GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

75% of all hernias are inguinal

o 50% are Indirect (M:F= 7:1), with a right
side predominance, and 25% are direct
o 3% are inguinal hernias have sliding
component most often on the left side
(left to right ratio = 4.5:1)
14% of hernias are umbilical
10% of hernias are incisional or ventral (F:M
2:1)
3-5% of hernias are femoral

Femoral hernia least common type of groin hernia, more

commonly seen in females due to broader pelvis of female
and wider femoral space.
*minimum risk of developing hernia is about 10% (highest
=27%)
*inherited hernia= 4x increase in patient with Family history
of hernia, due to Type III Collagen leads to weakening of
transversalis fascia

DIAGNOSIS REMAINS CLINICAL

1. If an incarcerated or strangulated hernia is
suspected the following imaging studies may be
helpful
2. Upright chest radiograph to exclude free air
(extremely rare)
3. Flat and upright abdominal films to diagnose a
small bowel obstruction (neither sensitive nor
specific) or to identify areas of bowel outside
the abdominal cavity
ASYMPTOMATIC HERNIA
1. Swelling or fullness at the hernia site
2. Aching sensation (radiates to the areas of the
hernia)
3. No true pain or tenderness upon examination
4. Enlarges with increasing intra-abdominal
pressure and/or standing
INCARCERATED HERNIA
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)

STRANGULATED HERNIA
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
Strangulated
hernia
are
differentiated
from
incarcerated hernia by the following
Pain out of proportion to examination findings
Fever or toxic appearance
Pain that persist after reduction of hernia
DIFFERENTIAL DIAGNOSES
Lipoma
Orchitis
Lymph node
Abscess
Hematoma
Hydrocele
Cysts
Varicocele
GOALS OF HERNIA SURGERY
Provide long lasting secure closure of pelvic
floor defect
Reduce pain
Improve quality of life
(MC cause of chronic pain = use of mesh)
Classically the existence of an inguinal hernia has been
reason enough for operative intervention. However,
recent studies have shown that the presence of
reducible hernia is not, in itself. An indication of surgery
and the risk of incarceration is less than 1%

GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

The question of observation versus surgical intervention

in this asymptomatic or minimally symptomatic
population was recently addressed in 2 randomized
clinical trials. The trials found similar results, namely
that after after long-term follow-up, no significant
difference in hernia-related symptomology was noted,
and that watchful waiting did not increase the
complication rate. (Annals of Surgery, 2013)
A clinically accepted practice in elected hernia repair
1. Physically fit for surgery
2. Symptomatic patients
*No urgency in doing repair, unless incarceration
episode
*High risk with perioperative complications, and
minimal symptoms, watchful waiting is a safe option
Current indication for tissue repair
1. Male young adult patient
2. Risk of mesh infection Hernia is a clean
operation, however the presence of
strangulated hernia or the possibility of bowel
resection may contaminate the operation.

3. High risk individuals to develop pain

e.g. Female, may develop gynecologic
problems perform tissue repair
4. History of chronic pain
*bowel resection not supported by data.
MANAGEMENT
All hernias must be repaired because they dont
resolve spontaneously.
En massereduction
Components of repair:
o Dissection of cord
o Ligation of hernia sac (MC site:
anteromedia )
o Repair of the floor
NYHUS CLASSIFICATION
Based on
1. Patency of processus vaginalis

2. Displacement
of
epigastric
vessels
(*hesselbachs triangle)
3. Weakness of floor (transversalis fascia)
Type I
Type II
Type III
Type IIIA
Type IIIB
Type IIIC
Type IV

Indirect hernia (IH) with paten

processus vaginalis only
IH with enlarged internal ring only
With defect (weakness) of the inguinal
floor
Direct hernia
Massive IH, pantaloon and sliding
hernia
Femoral hernia
Recurrent hernia

Early recurrent hernia always attributed to technical

reasons or secondary to tension
Late recurrent metabolic type

TYPES OF HERNIA SURGERY

1. Herniotomy
Closure of processus vaginalis (defect).
Ligation of hernia sac.
Pediatric hernia
2. Herniorrhaphy
Closure of the defect, repair of pelvic
floor using tissues
3. Hernioplasty
Closure of the defect, repair of the
pelvic floor using mesh
TYPES OF REPAIR OF THE FLOOR
1. TISSUE REPAIR
Use of patients own tissue to create a
new floor.
Non-anatomical
15-20% recurrence
2. MESH REPAIR
Use of prosthetic mesh in the creation
of the new floor
Serves as a bridge between two tissues
Anatomical
1-5% recurrence
2

GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

MARCY closure of internal ring type I & II

BASSINI approx TAA with IL, IPT; types II & III; 10% RR
McVAY - Cooper ligament TAA; Types II,III & IV
SHOULDICE gold standard; similar with bassini but
using continuous suturing (imbrications), 1.1% RR

