Hernia and Hernia Repair

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Hernia and Hernia Repair
Steven Roy Hofstetter, MD., FACS, Chief of
Surgical Services Department of Surgery, New
York University School of Medicine, Schwartz
Health Care Center 6 6C 530 First Avenue New
York 10016
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Hernia
Hernia is derived from the Latin for "rupture"
and is the protrusion of an organ or part of an
organ or other structure through the wall of the
cavity normally containing it. Sir Percivall
Pott described hernias in 1756 as "The disease
which makes the subject of the following tract,
is one in which mankind are, on many accounts,
much interested. No age, sex, rank, or condition
of life, is exempted from it the rich, the poor,
the lazy, and the laborious, are equally liable
to it it produces certain inconvenience to all
who are afflicted by it... It sometimes puts
the life of the patient in such hazard, as to
require one of the most delicate operations in
surgery and it has in all times, from the most
ancient down to the present, rendered those who
labor under it subject to the most iniquitous
frauds and impositions."
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Common Types of Hernias
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Inguinal Hernia
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Inguinal Canal
The inguinal canal in the anterior abdominal wall
stretches from the deep inguinal ring to the
superficial inguinal ring. The spermatic cord
traverses the inguinal canal in men. The round
ligament traverses the inguinal canal in women.
Anterior wall of the canal Aponeurosis of
external oblique muscle, aponeurosis of internal
oblique muscle for the lateral third of the
canal, and the superficial inguinal ring for the
medial third of the canal. Posterior wall of the
canal Transversalis fascia, conjoint tendon at
the medial third of the canal, and the deep
inguinal ring at the lateral third of the canal.
Superior wall of the canal Internal oblique
muscle and the transversus abdominis muscle.
Inferior wall of the canal Inguinal ligament,
lacunar ligament at the medial third of the canal
and iliopublic tract at the lateral third of the
canal.
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Anatomical types of Inguinal Hernia
Direct versus Indirect Inguinal hernias Indirect
hernias are hernias that enter the canal via the
deep inguinal ring. The hernia traverses the
entire length of the inguinal canal. The neck of
the inguinal sac lies lateral to the deep
epigastric artery. Direct hernias are hernias
that enter the inguinal canal directly via a gap
or defect in transversalis fascia, the floor of
Hesselbach's Triangle. The boundaries of the
triangle are medial boundary is the lateral
border of the rectus abdominis muscle, the
lateral boundary is deep epigastric artery, and
the lower boundary is the inguinal
ligament. Incidence Inguinal hernias are found
in 5 of male population, and represent 86 of
hernia cases. It occurs 5 times more often in
males and females.
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Anatomical types of Inguinal Hernia
Incomplete versus Complete hernias Incomplete
hernias (bubonocele) are hernias that do not pass
beyond the superficial inguinal ring of the
inguinal canal. Complete hernias descend into
the scrotum.
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Surgical Anatomy
Hesselbach's Triangle is defined as follows
Laterally The Inferior Epigastric artery and
veinMedially The Rectus SheathInferiorly The
Inguinal LigamentPosteriorly Transversalis
Fascia Direct versus Indirect hernias Hernias
medial to the epigastric vessels that enter the
inguinal canal via Hesselbach's Triangle are
Direct Hernias. Hernias that enter the canal via
the internal (deep) inguinal ring, are Indirect
Hernias.
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Indirect Inguinal Hernias
Hernias that enter the canal via the internal
(deep) inguinal ring, are Indirect Hernias.
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Direct Inguinal Hernia
Incidence 25 of hernia cases The hernia
contents enter the inguinal canal directly via a
gap or defect in transversalis fascia, the floor
of Hesselbach's Triangle. These hernias are
generally considered to be acquired, and may be
associated with heavy lifting, straining due to
constipation, coughing, or prostatic enlargement.
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Right sided hernias are more frequent than left
sided ones.
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Bilateral Hernia
Simultaneous Right and Left Inguinal Hernia
Common in children and elderly men If a left
inguinal hernia is present, there is a 25 risk
of an occult right inguinal hernia Both hernias
may be repaired with one surgical procedure
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History
Age Indirect hernia is usually seen in younger
adults. A direct hernia is common after the age
of 40. Pain Patient complains of patient
during the early stages when the hernia is
forming. The pain is intensified by straining.
Pain ceases when the hernia is fully formed.
Funiculitis (inflammation of the spermatic cord)
can be intensely painful. When the hernia gets
strangulated, pain is felt not only at the site
of the hernia, but all over the abdomen as well,
possibly due to drag on the omentum or
