abt Abdominal Wall, Including Hernia ‘Tananchai A. Lucktong, Thomas L. Gillespie, Gaétan Brochu, and Rachel L. Sloteavage A hernia of the abdominal wall isa clear, defined defect inthe muscles and fascia through which abdominal contents can protrude. This can potentially cause trapping of the contents (incarceration), bowel obstruction, and ischemia (strangulation), depending on what structures are involved and how tightly they become ‘entrapped. Hernias ean occur in various regions of the abdominal wall (Figure 11-1), For the purposes of this iscussion, hernias will be grouped into two primary categories those ofthe main abdominal wall and those of ‘the geoin or myopectineal orifice (MPO), There is also an independent hernia type, the obturator hernia, which wil be diseussed separately Pique 11-1 Possible sites of abdominal wall and groin hernias. Myopectineal orifice hernias include the inguinal and femoral hernias. (Itutrated by Charlotte R. Spear and Marce A. Marchionni,) 287ABDOMINAL WALL HERNIAS Anatomy Abdominal Wall Layers ‘The anatomy of the abdominal wall can be divided into eentral and lateral areas, comprised of several layers ‘each (Figure 11-2). The central abdominal wall consists ofthe linea alba, which is a fusion of the anterior and posterior rectus fascial layers at the midline, Lateral to this, the antesior and posterior rectus sheath encircle the rectus muscles superiorly. Unlike the anterior rectus sheath, which extends from xiphoid to pubis, the posterior rectus sheath extends only to just below the umbilicus, and terminates ata line known as the “Linea semilunaris,” emilunar ligament, or arcuate line, Below this line, the central abdominal wall is composed of ‘only the rectus musele and anterior rectus sheath, 3 Layers reinforced oalten Seasons thane facie pertonaumn C8 Fgwe 11-2 Layers of the main abdominal wall, including the changes above and below the arcuate line, Ant, anterior ex, external int, internal; bl, oblique; post, posterior tans. ab, tansversus abdomins, (lustrated by Charlotte R. Spear and Marco A, Marchionsi.) ‘The lateral abdominal wall is comprised of several layers with somewhat less prominent fascial layers. The external oblique muscle forms the most superficial layer, followed by the internal oblique muscle, then the ‘ransversue abdominis muscle. The transversalis fascia is the innermost layer, underlying the transversus abdominis muscle, and is closely associated with the peritoneum, Blood Supply and Innervation “The blood supply to the central abdominal wall is derived ftom the superior and inferior epigastric vessels, which run in 2 craniocaudal direction within the body of the rectus muscle, Perforator vessels supplying the 248overlying skin and subcutaneous tissue branch off the epigastric vessels and exit anteriorly along the length of the rectus abdominis. Blood supply and innervation for the lateral aspect of the abdominal wall comes primarily from segmental branches, which run from lateral to medal. ‘Main Hernia Types Hernias of the main abdomi ‘wall can be divided into several types. Ventral hernias are primary hernias with no associated prior incision and are located anywhere along the midline above or below the umbilicus, Unnbilical hernias occur specifically within the umbilicus, usually producing a protrusion of the umbilical skin, Incisional hemias develop along prior surgical incisions and may be located anywhere on the abdominal wal. All hernias can present as initial fist-time hernias or as zecurtences of prior repais, Special Situations Several special abdominal hernias exist outside of these broad categories; these are generally beyond the scope ofthis chapter. There ae two exceptions worth mentioning, First, the Spigelian hernia occurs a the junction ofthe inferior edge of the posterior rectus sheath and the lateral border ofthe rectus abdominis, a the arcuate line (Figure 11-3). Ie has «characteristic location inthe sight or left lower quadrant, and usually involves only the posterior elements, Because it does not typically penetrate the anterior portion of the abdominal wall, it ray not be a visible or palpable bulge on the surface, Aponourosis of Subcutanoous extemal obique muscle tseue Skin Anterior Hernia. eats sheath Internal Rectus obique abdominis aponewosis y mmuscie “ranaverslis ‘Transversus fascia abcomins muscle 24911+ Spigelian hernia, A, Schematic axial view. B, Spigelian hernia as seen on computed tomography (esal view). Note that the external oblique remains intact overlying this hernia. (A, From Jones DB, Fischer JE. Mauer Techniques in Surgery: Hernia. Philadelphia, PA: Lippincott Williams 8 Wilkins, A Wolters Kluwer business; 2013.) Secondly, parastomal hernias develop within the fascial opening of an ostomy, with herniation of additional viscera alongside the stoma. Parastomal hernias can affect stomal function, Many options are available 0 repair parastomal hernias, including the laparoscopic or open procedures discussed in the following paragraphs, as wel a relocation ofthe stoma to an area of intact abdominal wal Finally, itis important to note that che teem Sernia implies a least a partial defect in the abdominal wall On the contrary, rectus diastass is a thinning of the upper midline abdominal wall without a defect. ‘This is caused by stretching and attenuation of the linea alba, causing the rectus muscles to deviate laterally (Figure 11-4), Reetus diastasis often presents as a bulge on Valsalva, and can be confused with a ventral n line hernia. Because only attenuation ie present without a true abdominal wall defect, rectus diastasis doce not carry any risks of incarceration and strangulation and does not requize intervention, 250Higwet1-4A, A schematic of rectus diastasis. B, A patient with rectus diastasis, Note the bulging ofthe upper rmidline abdomen when the patient does a“sit-up” maneuver. (A, Reprinted with permission from Irion JM, Ison Gl. Women's Health in Physical Therapy. st ed. Philadelphia, PA: Lippincott Willams & Wilkins Copyright © 2010 Lippincott Willams & Wilkins, A Wolters Kluwer business) Clinical Considerations ‘The overall goal in hernia management is to minimize patient risk of incarceration or strangulation while ‘maximizing potential for a good outcome. Clinical presentation, surgical history, hemnia-specifc factors, and patient factors all play significant roles. Clinical Presentation Hemias have four typical presentation patterns: asymptomatic, symptomatic, subacute, and seute Asymptomatic hernias ace typically found during evaluation by a health care provider but may be noticed by the patient. These hemias may not require repair, as discussed in the following paragraphs. Asymptomatic hheanias are most often reducible, meaning the hernia contents can be returned to the true abdominal cavity ‘This may occur either spontaneously, such as when a patient lis inthe supine position, or manually, where the patient or healthcare provider can push the contents back into the abdomen. Among reducible hernias, ‘hose with smaller fascial defects or those requiring difficult manual reduction may pose a greater risk of complications Symptomatic hernias may present ina variety of ways, both with subaeute and acute symptoms, Reducible hhemnias may still be symptomatic. ‘The most common subacute presentation is pain at the hemia site or