniation at the relaxing
incision site.

 The McVay repair is particularly suited for strangulated femoral hernias because it provides obliteration of
the femoral space without the use of mesh.
 Mesh in hernia repair

 Mesh- a prosthetic material: Used to strengthen a hernia repair

 can be used
 to bridge a defect: mesh simply placed over the defect as a tension free patch
 to plug a defect: plug of mesh is simply pushed in the defect
 to augment a repair: defect is closed with sutures and mesh added for reinforcement

 A well placed mesh has good overlap (atleast 2-5 cm) around all margins of the defect.
 Mesh type

1. According to gross structure- 2 types are

 NET MESH: woven or knitted
 allows fibrous tissue ingrowth between strands & become integrated and adherent in host tissue within a few months
 initial fixation of mesh is by glue, suture or staple which may be absorbable.
 in laproscopic repair no fixation is required at all as friction is sufficient to hold the mesh

 FLAT SHEET:
 not porous but can be perforated with multiple holes
 dont allow host tissue ingrowth but become incapsulated by fibrous tissue
 always require strong, non absorbable fixation to prevent mesh migration
 Synthetic mesh

 Majorityof mesh used today are synthetic polymers of

polypropylene, polyester & PTFE
 these are non absorbable and provoke less tissue reaction
 Synthetic mesh
POLYPROPYLENE MESH POLYESTER MESH PTFE MESH
strong monofilament mesh braieded filament mesh flat sheets
• does not have any • may allow infection to take • don't allow any tissue
antibacterial properties hold, aided by its ingrowth
hydrophilic property
• used as a non-adhesive
• its hydrophobic nature and • its hydrophilic property tissue barrier between
monofilament allows rapid vascular and tissue layers
microstructure impede cellular infiltration within the
bacterial ingrowth. fibrils aiding host immune
responses to infection and
providing a stronger host
tissue interface
 Synthetic mesh

 Synthetic meshes are very strong.

 All mesh provoke a fibrous reaction.
 More dense or heavyweight mesh provoke greater rection leading to collagen contraction and
stiffening.
 Mesh shrinkage- progressive decrease in size of a mesh over time (natural contraction of fibrous
tissue embedded in mesh, reducing the mesh itself). Mesh shrinkage can cause tissue tension,
pain, hernia recurrence.
 LIGHTWEIGHT, LARGE PORE MESH- Mesh with thinner strand and large spaces between
them.
 Preferred as they have better tissuentegration, less shrinkage, more flexibility and improved
comfort
 Mesh in hernia repair

 the term light, medium, heavy are not precisely defined

 (mesh < 40 g/m2 referred as light and > 80g/m2 are heavy)
BIOLOGIC MESH
 Sheets of sterilised, decellularised, non-immunogenic connective tissue
 Derived from human or animal dermis, bovine pericardium or porcine intestinal submucosa
 Provide a “scaffold” to encourage neovascular ingrowth & new collagen deposition
 Eventually broken down by host enzyme and replaced and remodelled with “normal” host fibrous
tissue
 If infected, some biologic meshes break down rapidly before remodelling can occur
 Choice of biological mesh depende on clinical situation for which it is to be used.
 Expensive
 Mesh in hernia repair

 ABSORBABLE MESH:
 Synthetic absorbable mesh made from polyglycolic acid fibre
 Used in temporary abdominal wall closure and to buttress suture repair
 No current role in hernia repairas they absorband induce minimal collagen deposition

 TISSUE SPREADING MESH:

 Most mesh induces fibrosis and if placed in peritoneal cavity will promote unwanted adhesion
 Mesh designed for intraperitoneal use have diffrent surfaces.
 Good adherence and host tissue in growth is required on the parietal side of mesh but the opposite
side needs to prevent adhesion to bowel
 Coating of polycellulose, collagen, PTFE etc prevents adhesion
 Positioning of the Mesh

 placed on a firm, well vascularised tissue bed with overlap of

the defect
 can be placed-
1) ONLAY: Just outside the muscle in subcutaneous space
2) INLAY: Within the defect (mesh plugs in small defect)
3) SUBLAY: Between fascial layers in abdominal wall
(intraparial)/ immediately extraperitoneally against muscle or
fascia
4) INTRAPERITONEAL
 mesh

Limitation to the use of mesh:

1. Infection
2. Cost
 Treatment
Tension-Free Inguinal Hernia Repair

 Recognizing that tension in a repair is the principal cause of recurrence, the

tension-free repair has become the dominant method of inguinal hernia repair.

 Current practices in hernia management employ a synthetic mesh prosthesis to

bridge the defect, a concept first popularized by Lichtenstein.

