Quid Refert, Dummodo non Desinas, Tardius Ire

GENERAL ABDMINAL WALL AND HERNIA

SURGERY DR. MENDOZA

- The entire ligament that you see in the picture, some of

EPIDEMIOLOGY the important anatomic landmark particularly the
iliopubic tract, coopers ligament and blood vessels.
 Inguinal hernias- 75% of all hernias These are the critical structures in hernia repair because
 2/3 indirect, remainder are direct these are the structures that need to be approximated
 Incisional hernias- 15-20% or must be covered by mesh.
 Umbilical and epigastric- 10%
 Femoral- 5% CRITICAL TRIANGLE OF GROIN
- All hernias except internal hernias the basic defect or
component is the same TRAINGLE OF DOOM
- 1. There must be a defect in the fascia  The triangle of doom is bordered by:
- 2. There is a protrusion on that defect  medially by the vas deferens
- 3. It must be contained in an hernia sac  Laterally by the vessels of the spermatic cord.
 Prevalence of hernias increases with age  The contents of the space include
- Subtype of hernia that increases with age are direct external iliac vessels
hernia due to weakening of the abdominal musculature deep circumflex iliac vein
 Most serious complication  strangulation ( 1-3% of groin femoral nerve
hernias ) Genital branch of the genitofemoral nerve.
 Femoral- highest rate of complications 15-20%
- Usually femoral hernias occur in the females but they
are not the most common type of hernia in the females.
The most common type of hernia in female is indirect
hernia
 Dictum for the treatment of hernias
 ALL HERNIAS SHOULD BE REPAIRED AT THE TIME OF
DISCOVERY
- TO PREVENT complications which increases the
morbidity
- This dictum is already challenge because of the new
evidences that are coming up

MYOPECTINEAL ORIFICE OF FRUCHAUD

 Where majority of herniations occur

 Boundaries
 Superior- TAA ( transversus abdominis )
 Lateral- iliopsoas muscle - Located in the triangle of doom is the deep ring which is
 Inferior- pubic ramus where the spermatic cord emerges as it goes down to
the inguinal canal and ends to the scrotum.
 Medial- rectus muscle
- In the deep ring you can see a lot of structures. And if
 The myopectineal orifice is the site of indirect, direct,
the surgeon is not careful in dissection he is “DOOM”
femoral and some interstitial hernias, and it has become the
Hahaha… why because of the major blood vessels
focus of many recent advances in hernia surgery
located in the triangle of doom.
- Arterya corona mortis is the branch of the internal iliac
or obturator artery. In laparoscopic surgery this can be
injured leading to profuse bleeding that’s why this must
be avoided.
TRAINGLE OF PAIN
 The triangle of pain
 is a region bordered by the iliopubic tract and gonadal
vessels
 it encompasses the
lateral femoral cutaneous
femoral branch of the genitofemoral
Femoral nerves.

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 peritoneum Processus vaginalis canal of Nuck

- The problem in the males there is potential site of

herniation in the abdomen because of the descend of
testis.
- In triangle of pain there are nerves that can be injured - The descend of the testis will not go down vertically it
particularly the femoral branch of genitofemoral nerve, will took an oblique course in the process pushing all the
this can be clip transected, accidentally ligated which layers of the abdomen that’s why the scrotum is
can cause debilitating pain. represented by layers of the abdominal wall.
 The circle of death
 is a vascular continuation formed by  Abdominal wall is defined superiorly by costal margins,
the common iliac inferiorly by the symphisis pubis and pelvic bones, posteriorly
internal iliac, obturator by the vertebral column
inferior epigastric  It serves to support and protect abdominal and
External iliac vessels. retroperitoneal structures
 Abdominal wall is anatomically complex, layered structure
GROIN REGION POSTERIOR VIEW with segmentally derived blood supply and innervation
 Mesodermal in origin
 The muscle fibers of the rectus abdominis are arranged
vertically and are encased within aponeurotic sheath, the
anterior and posterior layers of which are fused in the
midline at the linea alba
 The lateral border of the rectus muscle assumes a convex
shape that gives rise to the surface landmark of the linea
semilunaris
 Three tendinous intersections that cross the rectus muscle
 Level of the xyphoid process
 Level of the umbilicus
 Halfway between the xyphoid process and umbilicus
 The external oblique muscle
 runs inferiorly and medially arising from the margins of
the lowest eight ribs and costal cartilages
 originates laterally on the latissimus dorsi and serratus
anterior muscles and iliac crest
 You can see the site of direct and indirect herniation  medially it forms a tendinous aponeurosis 
 Femoral canal- which is one of the potential site of CONTIGUOUS with the anterior rectus sheath
herniation  the inguinal ligament is the inferior most edge of the
 In females hernias is easy to repair because there is no external oblique aponeurosis
structures that is very significant unlike in the males.  the internal oblique muscles
 lies immediately deep to the external oblique muscle
LAYERS OF THE ABDOMEN  arise from the lateral aspect of the inguinal ligament,
iliac crest, and thoracolumbar fascia
ABDOMINAL WALL SPERMATIC CORD  fibers course superiorly and medially forming a
Skin Scrotum tendinous aponeurosis that contributes to both anterior
Campers and Scarpas Fascia Superficial spermatic fascia and posterior rectus sheath
External oblique muscle External spermatic fascia  the lower and inferior most fibers of the internal
Internal oblique muscle Cremasteric muscle oblique course fused with th lower fibers of the
Transversus abdominis -------------------------------------- transversus abdominis muscle  forming the conjoined
Transversalis fascia Internal spermatic fascia area
Pre-peritoneal fat Fat layer  contiguous with the cremasteric muscle in the inguinal

