Hernia (Latin, rupture; Greek, bud): A protrusion of viscus through an opening in the wall of the cavity in which it is contained.

Hernial (H) orifice H sac: an outpouch of peritoneum. External H: the sac protrudes completely through the abdominal wall Internal H: the sac is within the visceral cavity Interparietal H: the sac is within the abdominal wall

Reducible H: can be returned to the abdomen Irreducible H: cannot. Strangulated H: vascularity of the protruded viscus is compromised, usually at neck. Incarcerated H: Irreducible H. Richter’s H: the contents of the sac consist of only one side of the wall of the intestine.  

Sites of H Common: Groin, umbilicus, the linea alba, the semilunar line of Spieghel, the diaphragm, and surgical incisions Rare: Perineum, the superior lumbar triangle of Grynfelt, the inferior lumbar triangle of Petit, and the obturator and sciatic foramen of the pelvis

Symptoms and diagnosis Initial unawareness until the hernia is pointed out to them. Slow enlargement to the point of irreducibility and disfigurement, with the risk of strangulation. A wide variety of nonspecific discomforts related to the contents of the sac and the pressure by the sac on adjacent tissue.

Worse at the end of the day and relieved at night when the patient reclines and the hernia reduces Most hernias develop insidiously. But some are precipitated by a single forceful muscular event. Easy to diagnosis: Stand, strain or cough; not supine DDX: hydrocele by transillumination or sonography.

Indications for surgery In general, all hernias should be repaired unless local or systemic conditions in the patient preclude a safe outcome. Truss

Groin Hernia The most common site for abdominal herniation. Male/female: 25:1 Hernias arising above the abdominocrural crease are inguinal (Latin, groin), and those arising below the crease are femoral (Latin, thigh) or crural (Latin, leg).

Inguinal H: direct and indirect In men, indirect H outnumbers direct H at a ratio of 2:1. In women direct H are a rarity. Femoral H

Femoral Hernia A separate entity Uncommon, 2.5% of all groin H. Occasionally in women, especially in multiparous elderly women. Rarely in men. An irreducible mass about the size of a walnut at the medial base of Scarpa’s femoral triangle. DDX: enlarged lymph node and synovial cyst.

Indirect inguinal and femoral H are twice as common on the right as on the left. Delay in the atrophy of the processus vaginalis that follows the normally slower descent to the scrotum of the right testis. In femoral H, sigmoid colon’s tamponading the left femoral canal.

Epidemiology Estimated incidence is 3 to 4 % of the male population. Strangulation occurs in 1.3 to 3.0 % of groin H. Most strangulated H are indirect inguinal H, but the femoral H has the highest rate of strangulation (5 to 20%) of all H.

Anatomy of Groin H Sliding H: retroperitoneal organs such as the sigmoid colon, cecum, ureters, and urinary bladder may slide into an indirect sac. They thereby become a part of the wall of the sac and are susceptible to injury during hernioplasty. These sliding H often are large and partially irreducible. An indirect H sac is actually a dilated persistent processus vaginalis. Direct inguinal H sacs originate through the floor of the inguinal canal, that is Hesselback’s triangle.

Etiology Congenital or acquired A family history of groin H is usually strongly positive. A patent processus vaginalis is found in 80% of newborns and in 50% of 1-year-olds. Closure continues until the age of 2 years. The incidence of a patent processus vaginalis in adults is 20%. Having the potential for a hernia does not mean that a hernia will develop.

Other factors must be present to cause failure of the transversalis fascia. Erect stance of human beings. Muscle deficiency Destruction of connective tissue: fracture of the elastic fibers and alterations in the structure, quantity, and metabolism of collagen. Abdominal distention and chronic increase in intraabdominal pressure from ascites and peritoneal dialysis.

Basics of groin hernioplasty Anterior approach Posterior approach Synthetic mesh prostheses currently play a major role.

Bassini, Shoudice, McVay, etc. Classical hernioplasty has three parts: dissection of the inguinal canal, repair of the myopectineal orifice, and closure of the inguinal canal. The management of hernia sac: indirect, direct, sliding

Insufficient repair of the deep ring is the principal cause of indirect recurrence. In women, simple ring closure is the hernioplasty of choice with indirect inguinal H.  

Prosthetic material Marlex, Prolene, Trelex: knitted monofilament fibers of polypropylene (聚丙烯) Surgipro: knitted, branded strands of polypropylene Mersilene: polyester (聚酯) Dacron (達克龍) Gore-Tex: polytetrafluoroethylene (PTFE): encapsulation; The tendency of intestine to adhere to Gore-Tex is minimal.

Polyester and polypropylene permanent prostheses should never contact abdominal viscera directly. Infections and synthetic nonabsorbable prostheses

Anterior prosthetic groin hernioplasty Tension-free hernioplasty, Lichtenstein The prosthesis is implanted without a formal repair, thereby obviating tension. 8x16 cm patch Posterior (Properitoneal) prosthetic groin hernioplasty Stoppa procedure- Giant prosthetic reinforcement of the visceral sac Laparoscopic repair

Anterior view Posterior view

Bassini hernioplasty

Femoral hernia Repair

Complications Ischemic orchitis and testicular atrophy Thrombosis of the spermatic cord. Neuralgia Injury of sensory nerve (neuroma) Constricting scar tissue Adjacent inflammatory granuloma

The prevention of nerve injury is important since the treatment of neuralgic complications is often unsuccessful. Division (usually with ligation) of the genital branch of the genitofemoral nerve is routine. Most nerves require ligature to control bleeding. The ligature may also confine neuroma formation to within the neurilemma.

Recurrences 1 to 3 % in a 10-year follow-up. Caused by excessive tension on the repair, deficient tissues, inadequate hernioplasty, overlooked hernias. Recurrent hernias require a prosthesis for successful repair.

Umbilical hernia Epigastric hernia Spigelian hernia Lumbar hernia Pelvic hernia Parastomal hernia Incisional hernia