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04
INGUINAL HERNIA Feb. 18, 2016
Dr. Leyson

Canal begins on posterior abdominal wall where spermatic cord


OUTLINE passes through deep (internal) inguinal ring, a hiatus in transversalis
fascia
I. Introduction Canal concludes medially at superficial (external) inguinal ring, point
which spermatic cord crosses defect in external oblique aponeurosis.
A. History
Directed obliquely, inferomedially, through the inferior part of the
B. Anatomy anterolateral abdominal wall
C. Pathophysiology Lies parallel and 2-4 cm superior to the medial half of the inguinal
II. Diagnosis ligament
A. History Boundaries of inguinal canal
B. Physical Examination o Anterior
C. Imaging Aponeurosis of the external oblique muscle
III. Treatment More laterally, the internal oblique muscle
o Posterior
A. Open Approach
Lateral aponeurosis of the transersus abdominis
B. Laparoscopic Approach muscle and transversalis fascia
C. Prosthesis Considerations Posterior wall of transversalis fascia only
IV. Complications Medially the posterior wall is reinforced by the internal
A. Hernia Recurrence oblique aponeurosis
B. Pain o Superior: Arched fibers of the lower edge of the internal
oblique and by the transversus abdominis muscle and
C. Cord and Testes Injury
aponeurosis
D. Laparoscopic Complications o Inferior: Inguinal ligament (Pouparts) and lacunar
E. Hematomas and Seromas (Gimbernat) ligament
V. Outcomes The inguinal canal openings:
o The deep (internal) inguinal ring
** The whole trans is based on Schwartz Principles 9th and 10th ed, because The entrance to the inguinal canal
according to Dra. Leyson, mas prefer niya si 9th kesa kay 10th and sa Schwartz It is the site of an outpouching of the transversalis fascia
naman siya magbe-base ng questions. Italicized, not bold texts included in the Approximately 1.25 cm superior to the middle of the inguinal
lecture, either from 9th or 10th ed. Italicized + bold texts - found in 9th and 10th , ligament
included in the lecture. Red text included in the lecture, not found on the book
Inverted V or U shaped normal defect in the transversalis
fascia
INTRODUCTION
The arms of the ^, anterior and posterior, are a special
Inguinal hernia repair is the most commonly performed operation in thickening of the transversalis fascia, forming a sling
US Inferior border is formed by another thickening of the
Approximately 75% of abdominal wall hernias occur in the groin transversalis fasciathe iliopubic tractwhich is not always
Inguinal hernia repairs, 90% are performed in men and 10% in very aponeurotic
women o The superficial, or external inguinal ring
70% of femoral hernia repairs are performed in women The exit from the inguinal canal
o Inguinal hernias are five times more common than femoral Is a slit-like opening between the diagonal fibers of the
hernias aponeurosis of the external oblique
The most common subtype of groin hernia in men and women is the External ring (superficial) borders
indirect inguinal hernia o Triangular opening of the aponeurosis of the external oblique
Quality of life and avoidance of chronic pain are the most important o Superior cura is formed by the aponeurosis of the external
considerations in hernia repair oblique itself
o Medial crus is attached to the lateral border of the rectus sheath
HISTORY and to the tendon of the rectus sheath abdominis muscle
Early management involve routine excision of the testicle and o Inferior cura is formed by the inguinal ligament
wounds were closed with cauterization or left to granulate on their o Lateral crus is attached to the pubic tubercle\
own Spermatic cord, which is enveloped in 3 layers, traverses inguinal
Before advent of asceptic technique, mortality and recurrence is high canal and contains:
Bassini (1844-1924)- transformed inguinal hernia repair with minimal o Three arteries
morbidity o Three veins
McVay and Shouldice repairs - modification of Bassini repair o Two nerves
Desarda operation- modern variation of inguinal repairs o Pampiniform venous plexus
Lichtenstein (1980) tension-free repair; tissue-based repair and o Vas deferens
use of prosthetic material for inguinal floor reconstruction; (Lecture version)
reproducible regardless of hernia size and type Contents are:
o Superior to previous tissue-based repair in that mesh could o Vas deferens and its artery
restore the strength of the transversalis fascia, thereby avoiding o Testicular artery and venous (pampiniform) plexus
tension in the defect closure o The genital branch of the genitofemoral nerve
Laparoscopic inguinal hernia repair- minimizes postoperative pain o Lymphatic vessels and sympathetic nerve fibers
and improves recovery o Fat and connective tissue surrounding the cord and its coverings
Refinements of techniques have led to the development of in vrious amounts
o Intraperitoneal onlay mesh Ilioinguinal nerve
o Transabdominal preperitoneal (TAPP) repair Ilioinguinal lymph node
o Totally extraperitoneal (TEP) repair The key to remember is three:
o Three layers of fasciae, three arteries, three veins, three nerves,
ANATOMY as well as multiple lymphatics and one duct.
Inguinal canal is approx. 4 to 6cm cone shape in anterior portion Surrounding inguinal canal:
of pelvic basin o Iliopubic tract

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TRANSCRIBERS: Sarjery Trans Peeps
Inguinal Hernia

o Lacunar ligament Borders of femoral ring:


o Coopers ligament o Anterior: Iliopubic tract and inguinal ligament
o Conjoined tendon o Posterior: Coopers ligament
Iliopubic tract o Medial: Lacunar ligament
o An aponeurotic band o Lateral: Femoral vein
o Begins at ASIS and inserts to Cooper ligament from above
o Forms on the deep inferior margin of transversus
abdominis and transversalis fascia
o Helps form inferior margin of internal inguinal ring
o Continues as anteromedial border of femoral canal
o Combination of transversus abdominis aponeurosis,
transversalis fascia, lateral edge of the rectus sheath and
internal oblique muscle and fibers
Shelving edge - connects iliopubic tract to inguinal ligament
Lacunar ligament or ligament of Gimbernat - triangular fanning
of inguinal ligament as it joins pubic tubercle
o A triangular extension of the inguinal ligament before its
insertion upon the pubic tubercle
o Never forms the medial border of the normal femoral canal
o Situated 4-15 mm medial to the femoral ring
Coopers (pectineal) ligament - lateral portion of the lacunar ligament
that is fused to the periosteum of the pubic tubercle
o Periosteum of the pectineal line
o Insertion of the iliopuboc tract from above the priosteum
o Insertion of the lacunar ligament from below to the periosteum Nyhus classification-categorizes hernia defects by location, size and
o Origin of the pectineus tendon from below type
Conjoined tendon - fusion of inferio fibers of internal oblique and
transversus abdominis aponeurosis at point of insertion in pubic
tubercle
o The conjoined tendon does not exist (McVay)
Layers of the Abdominal Wall in the Inguinal Region
o Skin
o Subcutaneous fascia
o Innominate fascia (Gallaudet)
o External oblique aponeurosis
o Spermatic cord
o Transversus abdominis muscle and aponeurosis, internal
oblique muscle
o Anterior lamina of transversalis fascia
o Posterior lamina of transversalis fascia
o Preperitoneal connective tissue with fat
o Peritoneum
Indirect hernias - protrude lateral to inferior epigastric vessels
through deep inguinal ring
o Most common form of hernia and its usually congenital due to
patent processus vaginalis
Direct hernia - protrude medial to inferior epigastric vessels within
Hasselbachs triangle
o Usually acquired occur in old men with weak abdominal muscles
Borders of Hasselbachs triangle:
o Inferiolateral: Inguinal ligament
o Medial: Lateral edge of rectus sheath
o Superolateral: Inferior epigastric vessels
o Is defined as having the inferior (deep) epigastric vessels as its
superior and lateral border

Laparoscopic approach of hernia repair - posterior perspective to


peritoneal and preperitoneal spaces
Posterior prospective allows visualization of myopectineal orifice of
Fruchaud weak portion divided by inguinal ligament)
o Fruchaud believed that all hernias of the groin begin within the
groin
o Superior: Arch of internal oblique muscle and transversus
abdominis muscle
o Lateal: iliopsoas muscle
o Medial: lateral border of rectus muscle and its anterior
lamina
o Inferior: pubic pectineus
Femoral hernias protrude through small and inflexible femoral ring