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 canal  significant in the management of inguinal
hernia
 The transversus abdominis muscle is the deepest of the three
lateral muscles and runs transversely from the lowest six ribs,
the lumbosacral fascia, and the iliac crest, to the lateral
border of the rectus abdominis
 Arcuate line
 A.k.a. semicircular line of douglas
 lies roughly at the level of the ASIS
 Above the arcuate line ( anterior rectus sheath )
External oblique aponeurosis
External lamina of the internal oblique aponeurosis
 Above the arcuate line ( posterior rectus sheath)
Internal lamina of internal oblique aponeurosis
Transversus abdominis
 Below the arcuate line ( anterior rectus sheath)
 External oblique aponeurosis
 Laminae of the internal oblique aponeurosis
 Transversus abdominis aponeurosis
 Remember no aponeurotic posterior covering of this lower
portion of rectus muscle
 The main blood supply of anterior abdominal wall comes
from superior and inferior epigastric arteries
 Superior epigastric artery arise from internal thoracic
 Inferior epigastric from external iliac artery
 Lymphatic drainage
 Superficial inguinal
 Axillary areas
 Innervation of anterior abdominal wall
 T6-T12 ( anterior rami of spinal nerves )
Motor nerves to the rectus
Motor nerves to the oblique muscles
Motor nerves to the abdominis muscle
 T4-L1 ( afferent branch )
Skin
 T10 nerve roots
Sensation of the umbilicus
 The clinical significance of this entire ligament is related
surgery. Even though mesh repair is the standard procedure
surgeon still do open technique and in the open technique is
all about anatomy.
INGUINAL CANAL
 between deep and superficial inguinal rings
- the superficial ring a ring before the spermatic cord
enters the scrotum
- The deep ring is within the abdominal cavity. This is the
boundary between peritoneal cavity and the groin.
 Boundaries
 Superficial- External oblique aponeurosis
 Superior- Internal and transversus abdominis
 Inferior- shelving edge of inguinal ligament and lacunar
ligament
 Posterior ( floor) – transversalis fascia and aponeurosis
of transversus abdominis muscle
- The floor is the most important structure because this is
involved in direct inguinal hernia wherein there is
acquired weakening of the inguinal floor.
- This is also the reason why direct hernia is related in
elderly patient because of the presence of fascia and
muscle in which the basic component is collagen
wherein as we age collagen synthesis decreases.

OTHER ANATOMICAL STRUCTURE

 Inguinal ligament
 A.k.a pouparts ligament
 Inferior edge of external oblique muscle
 Lacunar ligament
 A.k.a ligament of limbernat  Contains the spermatic cord ( male) and round ligament of
 Triangular extension of the inguinal ligament before its the uterus ( female)
insertion upon the pubic tubercle - Hernia is easy to repair compared to man because you
 Triangular fanning of the inguinal ligament as it joins the can easily transect the round ligament. It is more
pubic tubercle tedious to repair hernia in the male because you need
 Coopers ligament to protect the cord
 Formed by periosteum and fascia along the superior  Contents of spermatic cord
ramus of the pubis  Cremasteric muscle
 Lateral portion of the lacunar ligament that is fused to  Testicular vessels
the periosteum of the pubic tubercle  Genital branch of genitofemoral nerve
 Only type of hernia that is amenable in using coopers  Vas deferens
ligament is repair of femoral hernia using the MCVAY  Cremasteric vessels
repair.  NERVE SUPPLY TO THE GROIN
 Conjoined tendon  3 nerves are mainly sensory but do supply some of the
 Occur in 5-10% of the population motor function to the internal oblique and cremasteric
 commonly described as the fusion of the inferior fibers msucles
of the internal oblique and transversus abdominis
aponeurosis at thepoint were they insert on the pubic  ILIOHYPOGASTRIC NERVE
th st
tubercle  Arises from the 12 dorsal and 1 lumbar roots emerges
into the groin as it perforates the posterior part of the

