HERNIAS

MATA, FRANCISCO CASIO A.

GROUP 1

Justin P. Wagner, F. Charles Brunicardi, Parviz K. Amid, and David C. Che

Case: A 25 year old male, obese call center agent has been jogging
when he felt pain in his right groin getting worse while during exercise
while trying to reduce weight. On physical examination, a bulge was
felt on the tip of the examining finger at the right external inguinal
ring on coughing or abdominal straining. Patient underwent
laparoscopic hernia repair (TAPP) right.
DEFINITION

• The term “hernia” is derived from the Greek word hernios, which
means “budding.” Hernia
• A hernia is an abnormal protrusion of a viscus or the peritoneum
through a natural or aquired defect in the muscular wall of a cavity
• The protruded parts are generally contained in a sac-like structure,
formed by the membrane with which the cavity is naturally lined
Surgical History
• In 1890- Bassini
• Shouldice and Mc Vay, later revised this concept in 1945
• In the early 1980s, Lichtenstein – tension free repair
• Transabdominal preperitoneal (TAPP) repair
• Totally extraperitoneal (TEP) repair
Anatomy
Lacunar
ligament
Subtypes
• Indirect – most common subtype
• Direct
• Femoral
Pathophysiology
Acquired
• weakness in the abdominal wall musculature (Transversalis fascia)
• Direct
• Femoral (weakness of proximal femoral canal)
Congenital
• Persistent processus vaginalis (congenital)
• Indirect hernia
Diagnosis
History
• Symptomatic groin hernia
 groin pain
 change in bowel habits or urinary symptoms - sliding hernia
 Pressure or heaviness
 Sharp pain
• Duration and timing of symptoms
 increase in size and content over a protracted time.
 history of acute inguinal herniation following a strenuous activity
Diagnosis
History
• Hernia is reducible
 pushing the contents back into the abdomen
Diagnosis
Phyiscal Exam
• Standing position
• Inspection - abnormal bulge
• Palpation
• Valsalva’s maneuver
• Contralateral side
Diagnosis
Physical Exam
Inguinal occlusion test
• Indirect hernia
• controlled impulse
• Transmission of the cough impulse to
the tip of the finger
• Direct hernia
• persistent herniation
• impulse palpated on the dorsum
Diagnosis
Physical Exam
• Femoral Hernia
• palpable below the inguinal ligament, lateral to the pubic tubercle
• Femoral pseudohernia
• prominent inguinal fat pad in a thin patient
• Erroneous diagnosis of femoral hernia.
Imaging
• ultrasonography (US)
• computed tomography (CT)
• magnetic resonance imaging (MRI).
Imaging
Ultrasound
• least invasive technique
• sensitivity of 86% and specificity of 77%.
• Movement of abdominal contents through the canal is essential to making
the diagnosis
• false-negative result – lack of movement
• false-positive diagnoses - thin patients
Imaging
CT scan
• sensitivity of 80% and specificity of 65%
• sensitivity in detecting inguinal hernia
is expected to expand
Imaging
MRI
• reserved for cases where physical examination detects a groin bulge
• US is inconclusive
• sensitivity of 95% and specificity of 96%
• high cost and limited access
Treatment
• Surgical repair
• definitive treatment of inguinal hernias
• Nonoperative management
• appropriate consideration in minimally symptomatic patients
• safe for minimally symptomatic inguinal hernia patients
• targets pain, pressure, and protrusion of abdominal contents in the
symptomatic patient population
• recumbent position aids in hernia reduction via the effects of gravity
Treatment
• Emergent inguinal repair
• impending compromise of intestinal contents

Clinical signs
• Fever
• Leukocytosis
• hemodynamic instability
Open Approach
• Prostheses (Lichtenstein Tension-Free Repair, Plug and Patch
Technique, Prolene Hernia System )

• Tissue repairs ( Basssini, Shouldice and Mc Vay).

Tissue Repairs
• Tissue-based herniorrhaphy is a suitable alternative when prosthetic
materials cannot be used safely.
INDICATIONS
• operative field contamination
• emergency surgery
• when the viability of hernia contents
• is uncertain
Bassini Repair
Shouldice Repair
McVay Repair
Prosthetic Repairs
• Lichtenstein Tension-Free Repair
• Plug and Patch Technique
• Prolene Hernia System
Lichtenstein Tension-Free Repair
Plug and Patch Technique
Prolene Hernia System
Laparoscopic Approach
• Laparoscopic inguinal hernia repairs reinforce the abdominal wall via
a posterior approach
Methods:
• Transabdominal preperitoneal (TAPP) repair
• Totally extraperitoneal (TEP) repair
• IPOM
Transabdominal Preperitoneal Procedure
• intraperitoneal perspective
Indications
• bilateral hernias
• large hernia defects
• scarring from previous lower abdominal surgery
Totally extraperitoneal Procedure
Advantage
• access to the preperitoneal space without intraperitoneal infiltration
• minimizes the risk of injury to intra-abdominal organs and port site
herniation
Indications
• repair of bilateral inguinal hernias
• for unilateral hernias when scarring makes the anterior approach
challenging
Intraperitoneal Onlay Mesh Procedure
• permits the posterior approach without preperitoneal dissection
Indications
• anterior approach is unfeasible
• recurrent hernias that are refractory
• extensive preperitoneal scarring
Prosthesis Considerations
• Synthetic Mesh Material

• Polypropylene and polyester are the most common synthetic prosthetic materials used in
hernia

• Biologic Mesh

• commonly reserved for contaminated cases or when domain expansion is necessary in the
face of high infection risk
Anesthesia Method
• Anterior surgery can be done with, local, regional, or general
anesthesia.

• Laparascopic surgery has to be done with general anesthesia.

• Local anesthesia: Lidocaine, Marcaine with or without epinephrine.

• Important Point: The use of epinephrine in people with coronary
problems is contraindicated.

• Important Point: Before incision or prep inguinal nerve has to be

blocked.

• Epidural anesthesia is also a proper method.

• Indications of conservative surgery:

• Coexisting medical condition

• A small asymptomatic hernia
• An elderly person who is asymptomatic

• Important Point: Conservative treatment is not used in femoral

hernia
• Contraindications of Lap. Surgery
• A previous surgery in the area
• Primary medical condition
Complications of Hernia Surgery
• Hernia Recurrence
• Pain
• Spermatic Cord Damage and Ischemic Orchitis
• Visceral Injury
• Vascular Injury
• Hematomas and seroma
• Urinary Retention
• Ileus and Bowel Obstruction
Thank you!