abdominal cramping. This may occur continuously or intermittently, and is often exacerbated by heavy lifting ‘or physical activity. Symptomatic hernias should be fixed ifthe risk-benefit analysis favors repair. However, one should be certain that it is the hernia that is causing pain, because the symptoms may not be due to the hernia, so hernia repair will not relieve discomfort. Incarceration of a hemia is defined by “trapping” of the contents within the hernia, such that the intra abdominal contents are no longer reducible. Incarceration by itself, especially without pain, is not necessarily an indication for emergent management, However, incarcerated hernias are one step dloser to possible 251strangulation, defined as ischemia of the hernia contents, and require more urgent attention than reducible hernias. Newly incarcerated hernias should be repaired within 4 to 6 hours of presentation to avoid complications. An attempt to reduce the hernia under sedation by an experienced provider is acceptable in a ‘hemodynamically stable patient without lab abnormalities that indicate strangulation, such as leukocytosis or acidosis. After reduction, the patient must be observed in the hospital, beeausestrangulated contents may have been reduced back into the abdominal eavity. ‘The strangulated contents may infarct or may have already infiseted, necessitating exploratory abdominal surgery (eg, laparotomy, celiotomy). Acutely incarcerated ‘hernias that cannot be reduced often require urgent surgical repair. Chronically incarcerated hernias with no cvidence of strangulation should have surgical repair as soon as is feasible, after assessment of the patient’: comorbidities Patient presentation can provide critical information regarding the need for urgent or emergent hernia repair. Intractable nausea and vomiting, severe pain, tachycardia, fever, focal peritonitis, leukocytors, acidosis, or obstruction on imaging all point to the need for emergent surgery because these symptoms ean indicate the presence of strangulation, Strangulation is also identified by the presence of focal peritonitis, acidosis, leukocytosis, or change of color in the overlying skin, suggesting necrosis of underlying tissues, Ifthe hernia contents are strangulated, emergent surgical intervention is required and attempt should be made to reduce the hernia. If there ate infarcted organs in the hernia contents, they will also requite resection, Surgical History Patient history ean provide useful information regarding the nature of prior abdominal pathology and the likelihood of intra-abdominal adhesions. Both of these are factors that may affect the hemia repair. Prior abdominal incisions, prior fascial dehiscence, or postoperative abdominal wound infection all increase the risk for incisional hernia. A history of prior abdominal tubes or ostomies may create disruptions in the abdominal ‘wall chat will affect how hernia repair should be conducted. Old operative notes and discharge summaries can bbe vesy helpful in this regard Hernia Specific actors Adequate characterization of the hernia defeet and determination of the exact location are useful in operative planning. If hemia size and location cannot be established by physical exam alone, computed tomography (CT) is usefl co confirm the defect location and size, in addition to providing information about viseral involvement, the surrounding abdominal wall, and the position of a stoma, previously placed mesh, or ather implantable deviees. Patient Factors Modifiable Risk Factors ‘The decision for hernia repair should focus on modifiable risk factors, such as functional status, smoking, obesity, and medical comorbidities. Several of these risk factors may be modifiable to reduce perioperative morbidity, Nutritional optimization for the undernourished patient is critical to ensure adequate wound healing, especially with the large incisions used for repair of hernias of the main abdominal wall. Weight management for the obesity reduces overall perioperative morbidity, wound issues, and the sisk of hernia 252recurrence after repair. Smoking cessation is helpful from both 4 pulmonary complication and wound healing standpoint, and diabetes is associated with perioperative morbidity and mortality, limits wound healing, and increases the risk of infection. Hemoglobin AIC should be normalized if possible to <7 prior to elective surgery. Perioperative venous thromboembolism prophylaxis may also need to be considered. Routine rmcchanical prophylaxis with compression devices is appropriate for most patients, but high-risk patients may benefit from chemoprophylaxis (anticoagulation) as well. Patients already on anticoagulation will require 2 plan to bridge anticoagulation, Perioperative Planning. In addition to the reduction of modifiable risk factors, prehabilitation improves preoperative strength, mobility, and overall recovery for patients with poor functional status. Plans may need to be in place for alternative, nonnarcotic pain control options—lidocaine drip, regional blocks of the transversus abdorninis plane (TAP), and spinal or epidural blocks—which may reduce respi cory depression and aid in improving postoperative pain control, ambulation, and early retun of bowel function. OfRen, such interventions are incoxporated into perioperative prebabilitation and enhanced recovery protocols Patient Counseling cnt counseling typically strangulation prior to repair. ‘This is et Preoperative pa includes information regarding potential for bowel obstruction ot jal in understanding the tisk of repair versus nonoperative management, especially in thore at the higher risk for pesioperative morbidity and mortality. Recurrence risk after repair should focus on individual patient factors such as ior abdominal surgery, obesity, age, smoking status, overall activity level, and hemia size. Specific risks of hernia repair should be reviewed, including the risks of seroma, mesh infection, nerve impingement, and bowel injury, all discussed in che following paragraphs. Available online risk assessment tools can be very useful for patient education, including the American College of Surgeons risk ealeultor. Surgical Approaches ‘The technique chosen must minimize the risk of recurrence while also limiting the potential for morbidity Options for repair of hernias of the abdominal wall inchude primary, mesh, and component separation repairs Primary Repair Primary repair involves physical closure of the hernia defect with suture alone, This approach is reserved for hernias that are at low risk for recurrence: very small hernia defects and inital hernias in patients with ‘minimal risk factors for recurrence, such as obesity and smoking. Primary repair of an abdominal wall hernia must be carefilly considered, because mesh repairs have much lower recurrence rates. Mesh Repair ‘Mesh repair involves placement of mesh to strengthen the repair and reduce tissue tension to minimize recurrence risk. Hemia mesh ean be broadly divided into absorbable or nonabsorbable and synthetic or biologie materials. Most commonly, a nonabsorbable synthetic mesh is used to achieve permanent closure of hernia defects. After implantation, abdominal wal tissues grow into the mesh pores, incomporating it into the 253abdominal wall to strengthen the repair. ‘Mesh is used mainly in hernias with a