HERNIA INGHINALA

Hammurabi of Babylon (1700 Described hernia reduction and application of bandages to

BC) prevent protrusion
Hippocrates (400 BC) Described hernia as "a tear in the abdomen."
Galen (200 BC) Described the anatomy of the abdominal wall
Heliodorus (200 BC) Described his original method for hernia repair.
Celsus (100 AD) Introduced translumination; described clinical signs that
differentiate a hernia from a hydrocele
Paulus Aegina Divided hernia into enterocele (abdominal viscera descend into
scrotum), and bubonocele (swelling remains in the groin and
does not descend into the scrotum)

Maupassius (1559) First operation to relieve a strangulated hernia

Caspar Stromayr (16th Wrote Practaica Coposa; defined direct and indirect hernias;
century) stressed importance of high dissection of the indirect sac;
sanctioned removal of testicle and spermatic cord for indirect
hernia
Littre Reported a Meckel's diverticulum in a hernia sac
DeGarengeot Described the appendix in a hernia sac
Vesalius (Flemish) and allopius
Described the inguinal ligament.
(Italy) Poupart (France)
Heister First to describe direct hernias. (1724)
Pott (England) Anatomy of congenital hernias; methods of incarceration
Camper (Holland) Described the superficial subcutaneous fascia
Scarpa (Italy) Described deep subcutaneous fascia; anatomic and surgical
importance of sliding hernias (en glissade) (1814)
Sir Ashley Cooper (England) Described anatomy and surgical treatment of crural and
umbilical hernias; anatomy of the groin including the
superior pubic (Cooper) ligament; cremasteric fascia and the
transversalis fascia
Hunter Emphasized the role of the processus vaginalis
Morton Described the conjoined tendon.
Cloquet Noted postnatal closure of the processus vaginalis; made
observations of the iliopubic tract
Hesselbach (Germany) Defined iliopubic tract; described importance of the medial
triangle of the groin (included the femoral canal). ; described the [1]

"corona mortis" (arterial circle formed by the deep epigastric and obturator arteries).

De Gimbernat Described medial ligament of the femoral canal (lacunar

ligament), and division of that ligament in the treatment of
strangulated femoral hernias.
Richter (Germany) Described partial obstruction and incarceration of a wall of the
bowel in a hernia defect. [2,3]
Remember anatomic
 vase testiculare acoperite de peritoneu
vase testiculare şi ram genital al N. genitofemural fascia extraperitoneală (ţesut conjunctiv lax)

canal (duct) deferent fascia transversalis

vase cremasterice m. transvers abdominal
vase iliace externe acoperite de peritoneu
m. oblic intern
canal deferent acoperit de peritoneu
peritoneu m. oblic extern
vase epigastrice inferioare
lig. ombilical medial (a. ombilicală)
fascia ombilicală prevezicală
vezica urinară
m. drept abdominal
m. piramidal
lig. ombilical median (uracă)

inele inghinale super- spină iliacă anterosuperioară

ficiale drept şi stâng
originea fasciei spermatice interne din fas-cia
transversalis la orificiul inghinal profund

N. ilioinghinal

simfiză pubiană (acoperită de fibre funicul spermatic

amestecate ale apone-vrozei
oblicului extern)
vase femurale

tubercul pubic m. cremaster şi fascia

cremaste-rică învelind
fascia spermatică externă funiculul spermatic
învelind funiculul spermatic

falx inguinalis (tendonul conjunct)

fibre intercrurale
lig. inghinal (Poupart)
canalul inghinal şi funiculul
spermatic [spermatic cord]
 linia albă
m. oblic extern
teaca dreptului abdomi-nal
aponevroza m. oblic extern (foiţa anterioară)

spina iliacă antero-superioară

fascia transversalis în in-teriorul
m. oblic intern (sec-ţionat trigonului inghinal
şi reflectat)

m. transvers abdominal

tendon conjunct
(falx inguinalis)
inel inghinal profund (în fascia
transversalis)

lig. inghinal reflectat (lig.