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 transversus abdomonis muscle and divides into lateral  vascular space is situated between the posterior and
and anterior cutaneous branches anterior laminae of the transversalis fascia, and it houses the
 Perforates the external oblique muscle about 3 cm inferior epigastric vessels.
above the external ring and provides sensation to the  The inferior epigastric artery supplies the rectus abdominis.
skin of the abdomen above pelvis  Nerves of interest in the inguinal region are the ilioinguinal,
 ILIOINGUINAL NERVE iliohypogastric, genitofemoral, and lateral femoral
 Arise from the first lumbar nerve root cutaneous nerves.
 Pierces the internal oblique muscle and proceeds within  The ilioinguinal and iliohypogastric nerves arise together
the cremasteric fascia following the spermatic cord from the first lumbar nerve (L1).
through the external ring  Ilioinguinal nerve emerges from the lateral border of the
 Provides sensation to the medial area of the thigh, over psoas major and passes obliquely across the quadratus
the base of the penis and upper scrotal area lumborum.
 Genito-femoral nerve  The genitofemoral nerve arises from L1–L2, courses along

st nd
Arises from 1 and 2 lumbar nerves the retroperitoneum, and emerges on the anterior aspect of
 Genital branch perforates the posterior wall near the the psoas. It then divides into genital and femoral branches.
internal ring, then proceeds through the canal in the
lateral bundle of the cremasteric muscle HESSELBACHS TRIANGLE
 Femoral branch passes behind the inguinal ligament and
enters the femoral sheath lateral to the femoral artery  Borders of hesselbachs triangle
 Inferiorly- inguinal ligament
 Inguinal canal approximately 4-6 cm long, cone shaped  Superolaterally- inferior epigastric vessels
region situated in the anterior protion of the pelvic basin  Medially- lateral edge of rectus sheath
 The canal begins on the posterior abdominal wall, where the
spermtatic cord passes through the deep (Internal inguinal
ring) a hiatus in the transversalis fascia.
 Superficial inguinal ring the point at which the spermatic
cord crosses a defect in the external oblique aponeurosis
 Boundaries
 Anterior- external oblique aponeurosis
 Lateral- internal oblique muscle
 Posterior- transversalis fascia and transversalis muscle
 Superior- internal oblique muscle
 Inferior- inguinal ligament ( pouparts ligament )
 The spermatic cord traverses the inguinal canal and contain
 3 arteries
 3 veins
 Two nerves
 Pampiniform plexus
 Vas deferens
 Classification of inguinal hernias  The significance in knowing the hesselbachs triangle because
 Indirect inguinal hernias this anatomic boundary will differentiate a direct or indirect
Protrude lateral to the inferior epigastric vessels, type of hernia. But as far as surgery is concern this two are
through the deep inguinal ring the same.
 Direct inguinal hernias  Hernia that occur in Hesselbachs triangle are direct inguinal
Protrude medial to the inferior epigastric vessels, hernias
within Hesselbachs triangle
 Femoral hernias protrude through a small and inflexible ring. FEMORAL SHEATH AND CANAL
 laparoscopic approach to hernia repair provides a posterior
perspective to the peritoneal and preperitoneal spaces  The boarders of femoral ring include
 Two potential spaces exist within the preperitoneum.  Anteriorly- iliopubic tract and inguinal ligament
 Bogros ( preperitoneal space)  Posteriorly- coopers ligament
Between the peritoneum and the posterior lamina  Medially- lacunar ligament
of the transversalis fascia
 Laterally- femoral vein
This area contains preperitoneal fat and areolar
 FEMORAL TRAINGLE
tissue.
 Boundaries
 Space of retzius
Superior- inguinal ligament
The most medial aspect of the preperitoneal space,
Lateral- Sartorius
which lies superior to the bladder
Medial- adductor longus muscle
 The posterior perspective also allows visualization of the
 Contents ( NAVEL)
myopectineal orifice of Fruchaud, a relatively weak portion
Femoral Nerves
of the abdominal wall that is divided by the inguinal
Femoral artery
ligament
Femoral vein
“Empty space”

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 Lymphatics  Collagen formation and structure deteriorates with age and
thus hernia formation is more common in the older
individual

NYHUS CLASSIFICATION

 Take note that femoral hernias always an emergency

HERNIA

 An abnormal protrusion of an organ or tissue through a

defect in its surrounding walls
 3 components
 Defect
 Hernial sac
 Contents
 Potential sites of hernia
 Umbilical
 Ventral
 Direct hernia
 Femoral
 Indirect hernia
 TERMINOLOGY
 REDUCIBLE- can be replaced within surrounding
musculature ETIOLOGY
 Incarcerated- cannot be reduced
 Strangulated- compromised blood supply to its contents
 Pantaloon- direct and indirect hernia
- 2 types of hernia that is coexisting to one another so
you have a weak inguinal floor and a patent processus
vaginalis. Or inguinal ring.
 Richter’s- contains antimesenteric portion of small
bowel
 Sliding- involves visceral peritoneum of an organ
Bladder
Ovary
 Littre’s- hernia contains meckel’s diverticulum
 Petit- hernia at inferior lumbar triangle
 Grynfelt- hernia at superior lumbar triangle

