A very comprehensive presentation on managment of Inguinal hernias

1. Management of Inguinal
Hernias
Dr JAWAD AHMED
First Year Resident
Surgical D unit
MTI-LRH

2. Outlines
• Introduction
• Anatomy of Inguinal Canal
• Types
• Epidemiology
• Etiology
• Presentation
• Classification
• Investigations
• Treatment
• Complication

3. Introduction
• Inguinal hernia is a protrusion of a
peritoneal sac through a
muscluoaponeurtoic barrier in inguinal
area.

4. Anatomy of Inguinal canal
• Inguinal canal is a tunnel that traverses the layers of the
abdmonial wall musculature, bounded on the lateral
deep aspect by an opening in the transversalis
fascia/transversus abdminis muscle which is called
internal or deep inguinal ring.
• It travels along the fused edges of the transversus
abdmoinis/internal oblique/inguinal ligament and iliopubic
tract posteriorly and layers of the external oblique
musculature anteriorly, ending on the medial superficial
aspect at an opening in the external oblique aponurosis
which is called external or superficial inguinal ring.

5. • Ingunial canal is 4-6cm long
• Located in the anteroinferior of the pelvic
basin
• It is cone shaped.
• Base is directed superolaterally and Apex
inferomedially.

6. • The inguinal canal houses spermatic cord
in males and round ligament in female.
• It is subject to hernia formation primarily
due to decreased mechanical integrity of
the internal ring and/or transversalis
fascia,allowing intra-abdominal contents to
encroach into this space and form the
characteristic bulge of the groin hernia.

7. • Hernia formation in inguinal canal can be prevented by
certain defence mechanism of inguianl canal which are:
• Obliquity of inguinal canal
• Arching of conjoint tendon
• Shutter mechanism of internal oblique
• Ball valve mechanism due to contraction of cremasteric
muscle which plugs to superficial ring
• When external oblique muscle contracts, intercrural
fibers of superifical ring appose, causing “slit-valve
mechanism”
• Hormones

9. Types of Inguial Hernia
• Direct Hernia: It occurs as a result of
weakness in the posterior wall of the
inguinal canal, which is usually a result of
attenuation of the transversalis fascia. The
hernia sac protruds through Hesselbach
triangle, whivh is the space bounded by
the inferior epigastric artery, the lateral
edge of rectus sheath and the inguinal
ligament.

10. • Indirect hernias: These passes through
the internal inguinal ring lateral to the
inferior epigastric vessels and Hesselbach
triangle and follow the spermatic cord in
males and round ligament in females.
• Pantaloon hernia: when both direct and
indirect hernias co-exist.

11. Variants of Inguial hernia
• Sliding hernia: usually indirect hernia, it
denotes that a part of the wall of the hernia sac
is formed by an intra-abdominal viscus usually
colon sometimes bladder.
• Richter Hernia: A portion of ( rather than the
entire circumference) of the bowel wall is
incarcerated.
• Littre Hernia: which contains Meckel
Diverticulum
• Amyand Hernia: An inguinal hernia that
contains the appendix.

13. Epidemiology
• The true incidence and prevalence of inguinal hernia worldwide is
unknown.
• The male to female ratio is greater than 10:1.
• The lifetime prevalence is estimated to be 25% in men and 2% in
women.
• Two third of inguinal hernias are indirect whereas nearly two-thirds
of recurrent hernias are direct.
• About 10% of inguinal hernias will become incarcerated and a
portion of these may become strangulated.
• Recurrence rates after surgical repair are less then 1% in children
and vary in adults related to the method of repair.
• Laproscopic studies have reported rates of contralateral defects as
high as 22% with 28% of these going on to become symptomatic
during short term followup.