m. cremaster (origine laterală) reflex Colles)

vase epigastrice inferioare (pro-fund faţă

de fascia transversalis)
fibre intercrurale
lig. inghinal (Poupart)

lig. lacunar (Gimbernat) fascia spermatică externă pe ieşirea

funiculului spermatic

m. cremaster (origine medială)

inel inghinal superficial

inel (orificiu) inghinal superficial

stâlp lateral

stâlp medial lig. fundiform al penisului

creastă pubiană

regiunea inghinală – vedere anterioară

 teaca dreptului (foiţa posterioară)

linia arcuată
spina iliacă antero-superioară
fascia transversalis (secţionată)

m. drept abdominal
linia albă
tract iliopubian
vase epigastrice inferioare

trigon inghinal (Hesselbach)

inel inghinal profund

vase testiculare şi ram genital al N. genitofemural

fascia iliopsoasului (acoperind N. femural)

m. iliopsoas

vase iliace externe

tendon conjunct (falx inguinalis)

inel femural (dilatat)

lig. lacunar (Gimbernat)
anastomoză arterială pubo-obturatorie (corona mortis)
canal deferent

lig. pectineal (Cooper)

ram pubic superior

a. obturatorie
simfiză pubiană

regiunea inghinală – vedere internă

 Clasificare hernii inghinale
1. Punct herniar
2. H. inghinala interstitiala
3. H. inghino-pubiana
4. H. inghino-funiculara
5. H. inghino-scrotala (labiala)
Punct herniar
h. Interstitiala
H. Inghinopubiana = pubonocel
H inghino-funiculara
H. inghino-scrotala
H inghino-pubiana
H inghino-pubiana
H inghino-scrotala
 teaca dreptului (foiţa posterioară)

linia arcuată
spina iliacă antero-superioară
fascia transversalis (secţionată)

m. drept abdominal
linia albă
tract iliopubian
vase epigastrice inferioare

trigon inghinal (Hesselbach)

inel inghinal profund

vase testiculare şi ram genital al N. genitofemural

fascia iliopsoasului (acoperind N. femural)

m. iliopsoas

vase iliace externe

tendon conjunct (falx inguinalis)

inel femural (dilatat)

lig. lacunar (Gimbernat)
anastomoză arterială pubo-obturatorie (corona mortis)
canal deferent

lig. pectineal (Cooper)

ram pubic superior

a. obturatorie
simfiză pubiană

regiunea inghinală – vedere internă

 vedere internă a peretelui abdominal anterior
diafragm pleură parietală

lig. rotund al ficatului

fascia diafragmatică
şi vv. paraombilicale
lig. falciform

peritoneu (margini
secţionate)
ombilic
fascia transversalis peritoneu
linia arcuată
fascia transversalis
(arcada Douglas)
m. oblic extern
m. oblic intern
m. drept abdominal
m. transvers abdominal
vase epigastrice
inferioare
lig. ombilical medial stâng (a.
trigon inghinal ombilicală stângă obliterată)
Hesselbach
fascia transversalis

plica ombilicală medială dreaptă

lig. interfoveolar
Hesselbach
lig. ombilical median (uracă o-
vase circumflexe bliterată) + vv. paraombilicale
iliace profunde în plica ombilicală
inel inghinal profund

ram cremasteric şi
ram pubic ale
a. epigastrice inferioare
fascia ombilicală prevezicală

