Inguinal Hernias

Table 37-5
Introduction
Inguinal hernia repair is the most commonly performed Imaging
operation in US Most common radiologic investigation
75% of abdominal wall hernias occur in groin • Ultrasonography—least invasive
Lifetime risk • CT
• Men—27% • MRI
• Female—3%
Inguinal hernia repairs Treatment
• Men—90% Surgical repair is the definitive treatment
• Females—10% Non operative repair strategy is safe for minimally
70% femoral hernia repair are performed in women symptomatic inguinal hernias
The most common subtype of groin hernia in both sexes • Recumbent position aids in hernia reduction via
is indirect inguinal hernia. the effects of gravity
• Relaxed abdominal wall
Table 37-1 • Trusses externally confine hernias
However they don’t prevent complications
History Femoral and symotomatic inguinal hernias carry higher
Early management often involved a conservative risk of complications
approach in ancient civilizations of Egypt and Greece
Surgery only reserved for complications Open Approach
Late 1700s to eatly 1800s
• Performed sac dissection, high ligation and Tissue Repairs
closure of the internal ring Suitable alternative when prosthetic materials cannot be
• High recurrence rate used safely
1844-1924 era of tissue based repairs Indications
• Bassini repair McVay repair • Operative field contamination
• Shouldice repair • Emergency surgery
In the early 1980s Tension free repair (Lichtenstein) • The viability of the hernia contents is uncertain
MIS by laparoscopic method Bassini repair
• Transabdominal preperitoneal repair (TAPP) • The repair includes the ff.
• Total extraperitoneal (TEP) o Dissection of the spermatic cord
o Dissection of the hernial sac with high
Anatomy ligation
o Extensive reconstruction of the floor of
Anatomy of the Groin Region from the post the inguinal canal
perspective • Triple Layer Repair
o The internal oblique, transversus
Posterior view of the myopectineal orifice of abdominis and transversalis fascia are
Fruchaud fixed to the shelving edge of the inguinal
ligament and pubic periosteum
Retroperitoneal view of major inguinal nerves • Shouldice Repair
o Recapitulates principles of Bassini repair
Pathophysiology o Its distribution of tension over several
Inguinal hernias may be congenital or acquired tissue layers results low recurrence
Most adult considered acquired defects in the abdominal rates
wall • Mcvay Repair
Pediatrics mostly congenital o Addresses both inguinal and femoral
• Considered an impedance of normal ring defects
development o Is indicated to femoral hernias
• Failure of the peritoneum to close results in a o In cases of the the use of prsthetic
patent processus vaginalis material is contraindicated
• But not necessarily indicate inguinal hernia but o A 2-4cm relaxing incision is made in the
predisposes to develop inguinal hernia anterior rectus sheath vertically from the
pubic tubercle
Triangle of Doom o To reduce tension on the repair but
increases postop pain and higher risk of
Triangle of Pain ventral abdominal herniation

Table 37-2 Prosthetic Repairs

Table 37-3
Vary Degrees of closure of the processus
Diagnosis
History
• Frequently report groin pain
• Localize sharp pain and referred pain
• Pressure or heaviness in the groin
• Change in bowel habits and urinary symptom
may indicate sliding hernia
• Mesh based hernioplasty
• The most common performed by general
surgeons
• Popularization of tension free prosthetic mesh
repairs
Lichtenstein Tension Free Repair
• Inguinal canal/floor is reinforced with prosthetic
mesh thereby minimizaing tension in the repoair
• This minimizes medial recurrence
Plug Patch technique
• Modified LTFR

