HERNIAS

Historical Perspective 15 th century - Castration with wound cauterization or hernia sac debridement 15 th century - Castration with wound cauterization or hernia sac debridement recommended a truss recommended a truss

Father of Modern Inguinal Hernia Repair EDUARDO BASSINI

Hernia Latin for rupture Latin for rupture an abnormal protrusion of an organ or tissue through a defect in its surrounding walls an abnormal protrusion of an organ or tissue through a defect in its surrounding walls Occur at sites where aponeurosis and fascia are not covered by striated muscle Occur at sites where aponeurosis and fascia are not covered by striated muscle

Which of the following statements is/are true regarding incidence of the abdominal wall hernia? A. T wo-thrirds of all inguinal hernias are classified as indirect. B. F emoral hernias are more common in females than in males. C. D irect hernias are common in females. D. H ernias generally occur with equal frequency in males and females E. P remature babies have a 10% incidence of having inguinal hernia.

Epidemiology 700,000 hernia repairs year 700,000 hernia repairs year Inguinal hernias -75% of all hernias Inguinal hernias -75% of all hernias 2/3 Indirect, remainder are direct 2/3 Indirect, remainder are direct Incisional hernias – 15 to 20% Incisional hernias – 15 to 20% Umbilical and epigastric – 10% Umbilical and epigastric – 10% Femoral – 5% Femoral – 5%

Epidemiology Prevelance of hernias increases with age Prevelance of hernias increases with age Most serious complication – strangulation Most serious complication – strangulation 1 to 3% of groin hernias 1 to 3% of groin hernias Femoral – highest rate of complications 15% to 20% Femoral – highest rate of complications 15% to 20% recommended all be repaired at time of discovery recommended all be repaired at time of discovery

Abdominal Wall Anatomy

Anatomy Inguinal ligament (Poupart’s) – inferior edge of external oblique Inguinal ligament (Poupart’s) – inferior edge of external oblique Lacunar ligament – triangular extension of the inguinal ligament before its insertion upon the pubic tubercle Lacunar ligament – triangular extension of the inguinal ligament before its insertion upon the pubic tubercle conjoined tendon (5-10%)- Internal oblique fuses with transversus abdominis aponeurosis conjoined tendon (5-10%)- Internal oblique fuses with transversus abdominis aponeurosis Cooper’s Ligament - formed by the periosteum and fascia along the superior ramus of the pubis. Cooper’s Ligament - formed by the periosteum and fascia along the superior ramus of the pubis.

Inguinal Canal Between deep and superficial inguinal rings Boundaries Superifical – external oblique aponeurosis Superior – internal and transversus Inferior – shelving edge of inguinal ligament and lacunar ligament Posterior (floor) – transversalis fascia and aponeurosis of transversus abdominis muscle

Inguinal Canal Contains the spermatic cord and round ligament of the uterus Contains the spermatic cord and round ligament of the uterus Spermatic cord Spermatic cord Cremasteric muscle fibers Cremasteric muscle fibers Testicular vessels Testicular vessels Genital branch of genitofemoral nerve Genital branch of genitofemoral nerve Vas deferens Vas deferens Cremasteric vessels Cremasteric vessels

Components of Hesselbach’s triangle include which of the following anatomic landmarks? A. P ectineal ligament B. L ateral border of the rectus sheath C. C ooper’s ligament D. I nguinal ligament E. I nferior epigastric vessels

Terminology Reducible – can be replaced within surrounding musculature Reducible – can be replaced within surrounding musculature Incarcerated – cannot be reduced Incarcerated – cannot be reduced Strangulated – compromised blood supply to its contents Strangulated – compromised blood supply to its contents

Sends sensory branches to the inner thigh and medial aspect of the scrotum A. I leoinguinal nerve B. G enitofemoral nerve C. B oth D. N either

A sliding inguinal hernia on the left side is likely to involve which of the following? A. J ejunum composing the posterior wall of the sac B. O vary and fallopian tube in a female infant C. O mentum D. S igmoid colon composing the posterior wall of the sac E. C ecum composing the anteromedial wall of the sac

