A case discussion on hernia. Useful for medical students. Primary reference: Schwartz Principles of Surgery.

1. Omar Khayyam Ramos Macadato

2. Sir Astley Cooper Recommended a truss rather than surgery; only indication
for surgery was strangulation
Lucas-Championnière 1881 Performed high ligation of an indirect inguinal hernia sac at
the internal ring
Edoardo Bassini 1844–1924 dissection of the layers of the inguinal canal to the
transversalis fascia & reconstruction of the floor of the
inguinal canal in several layers
Lotheissen, McVay,
Halsted, Shouldice
Described modifications of Bassini's repair to reduce the
recurrence rate and to avoid complications

3. Lichtenstein 1986 Introduced tension-free repair by reconstructing floor of
inguinal canal using mesh prosthetic material
Gilbert 1989 Devised technique for sutureless repair of inguinal hernia
using prosthesis through internal inguinal ring or for repair of
posterior inguinal wall
Rutkow 1993 Modified mesh-plug repair; plug and patch operation

4. Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed

5.  Skin and subcutaneous fat
 External oblique abdominal muscle
 Internal oblique abdominal muscle and transverse
abdominal muscle
 Transvers abdominal fascia
 Fat out of peritoneum
 Peritoneum
Abdominal Wall

6. Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed

7. Muscle Origin Insertion
External
oblique
 Inferior border of lower 8
ribs
 Lateral lip of iliac crest
 Aponeurosis ending in
midline raphe (linea alba)
Internal
Oblique
 Thoracolumbar fascia
 iliac crest between
origins of external and
transversus
 Lateral two-thirds of
inguinal ligament
 Aponeurosis to linea alba
 Lower border of ribs 9-12
Transversus
abdominis
 Thoracolumbar fascia
 medial lip of iliac crest
 lateral one-third of
inguinal ligament
 Costal cartilages lower
six ribs (ribs VII to XII)
 Aponeurosis ending in linea
alba
 pubic crest and pectineal
line
Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed

8. Muscle Origin Insertion
Rectus
abdominis
 Pubic crest
 Pubic tubercle
 Pubic symphysis
 Costal cartilages of ribs V to
VII
 xiphoid process
Pyramidalis
 Front of pubis and pubic
symphysis
 Into linea alba
Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed

9.  Inguinal ligament – formed by the lower
border of the external oblique aponeurosis
Other ligaments are also formed
 lacunar ligament
 pectineal (Cooper's) ligament
Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed

10. Inguinal ligament
Deep inguinal ring
Superficial inguinal ring
Int. oblique m.
Transversus abdominis
Tranversalis fascia
Ext. oblique m.
Boundaries
of the
Inguinal
Canal

12. Anatomy in
Posterior
Perspective

13. Schwartz’s Principles of Surgery 9th Edition
MYOPECTINEAL
ORIFICE OF FRUCHAUD

14. Hasselbach
Triangle
Right inferior epigastric left artery
and vein
HASSELBACH TRIANGLE
Rectus abdominis muscle
Inguinal ligament

15. RETROPERITONEAL
VIEW

16. MAJOR NERVES OF
THE INGUINAL
REGION
1
2
34
3a
3b

17. SENSORY DERMATOMES OF
THE MAJOR NERVES IN THE
GROIN AREA

18. Contents of the Inguinal
Canal
 Genital branch of the genitofemoral nerve
 Ilioinguinal nerve
 Spermatic cord (in men)
 Round ligament (in women)

19. Contents of the
Inguinal Canal

20. Contents of Spermatic Cord
 Ductus deferens
 Artery of the ductus deferens
 Testicular artery
 Pampiniform plexus of veins
 Cremasteric artery and vein
 Genital branch of the genitofemoral nerve
 Sympathetic and visceral afferent nerve
 Lymphatics
 Remnants of the processus vaginalis

21. Spermatic Cord

23. Femoral
Canal
Inguinal lig.
Femoral vein

24. TRIANGLE OF DOOM
 Lateral Border: Spermatic cord vessels
 Medial Border: Vas deferens
 Posterior Border: Peritoneal edge
 Contents:
 External iliac vessels
 Deep circumflex iliac vein
 Femoral nerve
 Genital branch of genitofemoral nerve

25. Schwartz’s Principles of Surgery 9th Edition

26. TRIANGLE OF PAIN
 Superomedial Border: Gonadal vessels
 Lateral Border: Reflected peritoneum
 Inferolateral Border: Iliopubic tract
 Contents:
 Lateral femoral cutaneous nerve
 Femoral branch of the genitofemoral nerve
 Femoral nerve

