GENERAL SURGERY
 The patient is then asked to perform Valsalva’s maneuver to
GROIN HERNIA
Dr. Wallace Y. Medina
75% hernia happens at the Groin area, until now it is the basic
requirement for the surgeon whenever he performs surgery by
knowing the detailed anatomy of the groin hernia.
GOALS OF HERNIA SURGERY:
1. Provide long lasting, secure closure of pelvic floor defect
2. Reduce Pain – refers to symptomatic. Hernia that interferes
with the daily activity of the patient that He cannot stand
for it like an hour. Lifts his objects.
3. Improve quality of life
Best surgery for the treatment of hernia is where the Surgeon is
well adept to.
RISK FACTORS:
A. Genetic – Type 3 collagen, Family History 4x
B. Acquired – Aneurysm Abdominal Aortic Aneurysm, Thoracic
Aneurysm, Hiatal hernia  Groin Hernia, Sleep Apnea
**Increase intraabdominal factors not scientifically proven
But the dictum is if you can minimize this, pre-operatively
DIAGNOSIS: Always clinical, no added sophistication is needed.
The imaging modalities (e.g. US, CT scan, Herniography) the only
role is if it’s confronted with complicated hernia  Hernia that
recurs after the repair, Hernia that develops infection when there
is a foreign body. But if it’s a first time case you see in the clinics
then your PE dominates & no added modalities, or examination
How do you perform your PE? Ask the patient to stand up,
erect position and then look at the area of involvement. Focus
on the scrotal area if there would be a bulge that will confirm
your diagnosis (Painful or Painless bulge) now if no bulge is
exhibited do perform Valsalva Maneuver (Straining) Always ask
the patient to stand up first in a super erect position and you ask
the patient to lie down.
There are times when the mass does not change then you can
perform the trans illumination test, you put the penlight in the
most dependent part of the scrotum if it illuminates it means
there is fluid there most common is HYDROCELE. Sometimes
hydrocele and hernia co-exist called Communicating Hydrocele
and by strict nomenclature actually is an indirect type of hernia.
Problem with the indirect type is the Patency of the processus
vaginalis  Open when the descend of the testes from the intra-
abdominal area to the scrotum area
When it remains open  INDIRECT HERNIA
DIRECT HERNIA – weakened tranversalis fascia
FEMORAL HERNIA – anatomical disparity, pelvis of the female is
broader and some anatomical spaces that are narrow.
 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.
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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.
 Painless or painful bulge
 Patent processus vaginalis  indirect hernia
 Weaken tranversalis fascia  direct hernia
 Anatomical disparity  femoral hernia
NYHUS CLASSIFICATION:
TYPE I - IH with patent processus vaginalis only; in children
TYPE II – IH with enlarged internal ring only
TYPE III – with defect (weakness) of the inguinal floor
A – Direct hernia
B – Massive indirect hernia, pantaloons & sliding hernia
C – Femoral hernia
TYPE IV – Recurrent hernias
Type I – Main problem of indirect hernia is patency of processus
vaginalis however in children it is the opening of the processus
vaginalis therefore the treatment is the closure of processus
vaginalis.
Type II – Pediatric type of hernia, patent processus vaginalis it
comes with the dilatation of the deep inguinal ring or internal
inguinal ring treatment is not enough to close the patent
processus vaginalis or the end/neck of your hernia sac it is
mandatory that you tighten the internal inguinal ring  MARCY
REPAIR
Type I & Type II – Pediatric patients
Type III – Adults
Type III – weakening of the pelvic floor
Type IV – Recurrence, either EARLY or LATE,
Early – Happens after 2yrs of surgery, Culprit: Surgeon
Late – More than 2yrs cut-off of 5yrs Culprit: Patient
(Some metabolic problems, persistent intra-abdominal
pressure, aging)
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GILBERT CLASSIFICATION:
ASYMPTOMATIC HERNIAS:
- Tolerable
- Painless
- Some maneuvers to bring back the abdominal contents
 Swelling or fullness at the hernia site
 Aching sensation (radiates into the area of hernia)
 No true pain or tenderness upon examination
 Enlarges with increasing intra-abdominal pressure and
or standing
**Classically, the existence of inguinal hernia has been a reason
enough for operative intervention. However, recent studies have
shown that the presence of a reducible hernia is not, in itself, an
indication for surgery and that the risk of incarceration is <1%
**2 randomized clinical trials. The trials found a similar results,
namely that after long-term follow-up, no significant difference in
hernia-related symptomology was noted, and that watchful
waiting did not increase the complication rate.
INCARCERATED HERNIAS:
a. Painful enlargement of a previous hernia or defect
b. Cannot be manipulated (either spontaneously or manually)
through the fascial defect
c. Nausea, vomiting and symptoms of bowel obstruction
(possible)
- Surgeon was able to reduce the content through taxis
- 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 (#1 prerequisite) and light
sedatives are administered, and the patient is placed in
the Trendelenburg position.
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- The hernia sac is elongated with both hands, and the
contents are compressed in a milking fashion to ease their
reduction into the abdomen.
- After anxiolytics, removal of pain wait for the effect,
positioning of the patient then you may now perform taxis
with two attempts only
- After the failed attempts, you may send the patient to the
operating room
- The indication for emergent inguinal hernia repair is
impending compromise of intestinal contents.
- Never do surgery to uncooperative patient, remove all
the anxiety of the patient you may give anxiolytics
 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.
 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.
 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.
STRANGULATED HERNIAS:
a. Patients have symptoms of an incarcerated hernia
b. Systemic toxicity secondary to ischemic bowel is possible
c. Strangulation is probable if pain and tenderness of an
incarcerated hernia persist after reduction
Danger is left dead tissue inside the body  perforation 
COLON  Septic (2days)
Strangulated hernias are differentiated from incarcerated hernia
by the following:
a. Pain out of proportion to examination findings
- History, PE
- Vascular type of pain  patient is toxic looking 
there’s a site of tenderness but out of proportion
b. Fever or toxic appearance
c. Pain that persists after reduction of hernia
A commonly accepted practice elective hernia repair:
1. Physically fit for surgery
2. Symptomatic patients
*No urgency in doing the repair, unless incarceration episode.
*High risk with perioperative complications, and minimal
symptoms, Watchful waiting is a safe action (e.g. recent MI,
diabetic, complications and asymptomatic  OBSERVATION)
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TREATMENT:
Surgical concept – closure of the defect and reinforcement of Most at risk for intraperitoneal infection  TAPP
the pelvic floor Both TAPP & TEP they put the mesh behind the transversalis fascia
 Tissue repair that’s why it is called posterior approach.
 Mesh repair – foreign body
**Tissue and mesh repair leads to the creation of new pelvic floor  Anterior approach (open approach)
TISSUE REPAIRS:
Types of Hernia Surgery: o Bassini repair
1. HERNIOTOMY – closure of the processus vaginalis (defect), o Shouldice repair
ligation of hernia sac o Mc-vay repair
o Pediatric Hernia o Marcy
2. HERNIORRHAPY – closure of the defect, repair of the pelvic PROSTHETIC REPAIRS:
floor using tissues o Lichtenstein tension free repair
3. HERNIOPLASTY – closure of the defect, repair of the pelvic o Plug and patch technique
floor using mesh o Prolene hernia system
 POSTERIOR APPROACH (LAPAROSCOPIC APPROACH)
Types of repair of the floor: o Transabdominal preperitoneal procedure
1. TISSUE REPAIR – use of patients own tissue to create a new o Totally extraperitoneal procedure
floor. Non-anatomical. 15-20% of recurrence. o Intraperitoneal Onlay Mesh procedure
2. MESH REPAIR – Use of prosthetic mesh in the creation of new In laparoscopic you perform repair from the inside or
floor. Serve as a bridge between two tissues. Anatomical. abdominal cavity going outward. While in anterior approach
1-5% recurrence. from the abdominal wall going to the fascia