higher risk for teeutrence, because the use of mesh is associated swith ssk aswell. Mesh can cause local tissue reactions, which can lead to scar seroma formation, and erosion of the mesh into surrounding tissue. Erosion can be especially problematic when the mesh is located within the peritoneal space, in diret contact with visceral structures. Some meshes are intended for intraperitoneal implantation, manufactured with biochemical properties to mitigate this risk. As a foreign body, mesh is also susceptible to infection, which can be dificult to eradicate. Biologie mesh and absorbable meshes are less susceptible to infection than are the synthetic and nonabsorbable forms, because these meshes are incorporated into stues or filly dissolve, Therefor, biologic materials and absorbable synthetics are used in situations of intra-abdominal contamination or uncontrolled diabetes, where the risk of mesh infection is high and/or only temporary closuce is indicated. When the risk of mesh implantation is very high, primary repair ray be used even for large defects, acepting the risk of recurrence while minimnzing the rs of mesh- related problems “Meth can be implanted in a variety of ways (Figure 11-5). It can be placed ar a reinforcing layer to upport 4 primary closute, in either an onlay ishion, superficial to the abdominal wall musculature of a6 an undesly, ep to muscle. Underlay mesh may be placed inthe prepsitoneal space, reducing the risk of erosion by using the peritoneum as a protective ayer for the viscera, or intraperitoneal, commonly needed in situations where piior abdominal surgery har limited the ability to separate the peritoneum from the other layer of the abdominal wall. Mesh can also be placed asa bridge across a hernia defect when the native tissues cannot be brought together, in very large hernia defects, Mesh can also be placed between layers ofthe sbdomsinal wall 45 par ofa component separation repair, as discussed in the next section ‘Figuce 15 Positions in which mesh can be implanted during hernia repair, Note that sublay and retrorectus mesh fall under the section Component Separation Repair. (Ilustration by Nancy Beauregard, CHU de Québec—Université Laval, Quebec, Canada) 254Components Separation Repair ‘This isa specific ype of mesh repair that is generally reserved for larger, more complex midline abdominal ‘wall hernias, including recurrent hernias. This typeof hernia repair involves separation of the individual layers ‘of the abdominal wall to gain length for tissue approximation to close the hernia defect. There are multiple techniques, most of which are beyond the scope of this chapter. For understanding, however, an example includes an anterior components separation that can be performed by dividing the external oblique aponeuross ateraly along the length of the abdominal wall (Figure 11-6). Beeause muscle fascia has a limited ability to stretch, incision of the aponeurosis allows the more flexible muscle to be pulled across a large hernia defect, approximating healthy tissue at the midline, Although these manewvers can produce up to 10 to 12 em ‘of advancement toward the midline for defect closure, components separation can aso be used to facilitate the placement of preperitoneal underlay mesh, as a barier against erosion, 255gure 1:6 A, A midline ventral hemia. B, A postoperative view after hemia repair with anterior components separation. Note the relaxing incision of the external oblique aponeuross laterally to the rectus muscles, The ecper abdominal wall layers are sil present, keeping the abdominal wall intact. (Images from Weaner SD, Fleshman JW, Fischer JE. Maver Technique in General Surgery Colon and Rectal Surgery Abdominal Operations Philadelphia, PA: Lippincott Wiliams & Wilkins, 2019. Copyright © 2019 Wolters Kluwer) inimally Invasive versus Open Approach Abdominal wall hernias can be repaired as deseribed previously through an open incision or through minimally invasive (laparoscopic or robotic) approach. ‘The advantages to minimally invasive approaches are less potential incisional motbidity, shorter length of stay, and quicker recovery when compared with open approaches. ‘The largest benefit of minimally invasive repair is significant reduction in surgical infection; however, these procedures can be more difficult because of the lack of tactile feedback and more restricted motion when compared with open surgery. Additionally, minimally invasive approaches may require further lysis of adhesions remote from the actual hernia ste, because laparoscopic and robotic ports ate often placed at some distance from the hemia and the abdominal wall must be cleared to those areas, Patients who undergo these approaches must also he abl to tolerate general anesthesia to allow for intraoperative paralysis, ‘As a result, the open approach generally has the advantage of potentially being more straightforward with a shorter operative time. The open approach may also avoid the need for paralysis, and therefore may not demand general anesthesia, as well as avoiding the need for distant adhesiolyss. Finally, an open approach makes more sense when concomitant skin removal or scar revision is requted Common Postoperative Issues Seroma Seroma can develop in the space previously occupied by the hernia contents or in other potential spaces that may have been created during dissection (Figure 11-7). Often, the peritoneal hernia sac is excised to reduce the tsk of seroma formation, but sac excision does not completely eliminate the tsk of seroma, especially among large hernias. Seromas can often be palpated, and the bulging raises concerns for possible hernia recurrence, On exam, the seroma will not increase in size with Valsalva, whereas hernia recurrence would, and seromas typically are not painful If physical exam is insufficient to confirm the diagnosis, ultrasound or CT can be used to clarify. In general, seromas will resorb aver time and do not requite any intervention. Drainage of an otherwise uncomplicated seroma is not recommended because it can lead to infection, 256igus 1-7 A postoperative seroma after incisional hernia repair as seen on computed tomography (axial view). Note the radiodensity on either side of the fluid collection representing tacks placed to fixate the edges of the mesh Infection Surgical site infection is problematic in hernia repair because it can lead to poor fascial healing or mesh infection requiring explantation, both of which increase the risk of hernia recurrence, Prevention is critical through the use of preoperative antibiotics, avoidance of mesh implantation in contaminated elds, ization of patient comorbidities, and using 2 minimally invasive approach when possible. Early recognition and management of superficial infection is critical in limiting the spread of infeetion from superficial tissues to the underlying mesh. Neuropathic Symptoms Periodically, patients undergoing abdominal wall hernia repair develop neuropathic symptoms related to intraoperative nerve damage, presenting as numbness, tingling, and hyperesthesia, Typically, minor issues ace selflimited, although some patients require local injection, steroids, and medications for neuropathic symptoms. This is a mote significant issue with hernias of the MPO. Recurrence Al hernias have the potential to recur following repair, Prior