Inguinal Hernias

Dorothy Sparks, PGY-1c

Historical Hernias
Hernias have been documented throughout history with varying success at 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 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:

Size and location of the hernia Degree of adipose tissue

Anatomic Considerations
The surgeon must also be aware of the precise location of the:
Femoral nerve Genitofemoral nerve Lateral femoral cutaneous nerves

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 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 Sheath Inferiorly by Coopers Ligament, and Laterally by the Ileopsoas Muscle Running diagonally thru the MPO is the inguinal ligament

Myopectineal Orifice of Fruchaud

Hesselbach's triangle
Boundaries:
Medial: Rectus abdominis muscle medially, Inferiorly: Inguinal ligament Laterally: Inf. Epigastrics

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

Diagnosis
Physical exam

The patient should be standing and facing the examiner Visual inspection may reveal a loss of symmetry in the inguinal area or bulge Having the patient perform valsalvas maneuver or cough may accentuate the bulge A fingertip is then placed in the inguinal canal; Valsalva maneuver is repeated Differentiation between indirect and direct hernias at the time of examination is not essential

Hernia Exam

Diagnosis
Physical exam
Incarcerated hernias sometimes can be reduced manually Gentle continuous pressure on the hernial mass towards the inguinal ring is generally effective (Trendelenburg)

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)

Nyhus Classification
Type III: Posterior wall defect

A. Direct inguinal hernia B. Indirect inguinal hernia- internal inguinal ring dilated (massive scrotal or sliding hernia) C. Femoral hernia A. Direct B. Indirect C. Femoral D. Combined

Type IV: Recurrent hernia

Inguinal Hernia
Indirect inguinal hernia
Is a congenital lesion Occurs when bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalis If the processus vaginalis does not remain patent an indirect hernia cannot develop 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

Proceeds directly through the posterior inguinal wall Direct hernias protrude medial to the inferior epigastric vessels and are not associated with the processus vaginalis They are generally believed to be acquired lesions Usually occur in older males as a result of pressure and tension on the muscles and fascia

Direct Hernia Route

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

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

Causes of Groin Hernias

Divided into two categories: congenital & acquired defects

Congenital factors are responsible for the majority of groin hernias Prematurity and low birth weight are significant risk factors Direct hernias are attributed to the wear and tear stresses of life Groin hernias have been demonstrated to occur more frequently in smokers than nonsmokers especially women

Specific Surgical Procedures

Lichenstein (Tension Free) Repair
McVay (Coopers Ligament) Repair

Shouldice (Canadian) Repair

Laproscopic Hernia Repair

Bassini Repair

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

Bassini Repair

McVay Repair
AKA: Coopers ligament Repair
Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias The conjoined tendon is sutured to Coopers ligament from the pubic cubicle laterally

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

Shouldice Repair
AKA: Canadian Repair

A 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 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

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

Laparoscopic Hernia Repair

Early attempts resulted in exceptionally high reoccurrence rates Current 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.