14. Etiology
• Mutifactorial i.e genetic, environmetal, metabolic or hormonal
• Weakness in abdominal wall musculature
• Presumed causes of groin hernias are:
• Coughing COPD Obesity Straining
• Constipation Prostatism Pregnancy
• Birth weight less than 1500g
• Family history of hernia
• Congenital connective tissue disorders
• Defective collagen synthesis
• Previous incision
• Arterial aneurysum
• Cigarette smoking
• Heavy weight lifting
• Ascities

15. Clinical Presentation
• Most inguinal hernias present as an intermitted bulge
that appears in the groin. In males, it may extend into
scrotal sac.
• Symptoms are usually related to exertion or long peroid
standing.
• The patient may complain of unilateral discomfort.
• In infants and childrens, a groin bulge is often noticed by
caregivers during episodes of crying or defecation.
• In rare cases, groin hernia may present as intestinal
obstruction.

16. Physical Examination
• The main diagnostic maneuver for inguinal
hernias is palpation of the inguinal region.
• The patient is best examined while standing or
straining.
• Hernias manifest as bulges with smooth,rounded
surfaces that become more evident with
straining.
• A cough impulse is normally palpable, and bowel
sounds can often be heard within the hernia on
ascultation. If there is no visible swelling, a
cough impulse is sought with the patient
standing.

17. • In order to differentaite between indirect
and direct hernia, the best technique is to
reduce the hernia with the patient in
supine position and place a thumb over
deep ring(ring occlusion test). Ask the
patient to cough, it should control the
hernia (no bulge) only if it is of indirect
variety

18. Classification
• Many classification systems have been devised
for ingunial hernias, few of them are listed below
• Gilbert classification
• Nyhus Classification
• Bendavid classification
• Halverson and McVay Classification
• Ponka’s Classification
• European Classification

21. Investigations
• Diagnosis of ingunial hernia is clinical but certain
investigations are performed in certain
circumstances
• Ultrasound abdomen and pelvis: It defines
defect and its contents. In old age, to look for
BPH, its size and to calculate post-voidal
volume. And to find any mass.
• CT scan: Its helpful in complex incisional hernia
determining the number and size of muscle
defects, identifiying the contents as well as
intraabdominal pathology.

22. • MRI: It is helpful in diagnosing sportsman’s groin
where pain is the presenting feature and to
distinguish occult hernia from orthopedic injury.
• Laproscopy: useful to identify occult
contralateral hernia.
Herniography: It can be performed in suspected
hernia when clinical diagnosis is unclear. This
procedure is done under floruoscopy following
injection of contrast medium in peritoneum.
Frontal and oblique radiographs are taken with
and without increased intra-abdominal pressure.

24. Treatment
Principle of hernia repair
1) Reduction of hernia content into the abdominal
cavity with removal of any non-viable tissue and
bowel repair if necessary.
2) Excision and closure of a peritoneal sac if
present or replacing it deep to the muscle.
3) Reapproximation of the walls of the neck of the
hernia if possible
4) Permanent reinforcement of the abdominal wall
defect with sutures or mesh.
5) Tension Free.

25. Treating precipitating factors
Chronic Bronchitis/ Bronchial asthma
BPH
Urethral stricture
Chronic Constiption

26. Conservative approach
• Truss: A truss is a surgical appliance
which provides support for the herniated
area, using a pad and belt arrangement to
hold it in the correct position, just when it
is put on before moving from bed.
– It is not curative
– Hernia should be reducible
– Contraindicated in case if irreducible hernia,
undesended testies, associated huge
hydrocele

28. Surgical Treatment
• Herniotomy ( excision of the hernial sac)
• Herniorrhapy
• Hernioplasty

29. Herniotomy
• It is performed for indirect ( congenital ) hernias.
• It is performed in pediatric age group and young adults.
• STEPS:
Classically an oblique skin incison is made parallel and 1-1.5cm above the
medial two third of the inguinal ligament.
After dividing the superficial fascia and securing hemostasis, the external obliqu
aponeurosis and the superficial inguinal ring are identified.
The external oblique aponeurosis is incised in the line of its fibers and this inguinal
canal is opened.
The contents of the inguinal canal (cord with its contents) can be visualized.
The sac of indirect hernia is present inside the covering of cord and lies lateral
to the inferior epigastric artery. Cord is lifted off the inguinal canal.
The sac is freed all around upto deep ring. The visualization of extraperitoneal
fats confirms the location of deep ring.
The neck of sac is transfixed and sac is excised. In cases where there is large
hernial sac reaching upto the scrotum. It might not be possible to separate the sac
completely. In these circumstances, the distal end of the sac can be left as such.

