1. Inguinal Hernia Dr. Budi Irwan , SpB-KBD Division of Digestive Surgery
Department of Surgery
Faculty of Medicine
University of North Sumatera
Adam Malik National Hospital

2. Definition
Abnormal protrusion of a peritoneal lined sac thru the musculoaponeurotic covering of the abdomen

3. Location Groin Umbilicus Linea alba (epigastric) Surgical incisions
Semi-lunar line
Diaphragm
Lumbar triangles
Pelvis

5. Groin Hernia In US 96% are inguinal, 4% femoral 20% bilateral
Most common in both sexes indirect.
Femoral hernias more common in elderly females
Male to female ratio in 9:1 for inguinal hernias, 1:3 for femoral hernias

6. Anatomy 4cm in length 2-4 cm cephalad to inguinal ligament
Extends between superficial and deep rings
Contains spermatic cord or round ligament

7. Anatomy Bounded superficially by external oblique
Cephalad by internal oblique, TA, transversalis
Inferior border is inguinal ligament
Floor is transversalis fascia

8. Parts of sac
3 parts
Sac
Contents
Covering of sac

9. Sac
Sac : A pouch of peritoneum,
4 parts
Mouth
Neck
Body
Fundus

10. Contents Omentum - Omentocoel / epiplocele Intestine - Enterocoel
Bladder - Cystocoel
Part of Intestine - Richter’s
W type intestine - Maydl’s Hernia
Meckel’s diverticulum - Littre’s hernia

11. Types
Direct
Indirect
Combined (Pantaloon)
Sliding

12. Types
Complete (Scrotal) (Vaginal)
Funicular (incomplete)
Bubonocoel

13. Layers
Skin, subcutaneous, campers, scarpa, external oblique fascia, cremaster, spermatic cord, cremaster, transversus abdominis, transversalis fascia, preperitoneal tissues, peritoneum

14. Broadly classified as indirect and direct depending on relationship to epigastric vessels.
Hesselbach’s triangle is inferior epigastric artery laterally, lateral border of rectus medially, inguinal ligament inferiorly.

15. An indirect hernia passes lateral to Hesselbach’s triangle.
A direct hernia passes thru Hesselbach’s triangle.
Indirect hernia has a congenital component, from processus vaginalis.
The processus is supposed to obliterate after descent of testes.

16. Hesselbach’s Triangle

17. Inguinal Anatomy shelving edge transversalis fascia
Men: spermatic cord
Women: round ligament
inferior epigastric
vessels
shelving edge
internal oblique
transversus abdominus
rectus abdominis
transversalis fascia
shelving edge
Now let’s look at internal anatomy. The spermatic cord/round ligament travels obliquely on the floor of the inguinal canal (transversalis fascia) from the internal ring and exits at the external ring formed by the external oblique aponeurosis into the scrotum/labia majorum. The roof is the external oblique aponeurosis, which also curves posteriorly to form the lower “sidewall” of the canal as the inguinal ligament. The upper “sidewall” of the inguinal canal is the shelving edge of the internal oblique and transversus abdominus muscles. The inferior epigastric vessels, rectus abdominis/shelving edge, and inguinal ligament form a multiplanar triangle, Hesselbach’s triangle, the floor of which is the transversalis fascia. Direct hernias are medial to the inferior epigastric vessels, whereas indirect hernias are lateral to these vessels. Large inguinal hernias can distort the transversalis fascia to such a degree that the only way to define the hernia is by its relationship to the inferior epigastric vessels.
This anatomy also highlights the critical role of weakness and defects in the transversalis fascia related to both indirect and direct hernias: the supero- and inferomedial margins of the internal ring are formed by the transversalis fascia.
transversalis fascia
pubic tubercle
internal ring external ring

20. Inguinal hernia Male inguinal hernia Female inguinal hernia

22. Indirect Hernia

23. Direct Hernia

24. Direct Inguinal Hernia

25. Direct hernias are usually not congenital.
Acquired by the development of tissue deficiencies of the transversalis fascia.
Development of femoral hernia less understood. Can result from increased intraabdominal pressure. The sac then migrates down the femoral vessels into thigh.