TRANSCRIBERS: Sarjery Trans Peeps Page 2 of 17


Inguinal Hernia

o Somatic sensation of skin in upper and medial thigh


o Innervates base of penis and upper scrotum
o Innervates mons pubis and labium majus
Iliohypogastric nerve- from T12-L1
o Pierces abdominal wall
o Courses between internal oblique and transversus abdominis,
supplying both
o Divides into lateral and anterior cutaneous branches
Common variant is hypogastric and ilioinguinal nerves exit superficial
inguinal ring as single entity
Genitofemoral nerve- from L1-L2
o Along retroperitoneum
o Emerges on anterior aspect of psoas
o Divides into genital and femoral branches
Anatomy of the groin region from the posterior perspective o Genital branch enters inguinal canal and courses ventral to iliac
vessels and iliopubic tract.
o Males: Travels through the superficial inguinal ring and supplies
the ipsilateral scrotum and cremaster muscle
o Females: Supplies the ipsilateral mons pubis and labium majus
Femoral branch
o Courses along the femoral sheath
o Supplies the skin of the upper anterior thigh
Lateral femoral cutaneous nerve
o Arises from L2L3
o Emerges lateral to the psoas muscle at the level of L4
o Crosses the iliacus muscle obliquely toward the anterior
superior iliac spine
o It then passes inferior to the inguinal ligament where it divides
to supply the lateral thigh
Posterior view of the myopectineal orifice of Fruchaud

Intraperitoneal points of reference:


o Five Peritoneal folds
o Bladder
o Inferior epigastric vessels
o Psoas

Retroperitoneal view of major inguinal nerves and their courses

Posterior view of intraperitoneal folds and associated fossa

Bogros (preperitoneal) space - between peritoneum and posterior


lamina of transversalis fascia
o Contains preperitoneal fat and areolar tissue
Space of Retzius - most medial aspect of preperitoneal space,
superior to the baldder
Vascular space - between posterior and anterior lamina of
transversalis fascia and houses inferior epigastric vessels
Inferior epigastric artery supplies rectus abdominis
o From external iliac artery
o Anastomose with superior epigastric, continuation of internal
thoracic artery
Epigastric veins - course parallel to arteries within rectus sheath,
posterior to rectus muscle
Inferior epigastric vessels deep in location; revealed by inspection
of the internal inguinal ring
Ilioinguinal and iliohypogastric nerves arise from first lumbar nerve
(L1)
Ilioinguinal nerve - from lateral border of psoas major and pass
obliquely across quadratus lumborum Anterior view of the five major nerves of the inguinal region
o Pierces, at point just medial to the ASIS, transversus and
internal oblique to enter inguinal canal and exits in superficial
inguinal ring

TRANSCRIBERS: Sarjery Trans Peeps Page 3 of 17


Inguinal Hernia

Lateral: vessels of the spermatic cord


o Contents: external iliac vessels, deep circumflex iliac vein,
femoral nerve, and genital branch of the genitofemoral
nerve
o These anatomic entities meet at the deep inguinal ring
Triangle of pain
o Bordered by the iliopubic tract inferolaterally and gonadal
vessels superiorly
o It encompasses the lateral femoral cutaneous, femoral
branch of the genitofemoral, and femoral nerves
Circle of death
o Vascular continuation formed by the common iliac, internal
iliac, obturator, inferior epigastric, and external iliac
vessels
Nerve supply of the inguinal area o The venous counterparts are similar in name, course, and
position

Nerve supply in the inguinal area

Borders and contents of the (A) triangle of doom and (B) triangle of pain.

Circle of Death

PATHOPHYSIOLOGY
A hernia is a protrusion of a viscus or part of a viscus through an
Sensory dermatomes of the major nerves in the groin
abnormal opening in the walls of its containing cavity
Inguinal hernias may be congenital or acquired
Important anatomic areas in laparoscopic hernia repair Most adult inguinal hernias acquired defects in the abdominal wall
o Triangle of doom o Although collagen studies have demonstrated a heritable
o Triangle of pain predisposition
o Circle of death Best-characterized risk factor in inguinal hernia formation
Triangle of doom o Weakness in the abdominal wall musculature
o Borders
Medial: vas deferens

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Inguinal Hernia

o However, a patent processus does not necessarily indicate an


inguinal hernia
Presence of a PPV likely predisposes a patient to the development
of an inguinal hernia
o Depends on the presence of other risk factors such as inherent
tissue weakness, family history, and strenuous activity
Repeated physical exertion may intra-abdominal pressure
o However, whether this process occurs in combination with a
PPV or through age-related weakness of abdominal wall
musculature is unknown
Positive family history was associated with an 8-fold lifetime
incidence of inguinal hernia
COPD significantly the risk of direct inguinal hernias
o As it is accompanied by repeated episodes of high intra-
abdominal pressure
Several studies have suggested a protective effect of obesity
o The risk of inguinal hernia development in obese men was only
50% that of normal weight males
o The risk in overweight males was 80% that of non-obese men
o A possible explanation is the increased difficulty in detecting
inguinal hernias in obese individuals
Microscopic examination of skin of inguinal hernia patients
demonstrated significantly ratios of type I to type III collagen
Type III collagen
o Does not contribute to wound tensile strength as significantly as
type I collagen
Additional analyses revealed disaggregated collagen tracts with
collagen fiber density in hernia patients skin
Recent studies have found an association between concentrations
of extracellular matrix elements and hernia formation

Congenital hernias
o Make up the majority of pediatric hernias
o Can be considered an impedance of normal development,
rather than an acquired weakness
o Normal course of development

The testes descend from the intra-abdominal


space into the scrotum in the 3rd trimester

Their descent is preceded by the


gubernaculum and a diverticulum of
peritoneum

These protrude through the inguinal canal


and becomes the processus vaginalis

Between 36 and 40 weeks of gestation:


Processus vaginalis closes and eliminates
the peritoneal opening at the internal
inguinal ring

o Failure of the peritoneum to close results in a patent processus


vaginalis (PPV)
Hence the high incidence of indirect inguinal hernias in
preterm babies
Children with congenital indirect inguinal hernias will present
with a PPV Varying degrees of closure of the processus vaginalis
(PV). A. Closed PV. B. Minimally patent PV. C. Moderately patent PV. D.
Scrotal hernia

TRANSCRIBERS: Sarjery Trans Peeps Page 5 of 17


Inguinal Hernia

DIAGNOSIS
HISTORY
Inguinal hernia presentation range from incidental discovery to
surgical emergencies such as incarceration and strangulation of the
hernia sac contents
Patients who present with a symptomatic groin hernia will frequently
report groin pain
Extrainguinal symptoms (change in bowel habits or urinary
symptoms) are less common
Inguinal hernias may compress adjacent nerves, leading to
o Generalized pressure
o Localized sharp pain
o Referred pain
Pressure or heaviness in the groin
o Common complaint
o Especially at the end of the day or following prolonged activity
Sharp pain
o Tends to indicate an impinged nerve
o May not be related to the extent of physical activity performed Examination of the contralateral side
by the patient o Compare the presence and extent of herniation between
Neurogenic pain sides
o May be referred to the scrotum, testicle, or inner thigh o Useful in the case of a small hernia
Questions should be directed to Inguinal occlusion test
o Elicit and characterize extrainguinal symptoms o Used to differentiate between direct and indirect hernias
o Characterize whether the hernia is reducible o Entails the examiner blocking the internal inguinal ring with a
Change in bowel habits or urinary symptoms finger as the patient is instructed to cough
o May indicate a sliding hernia consisting of intestinal contents or Indirect Hernia Direct Hernia
involvement of the bladder within the hernia sac Controlled impulse Persistent herniation
Important considerations of the patients history Transmission of the Impulse palpated on
o Duration of symptoms cough impulse to the the dorsum of the
o Timing of symptoms tip of the finger finger
Hernias will often in size and content over a protracted time
Much less commonly, a patient will present with a history of acute When results of PE are compared against operative findings
inguinal herniation following a strenuous activity o There is a probability somewhat higher than chance (i.e., 50%)
o It is more likely that an asymptomatic inguinal hernia became of correctly diagnosing the type of hernia
evident once the patient experienced symptoms after an acute o These tests should be used to detect hernias, but not to
event diagnose hernia types
Patients will often reduce the hernia by pushing the contents back External groin anatomy is difficult to assess in obese patients,
into the abdomen making the physical diagnosis of inguinal hernia challenging.
o Providing temporary relief o A further challenge to the PE is the identification of a femoral
As the defect size and more intra-abdominal contents fill the hernia hernia.
sac o Femoral hernias should be palpable below the inguinal ligament,
o Hernia may become harder to reduce lateral to the pubic tubercle.
Age (young vs. old) o In obese patients, a femoral hernia may be missed or
misdiagnosed as a hernia of the inguinal canal.
Occupation (nature?)
Local Symptoms: Swelling, discomfort and pain In contrast, a prominent inguinal fat pad in a thin patient, otherwise
known as a femoral pseudohernia, may prompt an erroneous
Systemic symptoms: if there is obstruction or strangulation
diagnosis of femoral hernia.
Precipitating Factors

