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INGUINAL HERNIA Feb. 18, 2016
Dr. Leyson
Page 1 of 17
TRANSCRIBERS: Sarjery Trans Peeps
Inguinal Hernia
Borders and contents of the (A) triangle of doom and (B) triangle of pain.
Circle of Death
PATHOPHYSIOLOGY
A hernia is a protrusion of a viscus or part of a viscus through an
Sensory dermatomes of the major nerves in the groin
abnormal opening in the walls of its containing cavity
Inguinal hernias may be congenital or acquired
Important anatomic areas in laparoscopic hernia repair Most adult inguinal hernias acquired defects in the abdominal wall
o Triangle of doom o Although collagen studies have demonstrated a heritable
o Triangle of pain predisposition
o Circle of death Best-characterized risk factor in inguinal hernia formation
Triangle of doom o Weakness in the abdominal wall musculature
o Borders
Medial: vas deferens
Congenital hernias
o Make up the majority of pediatric hernias
o Can be considered an impedance of normal development,
rather than an acquired weakness
o Normal course of development
DIAGNOSIS
HISTORY
Inguinal hernia presentation range from incidental discovery to
surgical emergencies such as incarceration and strangulation of the
hernia sac contents
Patients who present with a symptomatic groin hernia will frequently
report groin pain
Extrainguinal symptoms (change in bowel habits or urinary
symptoms) are less common
Inguinal hernias may compress adjacent nerves, leading to
o Generalized pressure
o Localized sharp pain
o Referred pain
Pressure or heaviness in the groin
o Common complaint
o Especially at the end of the day or following prolonged activity
Sharp pain
o Tends to indicate an impinged nerve
o May not be related to the extent of physical activity performed Examination of the contralateral side
by the patient o Compare the presence and extent of herniation between
Neurogenic pain sides
o May be referred to the scrotum, testicle, or inner thigh o Useful in the case of a small hernia
Questions should be directed to Inguinal occlusion test
o Elicit and characterize extrainguinal symptoms o Used to differentiate between direct and indirect hernias
o Characterize whether the hernia is reducible o Entails the examiner blocking the internal inguinal ring with a
Change in bowel habits or urinary symptoms finger as the patient is instructed to cough
o May indicate a sliding hernia consisting of intestinal contents or Indirect Hernia Direct Hernia
involvement of the bladder within the hernia sac Controlled impulse Persistent herniation
Important considerations of the patients history Transmission of the Impulse palpated on
o Duration of symptoms cough impulse to the the dorsum of the
o Timing of symptoms tip of the finger finger
Hernias will often in size and content over a protracted time
Much less commonly, a patient will present with a history of acute When results of PE are compared against operative findings
inguinal herniation following a strenuous activity o There is a probability somewhat higher than chance (i.e., 50%)
o It is more likely that an asymptomatic inguinal hernia became of correctly diagnosing the type of hernia
evident once the patient experienced symptoms after an acute o These tests should be used to detect hernias, but not to
event diagnose hernia types
Patients will often reduce the hernia by pushing the contents back External groin anatomy is difficult to assess in obese patients,
into the abdomen making the physical diagnosis of inguinal hernia challenging.
o Providing temporary relief o A further challenge to the PE is the identification of a femoral
As the defect size and more intra-abdominal contents fill the hernia hernia.
sac o Femoral hernias should be palpable below the inguinal ligament,
o Hernia may become harder to reduce lateral to the pubic tubercle.
Age (young vs. old) o In obese patients, a femoral hernia may be missed or
misdiagnosed as a hernia of the inguinal canal.
Occupation (nature?)
Local Symptoms: Swelling, discomfort and pain In contrast, a prominent inguinal fat pad in a thin patient, otherwise
known as a femoral pseudohernia, may prompt an erroneous
Systemic symptoms: if there is obstruction or strangulation
diagnosis of femoral hernia.
Precipitating Factors
PHYSICAL EXAMINATION
PE is essential to the diagnosis of inguinal hernia
Asymptomatic hernias
o Frequently diagnosed incidentally on PE
o May be brought to the patients attention as an abnormal bulge
Patient should be examined in a standing position to increase
intra-abdominal pressure, with the groin and scrotum fully
exposed
Inspection is performed first
o Goal: Identify an abnormal bulge along the groin or within
the scrotum
o If an obvious bulge is not detected
Palpation is performed to confirm the presence of the
hernia
Palpation
o Performed by advancing the index finger through the
scrotum toward the external inguinal ring
Allows the inguinal canal to be explored
o Patient is then asked to perform Valsalvas maneuver to
protrude the hernia contents
Reveal an abnormal bulge
Allow the clinician to determine whether the hernia is
reducible or not
o Taxis should not be performed when strangulation is suspected, o The iliohypogastric and ilioinguinal nerves are identified and
as reduction of potentially gangrenous tissue into the abdomen preserved.
may result in an intra-abdominal catastrophe. o Effort should be made to avoid removing nerves from their
o Preoperatively, the patient should receive fluid resuscitation, natural bed and disrupting the protective investing fascia.
nasogastric decompression, and prophylactic intravenous o The pubic tubercle is identified and the cord structures are
antibiotics. atraumatically dissected off of the pubis, encircled, and elevated
with a Penrose drain.