vase iliace externe plica ombilicală laterală (vase

epigastrice inferioare)
funiculul spermatic
N. femural
inelul femural
fascia iliopsoasă
teaca femurală
m. iliopsoas
lig. lacunar (Gimbernat)
vase iliace externe
lig. pectineal (Cooper)
tendon conjunct (falx inguinalis) fosa supravezicală
a. ombilicală (parte distală obliterată) plica vezicală transversală
nerv şi vase obturatorii m. obturator intern
canal obturator arc tendinos al
m. levator ani
ureter (secţionat)
glandă bulbouretrală Cowper învelită
reces anterior al fosei ischioanale veziculă în m. transvers perineal profund
a. vezicală superioară seminală
canal deferent prostată şi m. sfincter al uretrei
 Hernie inghinala
1. Oblica-externa
2. Directa
3. Oblica interna
Caracteristici
 Hernia oblica-externa
 Hernie de forta sau congenitala
 Prin orificiul inghinal profund
 Sac herniar cu colet lung
 Hernia directa
 Hernie de slabiciune
 Adeseori bilaterala
 Prin triunghiul de slaba rezistenta Gillis sau Hesselbach
 Sac herniar globulos
 Hernia oblica-interna
 Rara
 De slabiciune
 Sacul contine adesea vezica uriunara
1. Hernie inghinala Oblica-Externa dobandita
2. Hernie inghinala Oblica-Externa congenitala

Hernia congenitala
 Persistenta canalului peritoneovaginal la barbati iar la
femei a canalului Nuck
 Sacul herniar se afla in interiorul funiculului
spermatic
Hernie inghinala
congenitala
1. INGHINO-
TESTICULARA
2. HERNIE
CONGENITALA
FUNICULARA
Hernie inghinala
congenitala
3. FUNICULARA CU
CHIST DE
CORDON
SPERMATIC
4. HERNIE
INGHINALA
CONGENITALA
ASOCIATA CU
HIDROCEL
 HERNII CONGENITALE ASOCIATE CU
ECTOPIE TESTICULARA

1. Inghino-properitoneala
2. Inghino-interstitiala
3. Inghino-superficiala
 hernie Berger: prezenţă concomitentă
de hernie inghinală şi hernie femurală
(→ hernie cu saci multipli)
 - hernie Pantaloon: hernie inghinală
dublă („în bisac”, directă + indirectă).
ALTE CLASIFICARI
 CLASIFICARE HERNII INGHINALE
Many hernia classifications have been proposed in the last 4 decades, which
meet these criteria to varying degrees. The most popular classifications
are described below.
Casten divided hernias into 3 stages:

1. Stage 1: an indirect hernia with a normal internal ring

2. Stage 2: an indirect hernia with an enlarged or distorted internal ring
3. Stage 3: all direct or femoral hernias

The Halverson and McVay classification divided hernias into 4 classes:

1. Class 1: small indirect hernia

2. Class 2: medium indirect hernia
3. Class 3: large indirect hernia or direct hernia
4. Class 4: femoral hernia
Clasificarea Nyhus, este următoarea:
 tip I = hernie indirectă, cu inel inghinal profund normal;

 tip II = hernie indirectă, cu inel inghinal profund dilatat;

 tip IIIA = hernie inghinală directă;
 tip IIIB = hernie inghinală indirectă cu perete posterior
slab al canalului inghinal, sau hernie prin alunecare;
 tip IIIC = hernie femurală;
 tip IV = hernie recidivată (A = directă, B = indirectă, C
= femurală, D = altele).
Ponka's system defined 2 types of indirect hernia:
 (1) uncomplicated indirect inguinal hernia and

 (2) sliding indirect inguinal hernia

and three types of direct hernias:

(1) small defect in the medial aspect of Hesselbach's
triangle near the pubic tubercle;
(2) diverticular hernia in the posterior wall with an
otherwise intact inguinal floor; and
(3) a large diffuse direct inguinal hernia of the entire
floor of Hesselbach's triangle.
Gilbert designed a classification for primary and recurrent inguinal
hernias done through an anterior approach (Figure 28). It is based on
evaluating 3 factors:

1.presence or absence of a peritoneal sac

2.size of the internal ring
3.integrity of the posterior wall of the canal

In 1993, Rutkow and

Robbins added a type
6 to the Gilbert
classification to
designate double
inguinal hernias and a
type 7 to designate a
femoral hernia.
Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct.
 Type 1 hernias have a peritoneal sac passing through an intact internal ring that will not
admit 1 fingerbreadth (ie,<1 cm.); the posterior wall is intact.
 Type 2 hernias (the most common indirect hernia) have a peritoneal sac coming
through a 1-fingerbreadth internal ring (ie, </=2 cm.); the posterior wall is intact.
 Type 3 hernias have a peritoneal sac coming through a 2-fingerbreadth or wider
internal ring (ie, >2 cm.).
 Type 3 hernias frequently are complete and often have a sliding component. They
begin to break down a portion of the posterior wall just medial to the internal ring.
 Type 4 hernias have a full floor posterior wall breakdown or multiple defects in the
posterior wall. The internal ring is intact, and there is no peritoneal sac.
 Type 5 hernias are pubic tubercle recurrence or primary diverticular hernias. There is
no peritoneal sac and the internal ring remains intact. In cases where double hernias
exist, both types are designated (eg, Types 2/4). Descriptors such as L, Sld., Inc., Strang.
Fem. are used to designate lipoma, sliding component, incarceration, strangulation and
femoral components.
 Diagnostic diferential
 Hernia femurala
 Intre tipurile de hernii inghinale OE si D
 Hidrocel
 Chisturi de cordon
Diagnosticul definitiv
 Varicocel complet de hernie trebuie să
 Lipoame cuprindă următoarele: tipul
 Tu testiculare anatomo-clinic, varietatea
 Adenopatii (directă, indirectă), eventualul
stadiu complicat.
 Tratament
 Regula este chirurgical
 Ortopedic este exceptia
 Tratament chirurgical
1. Procedee anatomice
2. Procedee neanatomice
 Retrofuniculare
 Prefuniculare
3. Procedee cu transpozitia cordonului spermatic
4. Procedee plastice
5. Procedee laparoscopice
 Anestezie - orice
 Local anesthesia. Local infiltration can be performed on virtually any
inguinal hernia, but it is usually reserved for patients of average weight
with a primary unilateral hernia. The local anesthetic is usually a
combination of a rapid-acting anesthetic, such as lidocaine or
chloroprocaine, and a longer-acting agent, such as bupivacaine, which
also provides several hours of postoperative pain relief.
 Addition of sodium bicarbonate to buffer local instillation decreases
the pain at the injection site and accelerates the onset of the anesthetic
effect. Addition of epinephrine may provide some hemostasis and
prolong the effects of local anesthetics.
 The local infiltration technique consists of specific, layered infiltration.
The most sensitive areas are the skin, the external oblique aponeurosis,
and the neck of a hernia sac or a lipoma. Once the external oblique
aponeurosis is reached, a small area of it should be exposed and
infiltration through it should be accomplished. When the external
oblique is opened, infiltration can be performed around the obvious
nerves, over the symphysis, and where the cord structures are adherent
to an indirect sac at the internal ring -- an area that is almost always
sensitive during dissection.

 Cai de abord
Annandale – Lawson Tait

Bassini

Babcok-Meingot

Lavarde
 Procedeele anatomice
 Proc Bassini 1890 - Edoardo Bassini -- considered the
father of modern day hernia surgery
•Incizie LaRoque
•Manevra
Reymond de
depistare a sacului
Rezectia sacului – SOCIN
Proc Bassini
 ANDREWS HACKENBRUCH –refacerea canalului ingnhinal
Procedee care mentin canalul inghinal dar folosesc
Lig Cooper
 Lotheisen –primul care propune utilizarea lig
Cooper
 Hashimotto

