Hernia Dr. Nachmany

Lecture Subjects Anatomy – Inguinal & Femoral canals Clinical aspects of hernia Repair of Inguinofemoral Hernia: Open – Rrhaphy; Tension free. Laparoscopic

Anatomy, Embryology & Physiology The Inguinal Canal Anatomy, Embryology & Physiology

Anatomy Extends from the deep (fascia transversalis) to the superficial inguinal ring (ext. oblique) Parallel and above the inguinal ligament Walls of the Inguinal Canal: Anterior Posterior Superior Inferior

Walls of the Inguinal Canal Anterior wall - Aponeurosis of Ext. oblique Reinforced in its lateral third by origin of the Int. oblique strongest where it lies opposite the weakest part of the posterior wall (deep ring)

Walls of the Inguinal Canal Posterior wall - Fascia transversalis Reinforced in its medial third by the conjoint tendon Strongest where it lies opposite the weakest part of the anterior wall (superficial ring)

Walls of the Inguinal Canal – Cont. Inferior (floor) - Rolled-under inferior edge of aponeurosis of the Ext. oblique (→the inguinal lig.) Superior (roof) - Arching lowest fibers of the Int. oblique and transversus abdominis muscles

Deep Inguinal Ring ½ inch above the ligament Midway between ASIS and the Symphysis Lateral to the inferior epigastric vessels Margins of ring give origin to the internal spermatic fascia

Superficial Inguinal Ring Triangular defect in the aponeurosis of the external oblique Immediately above and medial to the pubic tubercle Margins give origin to the external spermatic fascia Physical Exam

Physiology and Mechanics

Physiology Inguinal canal - a passage through the lower abdominal wall Males - to and from the testis Females - round ligament of the uterus to the labium major Both sexes – Ilio-inguinal nerve

Mechanics of the inguinal Canal A potential weakness A design to lessen weakness: Oblique passage → weakest areas lying some distance apart Anterior reinforcement by Int. oblique in front of deep ring Posterior reinforcement by Conjoint tendon behind superficial ring

Mechanics of the inguinal Canal – Cont. On coughing/straining (defecation, parturition etc.) → Int. oblique and transversus abdominis muscles contract → flattening the roof → canal is virtually closed

Processus Vaginalis Spermatic Fasciae Gubernaculum Embryology Processus Vaginalis Spermatic Fasciae Gubernaculum

Embryology of the Inguinal Canal – Processus Vaginalis Prior to testicular/ovarian descent a peritoneal diverticulum called the processus vaginalis is formed

Embryology - Processus Vaginalis and creation of Spermatic fasciae The processus vaginalis passes through the layers of the abdominal wall and acquires a tubular covering from each layer: Fascia transversalis - Internal spermatic fascia Lower part of Int. oblique muscle - it takes some of its lowest fibers (Cremaster muscle & Fascia) Aponeurosis of the external oblique – Ext. spermatic fascia

Spermatic Cord Forms at the level of the Deep ring It is covered with three concentric layers of fascia derived from the layers of the anterior abdominal wall

Embryology oriented anatomy of spermatic fasciae

Embryology - Gubernaculum Extends from the lower pole of the developing gonad to the labioscrotal swelling In the male the testis descends during the 7th and 8th months of fetal life

Embryology - Gubernaculum The stimulus for the descent is testosterone, secreted by the fetal testes The testis follows the gubernaculum and descends behind the processus vaginalis Pulls down its duct, blood vessels, nerves and lymphatics In the female - extends from the uterus into the developing labium major Persists as the round ligament

Herniae of the Myopectineal orifice

A hernia - protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall Consists of: Sac Contents of the sac Coverings of the sac Complications: Incarceration Strangulation Bowel obstruction

Common Abdominal herniae are Inguinal: Indirect Direct Femoral Umbilical: Congenital Acquired Epigastric Separation of the rectiabdominis Diaphragmatic: Sliding Paraesophageal Incisional (POVH)

Indirect Inguinal Hernia The most common form of hernia 20 times more common in males one-third are bilateral more common on the right Congenital in origin Hernial sac is the remains of the processus vaginalis The sac enters the inguinal canal through the deep inguinal ring lateral to the inferior epigastric vessels

Direct Inguinal Hernia About 15 percent of all inguinal hernias Majority is bilateral The sac bulges directly anteriorly through the posterior wall of the inguinal canal Medial to the inferior epigastric vessels A disease of old men with weak abdominal muscles.