30. Henriorraphy
• It is strenthening of posterior wall of
inguinal canal.
• It is indicated in young adults with good muscle
tone.
• Those having weak posterior wall
• Dilated internal ring.

31. Types of Herniorrhaphy
• Lytle’s Method
• Bassini’s Repair
• Modified Bassini”s
• Shouldice
• Halstead’s
• Tanner’s muscle slide operation
• Wylly Andrew’s Repair
• Ferguson’s Repair
• McVay’s Repair
• Darning Repair
• Desarda Repair

36. Halstead’s Repair
• In this repair, (which otherwise resembles
Bassini ) external oblique aponeurosis is used to
strengthen the postrior wall.
• This exteriorzies the spermatic cord, placing it
beneath the layers of abdominal wall fascia.
• This technique is not appreciated because of the
high incidence of hydrocoels and testicular
atrophy as well as recurrence postoperatively.

38. Ferguson Repair
• In this,the arcing edges of conjoint tendon
is approximated and sutured to the
inguinal ligamant above the spermatic
cord.
• It leaves the spermatic cord beneath the
internal oblique muscle and the external
oblique aponeurosis.

39. McVay Repair
• In this procedure, interrupted suture is
applied between transversalis fascia to
copper’s ligament starting from public
tubercle medially towards femoral sheath
and later continued as suture repair
between transversalis fascia and iliopublic
tract laterally upto enterence of cord.
• It covers all three groin defects- indirect,
direct and femoral.

41. Darning Repair
• In this, continuous intervening network of
non-absorbable sutures are plaaced
between conjoint and inguinal ligament to
give good support to posterior wall of
inguinal hernia.

43. Hernioplasty
• Herniotomy
• Strengthening of the posterior wall of
inguinal canal with autologous tissue or
foreign material.
• Use of Prolene Mesh to bridge the gap
between inguinal ligament and conjoint
tendon.

44. Types of Hernioplasty
• Lichtenstein’s Tension Free Mesh
Hernioplasty
• Nyhus Condon (Iliopubic Tract Repair)
• Gilbert’s Plug ( Patch & Plug )
• Stoppa’s Repair
• Kugel Hugary Hernioplasty
• Laproscopic mesh repair

45. Lichtenstein’s Tension Free
• Prolene mesh is taken and fixed in the
inguinal ligament
• First bite is taken in the periosteum of
public tubercle and fix the mesh to a point
beyond the deep ring.
• Fix the mesh with inguinal ligament and
conjoint tension used 1/0 or 2/0 prolene
without tension.
• It is used in all types of inguinal hernia.

46. Mesh can be used..
• To bridge a defect: simply fixed over the
defect as tension free patch.
• To plug a defect: a plug of mesh is pused
into the defect.
• To augment a repair: the defect is closed
with sutures and the mesh is added for
reinforcement.

47. Types of Mesh
• Synthetic Mesh
– Polymer of polypropylene, polyester or
polytetrafluroethylene (PTFE)
– Non absorbable and provoke little tissue
reaction.
– Hydrophobic nature and monofilament
microstructure of polypropylene impede
bacterial ingrowth.

48. Type of Mesh
• Biological Mesh
– Sheets of sterilized, decellularised, non
immunogenic connective tissue
– Provide a scaffold to encourage neovascular
ingrowth and new collagen deposition
– Host enzymes eventually break down the
biological implant which is replaced and
remodelled with fibrous tissue.
– It is expensive.

49. Type of Mesh
Absorbable Mesh:
Also synthetic absorbable meshes, such as
those made of polyglycolic acid fibers.
Used in temporary abdominal closure and
to butre sutured repairs
No role in hernia repair as they absorb and
induce minimal collagen deposition.