 McVay
McVay - Hashimotto
 Proc Souldice 1945

Shouldice repair. Canadian surgeon E.E. Shouldice contributed

substantially to hernia surgery in the second half of the 20th century.
He founded a clinic that has since become a hospital devoted
exclusively to the treatment of abdominal wall hernias. The Shouldice
operation for hernia repair revitalizes Bassini's original technique. It
applies the principle of an imbricated posterior wall closure with
continuous monofilament suture. At the Shouldice hospital,
continuous stainless-steel wire is used for all layers of the repair,
including the ligatures used in the subcutaneous layer
Local anesthesia is routinely used and bilateral hernias are usually
repaired separately, 2 days apart. Patients walk to and from the
operating room, begin exercise therapy on the day of surgery, and
resume their usual activities within a reasonable time after the
operation
Proc Souldice
 Milestones in Hernia Repair: The Listerian Era

Marcy (1871) Publication of original paper on antiseptic herniorrhaphy

("A New Use of Carbolized Catgut Ligature")

Czerny (1876) Described ligating and excising the indirect peritoneal sac
through the external ring
Kocher Twisted and suture-transfixed the peritoneal sac in the
lateral muscles. through the external ring

MacEwen Reefed the peritoneal sac into a plug to block the internal
(1886) ring.
Lucas- Opened the external oblique aponeurosis to expose the
Championniere entire inguinal canal.
 Procedee neanatomice – cu
desfiintarea canalului inghinal

 Procedee retrofuniculare  Totul in spatele funiculului -

 POSTEMPSKI aduc orificiul superficial in
 WISSE dreptul celui profund

 Procedee prefuniculare
 FORGUE  Totul in fata funiculului -
 GIRARD aduc orificiul profund in
 FERRARIS dreptul celui superficial
 PASOKUKOTHI
 VILANDRE
 TH. IONESCU
 BINET Principiul Martinov
 WOFLER
 MUGNAI
ALB la ALB
 HALSTEDT ROSU la ROSU
 MARTINOV
 KIMBAROVSKI
 retrofunicular  prefunicular
 Procedee cu transpozitia cordomului spermatic
 Schmieden
 Marin Popescu-Urlueni
Procedee plastice
 Cu material autolog
 Piele - Loeve Rehn
 Fascia transversalis - Ziemann
 Sac herniar – Lischied
 M cremaster – Brenner
 Aponevroze – Adler
 Teaca drept abdominal – Halsted , Vreden
 Fascia lata – Wangensteen, Binet
 Cu material homolog
 Cu material heterolog
 Natural
 Sintetic - PLASE cele mai folosite plase neresorbabile sunt,
în USA, Goretex (plasă de politetrafluoroetilen = teflon) şi Marlex
(plasă polipropilenică), în Franţa, Mersilene (plasă poliesterică, din
dacron), iar în România, Tricotplastex (plasă poliesterică);
 Replaced rubber, metals and animal products. Initially
used for sutures, later knitted or woven into patches for
Nylon (1944)
hernia repair; disintegrates in tissue and loses most of
its tensile strength within 6 months.
Polyethylene mesh High-density polyethylene mesh (Marlex, 1958) resistant
(1958) to chemicals and sterilizable, but unraveled after being
Polypropylene mesh cut. Modified to polypropylene mesh (1962). Available
(1962) under various trade names (Hertra-2, Marlex,
PROLENE, Surgipro, Tramex, Trelex). Available as a flat
mesh as well as 3-dimensional devices (Altex,
Hermesh3, PerFix Plug, PROLENE Hernia System). [23]

Polyester mesh Composed of polyester fiber with the characteristics of

(MERSILENE) (1984) filigree; can be inserted into narrow spaces without
distortion. [16]

Expanded Teflon product; produces minimal adhesions when

polytetrafluoroethylene placed intraperitoneally. Does not allow significant fibroblastic or
[22,24]

angiogenic ingrowth; must be removed if infection occurs.