Femoral Hernia The femoral sheath - a protrusion of the fascial envelope lining the abdominal walls Surrounds the femoral vessels & lymphatics for 1 inch below the inguinal ligament

The Femoral Canal The femoral canal, the compartment for the lymphatics, occupies the medial part of the sheath. Its upper opening is the femoral ring: Anterior -Inguinal ligament Posterior - Pectineal ligament and the pubis Medial - sharp free edge of the Lacunar ligament Lateral - Femoral vein The femoral septum, which is a condensation of extraperitoneal tissue, plugs the opening The femoral vein is separated from it by a fibrous septum

Femoral Hernia Much more common in women The sac passes down the canal, pushing the septum On the lower end, it forms a swelling in the upper thigh With further expansion the sac may turn upward to cross the inguinal ligament The neck always lies below and lateral to the pubic tubercle

Surgical Repair of Hernia

Classification Those that close all or part of the myopectineal orifice Anterior Vs. Posterior Repair by suturing the tissues at boundaries: Bassini Shouldice Cooper (McVay) Those that cover the orifice with prosthetic mesh: Lichtenstein Plug and patch Laparoscopic

Anterior Repairs Dissection and hernia reduction is the same: incision 2 to 3 cm above and parallel to the inguinal ligament Dissection through the subcutaneous tissues and Scarpa’s fascia The external oblique fascia and external ring is identified The external oblique fascia is incised to expose the inguinal canal The ilioinguinal and iliohypogastric nerves should be preserved

Open Repair – Cont. The spermatic cord is mobilized at the pubic tubercle The Cremaster muscle is divided and separated from the cord The hernia sac is dissected from adjacent cord structures The sac should be opened and examined for visceral contents if it is large Neck of the sac is ligated at the level of the internal ring

Herniorrhaphy Bassini Shouldice McVay (Coopers ligament repair) Ileopubic tract

The Bassini repair Suturing the conjoined tendon to the inguinal ligament was the most popular repair before the tension-free repairs

The Shouldice repair Multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique: 1st suture line - transversus abdominis aponeurotic arch to the iliopubic tract 2nd line - internal oblique and transversus abdominis muscles and aponeuroses (Conjoint) to the inguinal ligament 3rd line - Conjoint to Ext. oblique 4th line - Conjoint to Ext. oblique

1st posterior suture - Transversus abdominis to Iliopubic tract

1st posterior suture - Transversus abdominis to Iliopubic tract (Cont

2nd posterior suture – Int 2nd posterior suture – Int. oblique and transversus abdominis to inguinal ligament

3rd posterior suture - Conjoint to Ext. oblique

4th posterior suture - Conjoint to Ext. oblique

Relaxing incision

Cooper Ligament (McVay) Repair For correction of all the Myopectineal orifice: Direct inguinal hernias Large indirect hernias Recurrent inguinal hernias Femoral hernias

Transversus abdominis aponeurosis to Cooper’s ligament

Lateral to the medial aspect of the femoral canal , the transversus abdominis aponeurosis is secured to the iliopubic tract An important principle - relaxing incision

Lichtenstein Repair Tension is the principal cause of recurrence Synthetic mesh prosthesis to bridge the defect Inferior suture line - Shelving edge of the inguinal (Poupart’s) ligament Superior line – Conjoint muscle & tendon

Posterior Repairs Open Repair: Stoppa Laparoscopic Trans Abdominal Pre-Peritoneal (TAPP) Total Extra Peritoneal (TEP)

Preperitoneal Anatomy

What’s that?

…and that?

Danger areas

The approach to the preperitoneal space

Arcuate line (3)

TEP

TAPP

Direct Hernia

Indirect Hernia

Trans-abdominal approach to the preperitoneal space

Dissection of indirect hernia

TAPP

Post Op. Complications