 There are several options for placement of mesh during anterior inguinal
herniorrhaphy, including the Lichtenstein approach, the plug-and-patch
technique, or the sandwich technique with both an anterior and preperitoneal
piece of mesh.
 The Lichtenstein tension-free hernia repair

 First pure prosthetic, tension free repair

 Operation begins with incision of the EOA and the isolation of the cord structure
 Any indirect hernia sac is mobilized off the cord to the level of the internal ring
 A large mesh tailored to fit along the inguinal canal floor is placed so that the curved end lies directly on
the top of the pubic tubercle
 The mesh patch extends underneath the cord until the spermatic cord and the tails of the mesh patch
meet laterally.
 Here an incision is made in the mesh and the cord is inserted between the tails of the mesh thereby
creating a new, tighter and more medial internal ring
 The tails are sutured together with one nonabsorbable stitch just proximal to the attachment of the cord
 Mesh is than sutured in a continous or interrupted fashion to the pubic tubercle inferiorly, the conjoint
tendon medially, and the inguinal ligament laterally
 The plug-and-patch technique
Rutkow and Robbins reported advances in Lichtenstin
repair
 Plug and patch repair is a tension free herniorraphy and can even be performed without the
suture
 Here a patch is placed in similar fashion to the modern Lichtenstin repair as it lies along the
inguinal canal from the pubic tubercle medially to beyond the cord laterally.
 In addition, a mesh plug in the form of an umbrella or cone is snugly fit up and into the internal
ring
 In this way the repair goes beyond the tightening of the internal ring, but serves to close the ring
around the spermatic cord
 Patch and plug can be sutured to the surrounding inguinal canal tissue in an interrupted or
continue fashion or alternatively both prostheses can be placed in appropriate position with no
suture affixment
 Wide internal ring defects often caused by large or chronic indirect sac, may require one or two
sutures to tack the plug in place to avoid slippage into the canal anteriorly or retroperitoneal space
The plug-and-patch technique
 POSTERIOR REPAIR
Preperitoneal Repair
 The open preperitoneal approach is useful for the repair of recurrent inguinal hernias, sliding hernias,
strangulated hernias, and femoral hernias.
 A transverse skin incision is made 2 cm above the internal inguinal ring and is directed to the medial
border of the rectus sheath.
 The muscles of the anterior abdominal wall are incised transversely, and the preperitoneal space is
identified.
 If further exposure is needed, the anterior rectus sheath can be incised and the rectus muscle
retracted medially.
 The preperitoneal tissues are retracted cephalad to visualize the posterior inguinal wall and the site
of herniation.
 The inferior epigastric artery and veins are generally beneath the mid portion of the posterior rectus
sheath and usually do not need to be divided.
 Preperitoneal Repair

 The posterior approach avoids mobilization of the spermatic cord and injury to the sensory
nerves of the inguinal canal, which is particularly important for hernias previously repaired
through an anterior approach.
 If the peritoneum is incised, it is sutured closed to avoid evisceration of intraperitoneal
contents into the operative field.
 The transversalis fascia and transversus abdominis aponeurosis are identified and sutured
to the iliopubic tract.
 Femoral hernias repaired by this approach require closure of the femoral canal by securing
the repair to Cooper's ligament.
 A mesh prosthesis is frequently used to reinforce the closure of the femoral canal,
particularly with large hernias.
 Laparoscopic Management

 Laparoscopic inguinal hernia repair is another method of tension-free mesh repair, based
on a preperitoneal approach.
 The laparoscopic approach provides the mechanical advantage of placing a large piece of
mesh behind the defect covering the myopectineal orifice and using the natural forces of
the abdominal wall to anchor the mesh in place.
 Quicker recovery, less pain, better visualization of anatomy, utility in fixing all inguinal
hernia defects, and decreased surgical site infections.
 Critics emphasize longer operative times, technical challenges, and increased cost.
 Although controversy exists about the utility of laparoscopic repair of primary unilateral
inguinal hernias, most agree that this approach has advantages for patients with bilateral or
recurrent hernias.
 Totally extraperitoneal (TEP) and Transabdominal preperitoneal (TAPP)

 Two techniques include a totally extraperitoneal (TEP) and a transabdominal preperitoneal (TAPP)
approach.

 The main difference between these two techniques is the sequence of gaining access to the
preperitoneal space.

 In TEP, dissection begins in the preperitoneal space using a balloon dissector while in TAPP, the
preperitoneal space is accessed after initially entering the peritoneal cavity.

 Using TEP approach, the preperitoneal dissection is quicker, and the potential risk for intraperitoneal
visceral damage is minimized. However, the use of dissection balloons is costly, the working space is
more limited, and it may not be possible to create a working space if the patient has had a prior
 Totally extraperitoneal (TEP) and Transabdominal preperitoneal (TAPP)

 Additionally, if a large tear in the peritoneal flap is created during a TEP approach, the
potential working space can become obliterated, necessitating conversion to a
transabdominal approach.