PHYSICAL EXAMINATION
PE is essential to the diagnosis of inguinal hernia
Asymptomatic hernias
o Frequently diagnosed incidentally on PE
o May be brought to the patients attention as an abnormal bulge
Patient should be examined in a standing position to increase
intra-abdominal pressure, with the groin and scrotum fully
exposed
Inspection is performed first
o Goal: Identify an abnormal bulge along the groin or within
the scrotum
o If an obvious bulge is not detected
Palpation is performed to confirm the presence of the
hernia
Palpation
o Performed by advancing the index finger through the
scrotum toward the external inguinal ring
Allows the inguinal canal to be explored
o Patient is then asked to perform Valsalvas maneuver to
protrude the hernia contents
Reveal an abnormal bulge
Allow the clinician to determine whether the hernia is
reducible or not

TRANSCRIBERS: Sarjery Trans Peeps Page 6 of 17


Inguinal Hernia

IMAGING o As a result, nonoperative management is an appropriate


In the case of an ambiguous diagnosis, radiologic investigations may consideration in minimally symptomatic patients.
be used as an adjunct to history and physical examination. No difference in intent-to-treat outcomes, quality of life, or cost-
Imaging in obvious cases is unnecessary and costly. effectiveness between nonoperative management and elective
o The most common radiologic modalities include repair among healthy inguinal hernia patients.
ultrasonography (US), computed tomography (CT), and A 2012 systematic review found that 72% of asymptomatic inguinal
magnetic resonance imaging (MRI). hernia patients developed symptoms (mostly pain) and had surgical
Each technique has certain advantages over physical examination repair within 7.5 years of diagnosis.
alone; however, each modality is associated with potential o Nevertheless, the complication rates of immediate and delayed
limitations. elective tension-free repair are equivalent.
US is the least invasive technique and does not impart any radiation A nonoperative strategy is safe for minimally symptomatic inguinal
to the patient. hernia patients, and it does not increase the risk of developing hernia
Anatomic structures can be more easily identified by the presence of complications.
bony landmarks; Nonoperative inguinal hernia treatment targets:
o However, because there are few bones in the inguinal canal, o Pain
other structures such as the inferior epigastric vessels are used o Pressure
to define groin anatomy. o Protrusion of abdominal contents in the symptomatic patient
Positive intra-abdominal pressure is used to elicit the herniation of population.
abdominal contents. The recumbent position aids in hernia reduction via the effects of
o Movement of these contents through the canal is essential to gravity and a relaxed abdominal wall.
making the diagnosis with US, and lack of this movement may Trusses externally confine hernias to a reduced state and
lead to a false-negative result. intermittently relieve symptoms in up to 65% of patients
A recent meta-analysis demonstrated that US detects inguinal hernia o However, they do not prevent complications
with a sensitivity of 86% and specificity of 77%. o May be associated with an increased rate of incarceration.
In thin patients, normal movement of the spermatic cord and Gradual enlargement of the abdominal wall defect facilitates
posterior abdominal wall against the anterior abdominal wall may spontaneous reduction of hernia contents.
lead to false-positive diagnoses of hernia. o The sheer volume of protruding tissue in an inguinal hernia does
CT and MRI provide static images that are able to: not necessarily signify severe morbidity.
o delineate groin anatomy Femoral and symptomatic inguinal hernias carry higher complication
o detect groin hernias risks, and so surgical repair is performed earlier for these patients.
o exclude potentially confounding diagnoses Swedish Hernia Registry demonstrate that emergent operation is
associated with a sevenfold increase in all-cause mortality over that
of elective surgery among 107,838 groin hernia repairs.
o For this reason, it is recommended that femoral hernias and
symptomatic inguinal hernias be electively repaired, when
possible.
The administration of preoperative prophylactic antibiotics in elective
inguinal hernia repair remains controversial.
Overall wound infection rates are higher than those expected for
clean operations, and there was a significant reduction in the rate of
wound infection among patients undergoing repair with a prosthetic
mesh.
o Although there is no universal guideline regarding the
administration of prophylactic antibiotics for open elective hernia
repair, it is our experience that meticulous perioperative protocol
and surgical technique are more reliable countermeasures to
prevent wound infection than antibiotics.
A meta-analysis determined that standard CT detects inguinal hernia Nevertheless, data trends and quality improvement measures have
with a sensitivity of 80% and specificity of 65%. resulted in routine administration of prophylactic perioperative
Although direct herniography has a higher sensitivity and specificity antibiotics in inguinal hernia repairs.
than CT, its invasiveness and limited availability restrict its routine Incarceration occurs when hernia contents fail to reduce; however, a
use.20 minimally symptomatic, chronically incarcerated hernia may also be
As CT imaging increases in resolution, its sensitivity in detecting treated nonoperatively.
inguinal hernia is expected to expand; however, this has yet to be Taxis should be attempted for incarcerated hernias without sequelae
clinically confirmed by surgical correlation. of strangulation, and the option of surgical repair should be
When used to diagnose inguinal hernia, MRI is frequently reserved discussed prior to the maneuver.
for cases where physical examination detects a groin bulge, but o To perform taxis, analgesics and light sedatives are
where US is inconclusive. administered, and the patient is placed in the Trendelenburg
In a 1999 study of 41 patients with clinical findings of inguinal hernia, position.
laparoscopy revealed that MRI was an effective diagnostic test, with o The hernia sac is elongated with both hands, and the contents
a sensitivity of 95% and specificity of 96%. are compressed in a milking fashion to ease their reduction into
MRI has become more sophisticated since 1999; however, its high the abdomen.
cost and limited access remain obstacles to more routine use. The indication for emergent inguinal hernia repair is impending
compromise of intestinal contents.
TREATMENT o As such, strangulation of hernia contents is a surgical
Surgical repair is the definitive treatment of inguinal hernias; emergency.
however, operation is not necessary in a subset of patients. o Clinical signs that indicate strangulation include:
o When the patients medical condition confers an unacceptable Fever
level of operative risk, elective surgery should be deferred until Leukocytosis
the condition resolves hemodynamic instability
o Operations reserved for life threatening emergencies. The hernia bulge is usually warm and tender, and the overlying skin
Rates of incarceration and strangulation are low in the asymptomatic may be erythematous or discolored.
population. Symptoms of bowel obstruction in patients with sliding or
incarcerated inguinal hernias may also indicate strangulation.

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Inguinal Hernia

o Taxis should not be performed when strangulation is suspected, o The iliohypogastric and ilioinguinal nerves are identified and
as reduction of potentially gangrenous tissue into the abdomen preserved.
may result in an intra-abdominal catastrophe. o Effort should be made to avoid removing nerves from their
o Preoperatively, the patient should receive fluid resuscitation, natural bed and disrupting the protective investing fascia.
nasogastric decompression, and prophylactic intravenous o The pubic tubercle is identified and the cord structures are
antibiotics. atraumatically dissected off of the pubis, encircled, and elevated
with a Penrose drain.
OPEN APPROACH o The cord is elevated 2 cm over the pubic symphysis in an
Open inguinal hernia repairs are subdivided into: avascular plane, and cremasteric fibers are preserved to avoid
o techniques that employ prostheses to create a tension-free injuring cord structures
repair
o those that reconstruct the inguinal floor using native tissue.
Tissue repairs are indicated when the use of prosthetic material is
contraindicated, (contamination or strangulation).
The option to administer locoregional anesthesia is an advantage of
the open approach.
o Common anesthetic agents include lidocaine or the longer-
acting bupivacaine, both with the option of adding epinephrine.
In advance of the initial incision, a field block or ilioinguinal nerve
block may be employed.
A regional block is an option for patients who cannot tolerate general
anesthesia, and it exerts a broader effect than local anesthesia
alone.
Exposure of the anterior inguinal region is common to the open
approaches.
An oblique or horizontal incision is performed over the groin

