INGUINAL HERNIA

MaxAngelo 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
Hesselbach’s triangle
 Acquired defectfrom
mechanical
breakdown over the
years
 ~1% Lifetime risk
 INDIRECT INGUINAL HERNIA
 Through the internal ring
of inguinalcanal
 Congenital
 Patent processus
vaginalis
 ~5% Lifetime risk
 Higher risk of
strangulation thandirect
INDIRECT INGUINAL HERNIA
 INCARCERATED STRANGULATED

 Hernia which cannotbe  Incarcerated hernia with

reduced resulting ischemia
 EPIDEMIOLOGY
 One of the most common surgical procedures
 Incidence:
 ~5-10% lifetime
 75% ofabdominal wall hernias
 Male >Female
 Indirect >Direct
 Right >Left
 1/3 may develop a contralateral inguinal hernia
 ETIOLOGY
 Multifactorial
 Weakness in abdominal wallmusculature
PRESUMED CAUSES OF GROIN HERNIATION
Coughing Valsalva's maneuvers
Chronic obstructive pulmonarydisease Ascites
Obesity Upright position
Straining Congenital connective tissuedisorders
Constipation Defective collagensynthesis
Prostatism Previous right lower quadrant incision
Pregnancy Arterial aneurysms
Birthweight <1500g Cigarette smoking
Family history of a hernia Heavy lifting
Physical exertion (?)
ANATOMY
Inguinal Hernia
 ABDOMINAL WALL
 Skin
 Subcutaneous fat
 Scarpa’s fascia
 External oblique muscle
 Internal oblique muscle
 Transversus abdominis
 Transveralis fascia
 Preperitoneal fat
 Peritoneum
 INGUINAL CANAL
 4-6 cmlong
 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
 +/- herniasac
 HESSELBACH’
S TRIANGLE
 Medial aspect ofRectus
abdominis muscle
 Inferior epigastric
vessels
 Inguinal ligament
POSTERIOR
MYOPECTINEAL ORIFICE
OF FRUCHAUD
 Superior
 Arch of IOM andTA

 Lateral
 Iliopsoas muscle

 Medial
 Lateral edge ofRA and
Pubic pectin

 Iliopubic tract
 Spermatic cord
 Iliac vessels
TRIANGLEOF DOOM
 External iliac vessels
 Deep circumflex iliacvein
 Femoral nerve
 Genital branch ofGF nerve
TRIANGLEOF 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;
INDIRECTSLIDINGORSCROTALHERNIAS 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 A–D are sometimes added, which correspondTO INDIRECT,
Type IV DIRECT, FEMORAL, ANDMIXED, RESPECTIVELY
DIAGNOSIS
 HISTORY
 Groin pain  Duration
 Extrainguinal symptoms  Progressiveness
 Change in bowelhabits
 Urinary symptoms
 Pressure on nerves
 Generalized pressure
 Local sharp pains
 Referred pain
 Scrotum, testicle or inner thigh
 PHYSICAL EXAMINATION
 Inspection
 Standing
 Palpation
 Inguinal Occlusiontest

Direct Indirect

Manifested Controlled
Cough
Impuls Dorsum of
Fingertip
e finger
DIFFERENTIAL DIAGNOSIS
 Malignancy  Undescended testicle
 Lymphoma  Femoral arteryaneurysm 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
CTScan
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 aTrendelenburg 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 tomushroom and prevent reduction.
STRANGULATED HERNIA
 Femoral > Indirect >Direct
 Fever, leukocytosis, and hemodynamicinstability.
 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 beingaddressed
OPERATIVETECHNIQUES
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 theinternal
oblique muscles is sutured to the
inguinal ligament
MCVAY REPAIR
 inguinal andfemoral
canal defects
 The conjoined tendonis
sutured to Cooper’s
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 earlyrecovery
RECURRENCE
 Around 1% forShouldice 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 thesurgical repair
COMPLICATIONS
 The overall risk of complications of inguinal hernia
repair islow.

 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 THEMANAGEMENT
OF ADULT INGUINAL HERNIA
PHILIPPINE JOURNAL OF SURGICALSPECIALTIES
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 laparoscopictechnique?
 Transabdominal Preperitoneal orTotal 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 THEMANAGEMENT
OF ADULT INGUINAL HERNIA
PHILIPPINE JOURNAL OF SURGICALSPECIALTIES
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
THANKYOU