Groin Hernias

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Groin Hernias

• Vic V. Vernenkar, D.O.
• St. Barnabas Hospital
• Bronx, NY

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Definition

• Abnormal protrusion of a peritoneal lined sac
  thru the musculoaponeurotic covering of the
  abdomen

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Introduction

• In US 96 are inguinal, 4 femoral
• 20 bilateral
• Most common in both sexes indirect.
• Femoral hernias more common in elderly females
• Male to female ratio in 91 for inguinal hernias,
  13 for femoral hernias

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Anatomy

• 4cm in length
• 2-4 cm cephalad to inguinal ligament
• Extends between superficial and deep rings
• Contains spermatic cord or round ligament

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Anatomy

• Bounded superficially by external oblique
• Cephalad by internal oblique, TA, transversalis
• Inferior border is inguinal ligament
• Floor is transversalis fascia

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Layers

• Skin, subcutaneous, campers, scarpa, external
  oblique fascia, cremaster, spermatic cord,
  cremaster, transversus abdominis, transversalis
  fascia, preperitoneal tissues, peritoneum

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Anatomy

• Broadly classified as indirect and direct
  depending on relationship to epigastric vessels.
• Hesselbachs triangle is inferior epigastric
  artery laterally, lateral border of rectus
  medially, inguinal ligament inferiorly.

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Anatomy

• An indirect hernia passes lateral to Hesselbachs
  triangle.
• A direct hernia passes thru Hesselbachs
  triangle.
• Indirect hernia has a congenital component, from
  processus vaginalis.
• The processus is supposed to obliterate after
  descent of testes.

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Hesselbachs Triangle
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Indirect Hernia
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Direct Hernia
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Anatomy

• Direct hernias are usually not congenital.
• Acquired by the development of tissue
  deficiencies of the transversalis fascia.
• Development of femoral hernia less understood.
  Can result from increased intraabdominal
  pressure. The sac then migrates down the femoral
  vessels into thigh.

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Anatomy

• Major nerves in the region are ilioinguinal,
  iliohypogastric, genitofemoral nerves.
• Ilioinguinal provides sensory to pubic region,
  upper labia, scrotum. Most commonly injured.
• Iliohypogastric supplies sensory to skin superior
  to the pubis.
• Genitofemoral sensory to scrotum and thigh.

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Diagnosis

• Careful physical exam
• Pain, dull dragging sensation
• A common reducible hernia does not cause
  significant symptoms.
• CT scan, US are adjuncts rarely needed.
• Cannot determine direct from indirect clinically.

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Nyhus Classification

• I indirect, internal ring normal (kids)
• II indirect, dilated internal ring
• III posterior wall defects, direct inguinal
  hernia, dilated internal ring, massive scrotal,
  sliding, femoral hernia
• IV recurrent hernia

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Indications for Operative Repair

• Early repair is justified when potential for
  strangulation is weighed against minimal risks
  for surgery.
• Not warranted in terminally ill without
  incarceration
• Patients with ascites should have it controlled
  before surgery
• Incarceration, strangulation

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Surgical Techniques

• Open anterior repair (Bassini, McVay, Shouldice).
• Open posterior repair (Nyhus, preperitoneal)
• Tension-free repair with mesh(Liechtenstein,
  Rutkow)
• Laparoscopic

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Open Anterior Repair

• Transversalis opened, hernia sac ligated, canal
  reconstructed using permanent sutures.
• Tension of the repair can lead to recurrence.

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Open Posterior Repair

• Divide the layers of the abdominal wall superior
  to the internal ring, enter preperitoneal space.
  Dissection continues behind and deep to the
  entire inguinal region.
• Suture tension problems.

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Tension-Free Repair

• Same initial approach as anterior repair
• Instead of sewing fascial layers together to
  repair defect, a prosthetic mesh onlay used
• Simple to learn, easy to perform, suited for
  local anesthesia, excellent results with
  recurrence less than 4.

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Techniques

• Coined by Liechtenstein in 1989
• Central feature is polypropylene mesh over
  unrepaired floor.
• Gilbert repair uses a cone shaped plug placed
  thru deep ring.
• Slit placed in mesh for cord structures

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Kugel Patch
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Bard Perfix Plug and Patch
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Prolene Hernia System
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Techniques

• Suture fixation of the superior edge not needed.
• Reduction of the slit around the cord did not
  reduce recurrences.
• The additional safeguard was the plug
• Closing the tails is also not necessary.
• Tight rings do not cause orchitis, trauma does.

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Techniques

• The genital branch of the femoral nerve, and the
  ilioinguinal nerve are allowed to pass thru the
  newly constructed deep ring.
• Suturing the plug is not necessary.
• Preformed plugs have no advantage over a hand
  fashioned one.

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Techniques

• Small indirect sacs are dissected and inverted,
  large one are transected and ligated.
• Direct sacs are inverted.
• If plugs are placed to repair direct defects, a
  mesh only must be placed over the plug to prevent
  expulsion.

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Techniques

• Suturing the mesh to the inguinal ligament is not
  important.
• Fixing the mesh to the rectus sheath 1-1.5cm
  medial and superior to the pubic tubercle is very
  important.
• Should have a surplus of mesh over inguinal
  ligament, the medial suture ensures surplus mesh
  inferiorly

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Laparoscopic Procedures

• Increasingly popular, controversial
• Early in the development, hernias were repaired
  by placing very large mesh over entire inguinal
  region on top of the peritoneum. Was abandoned
  because of contact with bowel.
• Today, most performed TEP or TAPP

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Laparoscopic Procedures

• In the TEP procedure, an inflatable balloon is
  placed in the preperitoneal space, and the repair
  is done preperitoneal. More skill required.
• In both TAPP and TEP, the hernia sac is reduced,
  and a large piece of mesh is placed to cover
  defects.

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Laparoscopic Procedures

• The argued advantage of these procedures was less
  pain and disability, faster return to work.
• Great for bilateral hernia, with no increase in
  morbidity.
• For recurrent hernia
• Disadvantages are cost, time.

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Recurrence