INGUINAL HERNIAS

M. Bardan Hanif
Tria Wijayanti

SMF ILMU BEDAH

RS- AL ISLAM BANDUNG
Anatomy of Inguinal region
Layers of Abdominal wall ??
- 9 layers
1) Skin
2) Campers fascia
3) Scarpas fascia
4) External oblique muscle & aponeurosis.
5) Internal oblique muscle & aponeurosis.
6) Transverse abdominus & aponeurosis.
7) Transversalis fascia
8) Preperitoneal fat.
9) Peritoneum.
Anatomy of Inguinal Canal
The inguinal canal is 4-6 cm long.

The inguinal canal starts in the abdomen from the point that the spermatic cord
crosses the internal/deep inguinal ring in the transversalis fascia (in women the
Round ligament).

This canal finally ends in the external/surface inguinal ring at the level of the
abdominal muscles where the spermatic cord passes from the aponeurosis of the
external oblique muscle.
Inguinal canal border
Anterior wall: external oblique aponeurosis throughout the length of the canal; its
lateral part is reinforced by muscle fibers of the internal oblique.
Posterior wall: transversalis fascia; its medial part is reinforced by pubic
attachments of the internal oblique and transversus abdominis aponeuroses that
frequently merge to variable extents into a common tendonthe inguinal falx
(conjoint tendon)and the reflected inguinal ligament.
Roof: laterally by the transversalis fascia, centrally by musculoaponeurotic arches
of the internal oblique and transversus abdominis, and medially by the medial crus
of the external oblique aponeurosis.
Floor: laterally by the iliopubic tract, centrally by gutter formed by the infolded
inguinal ligament, and medially by the lacunar ligament.
 The deep (internal) inguinal ring defect in fascia transversalis.
The superficial ring is a split that occurs in the diagonal, otherwise parallel fibers of
the external oblique aponeurosis. The lateral crus attaches to the pubic tubercle,
and the medial crus attaches to the pubic crest.
Definition
The term hernia is derived from the Greek
wordhernios, which means budding.

Hernia Protrusion of visceral contents through the

Abdominal wall.
Two key components

Defect Hernial Sac

Epidemiology
Seventy-five percent of all abdominal wall hernias occur in the groin.
Indirect hernias : direct hernias by about 2:1, with femoral hernias smaller
proportion.
Right-sided groin hernias are more common than those on the left.
The male:female ratio for inguinal hernias is 7:1.
Etiology
Inguinal hernia has two etiologies:
A) Congenital
B) Acquired

A) Congenital Hernia:
i. Congenital hernia consists most of the cases of pediatric hernias
ii. In the descent of the testes from the abdomen to the scrotom in the third
trimester, a part of the perituneum descends with it which is called the process
vaginalis.
iii. In the weeks 36-40 of gestation this process vaginalis closes.
iv. Lack of closure of process vaginalis results in a patent process vaginalis which
is a reason for the high prevalence of inguinal hernia in the preterm
neonates.
v. A lot of the process vaginalises close in a few months after birth and its
patency does not necessarily mean that a hernia will be formed.
Etiology
B) Acquired Hernia:
It seems that most cases of hernia come from an acquired defect in the abdominal
:wall and the reason for its formation is multifactorial

1- Strenuous physical activity can be a factor but it is not known whether the
hernia is just from physical activity or in the setting of a patent process vaginalis.
2- A positive family history which can increase its incidence 8 times.
3- COPD increases the direct hernia risk.
4- Collagen deficiency associated diseases like collagen type I deficiency relative to
type III.