mesentry. Swelling A direct hernia is seen as
a spherical swelling that tends not to extend to
the scrotum, whereas an indirect inguinal hernia
is pyriform in shape and extends to the scrotum.
In a complete hernia, the swelling extends from
the inner part of the inguinal ligament down to
bottom of the scrotum (in the congenital type) or
stops above the testis (funicular type).
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Physical Signs
Skin over swelling Check for inflammation
(redness, edema), scars reflecting previous
surgery. Impulse on coughing Ask the patient to
cough. The increase in intra-abdominal pressure
forces more contents (omentum or intestine) into
the sac. A momentary bulge is noticed at the
superficial inguinal ring with the act of
coughing. Consistency on palpation Hernias
containing omentum (omentocele or epiplocele)
feel granular and doughy. Hernias containing
intestine (enterocele) feel elastic. Strangulated
hernias feel tense and tender. A varicocele has a
bag of worms feel. Reducibility Application
of pressure at the lower edge of the swelling
towards the inguinal canal should reduce the
hernia. A hernia that cannot be reduced
(irreducibility, incarceration) may develop
because of adhesions of contents to each other or
to the sac or strangulation.
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Sliding Hernia
Seen in 3 of hernia procedures. Great care must
be taken to avoid visceral damage during the
repair.
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Pantaloon Hernia
Direct and indirect hernias co-existing on same
side of the groin. The hernia is named pantaloon
because the two hernia sacs are divided by
epigastric vessels, and so they look like a pair
of pants from the 17th century. Patients with
pantaloon hernias are at risk of developing
recurrent hernias. Patients who have this type of
hernia may feel pain or a bulge in the groin
area. If left untreated, the hernia may become
strangulated, which could lead to bowel
obstruction. Hoquet maneuver May be best
approached by ligating the inferior epigastric
vessels to convert the direct and indirect
components to a single sac.
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Richter's Hernia
It is named after German surgeon August Gottlieb
Richter (1742-1812). A hernia involving only
one sidewall of the bowel, which can result in
bowel strangulation leading to perforation
through ischemia without causing intestinal
obstruction or any of its warning signs.
Antimesenteric border only of the small
intestine is incarcerated in the deep inguinal
ring, therefore intestinal obstruction may be
absent, but gangrene of the bowel wall may occur.
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Strangulated Hernia
Pressure on the hernial contents, usually
intestine, may compromise blood supply and cause
ischemia, necrosis and gangrene. This
complication may have a 12-13 mortality, and
will require removal of a portion of intestine.
Bulge below inguinal ligament, female, age 80
Strangulated small intestine
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Surgical Treatment of Inguinal Hernia
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Tension-Free Hernioplasty
Suture permanent polypropylene mesh to strong
tissues in the groin to close the gap in the
inguinal canal. The mesh is inserted in the
pre-peritoneal space, to afford the strongest
mechanical advantage. The mesh is soaked in an
antibiotic solution prior to implantation, and
prophylactic antibiotics are administered
intravenously to reduce the risk of infection.
After surgery, patients are fully ambulatory,
and the sole restriction is to avoid very heavy
lifting for 30 days. Modern, water-proof
dressings allow the patient to bathe. A
prescription for pain medication is given, and
patients are encouraged to gradually return to
full activities as tolerated.
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Sutures used for Tension-Free Hernioplasty
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Mesh used for Tension-Free Hernioplasty
Microscopic view of mesh
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Steps in Tension-Free Hernioplasty
Direct Hernia Sac Exposed
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Steps in Tension-Free Hernioplasty
Hernia Sac Removed
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Steps in Tension-Free Hernioplasty
Pre-peritoneal Space Exposed by Opening
Transversalis Fascia
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Steps in Tension-Free Hernioplasty
Mesh Anchored at Pubis (near retractor)
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Steps in Tension-Free Hernioplasty
"Wings" of Mesh placed Posterior to Cord to
re-enforce internal ring
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Steps in Tension-Free Hernioplasty
Completed Tension-free Repair
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Bassini Repair
Sutures the conjoined tendon to the inguinal
ligament, which slides the patients own muscles
together to cover the hole in the abdominal wall
and repair the hernia. Incision closed with a
simple interrupted suture pattern. Recovery is
slower than with Tension-free Hernioplasty due to
more swelling at the operative site. 3-30
recurrence rate.
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Bassini Repair
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Shouldice Repair