26. Major nerves in the region are ilioinguinal, iliohypogastric, genitofemoral nerves.
Ilioinguinal provides sensory to pubic region, upper labia, scrotum. Most commonly injured.
Iliohypogastric supplies sensory to skin superior to the pubis.
Genitofemoral sensory to scrotum and thigh.

29. Diagnosis Careful physical exam Pain, dull dragging sensation
A common reducible hernia does not cause significant symptoms.
CT scan, US are adjuncts rarely needed.
Cannot determine direct from indirect clinically.

30. Indications Asymptomatic Symptomatic, non-obstructed
prevent visceral incarceration and/or strangulation
Symptomatic, non-obstructed
Treat discomfort from bulge
Prevent incarceration/strangulation
Visceral obstruction/strangulation
Release obstruction/manage viscera
Prevent recurrence
Most hernias are repaired to prevent the major consequence of hernia, namely, visceral obstruction progressing to strangulation. In third world countries, the most common cause of bowel obstruction is hernia. Symptomatic hernias without obstruction are repaired to treat the discomfort and prevent incarceration/strangulation. Incarcerated hernias with obstruction and/or strangulation are repaired to release the obstruction, assess and manage the viscera, and prevent hernia recurrence.

31. Surgical Techniques Open anterior repair (Bassini, McVay, Shouldice).
Open posterior repair (Nyhus, preperitoneal)
Tension-free repair with mesh(Liechtenstein, Rutkow)
Laparoscopic

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

33. BASSINI
MCVAY
SHOULDICE

34. Open Anterior Repair
Transversalis opened, hernia sac ligated, canal reconstructed using permanent sutures.
Tension of the repair can lead to recurrence.

35. Father of Modern Inguinal Hernia Repair
Bassini revolutionized the surgical repair of the groin hernia with his novel anatomical dissection and low recurrence rates – first operation in 1884
EDUARDO BASSINI

37. Open Posterior Repair
Divide the layers of the abdominal wall superior to the internal ring, enter preperitoneal space. Dissection continues behind and deep to the entire inguinal region.
Suture tension problems.

38. Tension-Free Repair Same initial approach as anterior repair
Instead of sewing fascial layers together to repair defect, a prosthetic mesh onlay used
Simple to learn, easy to perform, suited for local anesthesia, excellent results with recurrence less than 4%.

41. Techniques Coined by Liechtenstein in 1989
Central feature is polypropylene mesh over unrepaired floor.
Gilbert repair uses a cone shaped plug placed thru deep ring.
Slit placed in mesh for cord structures

42. Kugel Patch

43. Bard Perfix Plug and Patch

44. Prolene Hernia System

45. Techniques Suture fixation of the superior edge not needed.
Reduction of the slit around the cord did not reduce recurrences.
The additional safeguard was the plug
Closing the tails is also not necessary.
Tight rings do not cause orchitis, trauma does.

47. Techniques
The genital branch of the femoral nerve, and the ilioinguinal nerve are allowed to pass thru the newly constructed deep ring.
Suturing the plug is not necessary.
Preformed plugs have no advantage over a hand fashioned one.

48. Techniques
Small indirect sacs are dissected and inverted, large one are transected and ligated.
Direct sacs are inverted.
If plugs are placed to repair direct defects, a mesh only must be placed over the plug to prevent expulsion.

49. Techniques
Suturing the mesh to the inguinal ligament is not important.
Fixing the mesh to the rectus sheath 1-1.5cm medial and superior to the pubic tubercle is very important.
Should have a surplus of mesh over inguinal ligament, the medial suture ensures surplus mesh inferiorly

50. Laparoscopic Procedures
Increasingly popular, controversial
Early in the development, hernias were repaired by placing very large mesh over entire inguinal region on top of the peritoneum. Was abandoned because of contact with bowel.
Today, most performed TEP or TAPP

51. Types of Laparoscopic Inguinal Hernia Repair
IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned.
TAPP  (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized.
TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs

52. Laparoscopic Procedures
The argued advantage of these procedures was less pain and disability, faster return to work.
Great for bilateral hernia, with no increase in morbidity.
For recurrent hernia
Disadvantages are cost, time.