Terminology Pantaloon – direct and indirect components Pantaloon – direct and indirect components Richter’s – contains antimesenteric portion of small bowel Richter’s – contains antimesenteric portion of small bowel Sliding – involves visceral peritoneum of an organ, i.e. bladder, ovary Sliding – involves visceral peritoneum of an organ, i.e. bladder, ovary Littre’s – hernia contains Meckel’s diverticulum Littre’s – hernia contains Meckel’s diverticulum Petit – hernia at inferior lumbar triangle Petit – hernia at inferior lumbar triangle Grynfelt – hernia at superior lumbar triangle Grynfelt – hernia at superior lumbar triangle

Groin Hernias Indirect Indirect Direct Direct Femoral Femoral

Inguinal Hernia Classified as congenital vs. acquired Classified as congenital vs. acquired commonly thought that repeated increases in intra-abdominal pressure contribute to hernia formation commonly thought that repeated increases in intra-abdominal pressure contribute to hernia formation collagen formation and structure deteriorates with age, and thus hernia formation is more common in the older individual. collagen formation and structure deteriorates with age, and thus hernia formation is more common in the older individual.

Clinical Presentation Groin bulge Groin bulge Often asymptomatic Often asymptomatic Dull feeling of discomfort or heaviness in the groin Dull feeling of discomfort or heaviness in the groin Focal pain – raise suspicion for incarceration or strangulation Focal pain – raise suspicion for incarceration or strangulation Symptoms of bowel obstruction Symptoms of bowel obstruction

Inguinal hernia Male inguinal hernia Female inguinal hernia

Diagnosis Physical Exam Physical Exam 74.5% sensitive and 96.3% specific 74.5% sensitive and 96.3% specific examine the patient in the standing and supine positions examine the patient in the standing and supine positions difficult to distinguish direct and indirect on exam on alone difficult to distinguish direct and indirect on exam on alone

Diagnosis Radiologic Investigations Radiologic Investigations Herniography Herniography Suspected hernia, but clinical dx unclear Suspected hernia, but clinical dx unclear Procedure done under flouroscopy following injection of contrast medium Procedure done under flouroscopy following injection of contrast medium Frontal and oblique radiographs are taken with and without increased intra-abdominal pressure Frontal and oblique radiographs are taken with and without increased intra-abdominal pressure Ultrasonography Ultrasonography MRI MRI CT CT

Herniography Right direct inguinal hernia Left indirect inguinal hernia

Direct Inguinal Hernia

Medial to the inferior epigastric artery and vein, and within Hesselbach's triangle Medial to the inferior epigastric artery and vein, and within Hesselbach's triangle acquired weakness in the inguinal floor acquired weakness in the inguinal floor

Indirect Inguinal hernia Abdominal contents protrude through internal inguinal ring Abdominal contents protrude through internal inguinal ring

Indirect Inguinal Hernia Accepted hypothesis: incomplete or defective obliteration of the processus vaginalis during the fetal period Accepted hypothesis: incomplete or defective obliteration of the processus vaginalis during the fetal period remnant layer of peritoneum forms a sac at the internal ring remnant layer of peritoneum forms a sac at the internal ring more frequently on the right more frequently on the right

Femoral More common in females Up to 40% present as emergencies with hernia incarceration or strangulation Passes medial to the femoral vessels and nerve in the femoral canal through the empty space Inguinal ligament forms the superior border

Femoral palpation of the femoral canal just below the inguinal ligament in the upper thigh palpation of the femoral canal just below the inguinal ligament in the upper thigh NAVELS NAVELS

TABLE 1 Nyhus Classification of Groin Hernias Type I--indirect inguinal hernia Internal inguinal ring normal (i.e., pediatric hernia) Type II--indirect inguinal hernia Dilated internal inguinal ring with posterior inguinal wall intact Type III--posterior wall defects Direct inguinal hernia Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e., massive scrotal, sliding hernia) Femoral hernia Type IV--recurrent hernia

Which of the following statements is/are true regarding direct inguinal hernias? A. T he most likely cause is destruction of connective tissue resulting form physical stress. B. D irect hernias should be repaired promptly because of the risk of incarceration. C. A direct hernia may be a sliding hernia involving a portion of the bladder wall. D. A direct hernia may pass through the external inguinal ring. E. C olon carcinoma is a known cause of direct inguinal hernias.