27. Schwartz’s Principles of Surgery 9th Edition

28. CIRCLE OF DEATH
 Common Iliac
 Internal Iliac
 Obturator
 Aberrant Obturator
 Inferior Epigastric
 External Iliac

29. CIRCLE OF DEATH

30. Deep Inguinal Ring
Inguinal ligament
Superficial Inguinal Ring
Hasselbach Triangle
Inguinal Canal
Spermatic Cord
Adductor longus
Sartorius
Femoral nerve
Femoral artery
Femoralvein
Femoral ring
Femoral Triangle
Ductus deferens
TRIANGLE OF DOOM
Gonadal vessels
Iliac artery and vein
TRIANGLE OF PAIN
Ant. Epigastric a. & v.
ANATOMY
1
2
3
4
1. Femoral nerve
2. Femoral br. of genitofemoral
nerve
3. Ant. femoral cutaneous nerve
4. Lat. femoral cutaneous nerve
1
2
1. Iliac vein
2. Iliac artery
MYOPECTINEAL ORIFICE
OF FRUCHAUD
MYOPECTINEAL ORIFICE OF
FRUCHAUD
 SUPERIOR: Oblique muscles &
Transversus abdominis
 MEDIAL: Rectus muscle & sheath
 LATERAL: Iliopsoas
 INFERIORLY: Cooper’s ligament
(Pecten pubis)
CIRCLE OF DEATH
Abberant Obturator artery & vein
Obturator artery & vein
1. Common Iliac
2. Internal Iliac
3. Obturator
4. Aberrant Obturator
5. Inferior Epigastric
6. External Iliac

31. DEFINITION
 Defined as an abnormal protrusion of an organ or tissue through a defect in its
surrounding walls
 Abdominal wall hernias occur only at sites at which the aponeurosis and fascia
are not covered by striated muscle

32. Primary
Abdominal
Wall Hernia

33.  Coughing
 COPD
 Obesity
 Straining
 Constipation
 Prostatism
 Pregnancy
 Birthweight <1,500 g
 Family history of a hernia
 Valsalva maneuver
 Ascites
 Upright position
 Congenital connective tissue disorder
 Defective collagen synthesis
 Previous right lower quadrant incision
 Arterial aneurysms
 Cigarette smoking
 Heavy lifting
 Physical exertion

34.  75% of all hernias occur in the inguinal region
 Two-thirds are indirect, the remainder are direct inguinal hernias
 The lifetime risk of inguinal hernia is 27% in men and 3% in
women
 In males: peaks before the first year of age and after age 40.
 70% of femoral hernia repairs are performed in women
 The most common subtype of groin hernia in men and women is
the indirect inguinal hernia

35.  patent processus vaginalis
 obliterated processus vaginalis
 congenital structural malformations of the transversalis
fascia and transversus abdominis aponeurosis
 Denervation of the internal oblique muscle by adjacent
incisions

36. PATHOPHYSIOLOGY
CONGENITAL ACQUIRED
Pediatric Adult
Patency of the processus vaginalis Weak abdominal wall muscles
 Family history
 Low birth weight
 COPD  chronic cough
 Tissue weakness
 Right lower quadrant incision
 Straining 2° Prostatism
 Valsalva maneuver
 Hereditary collagen disorders
HERNIA

37. • Testes develops near the kidneys 7
weeks after conception
• Testes descends at the groin level
about 12 weeks after conception
• Testes descends into the scrotum
at about 4-6 weeks after birth

40. Varying degrees of closure of
the processus vaginalis
• A. Closed PV.
• B. Minimally patent PV.
• C. Moderately patent PV.
• D. Scrotal hernia.

41. Hernia
Types

42. Femoral Hernia

43. Indirect Inguinal Hernia

44. Direct Inguinal Hernia

45. Clinical classification
 Reducible hernia
 Irreducible hernia

46. Sliding hernia

47. Incarcerated
hernia
Strangulated
hernia

48. Other types of hernia
 Romberg's hernia or saddle bag hernia
 ipsilateral, concurrent direct and
indirect inguinal hernias
PANTALOON HERNIA

49.  hernias develop on both the right
and the left sides of the groin
 commonly congenital
 associated with age and straining
in elderly men
BILATERAL HERNIA

50.  Hernia through an incisional site
INCISIONAL HERNIA

51.  hernia through the spigelian
fascia
SPIGELIAN HERNIA

52. Other types of hernia
Hernias
Littre’s hernia Hernia involving a Meckel’s diverticulum
Petersen’s hernia Seen after bariatric gastric bypass;
Petit’s hernia hernia through Petit’s triangle (inferior lumbar triangle)
Grynfeltt’s hernia Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle)
Richter’s hernia Incarcerated or strangulated hernia involving only one sidewall of the bowel
Amyand’s hernia Hernia sac containing a ruptured appendix