abdominal surgery, obesity, age, smoking, patient level of activity, and the presence of chronic coughing or straining are factors that increase recurrence risk, Patients who have undergone hernia spar should be evaluated when new of recurrent symptoms arise to rule out the development of recurrent hernia, If physical exam is insufficient, further imaging with ultrasound or CT is appropriate MYOPECTINEAL ORIFICE (GROIN) HERNIAS Anatomy 257‘The groin hernia is notable for its extremely complex anatomy. All groin hernias are caused by a defect of the MPO of Fruchaud. ‘The MPO is an atea of inherent embryologie weakness in the pelvis caused by the egress of the testicle or round ligament and the ilise neurovascular bundle from the intra-abdominal compartment. Myopectineal Orifice Boundasies ‘There are clear boundaries of the MPO. The inferior boundary isa ridge on the superior pubic ramus known as the “pectineal ine or Coopers ligament.” ‘The lateral boundaty is the medial edge of the iliopsoas muscle. ‘The superior boundary is made of muscle fibers from the transversus abdominis and internal oblique, These fibers curve to intersect the medial boundary, the rectus muscle. Of note, 3% to 696 of the time, the muscles of the superior arch continue parallel to the rectus as a tendon inserting upon the pubic tubercle itself, known as ‘the “conjoint tendon.” ‘The MPO is nota plane but a cylinder (Figure 11-8). The irregular three-dimensional shape of the MPO changes when viewed from the anterior perspective (as seen in an open inguinal hernia repat) or the posterior perspective (asin a minimally invasive approach). Its shape is considered somewhere between an egg as seen. anteriorly and a quadrilateral as seen posteriorly (note the egg shape on the left of Figure 11-8). Femoral vein Femoral canal TB brevior pace Page 1-6 A schematic of the myopectineal orifice (MPO). Note the cylindrical shape that tunnels through the lower abdominal wall on the left groin. The right groin shows the anatomic structures passing through the space, with the relevant labels and locations of MPO hernias shown in the inset, left. (Illustrated by Charlotte R, Spear and Marco A. Marchionni,) Myopectineal Orifice Spaces ‘There are three types of MPO hernias: femoral, indirect inguinal, and direct inguinal hernias, differentiated by the area of the MPO in which they occur (sce Figure 11-8). The MPO is subdivided into two spaces by the ilioinguinal ligament (or Poupatt’s ligament), which runs obliquely from the anterior superior iia eres to the pubic tubercle, The area inferior to th ilioinguinal ligament is called the “femoral canal.” This inferior space of the MPO is where the femoral nerve, artery, vein, and lymphatics run. The “empty space" between 258the nerve and lymphatics is known ac the “femoral epace” and is where femoral hernias occur. The MPO space superior to the ilioinguinal ligament is called the “inguinal canal” and is where the spermatic cord oF round ligament exits the abdominal cavity. This is the space where the two primary types of MPO hernia, inditect and direct inguinal hernias, can be found, Inguinal Canal Anatomy Understanding the similarities and differences between direct and indirect inguinal hernias requires knowledge of the anatomy of the superior space of the MPO, known as the “inguinal canal." Importantly, the MPO does not contain any muscular layers, in contrast to the main abdominal wall. The superior space of the MPO is covered only by the transversilis fascia posteriorly and the aponeurosis of the extemal oblique anteriorly, the transversus abdominis and internal oblique muscles having ended as the superior border of the MPO, Specifically, the superior MPO space is bounded by the diagonal line of the ilioinguinal ligament inferiorly and laterally, the rectus muscle medially, the transverslis fascia posteriorly, and the aponeurosis of the external oblique anteriorly. The entrance of the spermatic cord or ound ligament to the inguinal canal is through a cephalad, posterior opening in the transversalis fascia, This is called the “internal inguinal ring," and is covered anteriorly by the aponeurosis of the external oblique. ‘The exit of the canal is a caudal anterior opening through the external oblique aponeurosis, called the “external ring,” which is covered posteriorly by the transversalis fascia. ‘This angled peneteation through the abdominal wall layers at two different points maximizes closure of the inguinal canal ater descent of the testicle; the fact that the “descent” of the round ligament leaves no grossly visible strcture is why inguinal hernia anatomy is commonly deseribed using a rule example, which will be continued here Embxyologic Considerations derstanding the path of descent of the testicle helps clarify the anatomy of the inguinal canal, Fist, che testicle exits the abdomen through the intemal rng inthe tansverais facia and enters the inguinal canal ‘The testile then travels medially through the narrow space between the transversal fascia posteriorly and the ‘extemal oblique aponeuross anteriorly, moving within the abdominal wall It then exits the canal through the exteznal sing, the hole inthe externa oblique aponeuross. As the testicle descends thzough the internal ring, the spermatic cord is wrapped by inferior fibers of the internal oblique, forming the eremasterc muscle, and it is temporarily enveloped by peritoneum, When the testicle arrives at its final position in the serotum, the peritoneal connection knovn as the “vaginal process” should invaginate, eliminating direct connection with the pesitoncal cavity, The envelope of residual peritoneum directly adherent to the testicle remains as the tunica vaginalis, If the connection between the tanica vaginalis and the intr-abdominal peritoneum fils to invaginate, the result isin a “pediatric hernia” in young chikiren. If left uncorrected, the peritoneum in the scrotum will expand, fill with fhid, and become a hydrocele (Figure 11-9). Tie peritoneum also eave ‘through the inguinal canal within the confines of the spermatic cord 259Connection Vaginal between Process peritoneal: Hydrocele cavity and tunica Ductus deferens vaginalis Epididymis Tunica vaginalis igue 1-9 The process of hydrocele formation, when the vaginal process fails to fully invaginate. (From Sadler ‘TW. Langman's Medical Fmbryolegy. 