An indirect hernia sac will generally be found on the anterolateral


surface of the spermatic cord after division of the cremasteric muscle
in the direction of its fibers.
The genital nerve is visualized along the inferolateral surface of the
cord adjacent to the external spermatic vein.
The floor of the inguinal canal is fully assessed for direct hernias.
o If a hernia is not visualized upon entry into the inguinal canal,
the preperitoneal space should be explored for a femoral hernia.
In addition to sac identification, the vas deferens and vessels of the
spermatic cord must be identified to allow dissection of the sac from
the cord.
o At the leading edge of the sac, the two layers of peritoneum will
fold upon themselves and reveal a white edge, which may help
in the identification of the sac.
The sac can then be grasped with a tissue forceps and bluntly
dissected from the cord. The dissection is carried proximally toward
the deep inguinal ring.
In cases where the viability of sac contents is in question, the sac
should be incised, and hernia contents should be evaluated for signs
of ischemia.
The defect should be enlarged to augment blood flow to the sac
contents.
Viable contents may be reduced into the peritoneal cavity
o Nonviable contents should be resected, and synthetic
Layers of the abdominal wall in the anterior open approach to hernia repair. B. prostheses should be avoided in the repair.
Identification of indirect and direct hernia,sacs with retraction of the spermatic In elective cases, the sac may be:
cord and ilioinguinal nerve o amputated at the internal inguinal ring
o or inverted into the preperitoneum.
o The incision begins two fingerbreadths inferior and medial to the o **Both methods are effective; however, patients undergoing sac
anterior superior iliac spine. excision had significantly increased postoperative pain in a
o It is then extended medially for approximately 6 to 8 cm. prospective trial.
o The subcutaneous tissue is dissected using electrocautery.
Dissection of a densely adherent sac may result in injury to cord
o Scarpas fascia is divided to expose the external oblique
structures and should be avoided;
aponeurosis.
o however, sac ligation at the internal inguinal ring is necessary in
o A small incision is made in the external oblique aponeurosis
these cases.
parallel to the direction of the muscle fibers.
A hernia sac that extends into the scrotum may require division within
o Metzenbaum scissors are introduced and spread beneath the
the inguinal canal, as extensive dissection and reduction risks injury
fibers to separate adhesions to the underlying ilioinguinal nerve.
to the pampiniform plexus, resulting in testicular atrophy and orchitis.
o The scissors are then used to incise the aponeurosis superior to
o At this point, the inguinal canal is reconstructed, either with
the inguinal ligament, splitting the external inguinal ring.
native tissue or with prostheses.
The flaps of the external oblique aponeurosis are elevated with
The following sections describe the most commonly performed types
Hemostat clamps.
of tissue-based and prosthetic-based reconstructions.
o The interior oblique fibers are dissected bluntly from the
overlying external oblique flaps.
TISSUE REPAIRS
o Dissection of the inferior flap reveals the shelving edge of the
inguinal ligament. Tissue-based herniorrhaphy is a suitable alternative when prosthetic
materials cannot be used safely.

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Inguinal Hernia

Indications for tissue repairs include: the iliopubic tract - sutured to the lateral edge of the rectus sheath
o operative field contamination using a synthetic, nonabsorbable, monofilament suture at the pubic
o emergency surgery tubercle
o when the viability of hernia contents is uncertain. o the suture progresses laterally, approximating the edge of the
General surgeons should understand inguinal anatomy and possess inferior transversalis flap to the posterior aspect of the superior
the expertise and ability to perform an effective tissue-based repair. flap
o At the internal inguinal ring: suture continues back in the medial
BASSINI REPAIR direction approximate superior transversalis fascia (TA) flap
The Bassini repair was an historic advancement in operative to inguinal ligament
technique. Its current use is limited, as modern techniques reduce o At the pubic tubercle: suture is tied to the tail of the original stitch.
recurrence. Next suture begins at the internal inguinal ring, continues
The original repair includes: medially, apposing the aponeuroses of the IO and TA to the
o dissection of the spermatic cord EO
o dissection of the hernia sac with high ligation o At the pubic tubercle: suture doubles back through the same
o extensive reconstruction of the floor of the inguinal canal structures laterally toward the tightened internal ring
o Division of the cremasteric muscle Lecture version
o High ligation of the hernia sac deep to the internal inguinal First suture line
ring o Starts at pubic tubercle by approximating the iliopubic tract to
the undersurface of the lateral edge of rectus abdominis
o The iliopubic tract, is sutured continuously to the posterior
aspect of the superior flap of the transversalis fascia until the
internal ring is encountered
o At this point, the internal ring has been reconstituted

Second suture line


o Reapproximation of the superior edge of the transversalis
fascia to the inferior fascial margin and the shelving edge of
the inguinal ligament
o The suture is then tied to the tail of the original stitch

Bassini repair. A. The transversalis fascia is opened


B. Reconstruction of the posterior wall by suturing the transversalis fascia
(TF), TAM, IOM medially to the inguinal ligament (IL) laterally. EO = external
oblique aponeurosis.

After exposing the inguinal floor, the transversalis fascia is


incised from the pubic tubercle to the internal inguinal ring.
Preperitoneal fat is bluntly dissected from the upper margin of
the posterior side of the transversalis fascia to permit adequate
tissue mobilization.
A triple-layer repair is then performed.
o To restore integrity of the floor Third suture line
The internal oblique, transversus abdominis, and transversalis o Started at the tightened inguinal ring
fascia are fixed to the shelving edge of the inguinal ligament and o Joining the internal oblique and transversus abdominis
pubic periosteum with interrupted sutures. aponeurosis to external oblique aponeurotic fibers just
The lateral aspect of the repair reinforces the medial border of the superficial to the inguinal ligament
internal inguinal ring.

SHOULDICE REPAIR
The Shouldice repair recapitulates principles of the Bassini repair,
and its distribution of tension over several tissue layers results in
lower recurrence rates
During dissection, the genital branch of the genitofemoral nerve is
routinely divided ipsilateral loss of sensation to the scrotum in men
(mons pubis and labium majus in women)
o posterior inguinal floor exposed incision in the
transversalis fascia between the pubic tubercle and internal
ring
o be careful to avoid injury to preperitoneal structures

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Inguinal Hernia

Fourth suture line o To fix the inferior margin of the mesh: a permanent, synthetic,
o Approximates the internal oblique muscle and transversus monofilament suture is used
abdominis to the band of the interior flap of the external oblique o avoid placing sutures directly into the periosteum of the pubic
aponeurosis superficial and parallel to Puopart ligament tubercle
o Similar and superficial to the third layer o Fixation is continued along the shelving edge of the inguinal
ligament from medial to lateral, ending at the internal ring.
MCVAY REPAIR o The upper tail of the mesh fixed to the internal oblique
addresses both inguinal and femoral ring defects aponeurosis and the medial edge to the rectus sheath using a
indicated for femoral hernias and in cases where the use of synthetic, absorbable suture.
prosthetic material is contraindicated The mesh prosthesis must be large enough to adequately cover the
Once the spermatic cord has been isolated, an incision in the posterior wall of the inguinal canal
transversalis fascia permits entry into the preperitoneal space. upper Current standard for inguinal hernia repair
flap - mobilized by gentle blunt dissection of underlying tissue In femoral hernias: a triangular extension of the inferior aspect of the
o Coopers ligament - dissected to expose its surface. A 2- to 4- mesh is sutured to Coopers ligament medially and to the inguinal
cm relaxing incision is made in the anterior rectus sheath ligament laterally
vertically from the pubic tubercle o The lateral tails of the mesh tailored to fit snugly around the
essential to reduce tension on the repair; however, it may cord at the internal ring (but not too tight to strangulate it) The
result in increased postoperative pain and higher risk of tails are sutured to the inguinal ligament with an interrupted
ventral abdominal herniation stitch and placed beneath the external oblique aponeurosis
o superior transversalis flap - fastened to Coopers ligament;
continued laterally along Coopers ligament to occlude the
femoral ring using either interrupted or continuous suture
o Lateral to the femoral ring, a transition stitch is placed to affix the
transversalis fascia to the inguinal ligament transversalis is
sutured to the inguinal ligament laterally to the internal ring
Uses coopers ligament instead of the inguinal ligament for the
medial portion of the repair
Coopers ligament identifies and is bluntly dissected to expose its
surface
The upper margin of the transversalis fascia is then sutured to
Coopers ligament
Repair is continued laterally along Coopers ligament