Digital exam of Inguinal Canal

 • A 3 dimensional prosthetic plug is placed in the • Due to higher theoretical risk of meshwork
space previously occupied by the hernia sac migration repair without fixation is not
Prolene Hernial System recommended
• Provides reinforcement to the anterior and
posterior aspects of the abdominal wall Trocar Site
Giant Prosthetic Reinforcement of the Visceral Sac
• Also knoen as STOPPA REPAIR Complications Specific to Herniorrhapy and
• Broad prosthetic mesh placed in the Hernioplasty
preperitoneal space from an anterior approach Hernia Recurrence
• Develops pain, bulging or mass at the site of
Laparoscopic Approach repair
Repairs reinforce the abdominal wall via a posterior • Common medical issues associated includes
approach malnutrition, immunosuppression, DM, steroid
Principal methods include use and smoking
• Transabdominal preperitoneal (TAPP) repair • Technical causes improper mesh size, tissue
• Totally Extraperioteal (TEP) repair ischemia, infection and tension in the
• Instraperitoneal Onlay Mesh (IPOM) repair reconstruction
They necessitate the administration of general • Diagnostic: Us, CT, MRI
anesthesia • Treatment posterior laparoscopic approach
This is superior than to open approach for bilateral or
recurrent inguinal hernia Pain
TEP and TAPP preferred alternatives for Lichtenstein • Acute or chronic
repair for recurrent hernias • 3 mechanism
o Nociceptive (somatic)-most common
Transabdominal Preperitoneal Procedure § Due to ligamentous or muscular
Useful for bilateral hernias, large hernia defects, and trauma and inflammation
scarring from previous lower abdominal surgery § Resolve spontaneously
o Neuropathic pain
Totally Extraperitoneal Procedure § Result direct nerve damage or
• The advantage is the access to the preperitoneal entrapment
space without intraperitoneal infiltration o Visceral Pain
• This minimizes the risk of injury to intra- § Refers to conveyed through
abdominal organs and port size herniation autonomic pain fibers
through an iatrogenic defect § Poorly localized
• Indicated for repair of bilateral hernia § Occur during ejaculation as a
result of sympathetic plexus
Intraperitoneal Onlay Mesh Procedure injury
• Permits posterior approach with preperitoneal o Chronic postoperative pain has been
dissection reported as many as 63% of inguinal
• Attractice procedure in cases where the anterior hernia repair
approach is unfeasible § 3 nerves possible involve in 70-
• In recurrent hernia that are refractory to other 90% of cases:
approach or where extensive preperitoneal • Ilioinguinal
scarring • Iliohypogastric
• Genitofemoral nerves
Prosthesis Considerations § Other chronic pain syndromes:
Synthetic Mesh Material • Local nerve entrapment
• Polypropylene and polyester are most common • Meralgia paresthetica
used • Osteitis pubis
• These are permanent and hydrophobic Greatest entrapment of II and IH in anterior repair
• They promote a local inflammatory response While the GF and lateral cutaenous nerves in
o Results cellular infiltration laparoscopic repair
o Scarring with slight contraction in size Irrespective of treatment the condition often takes
• Lightweight mesh material 6months to resolve

Biologic Mesh Cord and Testes Injury

• Used for contaminated cases • May result in ischemic orchitis or testicular
• Have lower tensile strength atrophy
• Higher risk of rupture • Occurs less than 1% of primary hernia repairs
• More durable and less prone to failure • In case of necrosis –ER orchiectomy
• Injury to vas deferens lead to infertility
Fixation Technique • In females the round ligament is the analog to
• The method of its fixation remains disputed the spermatic cord
• Suturing, stapling, and tacking prostheses entail
tissue perforation Laparoscopic Complication
• May cause inflammation, neurovascular injury Urinary Retention
and chronic pain development • Most common
• Improper prosthesis fixation may result in mesh Ileus and Bowel Obstruction
migration, repair failure, meshoma pain, and • Associated with higher incidence of ileus
hernia recurrence • This is self limited
• Fibrin glue fixation is alternative for track fication Vascular Injury
• Suture fixation show superior rates of chronic • Usually occur in iliac or femoral vessles—most
pain severe
 • Inferior epigastrics and external iliacs common
injured vessels
Visceral Injury
• Higher risks of injuring small bowels, colon, and
bladder
• Possible causes
o Trocar placement
o Electrocautery
o Instrument trauma outside of the camera
field
• Hematomas and Seromas

Outcomes
Among tissue repairs the Shouldice operation is the
most commonly performed technique
• Overall recurrence rate is 1%
The Lichtenstein technique overall recurrence rate is
0.2%.