12th ed. Philadelphia, PA: Lippincott Williams 8 Wilkins; 2012. Copyright © 2012 Lippincott Williams 8¢ Wilkins, A Wolters Kluwer business ) Inguinal Canal Spaces Both dizect and indirect hernias are caused by protrusion of abdominal contents into the inguinal canal through the transversal fascia defect, or internal sing. The difference between the indirect and direct hernias is the exact location of the transversalis defect. Just asthe MPO is divided into superior and inferior spaces (che inguinal and femoral canals) by the ilioinguinal ligament, the superior space (inguinal canal) subdivided vertically into wo spaces by the inferior epigastric artery and vein see Figure 11-8) [An indizect inguinal hemia occurs when abdominal contents hernate lateral to the epigastric vessels. The sac of an indiect hernia will protrude through a weakened inteenal inguinal ring and will follow the spermatic cord within the abdominal wall. This isthe same course taken by a pediatric hemnis or hydrocele, and most Inydrocels found later in life do have an associated indirect hernia and are congenital, A direct inguinal hernia occurs medial to the vasulature. The direct space is historically named Hesselbachs triangle, covering a large part of the floor ofthe inguinal canal. When there is a defect in Hesselbachs triangle, the hemia sac goes directly into the inguinal canal, andthe distal aspect will abut the spesmatie cord but does not travel through the internal ring along with it Myopectineal Orifice Hernia Types We now have defined three spaces where hemias can occur within the MPO. The space below the ilioinguinal ligament, the inferior space of the MPO, is where femoral hernias occur, The two spaces above the ilioinguinal ligament are, laterally, the indizcet, and medially the direc, spaces of the superior MPO, which can each develop hernias of the same name. A patient may have 2 hernia in one, :wo, or all three of these spaces, A hernia in both the direct and indirect space is called a “pantaloon hernia’; there is “leg” of peritoneum in both spaces, split by the fixed epigastric vessels, Women rarely if ever have direct inguinal hernias, The most common of the three MPO hemias in ‘women is the indirect hernia. It is important to note that women have a much higher incidence of femoral hernias than men, as a wider pelvis means a wider potential opening into the femoral space. 260Special Situations Other presentations of MPO hernias inchude a Richter’s hernia, where only a portion ofthe circumference of the bowel is incarcerated or strangulated through the hemia defect. This is quite dangerous, because the patient will nor have symptoms of bowel obstruction, because the bowel lumen is not involved, and strangulation can present with only pain. A sliding heenia occurs when the serosa of an organ is past of the ‘emia sac. Tis is more common in direct hernias because of the diteet path into the inguinal canal. It is dangerous because opening the hernia sa into a sliding hernia could eause intestinal contents to spill into the ‘hernia repair, preventing the use of mesh. A Littre's herni recurs when 2 symptomatic Meckel’s diverticulum is found in the hemia sac, and an Amyand’s ern contains the appendix. Clinical Considerations Patient Presentation, ‘The best next step in the management of the patient depends on the severity of symptoms. It has been shown that an asymptomatic hernia or a minimally symptomatic MPO hernia rarely causes complications; therefore, ‘watchful waiting is safe and surgery is not requized, but most will require repair in the future. In contrast, asymptomatic femnoral hernias should be repaired because they are more likely to incarcerate or staangulate Patients with symptomatic MPO hhemias have a bulge in the groin. The bulge may enlarge with any increases in intra-abdominal pressure, such as lifting or coughing, MPO hernias are typically associated with discomfort, frank pain, burning, or a dll ache that is worse after a long day of standing. On physical exam, the bulge of «director indirect inguinal hernia wil initiate above the ilioinguinal ligament but may extend all the way into the serotum or labia majora. A femoral hernia will be felt entirely below the ilioinguinal ligament. If physical exam is not confirmatory, ultrasound may be helpful, but CT and MRI usually are of no benefit. The patient or healtheare provider should be able to at least partially reduce the bulge in a straightforward symptomatic hernia, “The issues of incarceration and strangulation apply to MPO hernias in much the same way as main abdominal wall hernias. Reduction of newly incarcerated hernias may be attempted in hemodynamically stable patient without lab abnormalities, with postreduetion monitoring. Clinical signs concemning for strangulation will warrant operative exploration, sometimes requiring a separate laparotomy incision ifthe extent of ischemia cannot be filly evaluated via a groin incision, Surgical History Operative strategy will be different if this is a first-time MPO hernia or a recurrence, and a history of prior abdominal surgery may signify the need for distant lysis of adhesions in a planned minimally invasive repair. Hernia-Specifie Factors ‘The primary assessment in an MPO hernia is whether the hernia bulge initiates above or below the inguinal ligament; this is, whether an inguinal or femoral hernia is present, but there is no physical exam finding or imaging study chat will reliably differentiate indiect from direct inguinal hernias, Surgical techniques for repair of inguinal hernias are identical, whereas femoral hernias, ying in the inferior space of the MPO, require different repair techniques, because closuze ofa different MPO space is required. 261Surgical Approaches Surgical options for MPO hernias are based on surgeon preference, as well asthe presentation ofthe patient All surgical approaches adhere to the same overriding principles: hernia repairs should be performed in & tension-free manner, and mesh should not be used in contaminated wounds, ias of the MPO, but these ean be broadly divided into ‘wo categories: the anterior (open) approach and the posterior (minimally invasive) approach. Although these ‘There are a variety of surgical approaches to he ‘wo approaches can be used for hernias of the main abdominal wall as well the irregular shape of the MPO. causes the anatomy to be quite dissimilar, depending on the surgeon's viewpoint Anterior Approxch ‘The anterior, open approach for inguinal hernias requires an incision over the inguinal canal. The roof of the canal (aponeurosis of the external oblique) is opened, the heria is reduced, and the direct and/or indinect defects in the floor of the inguinal canal are repaired. Thie can be done with or without mesh, but a mesh ‘repair is standard for the MPO today. Lichtenstein Mesh Repair An anterior repair performed with mesh, which covers the anterior surface ofthe floor of the inguinal canal, is also known as a “Lichtenstein repair,” named for the surgeon who popularized the technique. In a typical Lichtenstein repair, mesh is affixed to the floor of the inguinal canal and covers both the direct and indirect spaces of the MPO, superior to the iloinguinal ligament. The edges of the mesh are fitted to the boundaries of the superior space of the MPO (Figure 11-10). A keyhole is fashioned in the mesh superiorly to allow the spermatic cord to enter the inguinal canal, thus creating a new internal inguinal ring. The aponeuross of the external oblique i closed over the mesh but left open inferiorly, creating 2 new external inguinal ring. gure 1110 Tn a Lichtenstein repair, the mesh is used to bridge the aponeurotic arch superiorly and the inguinal lament inferiorly. (From Hawa MT, Mulholland MW. Operative Tecbnigues in Foregut Surgery Philadelphia, PA: Wolters Kluwer Health; 2015. Copyright © 2015 Wolters Kluwer Health) ‘Tissue Repairs Although the use of mesh in the anterior approach is standard today, because the repair has less tension, 2 262lower recurrence rate, and less pain, itis important to understand the use of classical open approaches known as “tissue repairs” These repaits are useful in situations of a contaminated field, because they eliminate the need for placement of mesh and help limit the risk of infection, and are, therelor, still used