Hernias

1
Hernias

• Dorothy Sparks, PGY-Ic
• Western Reserve Care System
• Department of Surgery

2
Historical Hernias

• Hernias have been documented throughout history
  with varying success at either reduction or
  repair.

3
Trusses Techniques
4
Anatomic Considerations

• The inguinal region must be understood with
  regard to its three-dimensional configuration
• A knowledge of the convergence of tissue planes
  is essential
• If repairing the hernia laparoscopically, the
  anatomy must be well understood from the
  peritoneal surface outward
• There is a considerable amount of anatomic
  variability with regard to
• Size and location of the hernia
• Degree of adipose tissue

5
Anatomic Considerations

• The surgeon must also be aware of the precise
  location of the
• Femoral nerve
• Genitofemoral nerve
• Lateral femoral cutaneous nerves

6
Pelvic Inguinal Anatomy

• Both the ilioinguinal nerve and the genitofemoral
  nerve traverse the usual hernia-repair operative
  field. The femoral vein also runs just deep to
  the inguinal floor laterally.

7
Hesselbach's triangle

• Boundaries
• Medial
• Rectus abdominis muscle medially,
• Inferiorly
• Inguinal ligament
• Laterally
• Inf. Epigastrics

8
The Inguinal Canal

• In the adult it is approximately 4 cm in length
• Is located 2-4 cm cephalad to the inguinal
  ligament
• A canal extends between the internal (deep
  inguinal) ring and the external (superficial
  inguinal) ring opening
• The inguinal canal contains either the spermatic
  cord or the round ligament of the uterus

9
The Inguinal Canal

• The canal is bounded superficially by the
  external oblique aponeurosis
• The cephalad wall is comprised of the internal
  oblique muscle, transverses abdominis muscle and
  the aponeuroses of these muscles
• The inferior wall is formed by the inguinal
  ligament and lacunar ligament
• The posterior wall (floor) is formed by the
  transversalis fascia and the aponeurosis of the
  transversus abdominis muscle

10
The Inguinal Canal

• The inferior epigastric vessels serve as the
  superolateral border of Hesselbachs triangle
• The medial border is formed by the rectus sheath
• The inguinal ligament serves as the inferior
  border
• Hernias occurring within Hesselbachs triangle
  are considered direct hernias

11
External Oblique Aponeurosis (EOA)

• The aponeurosis is formed by two layers,
  (superficial and deep)
• The EOA serves as the superficial border of the
  inguinal canal and reflects posteriorly to form
  the inguinal ligament
• The inguinal ligament extends from the anterior
  superior iliac spine to the pubic tubercle
• Combined with the internal oblique and
  transversus abdominis they form the rectus sheath

12
Internal Oblique Muscle

• Superior border of the inguinal canal
• The medial aspect of the aponeurosis fuses with
  the transversus abdominis to form the conjoined
  tendon

13
Transversalis Fascia

• Is considered the downward continuation of the
  transversalis muscle
• The lower free margin of this muscle arches with
  the internal oblique muscle over the internal
  inguinal ring to form the transverses abdominis
  aponeurotic arch

14
Iliopubic Tract

• Is a fibrous continuation of endoabdominal fascia
  located posterior to the inguinal ligament that
  arches over the femoral vessels to compose a
  portion of the femoral sheath
• It is an extremely important structure in the
  repair of femoral hernias and in the
  preperitoneal repair (open and laparoscopic) of
  inguinal hernias

15
Preperitoneal Space

• Contains
• Adipose tissue
• Lymphatics
• Blood vessels
• External iliac artery
• Inferior epigastric artery
• Obturator artery
• Arteria corona mortis
• Nerves
• Lateral femoral cutaneous nerve
• Genitofemoral nerve

16
Diagnosis

• The patient usually presents (for groin hernia)
  with the complaint of a bulge in the inguinal
  region
• They may describe minor pain or vague discomfort
  associated with the bulge
• Extreme pain usually represents incarceration
  with intestinal vascular compromise
• Paresthesias may be present if inguinal nerves
  are compressed

17
Diagnosis

• Physical exam
• The patient should be standing and facing the
  examiner
• Visual inspection may reveal a loss of symmetry
  in the inguinal area or bulge
• Having the patient perform valsalvas maneuver or
  cough may accentuate the bulge
• A fingertip is then placed in the inguinal canal
  Valsalva maneuver is repeated
• Differentiation between indirect and direct
  hernias at the time of examination is not
  essential

