HERNIAS

Marcelyn Coley
Mount Sinai School of
Medicine
Basic Science Lecture

Historical Perspective

15th century Castration with

wound
cauterization or
hernia sac
debridement

recommended a
truss

Father of Modern Inguinal

Hernia Repair

EDUARDO BASSINI

Hernia

Latin for rupture

an abnormal protrusion of an organ or

tissue through a defect in its
surrounding walls

Occur at sites where aponeurosis and

fascia are not covered by striated
muscle

Which of the following statements

is/are true regarding incidence of the
abdominal wall hernia?
A.
B.
C.
D.
E.

Two-thrirds of all inguinal hernias are

classified as indirect.
Femoral hernias are more common in
females than in males.
Direct hernias are common in females.
Hernias generally occur with equal
frequency in males and females
Premature babies have a 10%
incidence of having inguinal hernia.

Epidemiology

700,000 hernia repairs year

Inguinal hernias -75% of all hernias

2/3 Indirect, remainder are direct

Incisional hernias 15 to 20%

Umbilical and epigastric 10%
Femoral 5%

Epidemiology

Prevelance of hernias increases with

age
Most serious complication
strangulation

1 to 3% of groin hernias

Femoral highest rate of

complications 15% to 20%

recommended all be repaired at time of

discovery

Abdominal Wall
Anatomy

Anatomy

Inguinal ligament
(Pouparts) inferior
edge of external
oblique
Lacunar ligament
triangular extension of
the inguinal ligament
before its insertion
upon the pubic tubercle
conjoined tendon (510%)- Internal oblique
fuses with transversus
abdominis aponeurosis
Coopers Ligament formed by the
periosteum and fascia
along the superior
ramus of the pubis.

Inguinal Canal

Between deep and

superficial inguinal rings

Boundaries

Superifical external
oblique aponeurosis
Superior internal and
transversus
Inferior shelving edge of
inguinal ligament and
lacunar ligament
Posterior (floor)
transversalis fascia and
aponeurosis of
transversus abdominis
muscle

Inguinal Canal

Contains the
spermatic cord and
round ligament of the
uterus
Spermatic cord

Cremasteric muscle
fibers
Testicular vessels
Genital branch of
genitofemoral nerve
Vas deferens
Cremasteric vessels

Components of Hesselbachs triangle

include which of the following anatomic
landmarks?
A.
B.
C.
D.
E.

Pectineal ligament
Lateral border of the rectus sheath
Coopers ligament
Inguinal ligament
Inferior epigastric vessels

Terminology

Reducible can be replaced

within surrounding musculature

Incarcerated cannot be reduced

Strangulated compromised blood

supply to its contents

Sends sensory branches to the inner

thigh and medial aspect of the
scrotum
A.
B.
C.
D.

Ileoinguinal nerve
Genitofemoral nerve
Both
Neither

A sliding inguinal hernia on the left

side is likely to involve which of the
following?
A.
B.
C.
D.
E.

Jejunum composing the posterior

wall of the sac
Ovary and fallopian tube in a
female infant
Omentum
Sigmoid colon composing the
posterior wall of the sac
Cecum composing the
anteromedial wall of the sac

Terminology

Pantaloon direct and indirect components

Richters contains antimesenteric portion
of small bowel
Sliding involves visceral peritoneum of an
organ , i.e. bladder, ovary
Littres hernia contains Meckels
diverticulum
Petit hernia at inferior lumbar triangle
Grynfelt hernia at superior lumbar triangle

Groin Hernias

Indirect
Direct
Femoral

Inguinal Hernia

Classified as congenital vs. acquired

commonly thought that repeated

increases in intra-abdominal pressure
contribute to hernia formation

collagen formation and structure

deteriorates with age, and thus hernia
formation is more common in the older
individual.

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

Inguinal hernia

Male inguinal hernia

Female inguinal hernia

Diagnosis

Physical Exam
74.5% sensitive and
96.3% specific
examine the patient
in the standing and
supine positions
difficult to
distinguish direct
and indirect on
exam on alone

Diagnosis

Radiologic Investigations

Herniography
Suspected hernia, but clinical dx unclear
Procedure done under flouroscopy following
injection of contrast medium
Frontal and oblique radiographs are taken
with and without increased intra-abdominal
pressure

Ultrasonography
MRI
CT

Herniography

Left indirect
inguinal hernia

Right direct inguinal hernia

Direct Inguinal Hernia

Direct Inguinal Hernia

Medial to the
inferior epigastric
artery and vein,
and within
Hesselbach's
triangle

acquired weakness
in the inguinal
floor

Indirect Inguinal hernia

Abdominal contents protrude through

internal inguinal ring

Indirect Inguinal Hernia

Accepted hypothesis:
incomplete or
defective obliteration
of the processus
vaginalis during the
fetal period
remnant layer of
peritoneum forms a
sac at the internal
ring
more frequently on
the right

Femoral

More common in females

Up to 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

Femoral

palpation of the femoral canal just

below the inguinal ligament in the
upper thigh

NAVELS

Which of the following statements

is/are true regarding direct inguinal
hernias?
A. The most likely cause is destruction of
connective tissue resulting form physical
stress.
B. Direct hernias should be repaired
promptly because of the risk of
incarceration.
C. A direct hernia may be a sliding hernia
involving a portion of the bladder wall.
D. A direct hernia may pass through the
external inguinal ring.
E. Colon carcinoma is a known cause of
direct inguinal hernias.