today, although rarely. Although technical details of tissue repairs are not asked on standardized test, they are frequent topics of questioning by attending surgeons on the wards, especially regarding their use in femoral hernias. Tissue repaits are surmmatized in Table 11-1 nal ‘Tame Cored McVay Conjiattnden to CoopesHgament Femoral + Relaingindbion seeded to medially conjoint tendon to Dee seduce tenon” singin iment ately Indect Bovrnt —Conjinttendon olininguinal ‘Direct. aaa ee ale ganeat Indect seduce wate” + WaLNOT repisfemorl hei ‘Shouldie Complex, multayred separ Dice + Reporely tension ee Indivet + WaLNOT rep femoral eri + Mayhavelowest recurrence rateof omepi Sila the proces dese obra ofthe main abdominal wal ete secon Components Sparaton Rai Posterior Approach ‘The posterior approach for inguinal and femoral hernias ie unually performed cither laparoscopically or robotiealy. The two primary minimally invasive techniques are the total extapesitoneal (TEP) approach and the transibdominal preperitoneal (TAPP) approach. Both posterior approaches use three small incisions and always use mesh. Interestingly, the posterior mesh approach isthe only approach in which a single piece of sesh wil cover all thre spaces of the MPO (direct, indirect, and femoral) Iti for thie reason that femoral hernias shouldbe repaied with a posterior approach ‘The primary difference between the two posterior techniques is the placement of the camera and instruments relative tothe peritoneum. The TEP procedute does nat involve entering the true intraperitoneal abdomen, A space is made between the rectus muscle and the peritoneum through which the entire operation is performed. It can only be done wsing laparoscopic equipment. With the TAPP procedure, the abdomen is entered in the same fashion as any other minimally invasive procedure, The peritoneum is then stipped off ‘the entire MPO, the mesh is placed, and then the peritoneum is reattached. ‘This can be done laparoscopically 4s well as sobotically. Both procedures sandwich « piece of mesh between the peritoneum and the MPO, and arc equally useful for direc, indirect, and femoral heenias (Figure 11-11) 263ect hia te lotr eps vess Spermatc cord ‘oep inguinal ing — tema ine essts ge 1:11 A, Anatomy of the inguinal canal, intrasbdominal view. B, Laparoscopic repair using total extraperitoneal approach, The mesh cavers the enite inguinal floor, including the posterior rectus sheath and its insertion on the pubis. (A, Reprinted with permission from Hawn MT, Mulholland MW, eds. Operative 015; Figure 34-1. B, From Jones DB, Fischer JE. Master Technigus in Surgery: Hernia. Philadelphia, PA: Lippincott Willams & Wilkins. Copyright © 2013 By Lippincott Williams 8 Wilkins, A Wolters Kluwer business) Techniques in Poregut Surgery. 1st ed. Philadelphia, PA: Wolters Khiwer Healthy Choosing a Technique When choosing the optimal surgical approach to hernia repair, the surgical approach should be tailored to the specific needs ofthe patient, Fits asa rl, mesh repairs should be offered to all patients regardless of whether an open or minimally n of the invasive approach is choten, This is assuming a mesh repair is not contraindicated by co 264surgical field in cases of strangulated hernias with ischemia or necrosis, or inadvertent bowel injury. Secondly, minimally invasive techniques have been shown (0 improve the speed of patient recovery because of less acute pain. Minimally invasive repairs are now strongly recommended for unilateral, frst time, and femoral hernia repaits. Additionally, they ate the preferred technique in women, because they ean repair occult femoral hernias. Surgical repair of MPO hernias has evolved. Large, open, mesh-fiee repairs such as che MeVay and Bassin’ repairs have been supplanted with less morbid, open, mesh repairs such as the Lichtenstein repair With the introduction and evolution of minimally invasive technologies as cost-effective options with even lower morbidity than open procedures, these approaches allow early and safe return to normal activities Common Postoperative Issues Nowadays, repairs of MPO hernias, whether by an anterior or posterior approach, are performed in the outpatient setting. As patients leave the medical setting immediately after completion of the repair, it is critical to counsel them regarding expected postoperative conditions, It is common for the patient to experience postoperative swelling or cechymoses in the serotum, lab, oF penis. This ean be very alarming to patients, Because the swelling and ecchymoses will be dependent and therefore located at some distance from the visible incisions. The use ofa scrotal support may help with these symptoms in male patients Neuropathic Symptoms ‘Neuropathie symptoms are much more common following MPO hernia repair, compared with the repair of main abdominal wall hernias. Ifan open approach is used, a zone of bypoesthesia may be observed at the skin incision, With regrowth of superficial innervation, the patient may notice symptoms of paresthesia such as burning or tingling Unfortunately, 596 to 10% of patients will experience chronic pain following MPO hernia repair. Chronic ‘pain is defined as pain at che repair site that persists longer than 12 weeks. There are three nerves that can be entrapped or damaged in the zone of hetnia repair, The most notorious of these is the ilioinguinal nerve, ‘which runs within the inguinal canal and along the course of the spermatic cord or round ligament. Patients ‘with injury to this nerve will present with pain radiating to the scrotum or labia, which worsens with sitting for long periods. On exam, there is typically numbness over the hemiscrotum or labia majora and the medial thigh. The ilioinguinal nerve does not pass through the internal inguinal ring and is, therefore, more ‘commonly damaged during an open approach to the inguinal canal. Damage to the genital branch of the _genitofemoral nerve will present similatly. The genitofemoral nerve does pass through the internal inguinal ring and is, therefore, most often damaged during a minimally invasive hernia repair. Finally, damage to the lateral femoral cutaneous nerve causes numbness to the anterior and lateral thigh. ‘There are numerous causes for this, mainly related to external compression, but injury to this nerve can also be caused during repair of MPO hernias. Occasionally, patients can feel the mesh used to repair the hemia, which can eause prolonged Aiscomfore at the site, Orchitis Restriction of blood flow to or ftom the testicle may cause orchits. This is more common in recurtent hernia 265reptir, because the pampiniform venous plexus will have been compromised in these patients because of scaring from prior repair. The patient may present with a swollen and tender testicle; this must be ilferentiated from the swelling alone that commonly follows MPO hernia repair. Orchitis is generally sell limiting and nonsteroidal anti-inflammatory drugs (NSAIDs) should be suficent treatment. Its uncommon to fully devascularize the testicle, because there is cola al circulation fom other arteries. In the long term, however, testicular atrophy can be expected in any testicle with compromised circulation. Pubic Inguinal Pain Syndrome ‘There are times when a patient will present with groin pain and no clear hema on exam, This presentation ‘as