LUGANSK STATE MEDICAL

UNIVERSITY

DEPARTMENT OF CLINICAL
ANATOMY AND OPR. SURGERY
 PROJECT ON :
 INGUINAL HERNIAS BY
 Yao Doe
Supervised by: Prof.
Konstantin Tkachenko
Presented On:
HERNIAS
Hernia is a protrusion of a viscus or
part of viscus through an abnormal
opening in the walls of its containing
cavity. it can be through abdominal
wall, muscle fascia or diaphragm.
Most common forms include,
inguinal, femoral and umbilical
accounting for about 75%.hernias
may be acquired or conginental.
 Aetiological factors
Two main aetiological factors for
acquired hernia are:
• Increased intra-abdominal pressure
such as powerful muscular effort or
• Abdominal weakness such as
advancing age or malnutrition
Composition of hernia
A hernia consists of three parts:
The sac-is a diverticulum of
peritoneum, consisting of mouth, neck,
body and fundus. The neck is usually
well defined, but in some direct inguinal
hernias and in many incisional hernias
there is no actual neck. Diameter of
neck is significant because
strangulation of bowel is a likely
complication where the neck is narrow
as in femoral and paraumbilical hernias
Covering of the sac-derived from layers of
abdominal wall through which the sac passes
Content-these can be:
• Omentum (omentocele)
• Intestine (enterocele)
• Portion of circumference of
intestine(Richter’s hernia)
• Portion of bladder(or a diverticulum)
• Ovary with or without corresponding
fallopian tube
• Michel’s diverticulum(litters hernia)
• Fluid as part of ascites or as a residuum
thereof.
 Classification
Irrespective of site hernias can be put into 5 classes:
• Reducible-content can be returned to abdomen
• Irreducible-contents can’t be returned but there are no
other complications
• Obstructed-bowel in the hernia has good blood supply but
bowel is obstructed
• Strangulated-blood supply of bowel is obstructed
• Inflamed-content of the sac become inflamed.
 INGUINAL HERNIA

Surgical Anatomy
• The inguinal canal is the weakest spot of the anterior
abdominal wall. It’s about 4 cm in length. It consists of 4
walls and two openings. The walls are:
• Anterior wall-formed by aponeurosis of external oblique
• Posterior wall which is formed by transverse fascia which
merges with inguinal ligament inferiorly. On medial border
transverse fascia is reinforced by tendinious fibers of
transversus abdominis called inguinal falx (henle’s ligament)
• Superior wall is formed by lower margin of transversus
abdominis and internal oblique. This passes over spermatic
cord or round ligament of the uterus.
• Inferior wall by curved margin of inguinal ligament.
 Content of inguinal canal

• Spermatic cord/round ligament

• Ilioinguinal nerve
• Genital branch of genital femoral nerve
• Obliterated processus vaginalis.
• NB: iliohypogastric nerve, which is not a
content of spermatic cord lies 0.5 inch
above the canal and should be borne in
mind during procedure.
The two rings are:
• Superficial inguinal-is a triangular aperture
formed as a result of separation of external
oblique into:
 Medial crus –which bounds the ring above
and inserts into pubic sympysis
 Lateral crus- bounds the ring below and
attached to pubic tubercle.
Medially and postrriorly the ring is reinforced by
tendinious fibers of external oblique, reflected
ligament (Colles ligament)
Superiorly and laterally, the ring is
strengthened by intercrural fibers .superficial
inguinal ring projects into medial inguinal fossa.
• Deep inguinal ring- resides on the
inner surface of anterior abdominal wall,
it’s a depression in transverse fascia,
which invaginates along the path of
spermatic cord and fuses with it.
Medially, the ring is reinforced by
tendinious fibers called the interfoveolar
ligaments. Posteriorly its reinforced by
peritoneum. On the peritoneum there is
the lateral inguinal fossa which
corresponds to deep inguinal ring.
Direct Inguinal hernia- it comes out through
Hesselbach’s triangle lying behind the
medial part of inguinal canal. the triangle is
bounded by inferior epigastric artery
laterally, medially by lateral edge of rectus
abdominis muscle and inferiorly by inguinal
ligament. The hernia pushes the medial part
of posterior wall of inguinal canal and comes
out through superficial ring. Occurs in
patients, who are flabby type, obese or of
asthenic origin with poor muscular
development. its never conginental. shows
less tendency towards strangulation
Oblique inguinal hernias – the hernia comes
out through the deep inguinal ring, so the sac
containing the intraabdominal viscera comes
out through the deep inguinal ring and follow
the course of the spermatic cord and comes
out through superficial inguinal ring to reach
the scorutum. its covering from inward to
outward are:

Skin, two layers of superficial fascia , extra

peritoneal tissue and peritoneum. the sac lies
in front of the spermatic cord and covers it
from above and below.
Choice of operation
Oblique inguinal hernia should as a rule be
treated by operation to avoid strangulation.
Surgical intervention should be advised even if
the hernia is small. The use of truss should be
condemned as it causes pressure atrophy of
muscle in inguinal region, reducing chances of
successful operation later , should it be
required. the use of truss is thus limited to
patients who refuse operation and others who
because of some reason can not under go
operation. Choice of operation must take into
consideration age groups:
Truss- condemned
Children- when the deep ring is not
stretched, and the hernia is due to
preformed sac, simply herniotomy,
removal of the sac is required.
Young adults-when inguinal defense
mechanism has been impaired,
herniorhappy, i.e. repair of posterior wall of
inguinal canal should be performed.
Older patient-whose muscle around
inguinal region are weak leading to direct
inguinal herniae, hernioplasty, i.e.
reconstructive repair of inguinal region is
the operation of choice
 Techniques of hernia repair
• Herniotomy involves removal of the sac
and closure of the neck
• Herniorrhaphy involves a form of
reconstruction to
o Restore the disturbed anatomy
o Increase the strength of the abdominal
wall
o Construct a barrier to recurrence
• Herniorrhaphy can be achieved with
following techniques
– Bassini +/- Tanner Slide
– Darn
– Shouldice
– Lichtenstein
– Other Mesh - Stoppa
– Laparoscopic
– Shouldice or Liechtenstein now regarded as
’gold standard’ as judged by low risk of
recurrence
– Laparoscopic hernia repair should be
reserved for bilateral or recurrent hernia
Herniorrhaphy (Hernioplasty) is a surgical procedure for
correcting hernia.
This technique can be divided into 4 groups:
• Groups 1 and 2: open "tension" repair
• A workable technique of repairing hernia was first
described by Bassini . the Bassini technique was a
"tension" repair, in which the edges of the defect are
sewn back together without any reinforcement or
prosthesis. In the Bassini technique, the conjoint tendon
(formed by the distal ends of the transversus abdominis
muscle and the internal oblique muscle) is approximated
to the inguinal canal and closed.
• Although tension repairs are no
longer the standard of care due to
the high rate of recurrence of the
hernia, long recovery period, and
post-operative pain, a few tension
repairs are still in use today; these
include the Shouldice and the
Cooper's ligament/McVayrepair
 Group 3
• The meshes used are typically made from
polypropylene or polyester. The operation is
typically performed under local anesthesia, and
patients go home within a few hours of surgery.
Patients are encouraged to walk and move around
immediately post-operatively, and they can usually
resume all their normal activities within a week or
two of the operation. Recurrence rates are very low
- one percent or less, compared with over 10% for
a tension repair. Rates of complications are
generally low but they can be quite serious, and
can include chronic pain, ischemic orchitis, and
testicular atrophy
Laparascopy
laparoscopic repair
."Lap" repairs are also tension-free, although the
mesh is placed within the pre-peritoneal space
behind the defect as opposed to in or over it. It
has no proven superiority to the open method
other than a faster recovery time and a slightly
lower post-operative pain score. Unlike the open
method, laparoscopic surgery requires general
anesthesia. It is usually more expensive and
consumes more Operating Room time than open
repair, carries a higher risk of complications, and
has equivalent or higher rates of recurrence
compared to the open tension-free repairs.
 Complications of hernia
repairs
• Urinary retention
• · Scrotal haematoma
• · Damage to the ileoinguinal nerve
• Ischaemic orchitis
• Recurrent hernia
Conclusion:
The whole problematic dealing with indications,
technical details of advantages and disadvantages of
different methods is in fluent development. Except of
some convincing and generally accepted indications,
it is not possible today to offer an univocally valuable
direction for hernial treatment, which could be
presented as a surgical dogma. There is only one law
valid, as in the rest of the surgery: the only criterion is
the profit of the patient – if there is possible to obtain
very good results using a certain method, then there
is no reason for its change…