Treatment

Non-Operative
Observation
Trusses can provide symptomatic relief

Hernia control in ~30% of patients

Operative

Bassini
Shouldice
McVay
Lichtenstein
Preperitoneal
Laparoscopic

Bassini (early 20th Century)

Shouldice (1930s)

Transversus abdominis to Thompsons ligament and

internal oblique musculoaponeurotic arches or
conjoined tendon to the inguinal ligament
Multilayer imbricated repair of the posterior wall of the
inguinal canal

McVay (1948)

Edge of the transversus abdominis aponeurosis to

Coopers ligament; incorporate Coopers ligament
and the iliopubic tract (transition suture)

BASSINI

MCVAY

SHOULDICE

Lichtenstein

First pure prosthestic, tension-free

repair to achieve low recurrence
rates

Prosthetic Repair

Polypropylene mesh most common and

preferred

allows 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 (PTFE) 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

Prospective study
Danish Hernia
database of over
13,000 hernia repairs
Compared reoperations for
recurrent hernia
Results: After 5 years
significantly lower
(1/4 less) recurrence
with mesh vs.
sutured repair

Laparoscopic

The cause of neuropathic

postherniorrhaphy inguinodynia
includes which of the following?
A.
B.

C.
D.
E.

Formation of scar tissue

Transection of the ilioinguinal,
iliohypogastric, or the
genitofemoral nerves
Suture entrapment of nerves
Staple entrapment of nerves
Periosteal reaction

Surgical Complications

Recurrence
Infection
Neuralgia
Bladder injury
Testicular injury
Vas Deferens injury

Other Hernias

Which of the following is/are true

statements regarding umbilical
hernias?
A. They are embryonic equivalent of a small
omphalocele
B. Repair in infants is usually deferred until
approximately 4 years of age
C. Repair in adults is usually indicated
D. The vest-over-pants type of repair is
stronger than simple approximation of
fascial margins
E. They are most common in Caucasian
infants

Umbilical
Incidence
Reported ~10%
several times greater in Black children
more common in premature children all
races
Most close spontaneously by age 2 or 3
Acquired rather than congenital in adults
Female to male ratio 3:1

Epigastric

midline junction of the

aponeuroses (linea
alba) between the
xiphoid process and
umbilicus
Paraumbilical hernia epigastric hernia that
borders the umbilicus
Estimated frequency 35%
More common in Males
3:1
20% may be multiple

Epigastric

Clinical

Often asymptomatic, incidental finding

If symptomatic, vague abdominal pain above the
umbilicus exacerbated by standing or coughing;
relieved in supine position
Severe pain secondary to incarceration/strangulation of
preperitoneal fat (often no peritoneal sac) or omentum
Exam: palpate small, soft, reducible mass superior to
the umbilicus
RARE to have strangulated bowel

Tx

Excise fat and sac, close primarily

An 82-year-old previously healthy woman has a 12-hour

history of severe epigastric pain associated with nausea and
vomiting. She has had no previous abdominal operations. Her
WBC count is 21,000/cu mm. The plain films and abdominal
CT shown are obtained.

Which of the following best

describes this patients
diagnosis?
A.
Pain in the medial thigh and knee is
B.
C.
D.

E.

uncommonly associated with this

condition
It is unusual in women
It is unusual in elderly patients
It is seldom associated with
intestinal necrosis
It is usually unilateral

Obturator

Rare form of hernia

Protrusion of intraabdominal contents through
obturator foramen
F:M ratio 6:1
The obturator foramen is
formed by the ischial and
pubic rami
obturator vessels and nerve
lie posterolateral to the
hernia sac in the canal
Small bowel is the most
likely intraabdominal
organ to be found in an
obturator hernia

Obturator

4 cardinal signs :
intestinal obstruction (80%)
Howship-Romberg sign (50%) History of
repeated episodes of bowel obstruction
that resolve quickly and without
intervention
Palpable mass (20%)

Tx: Sugical Repair

Spigelian Hernia

occurs along the

semilunar line, which
traverses a vertical
space along the
lateral rectus border

where more than 90%

of spigelian hernias
are found

Spigelian Hernia

Clinical

Swelling in middle to
lower abdomen lateral
to rectus muscle
Usually reducible
Up to 20% present
with incarceration

Tx: surgical

Mesh not required

Recurrence is
uncommon

Lumbar

Acquired lumbar hernias

Contains to anatomic
triangles, inferior and
superior lumbar triangles

back or flank trauma,

poliomyelitis, back surgery,
and the use of the iliac
crest as a donor site for
bone grafts

Grynfelts
Petits

Strangulation is rare
Soft swelling in lower
posterior abdomen

Sciatic

Via greater or lesser

sciatic notch
greater sciatic notch is
traversed by the
piriformis muscle, and
hernia sacs can protrude
either superior or inferior
to this muscle
suprapiriform defect 60%
Infrapiriform 30%
subspinous (through the
lesser sciatic foramen)
10%

Which of the following hernias is most

likely to recur after primary repair?
A.
B.
C.
D.
E.

Epigastric hernia
Spigelian hernia
Indirect hernia
Femoral hernia
Incisional hernia

Ventral wall (Incisional)

Highest incidence in midline

and transverse incisions
Up to20% after laparotomy
1/3 present in 5-10 years
postoperatively
Risk factors

obesity, DM, ascites,

steroids, smoking
malnutrition, wound
infection

Technical aspects of wound

closure

Type of incision
Excessive tension (prone to
fascial disruption)

Which of the following hernias

represent an incarceration of a limited
portion of small bowel?
A.
B.
C.
D.
E.

Spigelian hernia
Grynfelts hernia
Petits hernia
Richters hernia
Littres hernia