first recognized in athletes, causing it to historically be called “sports hernia.” Other common terms are inguinodynia,atbetc pubalgia, Bockey groin, oF Gilmore's groin. Typically, itis caused by a strain of the muscles of adduction that insert onto the pubis, There is an extensive differential diagnosis for this syndrome (Table 11-2), ipa injoiee (Genioutnay Ganoineninat Tnrabdominal herons Talseesiey Dowel ca Diveseliie eect tenet enone ‘A detailed history will often demonstrate that the patient acutely felt @ tear of a strain when lifting, coughing, or participating in sports that require rapid acceleration, Exacerbating factors need to be elicited, such as the complaint of an ongoing pulling or teasing sensation in the groin with activity. Additionally, sudden movements such as forceful rotation may exacerbate the pain, whereas rest will mitigate the symptoms, although the pain will retumn with the resumption of activities, In case of chronic groin pain, there will often, be an evolution of symptoms, typically worsening with ongoing activity. Most importantly, it has to be 266,determined whether the patient has ever felt a groin bulge. All patients should be asked about change in theie bowel or bladder habits, because associated pelvic floor weakness could cause constipation or urinary fiequency. “Phe examination should begin with the patient in upright position. If an inguinal hernia is present, it should be easily palpated, especially with a Valsalva mancuver. Ifno hemia is demonstrated, exam ofthe groin is repeated in the supine position. The purpose of ths isto isolate and demonstrate the injured museular or tendon insertion points. To evaluate the adductor longus, the hip should be rotated, flexed, and extended with and without resistance. The patient may have pi ‘with digital pressure on the adductor longus insertion with is maneuver, The insertions of the recs musee, transverlis fascia, and aponevrosis ofthe external oblique ‘onto the pubis should be assessed as well. Palpation ofthese insertion points during a “st-up” maneuver may bbe helpfil in identifying the injured structure, On examination of the pubic tubercle, pain upon palpation suggests osteitis pubie asthe source. ‘As discussed previously, radiologic studies surely play a ole in diagnosing a patient with a demonstrable ingpinal hernia. An ultasound may be wsed inthe diffcul-to-examine groin to rule out a hernia or testicular pathology. A CT can evaluate other pathologies of the gzoin and is les operator dependent than an ulteaound. MRI, however, i the exam of choice when tendon and muscle injuries are suspected in pubic inguinal pain syndcome. MRI can reveal asymmettic develapment ofthe muscles or inflammation af the pubie ‘fascia, [osteitis pubis ie suspected, a bone scan should be ordered ‘When pain in the inguinal region isthe major complaint and a symptomatic hernia is not the primary ‘cause, nonsurgical treatment isthe best approach, Numerous studies have demonstrated that pain prior to surgery isthe greatest predictor of developing chronic, debilitating pain after surgery. The sgniicance ofthis ‘cannot be overstated. Nonsurgical management is the nest best step and inchudes NSAIDs, limitation of activity, and physical therapy/chabiltation. Eventual surgical management of a concurrent inguinal hernia in unresolved groin strain is a decision that roquizes substantial thought by the surgeon, a6 well as candid discussion with the patient regarding the likelihood of a postive outcome. OBTURATOR HERNIA “The obturator hernia isa distinct category of hernia that does not fit well within the categories of abdominal ‘wall or MPO hernias. An obturator hernia isthe result of a defect in the pelvic floor at the obturator canal, an area inferior to the MPO (Figure 11-12). ‘There is commonly small bowel hemiating through the defect, i, emaciated, multiparous woman with crampy abdominal pain and medial thigh pain; itis, therefore, nicknamed “the litle old lady hernia.” ‘which causes symptoms of impingement of the obturator nerve. A notorious presentation ir a 70-year 267Most common: Jnguinal heenia {anatomically weakest) ‘Less common femoral hernia {anatomically less weak) Rare: ‘obturator hernia {anatomically least weak) Fyue 1112 Schematic depiction of the relationship of the obturator hernia compared with hernias of the rmyopectineal orifice. (From Jones DB, Fischer JE, Master Technigues in Surgery: Hernia. Philadelphia, PA: Lippincore Williams & Wilkins. Copyright © 2013 By Lippincott Williams 8 Wilkins, A Wolters Kluwer business) ‘The diagnosis of an obturator hemi is difficult and requires a very high level of suspicion, because the hernia is rare and its presentation is intermittent, In the acute setting, the patient may have a severe, concurrent small bowel obstruction. On exam, the patient may have paresthesias or shooting pain on the anteromedial thigh. ‘The pinching of the nerve by the hernia contents is exacerbated by medial rotation ofthe thigh, a clinical maneuver called the “Howship-Romberg sign.” Rarely, the hernia itself ean be felt as tender mass on rectal exam. ‘Typically, the diagnosis is made by a CT’ or during surgery for the management of a small bowel obstruction, With the increasing popularity of minimally evasive hernia repair for MPO hernias, asymptomatic, early obturator hernias are being identified more frequently. However, these are not generally repaired independently, but rather atthe time of surgical management of a small bowel obstruction CONCLUSION Hernia anatomy, no matter the sit, is complex and ean be confusing. The most important principles in this chapter relate to the identification of hernias that sequre surgical attention for elective or emergent repair, the understanding of how to reduce patient risk factors prior to surgery, and the complications that ean occur postoperatively. These concepts willbe clearest with a good understanding of the anatomy. However, they are universal for hernias ofthe main abdominal wall, MPO, and obturator canal equally. SUGGESTED READINGS American College of Surgeons. ACS Surgical Risk Calculator. htp/riskealeulator.faes.org/RiskCaleulator/ ‘Accessed May, 2018, 268Augenstein VA, Colavita PD, Wormer BA, ct al. CEDAR: Carolinas equation for determining associated sks, J Am Call Surg. 2015;221(4):S65-S66. Ellaar ©, Choi HR, Dills VD, et al. Groin injuries (athletic pubalgia) and return to play. Sports Healt 2016384)313-338, HeaniaSurge Group. International guidelines for groin hernia management. Horna, 2018;22(2):1-165, Questions (Choose the best answer fr each question. 