5. GENERAL CONSIDERATIONS Hernia of the abdominal wall Are the most common conditions requiring major surgery Perfect results continue to elude surgeons Rate of surgical failure( recurrence) is humbling Outcome of hernia repair is highly surgeon dependent
6. GENERAL CONSIDERATIONS Hernia of the abdominal wall No disease of the human body, belonging to the province of Surgeons, require in its treatment a greater combination of accurate anatomical knowledge w/ surgical skills than hernia in all its varieties.
11. Hernias of the Groin Anatomy The only structurally important layer of the groin of concern to hernia surgeon is the innermost aponeuroticofascial layer of the abdomen transverse abdominal muscle transverse aponeurosis transversalis fascia
12. Hernias of the Groin Anatomy The transverse aponeurotico fascia at the upper border of the fascial sheath is known as: Iliopubic Tract>> North American Surgeons Bandolette of Thomson>>French Surgeons Deep Crural Arch>>>English Surgeons
13. Hernias of the Groin Anatomy This innermost aponeuroticofascial layer of transverse aponeurotic fascia becomes the inferior crus of the deep ring The superior crus of the deep ring is formed by the transverse aponeurotic arch that insert on the pectineal line of the pubis (pectin pubis )
14. Hernias of the Groin Anatomy The portion of the tendon of the rectus abdominis that curves laterally to pectin pubis is known as HENLE’S ligament The angle of entrance of the deep ring is ACUTE medially and OBTUSE laterally
15. Hernias of the Groin Anatomy The MEDIAL border of Deep ring= the transverse aponeurosis & transversalis fascia; fibrous, definable, and palpable is the margin the Surgeons repair during hernia operation The LATERAL border of the Deep ring the transverse abdominal muscle is soft, elastic, muscular, & indistinct
16. Hernias of the Groin Anatomy The cremasteric muscle arising from the internal oblique muscle embraces interior aspect of spermatic cord in the inguinal canal The cremasteric vessels arise from the inferior epigastric vessels and pass through posterior wall of the inguinal canal; these vessels are w/ the genital nerve that supplies the tunica of the testis and cremasteric muscle
18. Anatomy Boundaries of the inguinal canal Anterior wall= external oblique muscle Posterior & Medial wall= transverse abdominal muscle and transversalis fascia Lateral border=transversus abdominis muscle The internal oblique muscle covers the deep ring and forms the shutter mechanism.
21. Anatomy Spermatic cord begins at deep ring & contains: Vas deferens Testicular Artery Testicular Veins Lymphatics Autonomic Nerves Fatty Tissue
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24. Definitions Hernia= protrusion of a viscus through an opening in the wall of the cavity in which it is contained. Features Clinically the important point in the definition is PROTRUSION , because without it diagnosis is essentially impossible. Anatomically important features: Hernial orifice= defect in innermost aponeurotic layer of abdomen Hernial Sac = out-pouching of peritoneum
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26. Hernias of the Groin Anatomy FRUCHAUD’S Myopectineal Orifice He emphasized that groin hernia begins within a single weak area bounded: Superiorly- Internal oblique Muscle and Transverse Abdominal Muscle Laterally- Iliopsoas Muscle Medially- rectus muscle & sheath Inferiorly- pectin pubis
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28. Hernias of the Groin Anatomy This bony muscular framework is: Bridged and Bisected by the inguinal ligament Traversed by the Spermatic Cord & Femoral Vessels Sealed like a drum on its inner surface by the Transversalis Fascia
29. Hernias of the Groin CLASSIFICATION Type I Indirect Inguinal Hernia Internal inguinal ring is normal Pediatric hernia Type II Indirect Inguinal Hernia Internal inguinal ring dilated Posterior inguinal wall intact Inferior deep epigastric vessels not displaced
30. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects A. Direct Inguinal Hernia Protrusion does not herniate thru internal (inguinal) abdominal ring The weakened transversalis fascia (post inguinal wall medial to inferior epigastric vessels) bulge outward in front of the mass.
31. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects A. Direct Inguinal Hernia All direct hernias, small or large, are type III A Three Varieties: Type 1 small defect in the medial aspect of Hesselbach’s triangle near pubic tubercle. Type 11 is a Diverticular Hernia that protrudes thru an otherwise intact inguinal floor. Type 111 is a large Direct inguinal Hernia that protrudes thru the entire floor of the Hesselbach’s triangle
34. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects B. Indirect Inguinal Hernias With large dilated ring that has expanded medially and encroaches on the posterior inguinal wall (floor) to a greater or lesser degree. Frequently with scrotal position Occasionally cecum on the right & the sigmoid in the left makes up a portion of the sac wall. This sliding hernia destroys a portion of the inguinal floor.