18
Hernia Exam
19
Diagnosis

• Physical exam
• Incarcerated hernias sometimes can be reduced
  manually
• Gentle continuous pressure on the hernial mass
  towards the inguinal ring is generally effective
  (Trendelenburg)

20
Nyhus Classification

• Type I Indirect inguinal hernia Internal
  inguinal ring normal (simple pediatric hernia)
• Type II Indirect inguinal hernia
• Internal inguinal ring dilated but posterior
  inguinal wall intact (inferior deep epigastric
  vessels not displaced)

21
Nyhus Classification

• Type III Posterior wall defect
• A. Direct inguinal hernia
• B. Indirect inguinal hernia- internal inguinal
  ring dilated (massive scrotal or sliding hernia)
• C. Femoral hernia
• Type IV Recurrent hernia
• A. Direct
• B. Indirect
• C. Femoral
• D. Combined

22
Inguinal Hernia

• Indirect inguinal hernia
• Is a congenital lesion
• Occurs when bowel, omentum or other abdominal
  organs protrudes through the abdominal ring
  within a patent processus vaginalis
• If the processus vaginalis does not remain patent
  an indirect hernia cannot develop
• Most common type of hernia

23
Indirect Hernia Route

• Note
• The hernia sac passes outside the boundaries
  of Hesselbach's triangle and follows the course
  of the spermatic cord.

24
Inguinal Hernia

• Direct inguinal hernia
• Proceeds directly through the posterior inguinal
  wall
• Direct hernias protrude medial to the inferior
  epigastric vessels and are not associated with
  the processus vaginalis
• They are generally believed to be acquired
  lesions
• Usually occur in older males as a result of
  pressure and tension on the muscles and fascia

25
Direct Hernia Route

• Note
• The hernia sac passes directly through
  Hesselbach's triangle and may disrupt the floor
  of the inguinal canal.

26
Incidence

• Approximately 700,000 hernia repairs are
  performed as an outpatient procedure each year
• Approximately 75 of all hernias occur in the
  inguinal region
• Approximately 50 of hernias are indirect
  inguinal hernias
• A vast majority occur in males
• Hernias more commonly occur on the right side

27
Causes of Groin Hernias

• Divided into two categories
  congenital acquired defects
• Congenital factors are responsible for the
  majority of groin hernias
• Prematurity and low birth weight are significant
  risk factors
• Direct hernias are attributed to the wear and
  tear stresses of life
• Groin hernias have been demonstrated to occur
  more frequently in smokers than nonsmokers
  especially women

28
Video Introduction
29
Surgical Management of Inguinal Hernias

• Inguinal hernias should be surgically repaired
  following diagnosis by exam
• The natural history of groin hernias is one of
  progressive enlargement and weakening with the
  potential for incarceration and obstruction of
  the intestine
• Hernias do not resolve spontaneously or improve
  with time
• Wearing a truss does not cure a hernia

30
The Operation

• The incision is made two finger breadths above
  the inguinal ligament
• Careful dissection through the subcutaneous and
  external oblique fascia is made
• The spermatic cord is mobilized
• The cremasteric muscle fibers are divided and
  separated from underlying cord structures
• The hernia sac is dissected from the cord
  structures and opened
• The neck of the sac is suture-ligated at the
  level of the internal ring (excess sac is removed)

31
Specific Surgical Procedures

• Lichenstein (Tension Free) Repair
• McVay (Coopers Ligament) Repair
• Shouldice (Canadian) Repair
• Laproscopic Hernia Repair
• Bassini Repair

32
Bassini Repair

• Is frequently used for indirect inguinal hernias
  and small direct hernias
• The conjoined tendon of the transversus abdominis
  and the internal oblique muscles is sutured to
  the inguinal ligament

33
Bassini Repair
34
McVay Repair

• AKA Coopers ligament Repair
• Is for the repair of large inguinal hernias,
  direct inguinal hernias, recurrent hernias and
  femoral hernias
• The conjoined tendon is sutured to Coopers
  ligament from the pubic cubicle laterally

35
McVay Repair

• Note
• This repair reconstructs the inguinal canal
  without using a mesh prosthesis.

36
Shouldice Repair

• AKA Canadian Repair
• A primary repair of the hernia defect with 4
  overlapping layers of tissue.
• Two continuous back-and-forth sutures of
  permanent suture material are employed. The
  closure can be under tension, leading to swelling
  and patient discomfort.