1, A'S7-year-old male construction worker presents tothe office with a complaint ofa bulge of his ‘midline abdominal wall. He first noticed it about 2 years after he underwent an uncompliated open splenectomy following a fill at work. He reports that the bulge has been getting larger, and the will have an occasional slight pain a the ste with heavy lifting. He was diagnosed with diabetes mellitus 2 weeks ago and started to take an ora hypoglycemic agent last week, and is a current smoker. He is obese. Physical exam confirms an easily reducible incisional hernia witha palpable defect of 6 em, What isthe next best step in his cate? A. CT ofthe abdomen and pelvis for operative planning. Optimizing modifiable risk factors to reduce postoperative complications Elective open hernia repaie with biologic mesh woe Emergent open hernia repair due tothe risk of strangulation TAP block to alleviate the patient's discomfort pe 2. A.42-year-old female presents to the office with a complaint ofa bulge of her upper midline abdominal wall, Her medical history consists of spontancous vaginal delivery of full-term triplets She reports that the bulge has become more prominent since recovering from the birth of her childzen, but she otherwise has no complaints, Physical exam reveals an otherwise thin woman “with 2 midline abdominal bulge on Valsalva and laterally displaced rectus muscles, but there is no visible or palpable mass or hernia defect. In addition to ordering CT of the abdomen and pelvis {for confirmation, how should this patient best be counseled? A. Reassute her that as you cannot feel the defect, it must be small and watchful waiting is appropriate [B, Inform her that you are concerned about the presence of Spigelian hernia. ©. Reassure her that her condition is not a trie abdominal wall defect and requires no intervention. [D. Inform her that you will need optimive her risk factors prior to hernia repair. IE, Ask her to take time off from work to minimize her chances of ineareeration, 3, A.27-year-old man presents to the emergency department for severe abdominal pain located at his “umbilicus over the last 4 hours. He reports having 2 bulge at his umbilius for 3 years, which 269would “come and go,” but is now “stuck His temperature is 101.7, his hear rate is 15 beats/minute, and his blood pressure is 143/92 mm Ig, His physical exam revels a softly distended abdomen with severe tenderness to palpation at a5 em bulge effacing the umbilicus. “The skin overlying the bulge has a purple discoloration, His white blood cell (WBC) count and lactate are elevated. What isthe next best step in his management? A. Admit the patient to the hospital for observation 1B, Administer narcotics for pain conteol and acetaminophen for fever. C. Plan for elective hemia repair wth biologie mesh D. Administer sedation for manual hernia reduction EE, Transfer the patient to the operating room for emergent exploration. 4, 65-year-old woman presents to the clinic with @ complain of a bulge in her left lower quadrant ‘She reports that she has some mild, persistent discomfort at the site. She has a history of end colostomy for perforated diverticulitis, which was reversed 5 yeats ago. Physical exam reveals an incarcerated hernia underlying her stoma site scar with a palpable defect of 2 em. The patient reports she would prefer to not have another surgery. What is important for her to understand regarding a nonoperative approach in her case? A. She is ata higher risk for infection, because this isthe site of 2 prior stoma, BB, She is at higher risk for complications, because the hernia is incarcerated. . She i at «higher risk for complications, because the hemia is not on the midline D. She is at a higher risk for the hernia enlarging, because itis not on the midline, EE, She is ata higher risk for strangulation because of her age. 5, 39-year-old man presents to the office for consultation regarding repair of his incisional hernia. ‘The hernia occurred after an exploratory laparotomy following 2 motor vehicle collision, and is ‘nereasingly painful with activity. His past medical history consists of well-controlled asthma requiring a rescue inhaler once 2 month, and diabetes mellitus with a recent hemoglobin A1C of 6.5%, He is sedentary and enjoys playing video games. Physical exam reveals a body mass index of 44.2 kg/mm?, and a periumbilical midline bulge that i reducible. Which of this patient's factore predict a higher risk of hernia recurrence after repair? |A. Prior surgery due to trauma BB. Increased coughing due to asthma . Presence of diabetes mellitus D. Low activity level E, Morbid obesity Answers and Explanations 1. Answer: B Prchabilitaton and reduction of modifiable risk factors are critical in planning for repair of asymptomatic ‘or minimally symptomatic hernias. For this man, weight management will reduce morbidity and the risk 270of recurrence, smoking cessation will ssist wound healing, and his hemoglobin A1C must be <7-4 prior to elective repair of his hernia, CT is not necessary in this first-time hernia, ‘There are no ismues of contamination to suggest that biologic mesh should be used. Emergent repair is not necessary for a reducible hernia, TAP block is used for pain control in the postoperative setting, For more information ‘on this topic, please see the section on Patient Factors 2. Answer: C ‘This woman has rectus diastasis, as shown by the physical exam finding of a mine bulge with lateral displacement of the rectus muscles and the absence of a hemia defect. She was at risk for this eondition because of he prior pregnancy. Rects diastase nota condition requting surgical repair, and therefore, she can be reassured and does not requir optimization of rik factors. Alo, because diastasis has no true defect ofthe abdominal wall, there is no chance of incarceration, Small hernia defects areata higher tsk ‘of complications, and watchful wating may not be appropriate, Although a Spigelian hernia would not Ihave palpable defect, i is located off the midline, For more information on this topic, please see the section on Main Hernia Typee. 3. Answer: E, ‘This man has an acutely incarcerated hernia. However, his fever, tachycardia, skin discoloration, and elevated WBC count and lactate ate extremely concerning for strangulation of hernia contents ‘Therefore, he equires emergent operative intervention, and the hernia should not be reduced for fear of reducing ischemic or necrotic tissue back into the abdomen, Observation is appropriate after manual reduction of an acutely incarcerated hernia in a non-ill-appearing patient. Symptomatic control with acetaminophen and narcotics will not resolve the primary issue, and strangulation of the contents prevents consideration of elective be repair, For more information on this topic, please se the section ‘on Clinical Presentation. 4, Answer: B ‘This woman has an incisional hernia, which has al the same risk factors of any other hernia of the main abdominal wall. The patient's age and the hernia location off the midline do not impart any increased risks, The increased risk of infection is present only with active (current) contamination, not a history of ‘bowel spillage from the stoma at the site. The fact that the hemia is incarcerated means it is at higher Fisk for bowel obstruction or strangulation than a reducible hernia. The patient must understand her increased risk in order to proceed with observation. For more information on this topic, please see the section on Clinical Considerations under the heading “Abdominal Wall Hernias” 5. Answer: “Modifiable risk factors must be minimized prior to clective hernia repair. However, both thie man's asthma and diabetes are very well controlled, and improvement is unlikely to be made. Low activity level ‘will reduce, nt increas his isk of recurrence. The reason for his prior surgery, a traumatic injury, docs not affect recurrence risk, Morbid obesity, on the contrary isthe largest risk factor affecting 10 :ate after hernia repair. For more information on this topic, please see the section on Patient Factors. am272