35. Hernias of the Groin CLASSIFICATION Type III Posterior Wall Defects B. Indirect Inguinal Hernias Deep ring may be dilated w/o displacement of inferior epigastric vessels. Direct or Indirect components of the hernial sac may straddle those vessels to form a pantaloon hernia C. Femoral Hernias Type IV Recurrent Hernia
38. Hernias of the Groin Men has 25 X risk to develop hernia than women Inguinal Hernia arises above the abdomino Crural Crease Femoral Hernia arises below the Abdomino Crural Crease Sac of DIRECT HERNIA protrudes directly OUTWARD and FORWARD
39. Hernias of the Groin Sac of INDIRECT HERNIA passes obliquely or indirectly towards and ultimately into the scrotum In men indirect hernia outnumber direct hernia at a ratio of 2:1 Both indirect inguinal and femoral hernia are twice as common on the right than on the left
41. Hernias of the Groin Epidemiology Strangulation occurs in 1.3% to 3% of groin hernias Femoral has a higher rate of strangulation; 2- 20% of all hernias Aging: Increases the incidence of groin Hernias Likelihood of Strangulation Need for Hospitalization
42. Hernias of the Groin Epidemiology 10% of women and 50% men with femoral hernia will develop an inguinal hernia Probability of groin hernia’s strangulation varies with Location & Duration INGUINAL HERNIAS After 3 months strangulation 2.8% After 2 years strangulation is 4.5% FEMORAL HERNIAS After 3 months strangulation is 32% After 21 months strangulation 45%
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46. Etiology cont’d These reduces the strength of the fascia and aponeurosis Fractures of the elastic fibers & alteration of the structure, quantity and metabolism of collagen have been demonstrated in the connective tissue structures in groin hernia patients. Hernias of the Groin
47. Etiology cont’d Muscle deficiency contributes to herniation insufficiencies of internal oblique muscle Fracture deformities of the pelvis; denervation of the shutter mechanism following a low cosmetic appendectomy incision. Hernias of the Groin
48. Hernia of the GROIN Symptoms Natural history is slow enlargement to the point of irreducibility and disfigurement with risk of strangulation even present Wide variety of non specific discomfort related to the contents of the sac and the pressure by the sac on the adjacent structures.
49. Hernia of the GROIN Diagnosis Simple physical examination will show an enlarge mass which transmit a palpable impulse when patient strains or coughs Those not detectable by physical exams. can be demonstrated by: Ultrasonography Computerized tomography Magnetic resonance imaging Herniography
50. Hernia of the GROIN . Diagnosis cont’d Strangulation produces Intense pain in the hernia Tenderness Intestinal obstruction Signs& symptoms of sepsis Does not enlarge or transmit an impulse when patient coughs
57. Hernias of the GROIN Taxis= manual manipulation required to reduce viscera entrapped in a hernial sac. Should not be done for strangulated hernia Trusses are contraindicated for femoral hernia
58. Hernias of the GROIN Indications for Surgery All hernias should be repaired unless local or systemic conditions in the patients preclude a safe outcome . Exceptions, hernias with wide neck and shallow sac
59. Surgery for GROIN Hernias 1. Aim is to prevent peritoneal protrusion through myopectineal orifice 2. Restoration of the integrity of the myopectineal orifice based on 3. Fruchaud’s concept of Groin hernias:
60. Surgery for GROIN Hernias Fruchaud’s concept of Groin hernias: a. Aponeurotic closure of the myopectineal orifice to the extent necessary b. Replacement of the defective transversalis fascia w/ synthetic prosthesis
61. Surgery for Groin Hernias REPAIR OF MYOPECTINEAL orifice Reconstruction of the Deep Ring Contrary to the belief of some surgeons the ANATOMY of the deep ring is such that strangulation of the spermatic cord by reconstruction of the posterior wall of inguinal canal is virtually impossible
62. Treatment of Groin Hernias Repair of the groin hernia could be: Anterior Approach = thru a groin incision where structures in & around the inguinal canal must be divided to reach the aponeuroticofascial layer
63. Treatment of Groin Hernias Repair of the groin hernia could be: Posterior Approach Tension is avoided by using a mesh prosthesis to patch or plug the myopectineal orifice replacing transversalis fascia layer
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65. Treatment of Groin Hernias In the anterior classical Hernioplasty only three has withstood time: 1. Marcy’s simple ring closure 2. Bassini’s operation original as done in Shouldice Hospital in Toronto 3. Mc Vay Lotheissen Cooper Ligament Repair
66. Treatment of Groin Hernias Classical Hernioplasty has three parts: 1. Dissection of the inguinal canal 2. Repair of the myopectineal orifice 3. Closure of the inguinal canal
79. surgery for Groin Hernias Cooper ligament repair (McVay) Repair the 3 most valuable areas for herniation in myopectineal orifice Deep ring Hesselbach’s triangle Femoral canal Involves the suturing of the transverse aponeurotic arch to cooper’s ligament medially; femoral sheath laterally
89. PROSTHETIC MATERIALS Non-degradable and biologic-tolerant synthetic mesh readily available 1. MARLEX 2. PROLENE 3. TRELEX Resemble one another are composed of limited monofilament fibers of polypropylene. All are porous slightly elastic, semi rigid and relatively heavy and they contain plastic memory and buckle when bent in two directions at once.
90. PROSTHETIC MATERIALS 4 . SURGIPRO MESH- is composed of knitted, braided strands of polypropylene. 5. MERSILENE-an open knitted mesh composed of pure and uncoated braided fibers of the polyester DACRON.
Includes high ligation of the hernia sac plus narrowing the internal ring by approximating the surrounding muscular and aponeurotic layers on the medial side
The Shouldice repair emphasizes a multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique. The Shouldice repair is associated with a very low recurrence rate and a high degree of patient satisfaction.
The Bassini repair is performed by suturing the transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament. was the most popular type of repair done before the advent of tension-free repairs.
In the Lichtenstein repair, a piece of prosthetic nonabsorbable mesh is fashioned to fit the canal. A slit is cut into the distal, lateral edge of the mesh to accommodate the spermatic cord. The mesh is held in place with the use of a continuous monofilament nonabsorbable suture.
The “tension-free” mesh repair has been modified from the original Lichtenstein repair. Gilbert reported using a cone-shaped “plug” of polypropylene mesh that when inserted into the internal inguinal ring would deploy like an upside-down umbrella and occlude the hernia. This plug is sewn to the surrounding tissues and held in place by an additional overlying mesh patch. This so-called plug and patch repair, an extension of Lichtenstein’s original mesh repair, has become the most commonly performed primary anterior inguinal hernia repair.
