INGUINAL HERNIA

Max Angelo G. Terrenal Post Graduate Medical Intern Veterans Memorial Medical Center
 WHAT IS AN
INGUINAL HERNIA?
Protrusion of a peritoneal sac through a
musculoaponeurotic barrier
Direct or Indirect
 DIRECT INGUINAL HERNIA
Within the floor of
Hesselbachs triangle
Acquired defect from
mechanical
breakdown over the
years
~1% Lifetime risk
 INDIRECT INGUINAL HERNIA
Through the internal ring
of inguinal canal
Congenital
Patent processus
vaginalis
~5% Lifetime risk
Higher risk of
strangulation than direct
INDIRECT INGUINAL HERNIA
 INCARCERATED STRANGULATED

Hernia which cannot be Incarcerated hernia with

reduced resulting ischemia
 EPIDEMIOLOGY
One of the most common surgical procedures
Incidence:
~5-10% lifetime
75% of abdominal wall hernias
Male > Female
Indirect > Direct
Right > Left
1/3 may develop a contralateral inguinal hernia
 ETIOLOGY
Multifactorial
Weakness in abdominal wall musculature
PRESUMED CAUSES OF GROIN HERNIATION
Coughing Valsalva's maneuvers
Chronic obstructive pulmonary disease Ascites
Obesity Upright position
Straining Congenital connective tissue disorders
Constipation Defective collagen synthesis
Prostatism Previous right lower quadrant incision
Pregnancy Arterial aneurysms
Birthweight <1500 g Cigarette smoking
Family history of a hernia Heavy lifting
Physical exertion (?)
ANATOMY
Inguinal Hernia
 ABDOMINAL WALL
Skin
Subcutaneous fat
Scarpas fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis
Transveralis fascia
Preperitoneal fat
Peritoneum
 INGUINAL CANAL
4-6 cm long
Anteroinferior of
pelvic basin
Cone-shaped
Base
superolateral margin
Apex
Inferomedially
 BOUNDARIES
Anterior
external oblique aponeurosis
Lateral
Internal oblique muscle
Posterior
fusion of the transversalis fascia
and transversus abdominus
muscle,
Superior
arch formed by the fibers of the
internal oblique muscle.
Inferior
inguinal ligament
 SPERMATIC CORD
Cremasteric muscle fibers
Vas deferens
Testicular artery
Testicular pampiniform
venous plexus
Genital branch of the
genitofemoral nerve
+/- hernia sac
 HESSELBACHS
TRIANGLE
Medial aspect of Rectus
abdominis muscle
Inferior epigastric
vessels
Inguinal ligament
POSTERIOR
MYOPECTINEAL ORIFICE
OF FRUCHAUD
Superior
Arch of IOM and TA

Lateral
Iliopsoas muscle

Medial
Lateral edge of RA and
Pubic pectin

Iliopubic tract
Spermatic cord
Iliac vessels
TRIANGLE OF DOOM
External iliac vessels
Deep circumflex iliac vein
Femoral nerve
Genital branch of GF nerve
TRIANGLE OF PAIN
Nerves
Lateral femoral cutaneous
Femoral branch of GF nerve
Femoral nerve
CLASSIFICATION
Inguinal Hernia
 NYHUS CLASSIFICATION SYSTEM

Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults
INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the inguinal
Type II canal; does not extend to the scrotum
Type IIIA DIRECT HERNIA; size is not taken into account
INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinal wall;
INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in this category because they are
Type IIIB commonly associated with EXTENSION TO THE DIRECT SPACE; also includes PANTALOON
HERNIAS
Type IIIC FEMORAL HERNIA
RECURRENT HERNIA; modifiers AD are sometimes added, which correspond TO INDIRECT,
Type IV DIRECT, FEMORAL, AND MIXED, RESPECTIVELY
DIAGNOSIS
 HISTORY
Groin pain Duration
Extrainguinal symptoms Progressiveness
Change in bowel habits
Urinary symptoms
Pressure on nerves
Generalized pressure
Local sharp pains
Referred pain
Scrotum, testicle or inner thigh
 PHYSICAL EXAMINATION
Inspection
Standing
Palpation
Inguinal Occlusion test

Direct Indirect

Manifested Controlled
Cough
Impulse Dorsum of
Fingertip
finger
DIFFERENTIAL DIAGNOSIS
Malignancy Undescended testicle
Lymphoma Femoral artery aneurysm or
Retroperitoneal sarcoma pseudoaneurysm
Metastasis Lymph node
Testicular tumor Sebaceous cyst
Primary testicular Hidradenitis
Varicocele Cyst of the canal of Nuck (female)
Epididymitis Saphenous varix
Testicular torsion Psoas abscess
Hydrocele Hematoma
Ectopic testicle Ascites
IMAGING
Inguinal Hernia
Ultrasound
CT Scan
MRI
MANAGEMENT
 CONSERVATIVE MANAGEMENT

Aimed at alleviating symptoms such as

pain, pressure, and protrusion of abdominal
contents

Assuming a recumbent position

Truss, an elastic belt or brief
 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 addressed
OPERATIVE TECHNIQUES
Inguinal hernia
ANTERIOR REPAIR
NON PROSTHETIC
Inguinal hernia
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
Inguinal hernia
LICHTENSTEIN TENSION-
FREE REPAIR
LAPAROSCOPIC HERNIA
REPAIR
Transabdominal Preperitoneal Procedure (TAPP)
Totally Extraperitoneal (TEP) Repair

Indications include bilateral inguinal hernia, recurring

hernia, need for early recovery
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
 EVIDENCE-BASED CPG ON THE
MANAGEMENT OF ADULT INGUINAL
HERNIA
 EVIDENCE-BASED CPG ON THE MANAGEMENT
OF ADULT INGUINAL HERNIA
PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES
1. What is the recommended treatment for inguinal hernia?
Mesh repair, Laparoscopic or the Open
2. If laparoscopic mesh repair is the preferred technique for inguinal hernias, what is
the recommended laparoscopic technique?
Transabdominal Preperitoneal or Total Extra Preperitoneal
3. Is fixation of the mesh necessary in laparoscopic repair?
No
4. If open mesh repair, what is the recommended technique
Lichtenstein, plug and mesh or Prolene Hernia System
 EVIDENCE-BASED CPG ON THE MANAGEMENT
OF ADULT INGUINAL HERNIA
PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES
5. What is the recommended treatment for recurrent inguinal hernia?
Mesh repair, either laparoscopic or open method
6. What is the recommended treatment for bilateral inguinal hernia?
Mesh repair, either laparoscopic or open method
7. Is antimicrobial prophylaxis recommended for elective groin hernia surgery?
Not routinely recommended using mesh
THANK YOU