53. Pathological
anatomy

54. INDIRECT INGUINAL HERNIA DIRECT INGUINAL HERNIA
EMBRYOLOGIC ACQUIRED
YOUNG MAN’S HERNIA (<50 YEARS OLD) OLDER MAN’S HERNIA (>50 YEARS OLD)
APPEARS SLOWLY APPEARS RAPIDLY
DISAPPEARS SLOWLY (MAY REQUIRE REDUCTION) DISAPPEARS RAPIDLY (SPONTANEOUS REDUCTION)
MAY BECOME SCROTAL NOT SCROTAL
MAY STRANGULATE STRANGULATION IS VERY RARE
IMPULSES TOUCH THE TIP OF EXAMINING FINGER IMPULSES TOUCH THE PULP OF THE EXAMINING
FINGER

55. PHYSICAL EXAMINATION
HISTORY &

56. TAXIS MANEUVER

57. COUGH IMPULSE
•Visible & Palpable cough
impulse.
•Reappear on straining,
standing or coughing

58. INVAGINATION TEST
 Felt on the pulp: direct hernia
 Felt on the tip: indirect hernia

59. THREE FINGER TEST / ZIEMAN’S TECHNIQUE
 Index finger: deep inguinal ring
(indirect hernia)
 Middle finger: superficial ing.
Ring (direct hernia)
 Ring finger: saphenous opening
(femoral hernia)

60. RING OCCLUSION TEST
 (-) ring occlusion test: bulging
of the hernia: INDIRECT
HERNIA
 (+) ring occlusion test: no
bulging of the hernia: DIRECT
HERNIA

61. DIFFERENTIAL DIAGNOSIS

62. NYHUS CLASSIFICATION SYSTEM
NYHUS CLASSIFICATION SYSTEM
Type I Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults
Type II Indirect hernia; internal ring enlarged
without impingement on the floor of the inguinal canal; does not extend to the Scrotum
Type IIIA Direct hernia; size is not taken into account
Type IIIB 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 commonly
associated with extension to the direct space; also includes pantaloon hernias
Type IIIC Femoral hernia
Type IV Recurrent hernia; modifiers A–D are sometimes added, which correspond
to indirect, direct, femoral, and mixed, respectively

64. Emergent repair
• Incarcerated hernias
• Strangulated hernias
• Sliding hernias

65. INCARCERATED HERNIA
 An incarcerated inguinal hernia without the sequelae of a
bowel obstruction is not necessarily a surgical emergency
 Reduction should be attempted before definitive surgical
intervention.
 Hernias that are not strangulated and do not reduce with
gentle pressure should undergo taxis.

66. How to reduce an incarcerated hernia in the ER
Apply ice to incarcerated hernia
Sedate the patient
Use the Trendelenburg position for inguinal hernias
Apply steady gentle manual pressure
Admit and observe for signs of necrotic bowel after reduction
Perform surgical herniorrhaphy ASAP

67. Treatment Approach on Strangulated Hernia
Rapid IVF resuscitation & Electrolyte replacement
Antibiotics
GI decompression: NGT insertion
Urgent surgery

68. Surgical Approach
Surgery
Viable bowel Reduced
Nonviable bowel
more bowel is pulled
Viable bowel is
transected
End-to-end
anastomosis
Groin approach not
possible
Explore
laparoscopy/laparotomy

69. INGUINAL HERNIA REPAIR
Open Anterior, Nonprosthetic
 Marcy Repair
 Bassini Repair
 Moloney Darn Repair
 Shouldice Repair
 McVay Cooper's Ligament Repair
Schwartz’s Principles of Surgery 8th Edition

70. MARCY REPAIR
 simplest nonprosthetic repair performed
today
 main indication is in Nyhus type I
 The essential features: high ligation of the
hernia sac plus narrowing of the internal
ring
Schwartz’s Principles of Surgery 8th Edition

71. BASSINI REPAIR
 Sutures approximate reflection of inguinal
ligament (Poupart’s) to the transversus
abdominis aponeurosis/conjoint tendon
 Major Components:
 Division of the external oblique aponeurosis
 Division of the cremaster muscle
 Division of the floor or posterior wall of the
inguinal canal
 High ligation of an indirect sac
 Reconstruction of the posterior wall
Schwartz’sPrinciplesofSurgery9thEdition

