Inguinal Hernias

The inguinal canal is approximately 4-6 cm long cone-shaped region situated in the
anterior portion of the pelvic basin. The canal begins on the posterior abdominal wall
where the spermatic cord passes through the deep (internal) inguinal ring, which is a
hiatus in the transversalis fascia, and it concludes medially at the superficial (external)
inguinal ring. The external inguinal ring is the point at which the spermatic cord crosses a
defect in the external oblique aponeurosis. The following are the boundaries of the
inguinal canal:
Anteriorly - external oblique aponeurosis
Posteriorly - transversalis fascia and transversus abdominis muscle
Laterally - internal oblique muscle
Superiorly - internal oblique muscle
Inferiorly - inguinal (Pouparts) ligament
The spermatic cord traverses the inguinal canal and is enveloped in 3 layers of
spermatic fascia. The spermatic cord is comprised of 3 arteries, 3 veins, 2 nerves, the
pampiniform venous plexus, and the vas deferens.
Structures that are worth noting that surround the inguinal canal include the iliopubic
tract, the lacunar ligament, Coopers ligament, and the conjoined tendon.
Inguinal hernias are typically classified as indirect, direct, and femoral depending on the
sire of herniation relative to the surrounding structures. Indirect hernias protrude through
the deep inguinal ring lateral to the inferior epigastric vessels. Whereas direct hernias
protrude within Hasselbachs triangle medial to the inferior epigastric vessels. The
borders of Hasselbachs triangle are:
Inguinal ligament - inferiorly
Lateral edge of rectus sheath - medially
Inferior epigastric vessels - superolaterally
Femoral hernias protrude through the femoral ring which is small and inflexible. The
borders of the femoral ring are:
Iliopubic tract and the inguinal ligament - anteriorly
Coopers ligament - posteriorly
Lacunar ligament - medially
Femoral vein - laterally
Hernia defects are often categorized by location, size, and type via the Nyhus
classification.
The laparoscopic approach to hernia repair provides a posterior perspective to the
peritoneal and preperitoneal spaces, and the reference points intraperitoneally are the
five peritoneal folds, bladder, inferior epigastric vessels, and the psoas muscle. The

vascular space is situated between the posterior and anterior laminae of the
transversalis fascia, and it contains the inferior epigastric vessels. Evaluation of the
internal inguinal ring will reveal the deep location of the inferior epigastric vessels. The
ilioinguinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves are of
particular interest.
Inguinal hernias may be congenital or acquired, and most adult hernias are considered
acquired defects in the abdominal wall. Although, collagen studies have demonstrated a
heritable predisposition to inguinal hernias. Congenital hernias make up the majority of
pediatric hernias and can be considered an impedance of normal development, rather
than an acquired weakness.
Surgical repair is the definitive treatment of inguinal hernias, although in a subset of
patients operation is not necessary. When the patients medical condition confers an
unacceptable level of operative risk, elective surgery should be deferred until the
condition resolves and operations are reserved for life-threatening emergencies. In the
asymptomatic population, rates of incarceration and strangulation are low, although the
natural history of untreated inguinal hernias is poorly defined. Nonoperative
management is an appropriate consideration in minimally symptomatic patients.
Nonoperative treatment targets pain, pressure, and protrusion of abdominal contents in
the symptomatic patient population.
Femoral and symptomatic inguinal hernias carry higher complication risks, therefore
surgical repair is performed earlier.
Open inguinal hernia repairs are subdivided into techniques that empty prostheses to
create a tension-free repair and those that reconstruct the inguinal floor using native
tissue. Tissue repairs are indicated when the use of prosthetic material is
contraindicated, often due to contamination or strangulation. Tissue repairs, aka tissuebased herniorrhaphy is a suitable alternative when prosthetic materials cannot be used
safely. Indications for tissue repairs include operative field contamination, emergency
surgery, and when the viability of hernia contents is uncertain. The Bassini repair is
seldom used today as modern techniques reduce recurrence. This original repair
includes dissection of the spermatic cord, dissection of the hernia sac with high ligation,
and extensive reconstruction of the floor of the inguinal canal. The shouldice repair
recapitulates principles of the Bassini repair, and its distribution of tension over several
tissue layers and results in lower recurrence rates. During dissection of the cord, the
genital branch of the genitofemoral nerve is divided, resulting in ipsilateral loss of
sensation to the scrotum in men or the mons pubis and labium majus in women. The
McVay repair addresses both inguinal and femoral ring defects. This technique is
indicated for femoral hernias and in cases where the use of prosthetic material is
contraindicated. Prosthetic repairs are most popular and use tension-free prosthetic
mesh repairs, and is the most commonly performed general surgical procedure. There

are a few different approaches to prosthetic repairs and they include: Lichtenstein
tension-free repair, the plug and patch technique, the proline hernia system, wound
closure, and giant prosthetic reinforcement of the visceral sac.
Laparoscopic inguinal hernia repairs reinforce the abdominal wall via a posterior
approach. Principal laparoscopic methods include transabdominal preperitoneal (TAPP)
repair, the totally extraperitoneal (TEP) repair, and the intraperitoneal onlay mesh (IPOM)
repair. The IPOM is much less common than the TAPP and TEP. The indications for
laparoscopic inguinal hernia repair are similar to those for open repair. The laparoscopic
approach to bilateral or recurrent inguinal hernias is considered superior to the open
approach. Concurrent inguinal hernia repair should be considered if a hernia patient is
scheduled to undergo another clean laparoscopic procedure such as a prostatectomy.