Being overweight is to some extent protective (maybe it is from the more difficult
diagnosis of hernia)
Etiology
 types of inguinal hernias:
Indirect inguinal hernia Indirect hernias protrude lateral to the inferior epigastric
vessels, through the deep inguinal ring
 Direct inguinal hernia This occurs when a portion of the intestine protrudes
through a weakness in the abdominal muscles along the wall of the inguinal canal.
These are common in adults, but rarely occur in children. Direct hernias protrude medial
to the inferior epigastric vessels, within Hesselbachs triangle. The borders of the
triangle are the inguinal ligament inferiorly, the lateral edge of rectus sheath medially,
and the inferior epigastric vessels superolaterally.
 Femoral hernias are much more common in women than in men. Femoral hernias
protrude through the small and inflexible femoral ring. The borders of the femoral ring
include the iliopubic tract and inguinal ligament anteriorly, Coopers ligament
posteriorly, the lacunar ligament medially, and the femoral vein laterally.
They may cause a lump that appears just below the groin and extends into the upper
portion of the thigh.
In a femoral hernia, a portion of the intestine protrudes through the passage that is
normally used by large blood vessels (the femoral artery and vein) when they pass
between the abdomen and the leg.
Femoral hernias are most common in older, overweight women.
The Nyhus classification categorizes hernia defects by
location, size, and type.
 Type 1, 2, and 3 hernias are indirect.
In type 1, the internal inguinal ring is normal.
In type 2 hernias, the inguinal ring is dilated, but less than 4 cm.
Type 3 hernias have the internal ring dilation measured at greater than 4 cm, commonly
with encroachment on the direct space and medial displacement of the inferior epigastric
vessels.
Type 4 and 5 hernias are direct. There is extensive destruction of the inguinal floor with type
4 hernias, whereas in type 5 hernias there is a smaller defect of no more than 2 cm, without
complete weakness of the direct space.
The system was later modified by Rutkow and Robbins to include pantaloon hernias (direct
and indirect combination), type 6, and
femoral hernias, type 7.
Rare varieties of Hernia :

Hernia-en-glissade or Sliding hernia.

Extraperitoneal bowel

Part of sac wall

Richters hernia
Littres hernia
SYMPTOMS
No symptoms to the life-threatening condition caused by strangulation of
incarcerated hernia contents.
Indirect hernias are more likely to produce symptoms than direct hernias.
Severe groin pain caused by groin strain is a problem because patients also
commonly have a coincidental asymptomatic inguinal hernia, discovered because
of the attention drawn by the groin strain.
The pain is commonly intermittent and radiation into the testicle is common.
Others complain of a sharper pain that is either localized or diffuse.
Characteristics of asymptomatic hernias are as follows:
Swelling or fullness at the hernia site
Aching sensation (radiates into the area of the hernia)
No true pain or tenderness upon examination
Enlarges with increasing intra-abdominal pressure and/or standing

Characteristics of incarcerated hernias are as follows:

Painful enlargement of a previous hernia or defect
Cannot be manipulated (either spontaneously or manually) through the fascial
defect
Nausea, vomiting, and symptoms of bowel obstruction (possible)
Characteristics of strangulated hernias are as follows:
Patients have symptoms of an incarcerated hernia
Systemic toxicity secondary to ischemic bowel is possible
Strangulation is probable if pain and tenderness of an incarcerated hernia persist
after reduction
Suspect an alternative diagnosis in patients who have a substantial amount of pain
without evidence of incarceration or strangulation
Physical Exam
The history is usually indicative of hernia but the physical exam is also
an important part of the evaluation.

The examination in obese patients is difficult.

This is best done in both the lying and standing position.

Physical Exam
A) First we look to see the bulging. If we do not have a bulging, we place a finger
inside the scrotum and raise it toward the external ring, and ask the patient to cough
or do the Valsalva maneuver until the hernial contents fall.

The valsalva maneuver causes an unusual bulging and it is possible to realize if this
bulging can be reduced or not.

B) We examine the contralateral side and compare the two sides to each other.

The extent of bulging on the two sides can be a criteria for the diagnosis of hernia
on one or both sides.
Physical Exam
The differentiation between a direct and an indirect inguinal hernia in the physical
exam:

There are different techniques for differentiating a direct from an indirect hernia in
physical exam.

- If the finger is inside the inguinal canal and the patient exerts pressure or coughs
and the hernia comes in contact with the tip of the finger it is a direct hernia.

