Inguinal Hernia

Management
Uncomplicated hernias require
either:
No treatment
Support with a truss
Operative treatment

Complicated hernias:
Always require surgery, often urgently

Management

Conservative
Management
Aimed at alleviating symptoms
such as pain, pressure, and
protrusion of abdominal contents
For Hernias that or not
strangulated or incarcerated can
be mechanically reduced
Assuming a recumbent position
Truss, an elastic belt or brief

TRUSS

Emergent repair
Incarcerated hernias
Strangulated hernias
Sliding hernias

INCARCERATED HERNIA
Reasons for incarceration
large amount of intestinal contents
within the hernia sac
dense and chronic adhesions of hernia
contents to the sac
small neck of the hernia defect in
relation to the sac contents

INCARCERATED HERNIA
An incarcerated inguinal hernia
without the sequelae of a bowel
obstruction is not necessarily a
surgical emergency

INCARCERATED HERNIA
Reduction should be attempted
before definitive surgical
intervention.

INCARCERATED HERNIA
Hernias that are not strangulated
and do not reduce with gentle
pressure should undergo taxis.

TAXIS
The patient is sedated and placed in a
Trendelenburg position.
The hernia sac is grasped with both hands,
elongated, and then milked back through
the hernia defect.

Pressure applied to the most distal portion

of the sac will cause the contents to
mushroom and prevent reduction.

STRANGULATED HERNIA
Femoral > Indirect > Direct
Fever, leukocytosis, and hemodynamic
instability.
The hernia bulge usually is very tender,
warm, and may exhibit red discoloration.

Taxis should not be applied to

strangulated hernias as a potentially
gangrenous portion of bowel may be
reduced into the abdomen without being

OPERATIVE TECHNIQUES

 Surgery aims to
Reduce the hernia contents
Excise the sac (herniotomy) in most
cases
Repair and close the defect either by
herniorrhapy or hernioplasty

Anterior repair
non prosthetic

OPEN APPROACH

OPEN Approach

Bassini Repair
Is frequently used
for indirect inguinal
hernias and small
direct hernias
The conjoined
tendon of the
transversus
abdominis and the
internal oblique
muscles is sutured
to the inguinal
ligament

Mcvay repair
inguinal and
femoral canal
defects
The conjoined
tendon is
sutured to
Coopers
ligament from
the pubic
cubicle laterally

Shouldice Repair

Anterior repair
prosthetic

Lichtenstein TensionFree Repair

The most commonly performed inguinal hernia repair today is the
Lichtenstein repair. A flat mesh is placed on top of the defect
It is a "tension-free" repair that does not put tension on muscles
It involves the placement of a mesh to strengthen the inguinal
region.
Patients typically go home within a few hours of surgery, often
requiring no medication beyond Paracetamol.
Patients are encouraged to walk as soon as possible
postoperatively, and they can usually resume most normal
activities within a week or two of the operation.

Lichtenstein
Tension-Free
Repair

MESH
PERMANENT MESH
Commercial meshes are typically made of prolene
(polypropylene) or polyester.
Mosquito-net mesh-Meshes made of mosquito net clothes, in copolymer of polyethylene and polypropylene have been used for
low-income.
ABSORBABLE MESH
Biomeshes are increasingly popular since their first use in 1999.
They are absorbable and they can be used for repair in infected
environment, like for an incarcerated hernia. Moreover, they
seem to improve comfort.

LAPAROSCOPIC HERNIA
REPAIR
Transabdominal Preperitoneal
Procedure (TAPP)
Totally Extraperitoneal (TEP) Repair

Indications include bilateral inguinal

hernia, recurring hernia, need for
early recovery

LAPAROSCOPIC HERNIA
REPAIR

RECURRENCE
Around 1% for Shouldice repair
Most recurrences are of the same
type as the original hernia
Recurrence Factors
Patient
Technical
Tissue

RECURRENCE
Patient factors
malnutrition, immunosuppression,
diabetes, steroid use, and smoking.

Technical factors
mesh size, prosthesis fixation, and
technical proficiency of the surgeon.

Tissue factors
wound infection, tissue ischemia, and
increased tension within the surgical repair

complications
The overall risk of complications of
inguinal hernia repair is low.
Common Complications
Pain, injury to the spermatic cord and
testes, wound infection, seroma,
hematoma, bladder injury, osteitis
pubis, and urinary retention