72. SHOULDICE REPAIR
 Initial approach similar to Bassini:
 2 continuous sutures:
 Iliopubic tract  rectus sheath inf.
Trans. Flap  sup. Flap int. inguinal
ring  back to superior flap  tie at
pubic tub.
 Int ing ring  apo. of int. obl. & trans.
abd.  ext. obl.  tie at pubic tub.
 distribution of tension over several
tissue layers results in lower
recurrence rates
Schwartz’s Principles of Surgery 10th Edition

73. MCVAY COOPERS LIGAMENT REPAIR
 addresses both inguinal and femoral
ring defects
• Indications:
• femoral hernias
• Prosthetic material is contraindicated
• Similar to Bassini except: Cooper’s
ligament sutured to transversus
abdominis aponeurosis/conjoint
tendon
Schwartz’s Principles of Surgery 10th Edition

74. PROSTHETIC INGUINAL HERNIA REPAIR
 Open Anterior, Prosthetic
 Lichtenstein Tension-Free Hernioplasty
 Mesh Plug and Patch
Schwartz’s Principles of Surgery 9th Edition

75. LICHTENSTEIN
TENSION-FREE
HERNIOPLASTY
Expands the
domain of the
inguinal canal by
reinforcing the
inguinal floor with
a prosthetic mesh
Schwartz’s Principles of Surgery 10th Edition

76. PLUG AND PATCH
TECHNIQUE
 Modification of the Lichtenstein repair; developed by
Gilbert and later popularized by Rutkow and Robbins
 Indirect: plug is placed alongside the spermatic cord
through the internal ring
 Direct: sac is reduced, and the plug is sutured to
Cooper’s ligament, the inguinal ligament, and the
internal oblique aponeurosis

77. PROLENE HERNIA SYSTEM
 provides reinforcement to the anterior and
posterior aspects of the abdominal wall
 The advantage of the preperitoneal mesh
position:
 increased intra-abdominal pressure pushes the
mesh into closer apposition to the abdominal
wall.
 The overlay flap reinforces the inguinal floor
similar to a tension-free repair.

78. LAPAROSCOPIC APPROACH
Transabdominal Preperitoneal Procedure
 Useful for bilateral hernias, large hernia defects, and scarring from previous lower
abdominal surgery

79. LAPAROSCOPIC APPROACH
Totally Extraperitoneal Procedure
 Advantage: access to the preperitoneal space
without intraperitoneal infiltration
 minimizes the risk of injury to intra-abdominal
organs and port site herniation through an
iatrogenic defect in the abdominal wall

80. POST- OPERATIVE COMPLICATIONS
• Pain
• Cord and Testis Injury
• Wound Infection
• Seroma
• Hematoma
• Bladder Injury
• Osteitis Pubis
• Urinary Retention
Schwartz’s Principles of Surgery 9th Edition

81. Evidence-based CPG on the
management of adult inguinal
hernia

82. 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

83. 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

84. REFERENCES
• Brunicardi, F. 2010. Schwartz's Principles of Surgery 10th Edition. McGraw-Hill Professional
Publisher. pp 1495-1516.
• Drake, R., V. Wayne, A.W.M. Mitchell. 2005. Gray’s Atlas of Anatomy. 1st Edition. Churchill
Livingstone. pp 1-648.
• Drake, R., V. Wayne, A.W.M. Mitchell. 2010. Gray’s Anatomy for Students. 2nd Edition. Churchill
Livingstone. pp 1-1136.
• Netter, F.H. 2014. Atlas of Human Anatomy: Including Student Consult Interactive Ancillaries and
Guides, 6th Edition. Netter Basic Science. Saunders. pp 1-640.
• Townsend, C.M. Jr. 2012. Sabiston Textbook of Surgery, 19th Edition. Saunders Publisher. pp 1-2152.
• Zollinger, R.M. Jr., and E. Ellison. 2010. Zollinger’s Atlas of Surgical Operations. McGraw-Hill Medical. pp
412-426.
• Lawrence, P.F., R. M. Bell, and M. T. Dayton. 2006. Essentials of General Surgery Lippincott Williams and
Wilkins. pp 1-613.
• Bendavid, R. 2001. Abdominal Wall Hernias: Principles and Managements. Springer Science and
Business Media. pp 1-792.

85. REFERENCES
Internet Sources
• Medscape/hernia
• http://surgery.med.nyu.edu/
• Bestmedicalpractice.com
Journals:
• Evidence-Based Clinical Practice Guidelines on the Management of Adult Inguinal
Hernia: Primary Inguinal Hernia, Recurrent Inguinal Hernia and Bilateral Inguinal
Hernia. Philippine Journal of Surgical Specialties. 2007

86. fin
Thank you!