50. Positioning of Mesh
• Onlay – it is just outside of the muscle in
the subcutaneous space.
• Inlay – it is placed within the defect, only
applies to mesh plugs in small defects
• Sublay – its in between fascial layers in
the abdominal wall, intrapariteal
• Immediaterly extraperitoneally – against
muscle or fascia
• Intraperitoneally.

51. Type of Mesh
Tissue Separating mesh:
It is used Intraperitoneally
It is used on Different surfaces, one being
sticky and another slippery
It has adherence and host tissue in growth
is required on the pariteal side of the mesh
Bowel side needs to prevent adhesion to
the bowel.

52. Other repairs using Mesh
• Patch & Plug Technique involves
placement of a preformed mesh plug in
the hernia defect that is sutured to the
facial margins of defect.
• Kugel’s repair is a preperiotoneal repair
in which a preformed mesh with a stiff ring
around the edges is placed in the
preperitoneal space.

53. Stoppa’s Repair
• The Stoppa Repair is a tension-free type of hernia repair. It is
performed by wrapping the lower part of the pariteal peritonium with
prosthetic mesh and placing it at a preperitoneal level over
Fruchaud's myopectineal orifice. It was first described in 1975 by
Rene Stoppa. This operation is also known as "giant prosthetic
reinforcement of the visceral sac" (GPRVS).
•
This technique has met particular success in the repair of
bilateral hernias, large scrotal hernias, and recurrent or
rerecurrent hernias in which conventional repair is difficult and which
carries a high morbidity and failure rate.
• The totally extra-peritoneal repair (TEP) uses exactly the same
principles as the Stoppa repair, except that it is
performed laparoscopically.

54. Laparoscopic Mesh Repair
• TAPP
Transabdominal Preparitoneal
Procedure
TEP
Total Extraperitoneal Procedure

55. TEP Repair
• It is more popular then TAPP.
• Through subumbilical incision (10mm)
extraperitoneal space is reached.
• After CO2 insufflation, another 5mm port is
created 4cm below the 1st
port in the midline, 3rd
port on the same line or RIF.
• Dissection is carried downwards carefully, then
medially upto public tubercle, iliopectneal line,
laterally to iliac vessels and inferior epigastric
vessels.

56. TEP Repair
• Once adequate spce is dissected 15 x
15cm mesh is placed and spread.
• Mesh may be sutured to iliopectinal
ligament.
• Displacement of mesh is not seen.
• Another side can be done on single
setting.

57. TAPP Repair
• Used in large indirect or irreducible inguinal hernia.
• Ports created
• Contents of hernia is reduced
• Hernial sac dissected in preperitoneal plane after making
horizontal incision at the upper part of the sac opening.
• Once sac is dissected & excised, prolene mesh of
15x10cm size or smaller is placed in preperitoneal
space.
• It is fixed with pubic bone using tacks.
• Peritoneum is closed with continuous prolene suture.

58. Compliations- Intra operative
• Injury to blood vessels ( inferior epigastric &
femoral.
• Injury to bowel and bladder
• Injury to ilioinguinal & iliohypogastric nerves
• Injury to cord structues

59. Complications – Immediate Post
Operative
• Urine retention
• Hematoma formation
• Infection
• Seroma
• Periosteitis of public tubercle
• Post herniorrhaphy hydrocele

60. Complications - Late
• Recurrence
– Recurrence rate
Bassini’ repair – 10%
Shouldice repair – 1%
Hernioplasty – 1 t0 3%
Other methods – 1 to 5%
• Testicular atrophy if testicular artery is
demaged
• Obstruction

61. Complication- Laproscopic hernia
repair
• Vascular injury
• Visceral Injury
• Trocar site complictations
• Bowel obstruction
• Hypercarbia syndrome
• Abdomen compartment syndormes

62. References
• Bailey and Loves
• Sabiston Textbook of Surgery
• Washington Manual of Surgery
• SRB’s Manual of Surgery

63. THANK YOU