HERNIA

Edmond Rukmana

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

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

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

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

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

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

Which of the following statements

is/are true regarding direct inguinal
hernias?
A.

B.

C.
D.
E.

The most likely cause is destruction of

connective tissue resulting form physical
stress.
Direct hernias should be repaired
promptly because of the risk of
incarceration.
A direct hernia may be a sliding hernia
involving a portion of the bladder wall.
A direct hernia may pass through the
external inguinal ring.
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

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.

B.

C.
D.

E.

They are embryonic equivalent of a

small omphalocele
Repair in infants is usually deferred until
approximately 4 years of age
Repair in adults is usually indicated
The vest-over-pants type of repair is
stronger than simple approximation of
fascial margins
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

Epigastric

midline junction of the

aponeuroses (linea
alba) between the
xiphoid process and
umbilicus
Paraumbilical hernia epigastric hernia that
borders the umbilicus
Estimated frequency
3-5%
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.

Obturator

Rare form of hernia

Protrusion of intra-abdominal
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

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)