PROSTHETIC REPAIRS PLUG AND PATCH TECHNIQUE


Mesh-based hernioplasty - most commonly performed general modification Lichtenstein repair
surgical procedure developed by Gilbert and later popularized by Rutkow and Robbins
Prior to placing the prosthetic mesh patch over the inguinal floor, a
LICHTENSTEIN TENSION-FREE REPAIR three dimensional prosthetic plug is placed in the space previously
expands the domain of the inguinal canal by reinforcing the inguinal occupied by the hernia sac
floor with a prosthetic mesh minimize tension In indirect hernia: plug is placed alongside the spermatic cord
Initial exposure and mobilization of cord structures is identical to through the internal ring
other open approaches For direct hernias: sac is reduced plug is sutured to Coopers
inguinal canal is dissected to expose the shelving edge of the ligament, the inguinal ligament, and IO aponeurosis
inguinal ligament, the pubic tubercle, and sufficient area for mesh Internal ring is therefore reinforced by the leaflets of the patch as well
The mesh is a 7 x 15 cm rectangle with a rounded medial as the plug
Edge, large enough to extend 2 to 3 cm superior to Hesselbachs The plug is fixed to Coopers and the inguinal ligament inferiorly and
triangle. the internal oblique aponeurosis superiorly
o The lateral portion of the mesh is split superior tail Place a mesh over the inguinal floor just like Lichtenstein repair
comprises two thirds of its width, and the inferior tail comprises
the remaining one third
o Medial edge of the mesh is affixed to the anterior rectus sheath
such that it overlaps the pubic tubercle by 1.5 to 2 cm.
o This refinement to the original Lichtenstein technique minimizes
medial recurrence

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Inguinal Hernia

lateral using an absorbable suture.


external ring - reconstructed in close apposition to the spermatic
cord to avoid the appearance of recurrence on future examination
Scarpas fascia and skin are appropriately closed

GIANT PROSTHETIC REINFORCEMENT OF THE VISCERAL SAC


also known as the Stoppa repair
a broad prosthetic mesh is placed in the preperitoneal space from an
anterior approach
In unilateral repair: an 8- to 10-cm Pfannenstiel or low transverse
incision is made above the internal inguinal ring
o The lateral aspect of the rectus sheath and the oblique muscles
are divided along the length of the incision
o The transversalis is incised preperitoneal space is dissected
widely

o The preperitoneal is dissected medially expose Coopers


ligament (or laterally over the iliopubic tract to the anterior
superior iliac spine)
Bilateral hernias: a lower midline incision allows for access and the
preperitoneal dissection spans the entire area between both anterior
superior iliac spines and both inguinal canals
For direct defects: TF sutured to Coopers ligament to obliterate the
sacs laxity
Indirect hernias: require directed dissection from the internal ring
Large or densely adherent indirect hernia sacs are dissected from
the cord at the internal ring and ligated, and the peritoneum is closed
o mesh should be large enough to cover the area from the midline
to 1 cm medial to the anterior superior iliac spine and from the
umbilicus to the pubic symphysis
o middle and lower corners of the mesh are clamped
o mesh is placed flat along the inferior margin of the preperitoneal
space
o medial clamp: directed into the space of Retzius
PROLENE HERNIA SYSTEM (PHS) o middle clamp: placed over the pubic ramus and iliac vessels
provides reinforcement to the anterior and posterior aspects of the lateral clamp: placed into the iliac fossa cover the spermatic
abdominal wall cord
Exposure of the inguinal canal is identical to that of other open o Splitting the mesh may predispose to hernia recurrence. the
approaches mesh may be fixed with interrupted sutures to the anterior
With an indirect hernia: sac is dissected from the spermatic cord, and abdominal wall; (but avoid injuring the lateral femoral cutaneous
the preperitoneal space is bluntly dissected through the internal ring nerve and the inferior epigastric vessels)
With a direct hernia: the transversalis fascia is opened at the defect, bilateral hernias: a single large mesh is placed into the preperitoneal
and the preperitoneal space is bluntly dissected to create space for space using up to eight clamps along its inferior edge transversalis
the mesh is reapproximated and the wound is closed
o The mesh has an underlay flap and an onlay flap, joined by a
short cylindrical connector
o underlay portion of the mesh: placed through the hernia defect
into the preperitoneal space
The advantage of the preperitoneal mesh position: increased intra-
abdominal pressure pushes the mesh into closer apposition to the
abdominal wall
overlay flap reinforces the inguinal floor similar to a tension-free
repair spermatic cord is placed through a slit in the onlay portion
of the mesh
3-4 circumferential interrupted sutures anchor the anterior layer of
the mesh to the inguinal canal floor

WOUND CLOSURE
Once the reconstruction of the inguinal canal is complete, the cord
contents are returned to their anatomic position.
EO aponeurosis reapproximated continuously from medial to

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Inguinal Hernia

TRANSABDOMINAL PREPERITONEAL PROCEDURE


confers the advantage of an intraperitoneal perspective
Indications:
o bilateral hernias
o large hernia defects
o scarring from previous lower abdominal surgery
The abdominal cavity is accessed using a dissecting trocar or open
Hasson technique
o Pneumoperitoneum is instilled to a level of 15 mmHg two 5-
mm trocars are placed lateral and slightly inferior to the umbilical
trocar avoid injury to the inferior epigastric vessels patient
is placed in the Trendelenburg position, pelvis is inspected
bladder, median and medial umbilical ligaments, external iliac,
and inferior epigastric vessels are visualized
o An incision is made in the peritoneum at the medial umbilical
ligament 3 to 4 cm superior to the hernia defect, and it is carried
laterally to the anterior superior iliac spine
For bilateral inguinal hernia repair, bilateral peritoneal incisions are
Giant prosthetic reinforcement of the visceral sac. A. Exposure of the advisable, leaving a midline bridge of tissue to avoid injuring a
preperitoneal space. B. Dissection of the hernia sac from the spermatic cord. potential patent urachus
C. Reduction of the sac and elevation of the cord. D. Orientation and o inferior edge of incised peritoneum is retracted preperitoneum
placement of the giant mesh is dissected to expose the spermatic cord
For direct hernia: sac is inverted and fixed to Coopers ligament to
LAPAROSCOPIC APPROACH prevent development of hematoma or seroma
reinforce the abdominal wall via a posterior approach For indirect hernia: sac will usually protrude anterior to the spermatic
Principal laparoscopic methods: cord sac is grasped and elevated superiorly from the cord
o transabdominal preperitoneal (TAPP) repair space is made for mesh placement sac is dissected from its
o totally extraperitoneal (TEP) repair adhesions cord is skeletonized
o intraperitoneal onlay mesh (IPOM) repair o The mesh usually measures 10 x 15 cm to completely cover
necessitate the administration of general anesthesia and its inherent the myopectineal orifice
risks
Any patient with a contraindication to the use of general anesthesia
should not undergo laparoscopic hernia repair. Occasionally, general
anesthesia induction may result in reduction of an incarcerated or
strangulated inguinal hernia
If the surgeon suspects this might have occurred, the
abdomen should be explored for nonviable tissue either via
laparoscopy or upon conversion to an open laparotomy
indications: similar to those for open repair
laparoscopic approach to bilateral or recurrent inguinal hernias is
superior to the open approach
Concurrent inguinal hernia repair - considered if a hernia patient is
scheduled to undergo another clean laparoscopic procedure, such
as prostatectomy
International Endohernia Society (IEHS) guidelines - offer a Grade A
View of mesh placement in posterior repairs. A large mesh overlaps the
recommendation that TEP and TAPP are preferred alternatives to myopectineal orifice
Lichtenstein repair for recurrent hernias after open anterior repair
The operating room configuration is identical for TAPP, TEP, and o rolled lengthwise and placed through the 12-mm trocar
IPOM procedures o It is unrolled in the preperitoneal space and secured
o Patient is placed in the Trendelenburg position, and video medially to Coopers ligament using a spiral tacker
screens are placed at the foot of the bed During this fixation, the surgeon palpates the end of the tacker
o Surgeon stands contralateral to the hernia, and the assistant from the abdominal surface to ensure its proper angle and to
stands opposite the surgeon stabilize the pelvis mesh is fixed lateral to the anterior
o The patients arms are tucked to the sides superior iliac spine
o Tacks are placed above the iliopubic tract to avoid injury to the
lateral cutaneous nerve of the thigh and the femoral branch of
the genitofemoral nerve
o The peritoneal edges reapproximated using tacks or
intracorporeal sutures as the mesh is stabilized
o The peritoneum closed to avoid contact between the mesh and
the intestine abdomen is desufflated, trocars removed
fascial defect of the 12-mm port and the skin incisions are closed
Lecture Version
12-mm vertical incision is performed through the umbilicus
Sharp dissection is performed to clear the subcutaneous
attachments around the umbilical ring
Kelly hemostat is then inserted through the umbilical ring and gently
widened to allow placement of a blunt 12-mm trocar
5-mm trocar is then placed in each lower quadrant
Patient is then placed in a Trendelburg posirion and the pelvic
anatomy is inspected:
o Identification of the bladder
Operating room setup for laparoscopic inguinal hernia repair. o Median and medial umbilical ligaments
o External iliac