37
Shouldice Repair
38
Lichtenstein Repair

• AKA Tension-Free Repair
• One of the most commonly performed procedures
• A mesh patch is sutured over the defect with a
  slit to allow passage of the spermatic cord

39
Lichtenstein Repair

• Note
• Open mesh repair. Mesh is used to reconstruct
  the inguinal canal. Minimal tension is used to
  bring tissue together.

40
Laparoscopic Hernia Repair

• Early attempts resulted in exceptionally high
  reoccurrence rates
• Current techniques include
• Transabdominal preperitoneal repair (TAPP)
• Totally extraperitoneal approach (TEPA)

41
Laparoscopic Mesh Repair

• Note
• Viewed from inside the pelvis toward the
  direct and indirect sites. A broad portion of
  mesh is stapled to span both hernia defects.
  Staples are not used in proximity to
  neurovascular structures.

42
Femoral Hernias

• Occur through a space bounded superficially by
  the ileopubic tract, inferiorly by Coopers
  ligament, laterally by the femoral vein and
  medially by the insertion of the ileopubic track
  into Coopers ligament
• Are demonstrated by a mass below the inguinal
  ligament
• Are more common in females than in males

43
Femoral Hernia Route

• Note
• The hernia sac follows the potential space
  along the femoral vessels. It may be palpable
  near the femoral ring or in the medial thigh.

44
Types of Ventral Hernias
1. Umbilical Hernia 2. Incisional Hernia 3.
Parastomal Hernia 4. Spegelian Hernia
45
Incisional Hernia

• Usually occur as a result of inadequate healing
  from a previous incision or excessive strain at
  the site of an abdominal wall scar
• Postoperative wound infections are the most
  common causative factor
• Obesity is one of the leading causes as well
• Weight reduction therapy is recommended prior to
  the repair of an incisional hernia
• Other risk factors include advanced age,
  malnutrition, ascites, postoperative hematoma,
  pregnancy and many others

46
Parastomal Hernia

• True Hernias need to remove and place in rectus
  muscle (missed the rectus)
• Prolapse keep stomas at same site, fix the
  mesentary (is in rectus but prolapsing thru)
• Pseudohernia secondary to being in the oblique
  muscle, need to move to rectus

47
Spiegelian Hernia

• Occurs at the lateral border of the rectus muscle
  through the linea semilunaris.
• The Linea semilunaris separates the rectus
  abdominis from the external and internal obliques
• Almost always inferior to the semicurcularis

48
Umbilical Hernias

• Most of these are congenital in origin
• A strong predisposition in individuals of African
  descent
• The defect closes spontaneously by the age of two
  in most patients
• Umbilical hernias that persist after the age of 5
  are frequently repaired (surgically),
  complications in children are unusual (in
  adulthood strangulation of bowels may occur)
• Umbilical hernias that present in adulthood are
  considered acquired hernias

49
Umbilical Hernia
50
Umbilical Hernias

• Patients with conditions that result in increased
  intra-abdominal pressure can develop aquired
  umbilical hernias
• Pregnancy, ascites or abdominal distention may
  cause umbilical hernias

51
Rare Hernias

• Hernias you arent likely to see or hear about
  except with Dr. Ghani or on the ABSITE.
• Richters hernia
• Littres Hernia
• Petits Hernia
• Grynfelts Hernia
• Sciatic Hernia
• Obturator Hernia

52
Rare Hernias

• Richters hernia
• Noncircumferential incarceration of the
  nonmesenteric bowel wall
• Littres Hernia
• Incarcerated Meckels
• Amyand's Hernia
• Acute appendicitis inside an incarcerated
• inguinal hernia

53
Rare Hernias

• Petits Hernia
• AKA Inferior Lumbar Hernia
• Boundaries
• Ext abdominal oblique
• Latissimus Dorsi
• Iliac Crest

54
Rare Hernias

• Grynfelts Hernia
• AKA Superior Lumbar Hernia
• Boundaries
• Internal abdominal oblique
• Lumbodorsal aponeurosis
• 12th rib

55
Rare Hernias

• Sciatic Hernia (Post. Pelvis)
• Herniation through the greater sciatic foramen,
  high rate of strangulation
• Obturator Hernia (Ant. Pelvis)
• Diagnosis by bowel gas below the superior pubic
  ramus.
• Howship-Romberg Sign seen w/Obturator Hernias
• Inner thigh pain with internal rotation

56
Living with A Hernia Weird AL