INGUINAL HERNIA
 3 classification
 INDIRECT – highest incidence
 DIRECT
 FEMORAL
 Classified as congenital versus acquired
- A congenital type of hernia is the indirect type of hernia.
The difference between direct and indirect with regards
to the defect. In direct hernia there is weakening of the
inguinal floor while in the indirect type of hernia there is PATHOPHYSIOLOGY
patent inguinal ring or dilated ring. So the content will
go to the scrotum because in indirect hernia it follows  Inguinal hernias may be congenital or acquired.
the course of the inguinal canal.  Most adult inguinal hernias are considered acquired defects
 Commonly thought that repeated increases in intra- in the abdominal wall
abdominal pressure contribute to hernia formation

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 the best-characterized risk factor is weakness in the
abdominal wall musculature
 Congenital hernias, which make up the majority of pediatric
hernias,  can be considered an impedance of normal
development, rather than an acquired weakness.
 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; however but it does not necessarily indicate an
inguinal hernia
 The presence of a PPV likely predisposes a patient to the
development of an inguinal hernia.
 the risk factors such as
 inherent tissue weakness
 family history
 strenuous activity
Repeated physical exertion may increase intra-
abdominal pressure
 Chronic obstructive pulmonary disease also significantly
increases the risk of direct inguinal hernias, as it is
accompanied by repeated episodes of high intra-abdominal
pressure.
 The risk of inguinal hernia development in obese men was
only 50% that of normal weight males, whereas the risk in
overweight males was 80% that of non-obese men.
 A possible explanation is the increased difficulty in detecting
inguinal hernias in obese individuals.
 Microscopic examination of skin of inguinal hernia patients
demonstrated significantly decreased ratios of type I to type
III collagen.
 Type III collagen does not contribute to wound tensile
strength as significantly as type I collagen.
CLINICAL PRESENTATION
 Groin bulge
 Often asymptomatic
 Dull feeling of discomfort or heaviness in the groin
 Focal pain- raise suspicion for incarceration or strangulation
 Symptoms of bowel obstruction
 In hernias there are no signs of inflammation such as mark
swelling, redness etc. typically in hernia there is only bulges
wherein if you ask the patient history there is waxing or
waning. There are days when the balls are enlarged and at
the end of the day when the patient lying down the mass
disappears.
HISTORY
 Inguinal hernias present along a spectrum of scenarios.
 These 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 such as a change in bowel habits or
urinary symptoms are less common.
 Inguinal hernias may compress adjacent nervesleading to
generalized pressure causing localized sharp pain, and
referred pain.
 Pressure or heaviness in the groin is a common complaint,
especially at the conclusion of the day or following prolonged
activity.
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 Sharp pain tends to indicate an impinged nerve and may not
be related to the extent of physical activity performed by the
patient.
 Neurogenic pain may be referred to the
 Scrotum
 Testicle
 Inner thigh.
 A change in bowel habits or urinary symptoms may indicate a
sliding hernia consisting of intestinal contents or involvement
of the bladder within the hernia sac.
 Important considerations of the patient’s history include the
duration and timing of symptoms.
 Hernias will often increase in size and content over a
protracted time.
 Patients will often reduce the hernia by pushing the contents
back into the abdomen, thereby providing temporary relief
 As the defect size increases and more intra-abdominal
contents fill the hernia sac, the hernia may become harder to
reduce.
PHYSICAL EXAMINATION
 Physical examination is essential to the diagnosis of inguinal
hernia.
 Asymptomatic hernias are frequently diagnosed incidentally
on physical examination or may be brought to the patient’s
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, with the goal of identifying an
abnormal bulge along the groin or within the scrotum.
 Palpation is performed by advancing the index finger through
the scrotum toward the external inguinal ring this allows
the inguinal canal to be explored.
 The patient is then asked to perform Valsalva’s maneuver to
protrude the hernia contents. These maneuvers will reveal
an abnormal bulge and allow the clinician to determine
whether the hernia is reducible or not.
 Examination of the contralateral side affords the clinician the
opportunity to compare the presence and extent of
herniation between sides  this is especially useful in the
case of a small hernia.
 Certain techniques of the physical examination have
classically been used to differentiate between direct and
indirect hernias.
 The inguinal occlusion test entails the examiner blocking the
internal inguinal ring with a finger as the patient is instructed
to cough.
 A controlled impulse suggests an indirect hernia, while
persistent herniation suggests a direct hernia.
 Transmission of the cough impulse to the tip of the finger
implies an indirect hernia, while an impulse palpated on the
dorsum of the finger implies a direct hernia.
 Femoral hernias should be palpable below the inguinal
ligament, lateral to the pubic tubercle.
 In obese patients, a femoral hernia may be missed or
misdiagnosed as a hernia of the inguinal canal.
 In contrast, a prominent inguinal fat pad in a thin patient,
otherwise known as a femoral pseudohernia, may prompt an
erroneous diagnosis of femoral hernia.
Jay 
 DIFFERENTIAL DIAGNOSIS
DIAGNOSIS
 Physical examination
 74.5% and 96.3% specific
 Examine the patient in the standing and supine position
 Difficult to distinguished direct and indirect on exam
alone
 Radiologic investigations- should only be used if there is
already complications such as strangulation or obstruction.
 HERNIOGRAPHY
NO longer use nowadays
Suspected hernia, but clinical diagnosis unclear
Procedure done after fluoroscopy following
injection of contrast medium
Frontal and oblique radiographs are taken with and
without increased intra-abdominal pressure
 Ultrasonography
US is the least invasive technique and does not
impart any radiation to the patient.
 CT scan
 MRI