 For these reasons, knowledge of a transabdominal technique is essential when performing

laparoscopic inguinal hernia repairs.

 The transabdominal approach allows immediate identification of the groin anatomy before
extensive dissection and disruption of natural tissue planes.
 Totally extraperitoneal (TEP) and Transabdominal
preperitoneal (TAPP)

 There are no absolute contraindications to laparoscopic inguinal hernia repair other than the inability
to tolerate general anesthesia.

 Patients who have had extensive prior lower abdominal surgery can require significant adhesiolysis
and may be best approached anteriorly.

 In particular, patients who have had a radical retropubic prostatectomy with the preperitoneal space
previously dissected can make accurate safe dissection challenging
 TEP

 In the TEP approach, an infraumbilical incision is used.

 The anterior rectus sheath is incised, the ipsilateral rectus abdominis muscle is retracted laterally, and blunt
dissection is used to create a space beneath the rectus.
 A dissecting balloon is inserted deep to the posterior rectus sheath, advanced to the pubic symphysis, and
inflated under direct laparoscopic vision.
 After it is opened, the space is insufflated, and additional trocars are placed.
 A 30-degree laparoscope provides the best visualization of the inguinal region.
 The inferior epigastric vessels are identified along the lower portion of the rectus muscle and retracted anteriorly.
 Cooper's ligament must be cleared from the pubic symphysis medially to the level of the external iliac vein.
 The iliopubic tract is also identified. Care must be taken to avoid injury to the femoral branch of the genitofemoral
nerve and the lateral femoral cutaneous nerve, which are located lateral to and below the iliopubic tract.
 Lateral dissection is carried out to the anterior superior iliac spine. Finally, the spermatic cord is skeletonized.
TEP
 TAPP

 In TAPP approach, an infraumbilical incision is used to gain access to the peritoneal cavity directly.
 Two 5-mm ports are placed lateral to the inferior epigastric vessels at the level of the umbilicus.
 A peritoneal flap is created high on the anterior abdominal wall extending from the median umbilical fold to the
anterior superior iliac spine. The remainder of the operation proceeds similar to a TEP procedure.
 A direct hernia sac and associated preperitoneal fat is gently reduced by traction if it has not already been reduced
by balloon expansion of the peritoneal space.
 A small indirect hernia sac is mobilized from the cord structures and reduced into the peritoneal cavity.
 A large sac may be difficult to reduce. In this case, the sac is divided with cautery near the internal inguinal ring,
leaving the distal sac in situ.
 The proximal peritoneal sac is closed with a loop ligature to prevent CO 2 escaping into peritoneal cavity and cause
loss of working space.
 After the hernial content is reduced, a 12 × 14 cm piece of polypropylene mesh is inserted through a trocar and
unfolded.
 TAPP

 It covers the direct, indirect, and femoral spaces and rests over the cord structures.
 It is imperative that the peritoneum is dissected at least 4 cm off the cord structures to prevent the
peritoneum from encroaching beneath the mesh, which can lead to recurrence.
 The mesh is carefully secured with a tacking stapler to Cooper's ligament from the pubic tubercle to the
external iliac vein, anteriorly to the posterior rectus musculature and transversus abdominis aponeurotic
arch at least 2 cm above the hernia defect, and laterally to the iliopubic tract.
 The mesh extends beyond the pubic symphysis and below the spermatic cord and peritoneum.
 The mesh is not fixed in this area, and tacks are not placed inferior to the iliopubic tract beyond the
external iliac artery.
 Staples placed in this area may injure the femoral branch of the genitofemoral nerve or the lateral femoral
cutaneous nerve.
 Staples are also avoided in the so-called triangle of doom bounded by the ductus deferens medially and
the spermatic vessels laterally to avoid injury to the external iliac vessels and femoral nerve.
 triangle of doom and pain

 Both are observed in laparoscopic hernia procedure.

 Triangle of Doom: formed medially by vas deferens,

laterally be testicular vessels and peritoneal reflection
below with the apex at internal ring.

 External iliac vessel lie in this triangle so extreme

care should be taken while dissecting hernia sac in
this triangle
 triangle of doom and pain

 Triangle of pain: formed by gonadal vessela

medially, iliopubic tract laterally and peritoneal
reflection below.

 Genitofemoral nerve and lateral cutaneous

nerve of thigh traverse this triangle.
 Injury to this nerve either by dissection or by
tacks causes severe postoperative pain.
 Tacks/stapeler should not be placed in this
triangle
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