Current indications for Tissue repair: Prosthesis consideration

1. Male young adult patient Synthetic mesh material
2. Risk of mesh infection – strangulated hernia do tissue repair Biologic mesh
3. High risk individuals to develop pain – women of Fixation technique
reproductive group, very low pain threshold
4. History of chronic pain – incidence of mesh repair, so do TAKE NOTE: IF YOU PERFORM A TISSUE REPAIR OF HERNIA OR YOU
tissue repair APPROXIMATE THE STRUCTURES USING SUTURES THEN YOU CALL IT
HERNIORHAPHY. IF YOU PUT A MESH THEN CALL IT AS
**The types of tissue repair and its outcome is dependent on the HERNIOPLASTY.
technique and experience of the surgeon.
OPEN VS. LAP HERNIA SURGERY:
Approach to Groin Hernia: A 2014 meta-analysis of seven studies comparing
1. Anterior approach – Creation of the new floor above the laparoscopic repair with Lichtenstein technique for treatment of
transversalis fascia recurrent inguinal hernia conducted that despite the
2. Posterior approach – creation of the new floor below the advantages to be expected with the former (e.g. reduced pain
transversalis fascia, pre-peritoneal layer. and earlier retain to normal activities), operating time was
significantly longer with the minimally invasive technique, and
Anterior Approach: the choice between the two approaches depended largely on
1. Bassini the availability of local expertise.
2. mcVay
3. Shouldice Complications of repair:
4. Lichtenstein 1. Recurrence
Posterior Approach: 2. Nerve entrapment
1. Nyhus repair – open, make an incision in the anterior 3. Ischemic orchitis, testicular atrophy, injury to vas
abdomen. Incision like in appendectomy  Rocky deferens,
davis. Once you split the peritoneal area that’s where 4. Bowel obstruction, adhesions
you approximate the ileopubic tract, external inguinal 5. Vascular injury
ligament to the transverse aponeurotic arch. Creation 6. Wound infections – Less than 1% infection rate, least
of the new floor is behind the tranversalis fascia  common complication is the Surgical site infection
Posterior approach. Anterior to the transversalis fascia
 Anterior approach Chronic Inguinal Post herniorrhapy pain:
2. Laparoscopic Repair  More than 3 months post-op
 TAPP – major incision, umbilicus you go through all Causes:
the layer of intraperitoneal cavity. After the 1. Recurrence
surgeon identify the hernia will try to flip the 2. Mesh related
peritoneum and make an incision dissect until the 3. Nerve related – anterior: Ilioinguinal & iliohypogastric
peritoneum falls back. Will expose the weakened posterior: Triangle of pain
area get a mesh place under the transversalis
fascia and after suturing the mesh around the TRAINGLE OF PAIN - is a region bordered by the iliopubic tract
weakening area and puts back the entire layer. and gonadal vessels
- It encompasses the
 TEP – will not go through the layer, once he lateral femoral cutaneous
reached the pre-peritoneal layer he will stop there femoral branch of the genitofemoral
and put the mesh. Femoral nerves
4. Infection

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 GENERAL SURGERY

Success in Hernia Surgery:

 Permanence of the operation – done under general
anesthesia
 Fewest complications
 Minimal cost
 Early return to work or other activities – applicable to
laparoscopic

**Anatomy & Surgical procedures were not discuss in this hand-

out

Black – PPT
Blue – Book
Red - Lecturer

“For I know the plans I have for you,” declared the Lord, “Plans to
prosper you and not to harm you, plans to give you hope and a
future”
Jeremiah 29:11

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