Surgical management of inguinal hernia

1. Mohammed Al-Saffar
SURGICAL MANAGEMENT OF
INGUINAL HERNIAS
RAMKUMAR

2. HERNIA
• A hernia is defined as an abnormal protrusion of an organ or
tissue through a defect in its surrounding walls.
• Groin hernia
• Inguinal
• Direct
• Indirect
• femoraL

3. EPIDEMIOLOGY

4. PREDISPOSING FACTORS

5. TYPES OF HERNIA - CONDITION

6. INGUINAL CANAL ANATOMY
• The inguinal canal is an oblique space measuring 4 cm
in length that lies above the medial half of the inguinal
ligament.
• Inguinal canal has 4 walls : anterior, posterior, roof, and
floor

10. CONTENTS OF THE INGUINAL CANAL
• Males : spermatic cord and ilioinguinal nerve
• Females : round ligament and the ilioinguinal nerve

11. THE SPERMATIC CORD

12. MANAGEMENT
• Uncomplicated hernias require either :
• No treatment
• Support with a truss
• Operative treatment
• complicated hernias :
• always require surgery, often urgently.

13. SURGICAL APPROACHES
• For any hernia the surgical option comprises 2 components :
• Herniotomy
• Herniorrhaphy or hernioplasty
• It is either :
• Open repair
Bassini repair
Shouldice repair
Tension free mesh repair
• Laparascopic repair

14. COMPONENTS OF THE HERNIA

15. HERNIAL SAC DISSECTION

16. BASSINI REPAIR
• The Bassini technique is a "tension" repair, in which the
edges of the defect are sewn back together, without any
mesh.The conjoined tendon is retracted upward
• the aponeurosis of the transversus abdominis muscle is
approximated to the iliopubic tract that lies adjacent to
the inguinal ligament with several interrupted 3-0 silk
sutures.
• The second layer of the repair involves suturing the
conjoined tendon to the inguinal ligament with interrupted
2-0 silk sutures.
• This suture line extends from the pubic tubercle to the
medial border of the internal ring.

17. SHOULDICE REPAIR
• With a no. 15 scalpel an incision is made in the transversalis
fascia. This incision is extended from the internal ring to the
pubic tubercle.
• The repair involves placing four lines of sutures.
• The first suture line
• is started at the pubic tubercle using 3-0 continuous
polypropylene, and the white line is approximated to the free
edge of the inferior transversalis fascial flap.

19. SHOULDICE REPAIR
• The 2nd suture line :
• At the internal ring the suture is tied and then continued
medially by approximating the free edge of the superior flap
to the shelving edge of the inguinal ligament. When the
pubic tubercle is reached, the suture is tied and divided.
• The third suture line is started at the level of the internal ring
where the conjoined tendon is approximated to the inguinal
ligament and tied when the pubic tubercle is reached.
• Using the same suture, the fourth suture line attaches these
same structures to one another and is tied at the level of the
internal ring.

24. TENSION – FREE REPAIR
• There are several options for placement of mesh during
anterior inguinal herniorrhaphy, including
• The Lichtenstein approach
• The plug-and-patch technique
• The sandwich technique with both an anterior and
preperitoneal piece of mesh.

25. TENSION – FREE REPAIR

26. TENSION – FREE REPAIR

27. PROLENE HERNIAL SYSTEM

28. COMPARISON OF OPEN APPROACHS

29. INDICATIONS FOR LAPAROSCOPIC REPAIR
• Bilateral inguinal hernia
• When the diagnosis of inguinal hernia is uncertain
• When the patient want to return to normal physical life
Laparoscopic repair is done by 2 approaches :
1. Transabdominal preperitoneal “TAPP”
2. Totally extraperitoneally “TEP”

30. CONTRAINDICATIONS
• The patient medical condition makes general
anesthesia more risky
• Patient who have planned pelvic or extraperitoneal
operations (eg, radical prostatectomy)
• Patient who have had a recurrence from a prior
laparoscopic repair
• Patient presented with strangulated hernia

31. • Less acute postoperative
pain
• Shorter convalescence
• Earlier return to work
• increased risk of femoral
nerve injury and
• Increased risk of spermatic
cord damage
• risk of developing
intraperitoneal adhesions
with the TAPP
• greater cost and duration of
the operation
ADVANTAGES DISADVANTAGES

32. TRANSABDOMINAL PREPERITONEAL
• The TAPP approach, first described by Arregui and
colleagues in 1992
• It requires laparoscopic access into the peritoneal
cavity and placement of mesh in the preperitoneal
space after reducing the hernia sac.

33. TOTALLY EXTRAPERITONEALLY
• The first TEP inguinal hernia repair was described by
McKernan and Laws in1993.
• This approach involves preperitoneal dissection and
mesh placement without entering into the abdominal
cavity.

34. THE MERCEDES BENZ SIGN

35. COMPLICATION
• Urinary retention
• Nerve injury
• Testicular ischemia and atrophy
• Injury to vas deferens
• recurrence

36. Thank You