CT and MRI provide static images that are able to
delineate groin anatomy, to detect groin hernias,
and to exclude potentially confounding diagnoses
MRI is frequently reserved for cases where physical
examination detects a groin bulge, but where US is
inconclusive.
TYPES OF HERNIA
 DIRECT INGUINAL HERNIA
 Medial to the inferior epigastric artery and vein and
within hesselbach’s triangle
 Acquired weakness in the inguinal floor
- There is prolong or repetitive straining or anything that
exert or increase intra-abdominal pressure can weaken
the floor combining with age of the patient
 Abdominal contents protrude through internal inguinal
Page 7 of 12
ring
- Doon sa canal mismo lumulusot yung sac nakapatong sa
may spermatic cord. And the usual location of the
hernial sac is in the anteromedial to the spermatic cord.
 INDIRECT INGUINAL HERNIA
 Lateral to the inferior epigastric vessels
 Accepted hypothesis: incomplete or defective
obliteration of the processus vaginalis during the fetal
period
- Normally as the testis descend the processus vaginalis
must be closed
 Remnant layer of peritoneum forms a sac at the internal
ring
 More frequently on the right
 Femoral hernia
 More common in females
 Upto 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
 Palpation of the femoral canal just below the inguinal
ligament in the upper thigh
 The bulge in femoral hernia is seen below the imaginary
line between the ASIS and symphisis pubis “ singit”
MANAGEMENT
 Surgical repair is the definitive treatment of inguinal hernias
however operation is not necessary in a subset of patients.
 Although the natural history of untreated inguinal hernias is
poorly defined, the rates of incarceration and strangulation
are low in the asymptomatic population.
 As a result, non-operative management is an appropriate
consideration in minimally symptomatic patients.
 Non-operative inguinal hernia treatment targets pain,
pressure, and protrusion of abdominal contents in the
symptomatic patient population.
 The recumbent position aids in hernia reduction via the
effects of gravity and a relaxed abdominal wall.
 Femoral and symptomatic inguinal hernias carry higher
complication risks, and so surgical repair is performed earlier
for these patients.
 Incarceration occurs when hernia contents fail to reduce
however a minimally symptomatic, chronically incarcerated
hernia may also be treated non-operatively.
 Taxis should be attempted for incarcerated hernias without
sequelae of strangulation, and the option of surgical repair
should be discussed prior to the maneuver.
 To perform taxis, analgesics and light sedatives are
administered, and the patient is placed in the Trendelenburg
position.
 The hernia sac is elongated with both hands, and the
contents are compressed in a milking fashion to ease their
reduction into the abdomen.
 The indication for emergent inguinal hernia repair is
impending compromise of intestinal contents.
 Strangulation of hernia contents is a surgical emergency.
 Clinical signs that indicate strangulation
 Fever
 Leukocytosis
 Hemodynamic instability.
 The hernia bulge is usually warm and tender, and the
overlying skin may be erythematous or discolored.
Jay 
  Symptoms of bowel obstruction in patients with sliding or
incarcerated inguinal hernias may also indicate strangulation
 .Taxis should not be performed when strangulation is
suspected, as reduction of potentially gangrenous tissue into
the abdomen may result in an intra-abdominal catastrophe.
 Preoperatively, the patient should receive fluid resuscitation,
nasogastric decompression, and prophylactic intravenous
antibiotics.
NON-OPERATIVE
 Observation
 Trusses can provide symptomatic relief
 Hernia control for 30% of patients
OPERATIVE TREATMENT
 Anterior approach ( open approach)
 TISSUE REPAIRS
Bassini repair
Shouldice repair
Mc-vay repair
Marcy
 PROSTHETIC REPAIRS
Lichtenstein tension free repair
Plug and patch technique
Prolene hernia system
 POSTERIOR APPROACH ( LAPAROSCOPIC APPROACH)
 Transabdominal preperitoneal procedure
 Totally extraperitoneal procedure
 Intraperitoneal Onlay Mesh procedure
- In laparoscopic you perform repair from the inside or
abdominal cavity going outward. While in anterior
approach from the abdominal wall going to the fascia
 Prosthesis consideration
 Synthetic mesh material
 Biologic mesh
 Fixation technique
TAKE NOTE: IF YOU PERFORM A TISSUE REPAIR OF HERNIA OR YOU
APPROXIMATE THE STRUCTURES USING SUTURES THEN YOU CALL IT
HERNIORHAPHY. IF YOU PUT A MESH THEN CALL IT AS HERNIOPLASTY
ANTERIOR APPROACH
TISSUE REPAIR
 Open inguinal hernia repairs are subdivided into techniques
that employ prostheses to create a tension-free repair and
those thatreconstruct the inguinal floor using native tissue
 Tissue repairs are indicated when the use of prosthetic
material is contraindicated such as contamination or
strangulation
 An oblique or horizontal incision is performed over the groin
 Tissue-based herniorrhaphy is a suitable alternative when
prosthetic materials cannot be used safely.
 Indications for tissue repairs includes
 operative field contamination
 emergency surgery
 viability of hernia contents is uncertain.
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TYPES OF TISSUE REPAIR
 BASSINI REPAIR
 Transversus abdominis to inguinal ligament and internal
oblique musculoaponeurotic arches or conjoined
tendon to the inguinal ligament.
- The main problem here is TENSION which is the number
1 enemy of hernia repair. And the main or common
complication Is RECURRENCE.
 Was an historic advancement in operative technique.
 Its current use is limited, as modern techniques reduce
recurrence.
 The original repair includes dissection of the
spermatic cord
dissection of the hernia sac with high ligation
extensive reconstruction of the floor of the
inguinal canal
 Preperitoneal fat is bluntly dissected from the upper
margin of the posterior side of the transversalis fascia -
permitting adequate tissue mobilization.
 A triple-layer repair is then performed.
 SHOULDICE REPAIR
 Standard procedure in tissue repair
 Multilayer imbricated repair of the posterior wall of
the inguinal canal
- VARIATION of bassini repair
- In choosing type of hernia repair you need to consider
1. Tension free
2. Least recurrence
 recapitulates principles of the Bassini repair
 Its distribution of tension over several tissue layers
results in lower recurrence rates.