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Inguinal Hernia

o Inferior epigastric vessels


Peritoneum hernia can then be identified in relation to this anatomy
Peritoneum at the medial umbilical ligament is then grasped and
incised
o The incision should be t least 3 to 4cm above the hernia defect
o To allow placement of a large mesh
o Allow for closure of the peritoneal defect at the conclusion of
the procedure

Trocar placement for totally extraperitoneal repair

INTRAPERITONEAL ONLAY MESH PROCEDURE


Unlike TAPP and TEP, the IPOM procedure permits the posterior
approach without preperitoneal dissection.
This procedure is done in cases where the anterior approach is
unfeasible such as recurrent hernias that are refractory to other
Trocar placement for transabdominal preperitoneal repair approaches or in situation where extensive preperitoneal scarring
would make TEP or TAPP challenging.
TOTAL EXTRAPERITONEAL PROCEDURE Port placement and inguinal hernia identification in IPOM are
The advantage of the TEP repair is the access to the pre-peritoneal identical to TAPP.
space without intraperitoneal infiltration which minimizes the risk of Hernia sac contents are reduced but the sac is not inverted from the
injury to intra-abdominal organs and port site herniation due to an preperitoneal space. The mesh is placed directly over the defect and
iatrogenic defect in the abdominal wall. fixed in place with sutures or spiral tacks.
TEP is indicated for repair of bilateral inguinal hernias or for unilateral o The lateral cutaneous nerve of the thigh and the genitofemoral
hernias when scarring makes the anterior approaching hard. nerve are especially prone to injury because these anchors are
An initial, small horizontal incision is made inferior to the placed through the peritoneum without preperitoneal inspection.
umbilicus. o IPOM may also lead to post-op morbidity, recurrence, and
Subcutaneous tissue is dissected to the level of the anterior reoperation.
rectus sheath; it is then incised lateral to the linea alba.
The rectus muscle is retracted superolaterally, and a dissecting PROSTHESIS CONSIDERATION
balloon is advanced through the incision toward the pubic An ideal mesh should be easy to handle, flexible, strong,
symphysis. immunologically inert, contraction-resistant, infection-resistant, and
Under direct visualization with a 30 laparoscope, the balloon is inexpensive to manufacture.
inflated slowly to bluntly dissect the pre-peritoneal space
The dissecting balloon is replaced with a 12-mm balloon trocar, SYNTHETIC MESH MATERIAL
and pneumopreperitoneum is achieved by insufflation to 15 mmHg. Polypropylene and polyester the most common synthetic prosthetic
A 5-mm trocar is placed suprapubically in the midline, and materials used in hernia repair.
another is placed inferior to the insufflation port o They are permanent and hydrophobic; they promote a local
The patient is placed in the Trendelenburg position, and the inflammatory response that results in cellular infiltration and
operation proceeds in an identical fashion to TAPP. scarring with slight contraction in size.
No modifications are necessary to repair bilateral inguinal hernias In selecting mesh material, the following properties must be
with the TEP approach. considered:
Prior to desufflation, any peritoneal rents should be repaired to o Mesh absorbability
avoid mesh from contacting intraperitoneal structures. o Thickness
After mesh placement, the preperitoneal space is desufflated o Weight
slowly under direct vision to ensure proper mesh positioning. o Porosity
Trocars are removed, and the anterior rectus sheath is closed o Strength
with an interrupted suture Mesh materials can be categorized according to fiber diameter and
fiber count.
o Heavyweight in density
o Lightweight in density
Lightweight materials include -d-glucan, titanium-coated
polypropylene, and polypropylenepoliglecaprone.
They have greater elasticity and less theoretical surface area
contact with surrounding tissues than their heavyweight
counterparts.
These materials are hypothesized to reduce scarring and
chronic pain with equivalent recurrence rates.
The use of lightweight mesh in TEP and TAPP repairs is
associated with fewer 3-month cumulative mesh-related
Balloon dissection of the preperitoneal space in a totally extraperitoneal complications.
inguinal hernia repair When available, lightweight mesh should be considered for all
prosthetic repairs to minimize postoperative chronic pain.
A disadvantage of commercial prostheses is their high cost

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Inguinal Hernia

o Some alternatives are used in prosthetic repairs such as


polypropylene and polyethylene mosquito nets which are
inexpensive and ubiquitous in sub-Saharan Africa and India
o They have similar mechanical properties to commercially
available hernioplasty meshes.

BIOLOGIC MESH
Commonly reserved for contaminated cases or when domain
expansion is necessary in the face of high infection risk.
Generally, they have lower tensile strength and subsequent higher
rates of rupture than synthetic prostheses, and varying degrees of
tensile strength and tissue biocompatibility between them.
In ventral hernia repairs, xenograft material was associated with a
lower rate of recurrence than allograft material.
A review of biologic materials concluded that cross-linked graft
materials are more durable and less prone to failure than noncross-
linked grafts.
Diminished ability to remodel adversely affects rates of infection and
incorporation.

FIXATION TECHNIQUE
Suturing, stapling, and tacking prostheses entail tissue perforation,
which may cause inflammation, neurovascular injury, and chronic
pain development.
Improper prosthesis fixation may result in mesh migration, repair
failure, meshoma, pain, and hernia recurrence.
Mesh may be fixed with fibrin-derived glue, and self-gripping mesh
has been developed to minimize trauma to surrounding tissues and
to reduce the risk for entrapment neuropathy.
For hernias repaired via a strictly preperitoneal approach, prosthesis
fixation may not be necessary at all.
Fibrin glue fixation is a successful alternative to tack fixation in hernia
repair with a synthetic prosthesis.
o Recent studies comparing fibrin glue fixation and suture fixation
in open hernia repair show superior rates of chronic pain with
both Lichtenstein and plug and patch techniques
In TEP repairs, fixation of mesh may not be compulsory.
o A prospective randomized trial comparing fixation and no
fixation in TEP repairs found a significant increase in new pain
and equivalent recurrence rates in the fixation group several
months after repair HERNIA RECURRENCE
In the preperitoneal approach, the re-approximation of surrounding Develops pain, bulging, or a mass at the site of an inguinal hernia
tissues and physiologic intraabdominal pressure, hypothetically, repair, seroma, persistent cord lipoma, and hernia recurrence should
prevent mesh migration. be considered
o Due to higher theoretical risk of mesh migration, repair without Common medical issues associated with recurrence include
fixation is not recommended for anterior or transperitoneal malnutrition, immunosuppression, diabetes, steroid use, and
approaches. smoking
Technical causes of recurrence include improper mesh size, tissue
COMPLICATIONS ischemia, infection, and tension in the reconstruction
Most common complications: As with primary hernias, US, CT, or MRI can elucidate ambiguous
o Bleeding physical findings
o Seroma When a recurrent hernia is discovered and warrants re-operation, an
o wound infection approach through a virgin plane facilitates its dissection and
o urinary retention exposure
o Ileus Extensive dissection of the scarred field and mesh may result in
o injury to adjacent structures injury to cord structures, viscera, large blood vessels, and nerves
Complications specific to herniorrhaphy and hernioplasty: After an initial anterior approach, the posterior laparoscopic
o hernia recurrence approach will usually be easier and more effective than another
o chronic inguinal and pubic pain anterior dissection
o injury to the spermatic cord or testis Conversely, failed preperitoneal repairs should be approached using
an open anterior repair.