Treatment Non-Operative Non-Operative Observation Observation Trusses can provide symptomatic relief Trusses can provide symptomatic relief Hernia control in ~30% of patients Hernia control in ~30% of patients

Operative Bassini Bassini Shouldice Shouldice McVay McVay Lichtenstein Lichtenstein Preperitoneal Preperitoneal Laparoscopic Laparoscopic

Bassini (early 20 th Century) Bassini (early 20 th Century) Transversus abdominis to Thompson ’ s ligament and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament Transversus abdominis to Thompson ’ s ligament and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament Shouldice (1930s) Shouldice (1930s) Multilayer imbricated repair of the posterior wall of the inguinal canal Multilayer imbricated repair of the posterior wall of the inguinal canal McVay (1948) McVay (1948) Edge of the transversus abdominis aponeurosis to Cooper ’ s ligament; incorporate Cooper ’ s ligament and the iliopubic tract (transition suture) Edge of the transversus abdominis aponeurosis to Cooper ’ s ligament; incorporate Cooper ’ s ligament and the iliopubic tract (transition suture)

BASSINI SHOULDICE MCVAY

Lichtenstein First pure prosthestic, tension-free repair to achieve low recurrence rates First pure prosthestic, tension-free repair to achieve low recurrence rates

Prosthetic Repair Polypropylene mesh most common and preferred Polypropylene mesh most common and preferred allows for a fibrotic reaction to occur between the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect allows for a fibrotic reaction to occur between the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect Polytetrafluoroethylene (PTFE) mesh Polytetrafluoroethylene (PTFE) mesh often used for repair of ventral or incision hernias in which the fibrotic reaction with the underlying serosal surface of the bowel is best avoided often used for repair of ventral or incision hernias in which the fibrotic reaction with the underlying serosal surface of the bowel is best avoided

Prospective study Danish Hernia database of over 13,000 hernia repairs Compared re-operations for recurrent hernia Results: After 5 years significantly lower (1/4 less) recurrence with mesh vs. sutured repair

Laparoscopic

The cause of neuropathic postherniorrhaphy inguinodynia includes which of the following? A. Formation of scar tissue B. Transection of the ilioinguinal, iliohypogastric, or the genitofemoral nerves C. Suture entrapment of nerves D. Staple entrapment of nerves E. Periosteal reaction

Surgical Complications Recurrence Recurrence Infection Infection Neuralgia Neuralgia Bladder injury Bladder injury Testicular injury Testicular injury Vas Deferens injury Vas Deferens injury

Other Hernias

Which of the following is/are true statements regarding umbilical hernias? A. T hey are embryonic equivalent of a small omphalocele B. R epair in infants is usually deferred until approximately 4 years of age C. R epair in adults is usually indicated D. T he “vest-over-pants” type of repair is stronger than simple approximation of fascial margins E. T hey are most common in Caucasian infants

Umbilical Incidence Reported ~10% Reported ~10% several times greater in Black children several times greater in Black children more common in premature children all races more common in premature children all races Most close spontaneously by age 2 or 3 Most close spontaneously by age 2 or 3 Acquired rather than congenital in adults Acquired rather than congenital in adults Female to male ratio 3:1 Female to male ratio 3:1

Epigastric midline junction of the aponeuroses (linea alba) between the xiphoid process and umbilicus midline junction of the aponeuroses (linea alba) between the xiphoid process and umbilicus Paraumbilical hernia - epigastric hernia that borders the umbilicus Paraumbilical hernia - epigastric hernia that borders the umbilicus Estimated frequency 3-5% Estimated frequency 3-5% More common in Males 3:1 More common in Males 3:1 20% may be multiple 20% may be multiple