 During dissection of the cord, the genital branch of the
genito- femoral nerve is routinely divided  resulting
in ipsilateral loss of sensation to the scrotum in men or
the mons pubis and labia majora in women.
 MC-VAY REPAIR
 Edge of the transversus abdominis aponeurosis to
coopers ligament
 Incorporate coopers ligament and the iliopubic tract (
transition suture)
- ONE critical structure id is the iliopubic tract which is a
very tough structure.
 Addresses both inguinal and femoral ring defects.
 This technique is indicated for femoral hernias
 Also used in cases where the use of prosthetic material
is contraindicated
 The upper flap is mobilized by gentle blunt dissection of
underlying tissue.
 Cooper’s ligament is bluntly dissected to expose its
surface this incision is essential to reduce tension on
the repair but this it may result in increased
postoperative pain and higher risk of ventral abdominal
herniation.
Jay 
 TYPES OF REPAIR INDICATION
Marcy repair  Closure of the inguinal ring
 Used in type 1 and 2
 Done in pediatric patient
BASSINI REPAIR  Approximation of TAA with
inguinal ligament and iliopubic
tract
 Used in type 2 and 3
 10% recurrence rate
MCVAY REPAIR  Used of Coopers ligament
 Used primarily in femoral hernia
 Can be in type 2, 3 and 4
SHOULDICE REPAIR  Similar with Bassini but using a
continuous suturing (
imbrication)
 Gold standard for tissue repair
 1.1 recurrence rate
Take note that the basis for the classification is the NYHUS
classification
PROSTHETIC REPAIR
 LICHTENSTEIN TENSION-FREE REPAIR
 First pure prosthetic, tension free repair to achieve low
recurrence rates
 A tension free repair
 Very low recurrence rate almost zero
 The principle of hernia repair in general
1. Dissect the floor
2. Isolate the cord
3. Prepare the floor
- With mesh repair 2 steps only no repair of the floor
you just put the Mesh. Exposed the area or inguinal
canal “the myopectineal orifice and put the mesh kaya
daw ang tawag is onlay mesh ipapatong lang daw and
put anchoring stitches so that the mesh will not move.
- The basic action of the mesh it will not give strength
instead it induces a severe fibrotic reaction wherein a
mesh is considered as a foreign body. A scar tissue is
ugly but strong
- Contraindication for mesh placement
1. Infection in the area or recurrence because this will add
inflammatory reaction to the area
 Expands the domain of the inguinal canal by reinforcing
the inguinal floor with a prosthetic mesh  thereby
minimizing tension in the repair.
 In the case of a femoral hernia  a triangular extension
of the inferior aspect of the mesh is sutured to Cooper’s
ligament medially and to the inguinal ligament laterally.
 A three dimensional prosthetic plug is placed in the
space previously occupied by the hernia sac.
 In the case of an indirect hernia, the plug is placed
alongside the spermatic cord through the internal ring.
 For direct hernias, the sac is reduced, and the plug is
sutured to Cooper’s ligament, the inguinal ligament, and
the internal oblique aponeurosis.
 PROLENE HERNIA SYSTEM
 Provides reinforcement to the anterior and posterior
aspects of the abdominal wall.
 Exposure of the inguinal canal is identical to that of
other open approaches.
 PLUG AND PATCH TECHNIQUE
 A modification of Lichtenstein repair
Page 9 of 12
 Prior to placing the prosthetic mesh patch over the
inguinal floor , three dimensional prosthetic plug is
placed in the space previously occupied by hernia sac
 For indirect hernia the plug is paced alongside the
spermatic cord through the internal ring
 For direct hernias, the sac is reduced and the plug is
sutured to coopers ligament
 Evidenced based prospective study: MESH AND SUTURED
INGUINAL REPAIR
 Danish hernia database of over 13,000 hernia repairs
 Compared re-operations for recurrent hernia
 Results: after 5 years significantly lower ( ¼ less
recurrence with mesh versus sutured repair
 Mesh-based hernioplasty is the most commonly performed
general surgical procedure, owing to the technique’s efficacy
and improved outcomes.
WOUND CLOSURE
 Once the reconstruction of the inguinal canal is complete,
the cord contents are returned to their anatomic position.
 The external oblique aponeurosis is then reapproximated
continuously from medial to lateral using an absorbable
suture.
 The external ring should be reconstructed in close apposition
to the spermatic cord to avoid the appearance of recurrence
on future examination.
 Scarpa’s fascia and skin are ppropriately 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.
POSTERIOR ( LAPAROSCOPIC APPROACH)
 Laparoscopic inguinal hernia repairs reinforce the abdominal
wall via a posterior approach.
 Principal laparoscopic methods include
 transabdominal preperitoneal (TAPP) repair
 totally extraperitoneal (TEP) repair
 Intra-peritoneal onlay mesh (IPOM) repair ( less
common)
 The indications for laparoscopic inguinal hernia repair are
similar to those for open repair.
 Most surgeons would agree that the laparoscopic approach
to bilateral or recurrent inguinal hernias is superior to the
open approach.
TYPES OF LAPAROSCOPIC APPROACH
 TRANSABDOMINAL PREPERITONEAL PROCEDURE ( TAPP)
 confers the advantage of an intraperitoneal perspective
 useful for
bilateral hernias
large hernia defects
Scarring from previous lower abdominal surgery.
 TOTALLY EXTRAPERITONEAL PROCEDURE ( TEP)
 The advantage of the TEP repair is the access to the
preperitoneal space without intraperitoneal infiltration
 This approach minimizes the risk of injury to intra-
abdominal organs and port site herniation through an
iatrogenic defect in the abdominal wall.
Jay 
  As with TAPP, TEP is indicated for repair of bilateral  Ischemic orchitis is likely caused by injury to the
inguinal hernias or for unilateral hernias when scarring pampiniform plexus and not to the testicular artery
makes the anterior approach challenging.  It Is usually manifest within 1 week of inguinal hernia
 INTRAPERITONEAL ONLAY MESH PROCEDURE( IPOM) repair as an enlarged, indurated, and painful testis
 In contrast to TAPP and TEP, the IPOM procedure  Usually self- limited
permits the posterior approach without preperitoneal
dissection. OPEN APPROACH COMPLICATION
 It is an attractive procedure in cases
where the anterior approach is unfeasible
recurrent hernias that are refractory to other
approaches
Where extensive preperitoneal scarring would
make TEP or TAPP challenging.