PAIN
Pain after inguinal hernia repair is classified into acute or chronic
manifestations of three mechanisms:
o Nociceptive (somatic)
o Neuropathic
o visceral pain
Nociceptive pain - most common.
o usually a result of ligamentous or muscular trauma and
inflammation
o reproduced with abdominal muscle contraction.
o Treatment consists of rest, nonsteroidal anti-inflammatory
drugs (NSAIDs), and reassurance

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Inguinal Hernia

o resolves spontaneously in most cases Lateral femoral cutaneous nerve


Neuropathic pain Formication
o occurs as a result of direct nerve damage or entrapment o Sensation of insects crawling on or under the skin
o may present early or late Neuroctomy
o Manifests as a localized, sharp, burning or tearing o Failure of conservative management
sensation o Nerves were approached using an opne anterior approach
o May respond to pharmacologic therapy and to local steroid o Divided proximally as they pierced the internal oblique muscle
or anesthetic injections when indicated. o Superficial dissection of the quadrates lumborum muscle
Visceral pain o Identification of the proximal portion of the ilioinguinal and
o refers to pain conveyed through afferent autonomic pain iliohypogastric nerves, which are then divided
fibers
o Usually poorly localized and may occur during ejaculation CORD AND TESTIS INJURY
as a result of sympathetic plexus injury Injury to spermatic cord structures may result in ischemic orchitis or
Chronic postoperative pain remains an important measure of clinical testicular atrophy
outcome Spermatic cord and Testes are prone to hematoma formation or
Meticulous nerve identification may prevent injury that results in ischemia with excessive handling
debilitating chronic postoperative pain syndromes Significant scrotal hematoma blue and black discoloration of the
Moderate-to-severe pain adversely affects physical activity, social scrotum
interactions, healthcare utilization, employment, and productivity in o Self-limiting
6% to 8% of patients Ischemic orchitis is likely caused by injury to the pampiniform
Pain in this subset of patients comprises a tremendous individual and plexus and NOT to the testicular artery
societal burden o Usually manifests within 1 week of inguinal hernia repair as
Post-herniorrhaphy inguinodynia is a debilitating chronic an enlarged, indurated, and painful testis, and it is almost
complication caused by a combination of nociceptive, neuropathic, certainly self-limited.
and visceral elements o Occurs in <1% of primary hernia repairs
o Incidence is independent of the method of hernia repair o Emergent orchiectomy is only necessary in the case of
o The original operative technique determines options for necrosis
intervention and remedial surgery o Present with a low-grade fever
o Treatment is based on repair technique, subsequent re- o More commonly shows with an enlarged, indurated, and painful
operations, pain character, and the presence of recurrence, testicle
meshoma, and fixation material. o Likely caused by injury to the pampiniform plexus
Selective ilioinguinal, iliohypogastric, and genitofemoral neurolysis esp. those with large hernias
or neurectomy, remova of mesh and fixation material, and revision of o Reassurance, NSAIDs, and comfort measures are enacted to
the repair are common options for treatment allow self-limited resolution
Anatomic variation and cross-innervation of the inguinal nerves in the o Long-term effects of ischemic orchitis are rare
retroperitoneum and inguinal canal make selective neurectomy less o Ultrasound demonstrate the reduction of testicular blood flow to
reliable help determine whether it is testicular ischemia or necrosis
When inguinodynia is refractory to pharmacologic and interventional Injury to the testicular artery also may lead to testicular atrophy,
measures, triple neurectomy with removal of meshoma is arguably which is manifest over a protracted period.
the most effective option for the majority o Treatment for ischemic orchitis most frequently consists of
Refractory inguinodynia with concurrent orchialgia also requires reassurance, NSAIDs, and comfort measures
resection of the paravasal nerves o Manifest over a protracted period
Other chronic pain syndromes include local nerve entrapment, o Is not a surgical emergency
meralgia paresthetica, and osteitis pubis o Long-term implications are significant and irreversible
At greatest risk of entrapment are the ilioinguinal and Intraoperatively, proximal ligation of large hernia sacs to avoid cord
iliohypogastric nerves in anterior repairs manipulation minimizes the risk of injury.
Genitofemoral and lateral femoral cutaneous nerves in laparoscopic Injury to the vas deferens within the cord may lead to infertility
repairs o In open inguinal hernia repairs, isolating the vas deferens along
Clinical manifestations of nerve entrapment mimic acute neuropathic with the cord structures using digital manipulation may cause
pain, and they occur with a dermatomal distribution injury or disruption
Injury to the lateral femoral cutaneous nerve results in meralgia o In laparoscopic approach, grasping the vas may result in a crush
paresthetica, characterized by persistent paresthesias of the injury.
lateral thigh o Transections of the vas deferens should be addressed with
o pins and needles sensation over the lateral aspect of the thigh a urologic consult and early anastomosis, if possible.
Initial treatment of nerve entrapment consists of rest, ice, NSAIDs, o One study found prosthetic mesh may exert long-term
physical therapy, and possible local corticosteroid and anesthetic deleterious effects upon the vas deferens, causing azoospermia
injection. o Chronic scarring may lead to vas deferens obstruction,
resulting in decreased fertility rates and a dysejaculation
Osteitis pubis is characterized by inflammation of the pubic
syndrome.
symphysis and usually presents as medial groin or symphyseal pain
that is reproduced by thigh adduction Pain and burning during ejaculation are usually self-limited, and
more common causes, such as sexually transmitted diseases,
Avoiding the pubic periosteum when placing sutures and tacks
should be excluded.
reduces the risk of developing osteitis pubis.
In females, the round ligament is the analog to the spermatic cord,
CT scan or MRI excludes hernia recurrence, and bone scan is
and it maintains uterine anteversion.
confirmatory for the diagnosis
Injury to the artery of the round ligament does not result in clinically
Initial treatment is identical to that of nerve entrapment
significant morbidity.
If pain remains intractable, orthopedic surgery consultation should
be sought for possible bone resection and curettage.
LAPAROSCOPIC COMPLICATIONS
Irrespective of treatment, the condition often takes 6 months to
The risks of the TEP technique mirror those of open anterior repairs,
resolve
as the peritoneal space is not violated.
Sharp localized pains, parasthesias, or numbness over the
Complications of transabdominal laparoscopy include:
cutaneous distribution of the affected nerve
o urinary retention
Ilioinguinal, along with the iliohypogastric nerve, may also become o paralytic ileus
entrapped within the mesh in tension-free repairs o visceral injuries,

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Inguinal Hernia

o vascular injuries o Patient presentation is usually delayed with urine extravasation