- If with closure of the internal ring with the finger while the patient strains
(coughs) the hernial sac does not bulge out the hernia is an indirect one, and if the
hernial sac bulges the hernia is a direct one.
Physical examination
by simple inspection when a visible bulge is present.
Nonvisible hernias require digital examination of the inguinal canal
This is best done in both the lying and standing position. The examiner should place
the tip of the index finger at the most dependent part of the scrotum and
direct it into the external inguinal ring. The patient is then asked to strain.
The ritual of having the patient cough is discouraged as it results in the overdiagnosis
of a hernia because of the difficulty of differentiating a normal expansile bulge of
muscle from a true hernia, especially in asthenic individuals.
 indirect hernia will push against the fingertip, whereas a direct hernia will
push against the pulp of the finger.
In addition, applying pressure over the mid-inguinal point (midway between the
anterior superior iliac spine and the pubic tubercle, and just above the inguinal
ligament) with the fingertip will control an indirect hernia and prevent it from
protruding when the patient strains. A direct hernia will not be affected with this
maneuver.
A femoral hernia presents as a swelling below the inguinal ligament and just lateral
to the pubic tubercle
Diagnosis
The diagnosis is based on history, physical exam and sometimes imaging.

Imaging in hernia:

In some conditions physical exam cannot diagnose the hernia:

1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam

In these conditions imaging is important

Differential Diagnosis
1-Malignancy: Lypoma, metastasis, testicular tumory
2-Testeicular primary conditions : Varicocele, Epididimitis, Testicular torsion,
Hydrocele, Ectopic testes, undescended testes
3- Aneurism or pseudoaneurism of the femoral artery
4- Lymphadenopathy
5- Sebacious cyst
6- Hydroadenitis
7- Varices
8-Psoas Abcess
9- Hematoma
10- Ascites
Treatment
Nonoperative therapeutic measures include the following:
Trusses
Binders or corsets
Hernia reduction
Surgical options depend on type and location of hernia.
 Treatment
Open Repair
Anterior Repairs, Nonprosthetic
i) Bassinis repair
ii) Shouldice Repair
iii) McVay Repair
iv) Moloney darn
Anterior Repairs, Prosthetic
i) Lichtenstein tension free Hernioplasty
ii) Mesh plug and patch
iii) Read-Rives
iv) Kugel
v) Nyhus-Condon
vi) Wantz, Stoppa, and Rives
Bassinis Repair
Shouldice Hospital Repair
Lichtenstein Tension-Free Repair
Initial Incision
Classically an oblique skin incision is made between the anterior superior iliac spine
and the pubic tubercle. Many surgeons now use a more horizontally placed skin
incision that follows the natural skin lines for cosmetic reasons.
Mobilization of the Cord Structures
The superior flap of the external oblique aponeurosis is bluntly dissected off the internal oblique muscle laterally
and superiorly. The iliohypogastric nerve is identified at this time. It can be left in situ or freed from the
surrounding tissue and isolated from the operative field by passing a hemostat under the nerve and grasping the
upper flap of the external oblique aponeurosis. Routine division of this nerve along with the ilioinguinal nerve is
practiced by some surgeons but not advised by most. The cord structures are then separated from the inferior flap
of the external oblique aponeurosis by blunt dissection, exposing the shelving edge of the inguinal ligament and
the iliopubic tract. The cord structures are lifted en masse with the fingers of one hand at the pubic tubercle so
that the index finger can be passed underneath to meet the index finger of the other hand. Blunt dissection is
used to complete mobilization of the cord structures and a Penrose drain is placed around them for retraction
during the course of the procedure.
Division of the Cremaster Muscle
Complete division of the cremaster muscle, especially when dealing with an indirect hernia, has been common
practice. The purpose is to facilitate sac identification and to lengthen the cord for better visualization of the
inguinal floor.
High Ligation of the Sac
The term high ligation of the sac is used frequently as its historic significance has ingrained it in the description of
most of the older operations. By convention, for this chapter, high ligation should be considered equivalent to
reduction of the sac into the preperitoneal space without excision. Both methods work equally well and are highly
effective. There is a perception among some surgeons that sac inversion will be associated with a decreased
incidence of future adhesive complications and results in less pain because the richly innervated peritoneum is
not incised. However, this has not been scrutinized by a randomized trial. 42 Sac inversion, in lieu of excision,
does protect intra-abdominal viscera in cases of unrecognized incarcerated sac contents or a sliding hernia.
Relaxing Incision
A relaxing incision divides the anterior rectus sheath, extending from the pubic
tubercle superiorly for a variable distance. Some surgeons prefer to "hockey stick"
the incision laterally at the superior extent. The rectus muscle itself is strong
enough to prevent future incisional herniation. The relaxing incision works by
allowing the various components of the abdominal wall to displace laterally and
inferiorly.
Wound Closure
The external oblique fascia is closed, serving to reconstruct the superficial
(external) ring. The external ring must be loose enough to prevent strangulation of
the cord structures, yet tight enough to avoid an inexperienced examiner from
confusing a dilated ring with a recurrence.
Inguinal Hernia Repairs
Marcy
Indication is in Nyhus type I indirect inguinal hernias where the internal ring is
normal.
It is appropriate for children and young adults in whom concern remains about the
long-term effects of prosthetic material. The essential features of this operation are
high ligation of the hernia sac plus narrowing of the internal ring.
Displacing the cord structures laterally allows the placement of sutures through the
muscular and fascial layers
 Bassini's
The major components of Bassini's "radical cure" are as follows:
1. Division of the external oblique aponeurosis over the inguinal canal through the
external ring
2. Division of the cremaster muscle lengthwise followed by resection so an indirect hernia
is not missed, while simultaneously exposing the floor of the inguinal canal to more
accurately assess for a direct inguinal hernia.
3. Division of the floor or posterior wall of the inguinal canal for its full length.
4. High ligation of an indirect sac.
5. Reconstruction of the posterior wall by suturing the transversalis fascia, the
transversus abdominis muscle, the internal oblique muscle (Bassini's famous
"triple layer") medially to the inguinal ligament laterally, and possibly the iliopubic tract.
 Moloney Darn
name from the way a long nylon suture is repeatedly , similar to a mesh.
The initial layer consists of a continuous nylon suture to oppose the usual elements
of the abdominal wall medially (transversalis fascia and the transversus abdominis,
rectus, and internal oblique muscles) to the inguinal ligament.
This first suture is continued into the muscle about the cord,
weaving in and out to form reinforcement around the cord,
and is finally tied to the inguinal ligament on
the lateral side of the cord
Mesh Plug and Patch
The groin is entered through a standard anterior approach. The hernia sac is dissected away from surrounding
structures and reduced back into the preperitoneal space.
A flat sheet of polypropylene mesh is rolled up like a cigarette and held in place with suture. The use of a
prefabricated, commercially-available prosthesis that has the configuration of a flower is recommended by Rutkow
and Robbins. The prosthesis is then individualized for each patient by removing some of the petals to avoid
unnecessary bulk. This step is important, as rarely erosion into a surrounding structure such as the bladder has
been reported. Millikan further modified the procedure by recommending that the inside petals be sewn to the ring
of the portion of the internal ring, which forces the outside of the prosthesis underneath the inner side of the defect,
making it act like a preperitoneal underlay. For direct hernias, the inside petals are sewn to Cooper's ligament and
the shelving edge of the inguinal ligament as well as the musculoaponeurotic ring of the defect superiorly, again
forcing the outside of the mesh to act as an underlay. The patch portion of the procedure is optional, and involves
placing a flat piece of polypropylene in the inguinal space, widely overlapping the plug in a fashion similar to the
Lichtenstein procedure (Fig. 36-22B). The difference is that only one or two sutures, or perhaps no sutures, are used
to secure the flat prosthesis to the underlying inguinal floor. Some surgeons place so many sutures that they have
in effect performed a Lichtenstein operation on top of the plug. To the credit of its proponents, the plug and patch,
in all of its varieties, has been skillfully presented and has rapidly become a popular repair. Not only is it fast, but it
is also easy to teach, making it popular in both private and academic centers
Laparoscopic repair
1) TAPP (Transabdominal preperitoneal repair)
2) TEP ( Total extraperitoneal repair)
TAPP Video
Complications
Recurrence
Chronic groin pain
Nociceptive
Neuropathic
Cord and testicular
Hematoma
Ischemic orchitis
Testicular atrophy
Injury to vas deferens
Hydrocele
Testicular descent
Bowel and bladder injury
 Osteitis pubis
Prosthetic complications
Contraction
Erosion
Infection
Rejection
Fracture
Miscellaneous complications
Seroma
Hematoma
Wound infection
General complications
Complications of Hernia Surgery
1-Pain

2-Spermatic Cord Damage and Ischemic Orchitis

3-Vas deferans cut

4-Wound infection

5-Seroma

6-Urinary Retention