PROSTHESIS CONSIDERATION

 SYNTHETIC MESH MATERIAL

 Polypropylene mesh
most common and preferred allowing 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 ( PFTE) 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
 POLYPROLENE AND POLYESTER are the most common LAPAROSCOPIC APPROACH COMPLICATION
synthetic prosthetic material used in hernia repair
 These materials are permanent and hydrophobic, and
they promote a local inflammatory response that results
in cellular infiltration and scarring with slight
contraction in size
 BIOLOGIC MESH
 Indications is not been absolutely defined
 Commonly reserved for contaminated cases or when
domain expansion is necessary in the face of high
infection risk
 FIXATION TECHNIQUE
 Independent of prosthesis material

SURGICAL COMPLICATIONS

 RECURRENCE
 Common medical issues associated with recurrence
include
Malnutrition
Immunosuppression
Diabetes
Steroid use
Smoking  The most common cause of urinary retention after hernia is
 After an initial anterior approach, the posterior or general anesthesia
laparoscopic Is usually done to address this problem  Laparoscopic abdominal approach is associated with higher
 Infection incidence of ileus though this is usually self-limited it
 Neuralgia- because of the transection of triangle of pain warrants observation, IV fluid maintenance and possibly
 Pain after inguinal hernia repair is classified into three nasogastric decompression
Nociceptive pain – most common  The presence of abdominal adhesions from previous surgery
Neuropathic pain may predispose to visceral injuries
Visceral pain  The most severe vascular injuries usually occur in iliac or
 Bladder injury femoral vessels, either by misplaced sutures in anterior
 Testicular injury repairs
 Vas deferens injury  Injury to spermatic cord vessels may result in a scrotal
 Injury to spermatic cord may result in ischemic orchitis hematoma
or testicular atrophy