o bowel obstruction (less common) through a trocar site or peritonitis
o Hypercapnia o Cystotomies must be repaired in several layers with prolonged
o gas embolism catherization
o Pneumothorax
VASCULAR INJURY
URINARY RETENTION The most severe vascular injuries usually occur in iliac or
General anesthesia - most common cause of urinary retention after femoral vessels, either by misplaced sutures in anterior repairs,
hernia repair or by trocar injury or direct dissection in laparoscopic repairs.
o Routine in laparoscopic hernia repairs o In these cases, exsanguination may be swift.
Other risk factors for postoperative urinary retention include pain, Conversion to an open approach may be necessary, and bleeding
narcotic analgesia, and perioperative bladder distention should be temporarily controlled with mechanical compression until
Initial treatment of urinary retention requires decompression of the vascular control is obtained.
bladder with short-term catheterization The most commonly injured vessels in laparoscopic hernia
Patients will generally require an overnight admission and trial of repair include the inferior epigastrics and external iliacs.
normal voiding before discharge Although apparent upon initial approach, these vessels may be
Failure to void normally requires reinsertion of the catheter for up to obscured during mesh positioning, and tacks or staples may injure
a week them.
Chronic requirement of a urinary catheter is rare, although older Often, due to tamponade effect, injury to the inferior epigastric
patients may require prolonged catheterization. vessels is not apparent until the adjacent trocar is removed.
If injured, the inferior epigastrics may be ligated with a percutaneous
ILEUS AND BOWEL OBSTRUCTION suture passer or endoscopic hemoclips.
The laparoscopic transabdominal approach is associated with If the tissue pressure exerted by pneumoperitoneum is greater than
a higher incidence of ileus than other modes of repair an injured vessels hydrostatic intraluminal pressure, bleeding will
This complication is self-limited not manifest until pneumoperitoneum is released.
It necessitates sustained inpatient observation, intravenous fluid The presentation of an inferior epigastric vein injury is often delayed
maintenance, and possibly nasogastric decompression. because of this effect, and it may result in a significant rectus sheath
Abdominal imaging may be helpful to confirm the diagnosis and to hematoma.
exclude bowel obstruction Accordingly, the surgeon should be aware of this intraoperative
Prolonged absence of bowel function, in conjunction with a consideration.
suspicious abdominal series, should raise concern for obstruction Inferior epigastric
CT of the abdomen is helpful to distinguish anatomic sites of o Usually injured during trocar placement in a TAPP
obstruction, inflammation, and ischemia. o The lateral position of the two accessory trocars may coincide
In TAPP repairs, obstruction occurs most commonly secondary with the course of the inferior epigastrics
to herniation of bowel loops through peritoneal defects or large o Identification of the vessels by direct visualization or
trocar insertion sites transillumation should be performed to minimize the risk
The use of smaller trocars and the preponderance of TEP repairs o May aldo be ligated with use of a percutaneous suture passer
have reduced the frequency of this complication External iliac
True obstruction warrants reoperation o Can be easily identified with minimal dissection
Umbilical trocar site herniation o Immediately inferior to the spermatic cord
Adherence to the implanted prosthesis The surgeon should be wary of the tampinading effects of
Pneumoperitoneum
VISCERAL INJURY
Small bowel, colon, and bladder are at risk for injury in laparoscopic
hernia repair. HEMATOMAS AND SEROMAS
The presence of intra-abdominal adhesions from previous surgeries Hematomas may present as localized collections or as diffuse
may predispose to visceral injuries. bruising over the operative site.
Direct bowel injuries may also result from trocar placement. Injury to spermatic cord vessels may result in a scrotal hematoma.
In re operative abdominal surgery, open Hasson technique and Although they are self-limited, characteristic dark blue discoloration
direct visualization of trocars are recommended to reduce the of the entire scrotum may alarm patients.
likelihood of visceral injury. Intermittent warm and cold compression aids in resolution.
Bowel injury may also occur secondary to electrocautery and Hematomas may also develop in the incision, retroperitoneum,
instrument trauma outside of the camera field. rectus sheath, and peritoneal cavity.
Missed bowel injuries are associated with increased mortality. If The latter three sites are more frequently associated with
injury to the bowel is suspected, its entire length should be examined, laparoscopic repair.
and conversion to open repair may be necessary. Bleeding within the peritoneum or preperitoneal space may not be
Bladder injuries are less common than visceral injuries, and readily apparent on physical examination.
they are usually associated with perioperative bladder For this reason,close monitoring of subjective complaints, vital signs,
distention or extensive dissection of perivesical adhesions. urine output, and physical parameters is necessary.
o As with bladder injuries encountered in open surgery, Seromas are loculated fluid collections that most commonly develop
cystotomies must be repaired in several layers with 1 to 2 weeks within 1 week of synthetic mesh repairs.
of Foley catheter decompression. Large hernia sac remnants may fill with physiologic fluid and mimic
o A confirmatory cystogram may be performed before catheter seromas.
removal to confirm healing of the injury. Patients often mistake seromas for early recurrence.
o Suprapubic trocar placement in a TEP may also lead to bladder Treatment consists of reassurance and warm compression to
injury accelerate resolution.
o Rarely, a patent urachus will be divided during the course of To avoid secondary infection, seromas should not be aspirated
peritoneal flap mobilization in a TAPP unless they cause discomfort or they restrict activity for a prolonged
o Preoperative prophylactic catherization or patient directed time.
bladder emptying may be performed for laprocospic cases
o Which decompresses the bladder and therefore places it away OUTCOMES
from contiguous structures such as Coopers ligament and the The incidence of recurrence is the most-cited measure of
spermatic cord postoperative outcome following inguinal hernia repair.

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Inguinal Hernia

In evaluating the various available techniques, other salient signifiers o Place no restriction on patient function
of outcome include complication rates, operative duration, hospital o Simple and inexpensive to manufacture
stay, and quality of life. o Common brand names:
Among tissue repairs, the Shouldice operation is the most commonly Marlex (Davol, Cranston, RI)
performed technique, and it is most frequently executed at Prolene (Ethicon, Somerville, NJ)
specialized centers. ProLite (Covidien, Norwalk, Conn)
In experienced hands, the overall recurrence rate for the Shouldice
repair is about 1%. SPORTS HERNIA
o Although it is an elegant procedure, its meticulous nature Occult hernias
requires significant technical expertise to achieve favorable Sportmans hernia or athletic pubalgia
outcomes, and it is associated with longer operative duration Commonly seen in athletes that perform repetitive kicking, or
and longer hospital stay. turning, as in hockey, soccer, and football
Hernia recurrence is drastically reduced as a result of the o Which results in a weakness or tearing of the posterior
Lichtenstein tension-free repair inguinal wall
Compared with open elective tissue-based repairs, mesh repair is A similar abrupt motion in a non-athlete also may lead to this
associated with fewer recurrences (OR 0.37, CI 0.260.51) and with condition
shorter hospital stay and faster return to usual activities. In a multi- Presentation:
institutional series, 3019 inguinal hernias were repaired using the o May be acute, but more often, the deep groin pain
Lichtenstein technique, with an overall recurrence rate of 0.2%. o Presents in an insidious manner
Among other tension-free repairs, the Lichtenstein technique o Gradually worsening with increasing activity
remains the most commonly performed procedure worldwide. o Pain is aggravated by movements and sudden increases in
The Stoppa technique results in longer operative duration than the intra-abdominal pressure from coughing or sneezing
Lichtenstein technique. with an overall recurrence rate of 0.2%. o Present with tenderness to palpation over the pubic bone
Among other tension-free repairs, the Lichtenstein technique and inguinal canal
remains the most commonly performed procedure worldwide. Initial treatment of a sports hernia is conservative
The Stoppa technique results in longer operative duration than the o Rest
Lichtenstein technique. o NSAIDs
o Nevertheless, postoperative acute pain, chronic pain, and o Deep tissue massage
recurrence rates are similar between the two methods. o Physiotherapy
Perhaps the most compelling advantage of the Lichtenstein o Should the pain return upon gradual return to normal
technique is that non expert surgeons rapidly achieve similar activities after 6 to 8 weeks of conservative management,
outcomes to their expert counterparts. surgical exploration is necessary
Guidelines issued by the European Hernia Society recommend the Inguinal Exploration
Lichtenstein repair for adults with either unilateral or bilateral inguinal Fully assess the internal and external oblique
hernias as the preferred open technique. musculature and aponeuroses, inguinal rings,
Compared to open approaches, laparoscopic primary inguinal hernia ligaments and tendons, and pubic tubercle
repair produces equivalent recurrence rates and improved recovery Repair of the posterior floor by open laparoscopic
time, pain prevention, and return to normal activities. approach is
Because laparoscopic surgery requires specialized instruments and currently an effective strategy
longer operative times, its cost is higher than conventional open
repair; however, the potential financial benefit of shorter recovery PEDIATRIC HERNIA
and decreased pain may offset these costs in the long term. 0.8 and 44% incidence
Perhaps the most salient difference between open and laparoscopic With 10-fold increased incidence in boys vs. girls
techniques is the number of cases needed to develop technical Right-sided hernias are more common than left-sided hernias
proficiency. Approximately 10% of hernias presenting as bilateral
The frequency with which the above inguinal hernia repair Differential diagnosis
techniques are performed reinforces the importance of broad Undescended testes
experience. Testicular mass
Repair and 4.9% in those undergoing open repair, and the outcomes Varioceles
of laparoscopic repairs improved after each surgeon performed at Hydrocoeles
least 250 cases. o Hydrocoeles that present at birth do not necessarily
More recently, Lal and colleagues found that surgeons sustained a increase the likelihood that a PPV is present and will
decrease from 9% to 2.9% in postoperative recurrences after resolve on their own
performing 100 TEP operations. o Hydroceoeles that present following birth may be more
Other studies also suggest surgeons develop proficiency in these likely associated with a PPV that will not spontaneously
laparoscopic techniques after performing 30 to 100 cases; however, close
this estimate has decreased precipitously since laparoscopic Must be treated emergently
technique was first introduced. Open approach using a groin incision over the internal ring
In TAPP repair, the risk of intra-abdominal injury is higher than in Dilated internal ring can be repaired using the Marcy techniqu
TEP repair.
A Cochrane systematic review found that rates of port-site hernias Transcribers Note:
and visceral injuries were higher for the TAPP technique, whereas 1. Thanks sa notes from our 2B classmates and
TEP may be associated with a higher rate of conversion to an
sa 2C
alternative approach; however, neither finding was sufficiently
2. We do hope na natulungan kayo ng mga
compelling to recommend one technique over the other. ginawa naming transcriptions and pasensya
po sa mga minor errors
ADDITIONAL (SOURCE, 9TH ED./LECTURE)
3. Konting linggo na lang, kapit lang, magiging
MESH CHOICE
3rd years na tayo. #claimingit
Ideal mesh should be
o Easy to handle
o Provide adequate strength -FIN-
o Inert
o Resist contraction
o Avoid infection

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