53. Trochar placement for both TEP & TAPP

57. Complications Recurrence Neuralgia Ilioinguinal Iliohypogastric
Genitofemoral
Lateral cutaneous
Ischemic orchitis
Injury to vas deference
Wound infection
Bleeding

58. Recurrence Type of repair Recurrence McVay 9% Shouldice 7-11%
Liechtenstein
0-4%
Laparoscopic
0-1%

59. Umbilical Hernia Women> men Risk factors May rupture with ascites
Obesity
Pregnancy
May rupture with ascites
Repair primarily or with mesh

60. Common in infants
Close spontaneously if <1.5 cm
Repair if > 2 cm or if persists at age 3-4 years
Repair primarily or with mesh

61. Epigastric Hernia Incidence 1-5% Men> women
Pre-peritoneal fat protrusion through decussating fibers at linea alba
Between xiphoid and umbilicus
20% multiple
Repair primarily

62. Incisional Hernia Risk factors Laparoscopic vs. open repair Technical
Wound infection
Smoking
Hypoxia/ ischemia
Tension
Obesity
Malnutrition
Laparoscopic vs. open repair

63. Parastomal Hernia Variant of incisional hernia
Paracolostomy > paraileostomy
Low rate if through rectus muscle
Traditionally relocate stoma, repair defect
Concern for mesh erosion
Laparoscopic repair

64. Spieghelian Hernia Rare
Hernia through subumbilical portion of semi-lunar line
Difficult to diagnose
Clinical suspicion (location)
CT scan
Repair primarily or with mesh

65. Lumbar Hernia Congenital, spontaneous or traumatic
Grynfeltt’s triangle
12th rib, internal oblique and sacrospinalis muscle
Covered by latissimus dorsi
Petit’s triangle
Latissimus dorsi, external oblique and iliac crest
Covered by superficial fascia

66. Pelvic Hernia Obturator hernia Sciatic hernia Perineal hernia
Most commonly in women
Howship-Romberg sign
Sciatic hernia
Perineal hernia

67. Spigelian Hernia
Defect through transversus abdominus and internal oblique muscles
Occurs at junction of arcuate line and linea semilunaris
Fascial defect 1-2 cm
Covered by external oblique aponeurosis
A Spigelian hernia is the result of a partial thickness abdominal wall defect through the transversus abdominus and internal oblique muscles at the junction of the arcuate line and the linea semilunaris. At this point, the posterior rectus sheath transitions from partial internal oblique aponeurosis with transversalis fascia, to only transversalis fascia. The 1-2 cm defect with resultant sac is covered by the external oblique aponeurosis, making diagnosis challenging.

68. May require imaging studies for diagnosis
Presentation
Lower abdominal swelling lateral to rectus
Focal discomfort/pain
May require imaging studies for diagnosis
Ultrasound or CT
Repair: open or laparoscopic, on-lay mesh
The presentation may be a subtle bulge or subclinical, manifested by focal discomfort or pain alone. Ultrasound and CT scan may be required to make the diagnosis. Repair may be open or laparoscopic. Repair requires on-lay mesh. The laparoscopic approach is particularly well-suited for this hernia, given the absence of a prominent external bulge due to coverage by the external oblique aponeurosis.

69. Points to Remember
Hernias represent fascial defects with protrusion of a peritoneal sac or preperitoneal fat
Asymptomatic bulge most common
Hernia risk is related to visceral obstruction or strangulation
Tension-free repair with mesh produces lowest recurrence rates
An abdominal wall hernia is a fascial defect that allows protrusion of a peritoneal sac or preperitoneal fat through it. The most common presentation is the asymptomatic bulge. Hernias cause concern because of the risk for visceral obstruction or strangulation. Repair is best performed by accepting the fascial defect and covering it with mesh, rather than reproducing tissue tension to close the defect. A tension-free repair with mesh has the lowest rate of recurrence.