Page 10 of 12 Jay 
 OTHER HERNIAS  Examination: palpate small, soft, reducible mass
superior to the umbilicus rare to have strangulated
ABDOMINAL HERNIAS bowel
 A.k.a ventral hernias  Treatment: excision of fat and sac close primarily
 Represents defects in the parietal abdominal wall fascia and
muscle through which intra-abdominal or preperitoneal SPIGELIAN HERNIA
contents can protrude
 Types of abdominal hernia  Can occur anywhere along the length of spigellian line or
 Acquired hernias zone which traverses a vertical space along the lateral rectus
Develop via slow architectural deterioration of the border
musculoaponeurotic tissues  Where more than 90% of spigelian hernias are found
May develop from failed healing of an anterior  An aponeurotic band of variable withdt at the lateral border
abdominal wall incision ( incisional hernia) of the rectus abdominis
Common findings  Most frequent location above the level of the arcuate line
 Can be asymptomatic  Not clinically evident and may come to medical attention
 mass or bulge -- Increasing in size with only if there is incarceration or pain already
valsalva maneuver  Clinical
 the mass can be reduce spontaneously with  Swelling in middle to loer abdomen lateral to rectus
recumbency or with manual pressure muscle
 incarcerated hernias  Usually reducible
a hernia that cannot be reduced  Upto 20% present with incarceration
requires surgical resection  true surgical  Treatment:
emergency  Surgical
maybe accompanied by nausea, vomiting, and  Mesh nor required
significant pain  Recurrence is uncommon
 strangulated hernia
blood supply of incarcerated bowel is compromised OBTURATOR HERNIA
localized ischemia may lead to infarction and  Rare form of hernia
perforation  Protrusion of intra-abdominal content through obturator
 primary ventral hernias ( non-incisional ) - named foramen
according to their anatomic location  F:M ratio – 6:1
 The obturator foramen is formed by ischial through
UMBILICAL HERNIA obturator foramen
 Obturator vessels and nerve lie postero-lateral to the hernia
 reported incidence – 10% sac in the canal
 Several times greater in black children  Small bowel is most likely intRa-abdominal organ to be found
 Occur at umbilical ring and present at birth or develop later in an obturator hernia
in life
 More common in premature infants in all races LUMBAR HERNIA
 Congenital hernias most are close spontaneously by 52 or
3 years ( sa book 5 years)  Acquired lumbar hernias – back or flank trauma,
 Acquired rather than congenital in adults poliomyelitis, back surgery and the sue of the iliac crest as a
 Female to male ratio 3:1 donor site for bone grafts
 Contain two anatomic triangles
EPIGASTRIC HERNIA  Grynfelts- superior lumbar triangle
 Petit’s- inferiorlumbar triangle
 Midline junction of the aponeuroses ( linea alba) between  Strangulation is rare
xiphoid process and umbilicus  Soft swelling in lower posterior abdomen
 Paraumbilical hernia- epigastic hernia that borders the
umbilicus SCIATIC HERNIA
 Estimated frequency 3-5%
 More common in males  Via greater or lesser sciatic notch
 small, maybe multiple ( 20% of the population)  Greater sciatic notch is traversed by the piryformis muscle,
 found to contain omentum or a portion of falciform and hernia sac can protrude either superior or inferior to
ligmament this muscle
 if congenital due to defective midline fusion of developing  Suprapiriform defect- 90%
lateral abdominal wall elements  Infrapiriform- 30%
 Clinical  Subspinous ( thorugh th lesser sciatic foramen ) 10%
 Often asymptomatic
 If symptomatic, vague abdominal pain above the VENTRAL WALL ( INCISIONAL HERNIA)
umbilicus exacerbated by standing or coughing, relived
by supine position  Aside from groin hernia incisional hernia is also commonly
 Severe pain secondary to incarceration/ strangulation of encountered because of previous surgery
preperitoneal fat ( often no peritoneal sac ) or omentum  Highest incidence in midline and transverse incisions

Page 11 of 12 Jay 
  Upto 20% after laparotomy RECURRENCE RATE
 1/3 present in 5-10 years postoperatively
 Develop at incision sites following open abdominal surgery
 Etiology
 Obesity
 Primary wound healing defects
 Multiple prior procedures
 Prior incisional hernias
 Technical errors during repair
 DM
 Ascites
 Steroids smoking
 Malnutrition
 Wound infection
 Technical aspects of wound closure
 Type of incision
 Excessive tension ( prone to fascial disruption)

_________________________________________________________

THE END
RED – FROM THE BOOK
BLACK- FROM THE POWERPOINT
VIOLET- FROM THE MANUAL (NOT DISCUSSED)
BLUE- FROM THE LECTURER
GREEN- PREVIOS POWERPOINT OF DOC MENDOZA

SAYANG SPACE ILAGAY KO LANG ADDITIONAL INFORMATION

ALGORTHYTHM OF HERNIA

Page 12 of 12 Jay 