Types
a. Nyhus repair
b. Laparascopic repair
- TAPP
- TEP
-

IPOM no longer done due to a lot

of complications

OPEN VERSUS LAPAROSCOPIC HERNIA SURGERY

A 2014 meta-analysis of seven studies comparing
laparoscopic repair with Lichtenstein technique for
treatment of recurrent inguinal hernia concluded that
despite the advantages to be expected with the former
(e.g. Reduced pain and earlier return to normal
activities), operating time was significantly longer with
the minimally invasive technique and the choice
between the two approaches depended largely on the
availability of local expertise.
COMPLICATIONS OF REPAIR
1. Recurrence (MC site? Assign#1)
2. Nerve entrapment
3. Ischemic orchitis, testicular atrophy, injury to
vas deferens
4. Bowel obstruction, adhesions
5. Vascular injury
6. Wound infection <1% infection rate

APPROACH TO GROIN HERNIA

1. ANTERIOR APPROACH (all anterior repair is
herniorrhapy)

Creation of the new floor above the

transversalis fascia
Types (a-c = tissue repair)
a. Bassini
b. McVay
c. Shouldice
d. Lichtenstein gold standard
2. POSTERIOR APPROACH
Creation of the new floor below the
transversalis fascia, preperitoneal layer
(space of Bogros)

CHRONIC INGUINAL POST-HERNIORRHAPY PAIN

3 months post-op
Causes
1. Recurrence
2. Mesh related (meshoma)
3. Nerve related (mc= nerve entrapment of
genitofemoral nerve)

4. Infection
Success in Hernia Surgery
Permanence of the operation
Fewest complications
Minimal cost
Early return to work or other activities

GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

Groin Anatomy

Two important openings of inguinal area

1. Internal inguinal ring area of indirect inguinal
hernia
2. Superficial inguinal ring direct inguinal hernia
Important to identify, because this is where the
spermatic cord is located
Area of inguinal canal
MC site of sac: anteromedial, followed by anterolateral
Space of Bogros: vascular and avascular

Hesselbachs triangle - to differentiate IH and DH

o
o
o

base is the inguinal ligament

lateral border is formed by the inferior epigastric
vessels
Medial border is the lateral edge of the rectus
sheath.

*No hernia will close, it will remain as is or it will grow

bigger. Hernia is different from defect.

SURGICAL ANATOMY
ABDOMINAL WALL LAYER
1. Skin
2. Campers
3. Scarpas
4. External oblique
aponeurosis
5. Internal oblique
6. Transversus abdominis
7. Transversalis fascia

SPERMATIC CORD
Scrotum
Superficial spermatic
fascia
External spermatic fascia
forms inguinal ligament
Cremaster muscle
No derivative, forms arch
of internal inguinal ring
Internal spermatic fascia
Processus vaginalis (M)
Canal of Nuck (F)
Hernia sac
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GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

8. Preperitoneal layer
9. peritoneum

GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

Nerves of Groin area

Hesselbach and Femoral canal

ILIOINGUINAL NERVE
runs medially through the inguinal canal along
with the cord structures traveling from the
internal ring to the external ring.
It innervates the upper and medial parts of the
thigh, the anterior scrotum, and the base of the
penis
ILIOHYPOGASTRIC NERVE
Runs below the external oblique aponeurosis
but cranial to the spermatic cord then
perforates the external oblique cranial to the
superficial ring
It innervates the skin above the pubis
GENITAL BRANCH OF THE GENITOFEMORAL NERVE
This branch travels with the cremasteric vessels
through the inguinal canal
It innervates the cremaster muscle and provides
sensory innervations to the scrotum

GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

SENSORY DISTRIBUTION

LIGAMENTS OF THE INHUINO-FEMORAL CANAL

1. ILIOINGUINAL LIGAMENT (IL)
From external oblique aponeurosis; ASIS
pubic tubercle
Crural arch, fallopian arch, femoral arch,
Pouparts ligamentum inguinale

4. Coopers ligament
Union of transversalis fascia and
periosteum of superior pubic ramus joins
IPT and lacunar ligament into the pubis.
LIGAMENTS OF INGUINO-FEMORAL CANAL

Inguinal hernia is a pathologic hole within the

Transversalis fascia that occurs within the area of a
poorly reinforced and ___ hernia prone anatomic hole
___ called the MYOPECTINEAL ORIFICE
MYOPECTINEAL ORIFICE OF FRUCHAUD

2. ILIOPUBIC TRACT (IPT)

Thickened lateral extension of transversalis
fascia between Coopers and IL
3. Lacunar ligament
Forms medial border of femoral canal
Gimbernat, ligamentum lacunae

Boundaries
Superior: transverse abdominis, internal oblique
muscle
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GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

Lateral: Iliopsoas muscle

Inferior: Pectin pubis (Coopers ligament)
Medial: Rectus muscle
This orifice is lined entirely by Tranversalis fascia
INGUINAL ANATOMY: POSTERIOR VIEW

cutaneous, femoral branch of genitofemoral ,

and the femoral nerves

UMBILICAL LIGAMENTS

TRIANGLE OF DOOM
Bordered medially by vas deferens and
laterally by the vessels of the spermatic cord.
The contents of the space include the external
iliac vessels, deep circumflex vein, femoral
nerve and genital branch of genitofemoral
nerve.

TRIANGLE OF PAIN
Region bordered by the IPT and gonadal
vessels, and it encompassesthe lateral femoral
8

GENERAL SURGERY

HERNIA DR. WALLACE MEDINA

Highlighted in the PPT
Recording from Dr. Medinas lecture