• Developed during World War II by Dr. E. E.
  Shouldice, a Canadian surgeon, this technique is
  widely used as a non-mesh option for hernia
  repair.
• Two permanent, continuous back-and-forth sutures
  are used to close the hole in the abdomen wall.
• By sliding four layers of tissue together, this
  technique is considered a more secure closure of
  the hole in the abdominal wall than the
  single-layer Bassini repair. In addition, the
  Shouldice technique uses the deepest layers of
  muscle while the Bassini repair uses more
  superficial layers.
• High success rate and low rate of recurrence.
• Tension in the closure of the incision can lead
  to swelling and patient discomfort lasting
  several weeks.

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Shouldice Repair
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Laparoscopic Hernia Repair
Less invasive than an open approach. It uses
three ports, or trochars, inserted into the area
of the surgery through which a TV camera and
instruments are placed to allow surgeons to
visualize the anatomy, define the hernia defect,
and implant the mesh. Two 5-mm and one 10-mm hole
for the ports. In the older Trans-Abdominal
Pre-Peritoneal (TAPP) procedure, the ports and
mesh enter the abdominal cavity. The newer
Totally Extra-Peritoneal (TEP) technique, stays
out of the abdominal cavity and places the mesh
in the same anatomic space as in the tension-free
repair.
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Laparoscopic Hernia Repair
Techniques    - trans-abdominal pre-peritoneal
(TAPP)    - totally extra-peritoneal (TEP)
Advantages    - less pain and more rapid
return to work    - better for recurrent and
bilateral hernias Disadvantages    - cost    -
learning curve higher recurrence rate    -
nerve irritation        - genitofemoral nerve.
(2)        - Ileo-inguinal nerve.
(1.1)        - lateral femoral cutaneous nerve.
(1.1)
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Complications of Hernioplasty
Intra-operative Injury to vas deferensInjury
to viscera (colon, bladder)Bleeding
Post-operative Testicular atrophy
Recurrence     - Bassini (3-33)     -
Shouldice (0.8)     - Laparoscopic repair
(2-6)
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Other types of Hernias
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Femoral Hernias
Femoral hernias are most often found in women and
occur at the upper thigh near the groin area.
This type of hernia has a high risk of
incarcerating the small bowel, which can then
lead to a strangulated hernia and become a
life-threatening condition. Patients who have a
femoral hernia may feel a tender bulge in the
upper thigh, just under the groin area. Unless a
significant medical condition prevents it, all
hernias should be repaired with surgery.
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Femoral Hernias
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Epigastric Hernia

• Linea alba defect in upper midline
• 5 of hernias
• Repair by resection of fat and primary facial
  closure

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Umbilical Hernia

• Failure of closure of umbilical ring
• Common in males, and premature infants
• Acquired in adults with cirrhosis, obesity,
  ascites, malnutrition
• Repairs    - Mayo "vest-over-pants"    -
  Primary mass closure
• Current trends in repair include mesh
  implantation into the pre-peritoneal space to
  obtain a tension-free closure of the umbilical
  ring and remain extra-peritoneal.

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Incisional Hernia

• 10 of cases more common in females
• Unrecognized or late dehiscence
• Etiology   
• wound infection     
• technical errors
• increased intra-abdominal pressure
• Multiple defects common "button-hole"
• Risk of incarceration
• Repair    - tension-free Mesh implantation -
  Stoppa repair    - sutures should pass through
  normal fascia
• 24 recurrence with traditional primary closure
  methods

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Incisional Hernia
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Incisional Hernia
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Incisional Hernia
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Incisional Hernia Double Layered Marlex Mesh
Repair
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Incisional Hernia Completed repair
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Spigelian Hernia

• Named for Adrian vander Spieghel Flemish
  anatomist, (1578 - 1625).
• Spontaneous lateral ventral hernia below the
  umbilicus and lateral to the rectus muscle, at
  junction of vertical semilunar line and
  horizontal semicircular line 90 located 0 - 6 cm
  above anterior superior iliac spine (Spigelian
  belt of Spagel).
• Characteristics    - median age 50
  years    - more common in males than
  females    - more common on right side than left
  side
• Treatment facial closure

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Spigelian Hernia
Plain Abdominal x-ray showing intestinal
obstruction in a patient with a Spigelian Hernia.
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Spigelian Hernia
CAT Scan of abdomen demonstrating an incarcerated
Left Spigelian Hernia. Note air above fascia on
patient's left.
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Lumbar Hernia

• External oblique, iliac crest, Lattissimus dorsi
  
• Acquired (55) trauma or renal surgery
• Congenital    - Superior (Grynfelt-Lesshaft
  triangle)    
•  - Inferior (Petit's hernia)

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Obturator Hernia

• 0.1 of hernias, 0.2 of bowel obstructions
• Greater incidence in females than males ( 91)
• Frail women in 7th or 8th decade
• More common on right
• 20 bilateral
• Medial groin pain secondary to obturator nerve
  impingement
• Howship-Romberg sign (hip-knee pain)
• Repair via abdominal approach with mesh
• 25 mortality

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Perineal Hernia

• Complication of abdominal-perineal resection
• Has a distinct sac, i.e. not a rectocele (pelvic
  floor relaxation)
• Most common in females

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Sciatic Hernia

• Gluteal hernia via greater sciatic notch
• Presents with sciatica
• Repair by abdominal or gluteal approach

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Summary
1. Hernias are the second most common cause of
intestinal obstruction, and a strangulated hernia
is a life-threatening condition. 2. Barring
significant medical contradications. All Hernias
Should Be Repaired. 3. Tension-free Mesh
Hernioplasty is a safe and effective out-patient
technique of repairing an inguinal hernia in the
setting of a modern university medical center.
4. Following hernia repair, patients may return
to full and unrestricted activities.