Polyglycolic acid mesh Absorbable mesh; loses strength after 8 -12 weeks;
(Dexon) should not be used as a sole prosthesis for the repair of
Polyglactin 910 mesh abdominal or groin hernias
(Vicryl)
 TENSION FREE PROCEDURES
Stoppa (1967) and colleagues used the posterior approach
to implant an impermeable barrier around the entire
peritoneal bag, demonstrating that permanent repair of
groin hernias does not require closure of the abdominal
wall defect per se. Without having stated it, their repair used
a tension-free technique In Stoppa's approach, the mesh is
held in place by intra-abdominal pressure, an application of
Pascal's principle
Wantz furthered Stoppa's work by using it for unilateral
hernia repair.
Essential to these and all subsequent tension-free repairs is
the application of a barrier prosthesis, usually a permanent
mesh.
STOPPA WANTZ
1993 RUTKOW – ROBINS proc.

Perfix Plug. Flower-shaped

polypropylene mesh plug with multiple
petals, and onlay graft with slit to
accommodate the spermatic cord.
1997 - PROLENE Hernia System (PHS) bilayer patch
repair. Bilayer polypropylene mesh. Three-in-one device
with round disc for properitoneal repair, plug effect of
connector, and oblong shaped onlay component.
 Tension free
 The most important advance in hernia surgery has been
the development of tension-free repairs.
 In 1958, Usher described a hernia repair using Marlex
mesh. The benefit of that repair he described as being
"tension-eliminating" or what we now call "tension-
free".
 Usher opened the posterior wall and sutured a swatch of
Marlex mesh to the undersurface of the medial margin
of the defect (which he described as the transversalis
fascia and the conjoined tendon) and to the shelving
edge of the inguinal ligament. He created tails from the
mesh that encircled the spermatic cord and secured
them to the inguinal ligament.
USHER
PROC. LICHTENSTEIN - 1984
PROLENE Hernia System - 1997
 PROCEDEE
ENDOSCOPICE
PROPERITONEALE
- 1991 -
PROCEDEE LAPAROSPOPICE
TRANPERITONEALE
GILBERT - 1985
 In light of the huge benefit gained by the laparoscopic approach to
cholecystectomy -- and the rapid acceptance of that technique by most
surgeons -- much interest was given to the concept of laparoscopic
hernioplasty, which was introduced widely around 1990. However, many
surgeons who explored this approach to hernia repair found the learning
process to be longer and more challenging than that seen for
laparoscopic cholecystectomy or open herniorrhaphy. For this and other
reasons, the optimal and most appropriate use of the laparoscopic
technique remains a subject of debate among general surgeons.
 Laparoscopic herniorrhaphy requires general rather than local
anesthesia, takes more time, costs more, and carries the potential for
more significant surgical complications than those encountered with
open techniques. As a result, at least one large trial has concluded that
laparoscopy should remain the province of specialists, with open
procedures the approach of choice for most general surgeons
 COMPLICATII POSTOPERATORI
 Hematoame.
 Seroame
 Hemoragii din plaga
 Supuratii de plaga
 Edem scrotal
 Necroza testiculara
 Recidiva herniara
 Nevralgia inghinala
 reparare deschisă cu plasă

reductibilă
reparare laparoscopică
hernie palpabilă
unilaterală
reparare deschisă, po-sibil
încarcerată prin laparotomie

reparare deschisă cu plasă properitoneală

hernie recurentă reparare deschisă cu plasă

ISTORIC: reparare laparoscopică

deformare parietală
EXAMEN FIZIC
durere

tehnică alloplastică
deschisă bilaterală

hernie palpabilă tehnică alloplastică

bilaterală deschisă în etape

aplicare laparoscopică de plasă

blocadă a nervului
reexaminare la 1-3 luni

durere persistentă în
absenţa detectării iritaţie nervoasă injecţie de steroizi sau alcool
vreunei hernii

întindere musculară evitare a efortului fizic,

căldură locală, AINS