Epigastric Clinical Clinical Often asymptomatic, incidental finding Often asymptomatic, incidental finding If symptomatic, vague abdominal pain above the umbilicus exacerbated by standing or coughing; relieved in supine position If symptomatic, vague abdominal pain above the umbilicus exacerbated by standing or coughing; relieved in supine position Severe pain secondary to incarceration/strangulation of preperitoneal fat (often no peritoneal sac) or omentum Severe pain secondary to incarceration/strangulation of preperitoneal fat (often no peritoneal sac) or omentum Exam: palpate small, soft, reducible mass superior to the umbilicus Exam: palpate small, soft, reducible mass superior to the umbilicus RARE to have strangulated bowel RARE to have strangulated bowel Tx Tx Excise fat and sac, close primarily Excise fat and sac, close primarily

An 82-year-old previously healthy woman has a 12-hour history of severe epigastric pain associated with nausea and vomiting. She has had no previous abdominal operations. Her WBC count is 21,000/cu mm. The plain films and abdominal CT shown are obtained.

Which of the following best describes this patient’s diagnosis? A. P ain in the medial thigh and knee is uncommonly associated with this condition B. I t is unusual in women C. I t is unusual in elderly patients D. I t is seldom associated with intestinal necrosis E. I t is usually unilateral

Obturator Rare form of hernia Protrusion of intra-abdominal contents through obturator foramen F:M ratio 6:1 The obturator foramen is formed by the ischial and pubic rami obturator vessels and nerve lie posterolateral to the hernia sac in the canal Small bowel is the most likely intraabdominal organ to be found in an obturator hernia

Obturator 4 cardinal signs : 4 cardinal signs : intestinal obstruction (80%) intestinal obstruction (80%) Howship-Romberg sign (50%) –History of repeated episodes of bowel obstruction that resolve quickly and without intervention Howship-Romberg sign (50%) –History of repeated episodes of bowel obstruction that resolve quickly and without intervention Palpable mass (20%) Palpable mass (20%) Tx: Sugical Repair Tx: Sugical Repair

Spigelian Hernia occurs along the semilunar line, which traverses a vertical space along the lateral rectus border occurs along the semilunar line, which traverses a vertical space along the lateral rectus border where more than 90% of spigelian hernias are found where more than 90% of spigelian hernias are found

Spigelian Hernia Clinical Clinical Swelling in middle to lower abdomen lateral to rectus muscle Swelling in middle to lower abdomen lateral to rectus muscle Usually reducible Usually reducible Up to 20% present with incarceration Up to 20% present with incarceration Tx: surgical Tx: surgical Mesh not required Mesh not required Recurrence is uncommon Recurrence is uncommon

Lumbar Acquired lumbar hernias – back or flank trauma, poliomyelitis, back surgery, and the use of the iliac crest as a donor site for bone grafts Contains to anatomic triangles, inferior and superior lumbar triangles Grynfelt’s Petit’s Strangulation is rare Soft swelling in lower posterior abdomen

Sciatic Via greater or lesser sciatic notch Via greater or lesser sciatic notch greater sciatic notch is traversed by the piriformis muscle, and hernia sacs can protrude either superior or inferior to this muscle greater sciatic notch is traversed by the piriformis muscle, and hernia sacs can protrude either superior or inferior to this muscle suprapiriform defect 60% suprapiriform defect 60% Infrapiriform 30% Infrapiriform 30% subspinous (through the lesser sciatic foramen) 10% subspinous (through the lesser sciatic foramen) 10%

Which of the following hernias is most likely to recur after primary repair? A. E pigastric hernia B. S pigelian hernia C. I ndirect hernia D. F emoral hernia E. I ncisional hernia

Ventral wall (Incisional) Highest incidence in midline and transverse incisions Highest incidence in midline and transverse incisions Up to20% after laparotomy Up to20% after laparotomy 1/3 present in 5-10 years postoperatively 1/3 present in 5-10 years postoperatively Risk factors Risk factors obesity, DM, ascites, steroids, smoking malnutrition, wound infection obesity, DM, ascites, steroids, smoking malnutrition, wound infection Technical aspects of wound closure Technical aspects of wound closure Type of incision Type of incision Excessive tension (prone to fascial disruption) Excessive tension (prone to fascial disruption)

Which of the following hernias represent an incarceration of a limited portion of small bowel? A. S pigelian hernia B. G rynfelt’s hernia C. P etit’s hernia D. R ichter’s hernia E. L ittre’s hernia