OPEN APPROACH o The cord is elevated 2 cm over the pubic symphysis in an
Open inguinal hernia repairs are subdivided into: avascular plane, and cremasteric fibers are preserved to avoid
o techniques that employ prostheses to create a tension-free injuring cord structures
repair
o those that reconstruct the inguinal floor using native tissue.
Tissue repairs are indicated when the use of prosthetic material is
contraindicated, (contamination or strangulation).
The option to administer locoregional anesthesia is an advantage of
the open approach.
o Common anesthetic agents include lidocaine or the longer-
acting bupivacaine, both with the option of adding epinephrine.
In advance of the initial incision, a field block or ilioinguinal nerve
block may be employed.
A regional block is an option for patients who cannot tolerate general
anesthesia, and it exerts a broader effect than local anesthesia
alone.
Exposure of the anterior inguinal region is common to the open
approaches.
An oblique or horizontal incision is performed over the groin
Indications for tissue repairs include: the iliopubic tract - sutured to the lateral edge of the rectus sheath
o operative field contamination using a synthetic, nonabsorbable, monofilament suture at the pubic
o emergency surgery tubercle
o when the viability of hernia contents is uncertain. o the suture progresses laterally, approximating the edge of the
General surgeons should understand inguinal anatomy and possess inferior transversalis flap to the posterior aspect of the superior
the expertise and ability to perform an effective tissue-based repair. flap
o At the internal inguinal ring: suture continues back in the medial
BASSINI REPAIR direction approximate superior transversalis fascia (TA) flap
The Bassini repair was an historic advancement in operative to inguinal ligament
technique. Its current use is limited, as modern techniques reduce o At the pubic tubercle: suture is tied to the tail of the original stitch.
recurrence. Next suture begins at the internal inguinal ring, continues
The original repair includes: medially, apposing the aponeuroses of the IO and TA to the
o dissection of the spermatic cord EO
o dissection of the hernia sac with high ligation o At the pubic tubercle: suture doubles back through the same
o extensive reconstruction of the floor of the inguinal canal structures laterally toward the tightened internal ring
o Division of the cremasteric muscle Lecture version
o High ligation of the hernia sac deep to the internal inguinal First suture line
ring o Starts at pubic tubercle by approximating the iliopubic tract to
the undersurface of the lateral edge of rectus abdominis
o The iliopubic tract, is sutured continuously to the posterior
aspect of the superior flap of the transversalis fascia until the
internal ring is encountered
o At this point, the internal ring has been reconstituted
SHOULDICE REPAIR
The Shouldice repair recapitulates principles of the Bassini repair,
and its distribution of tension over several tissue layers results in
lower recurrence rates
During dissection, the genital branch of the genitofemoral nerve is
routinely divided ipsilateral loss of sensation to the scrotum in men
(mons pubis and labium majus in women)
o posterior inguinal floor exposed incision in the
transversalis fascia between the pubic tubercle and internal
ring
o be careful to avoid injury to preperitoneal structures
Fourth suture line o To fix the inferior margin of the mesh: a permanent, synthetic,
o Approximates the internal oblique muscle and transversus monofilament suture is used
abdominis to the band of the interior flap of the external oblique o avoid placing sutures directly into the periosteum of the pubic
aponeurosis superficial and parallel to Puopart ligament tubercle
o Similar and superficial to the third layer o Fixation is continued along the shelving edge of the inguinal
ligament from medial to lateral, ending at the internal ring.
MCVAY REPAIR o The upper tail of the mesh fixed to the internal oblique
addresses both inguinal and femoral ring defects aponeurosis and the medial edge to the rectus sheath using a
indicated for femoral hernias and in cases where the use of synthetic, absorbable suture.
prosthetic material is contraindicated The mesh prosthesis must be large enough to adequately cover the
Once the spermatic cord has been isolated, an incision in the posterior wall of the inguinal canal
transversalis fascia permits entry into the preperitoneal space. upper Current standard for inguinal hernia repair
flap - mobilized by gentle blunt dissection of underlying tissue In femoral hernias: a triangular extension of the inferior aspect of the
o Coopers ligament - dissected to expose its surface. A 2- to 4- mesh is sutured to Coopers ligament medially and to the inguinal
cm relaxing incision is made in the anterior rectus sheath ligament laterally
vertically from the pubic tubercle o The lateral tails of the mesh tailored to fit snugly around the
essential to reduce tension on the repair; however, it may cord at the internal ring (but not too tight to strangulate it) The
result in increased postoperative pain and higher risk of tails are sutured to the inguinal ligament with an interrupted
ventral abdominal herniation stitch and placed beneath the external oblique aponeurosis
o superior transversalis flap - fastened to Coopers ligament;
continued laterally along Coopers ligament to occlude the
femoral ring using either interrupted or continuous suture
o Lateral to the femoral ring, a transition stitch is placed to affix the
transversalis fascia to the inguinal ligament transversalis is
sutured to the inguinal ligament laterally to the internal ring
Uses coopers ligament instead of the inguinal ligament for the
medial portion of the repair
Coopers ligament identifies and is bluntly dissected to expose its
surface
The upper margin of the transversalis fascia is then sutured to
Coopers ligament
Repair is continued laterally along Coopers ligament
WOUND CLOSURE
Once the reconstruction of the inguinal canal is complete, the cord
contents are returned to their anatomic position.
EO aponeurosis reapproximated continuously from medial to
BIOLOGIC MESH
Commonly reserved for contaminated cases or when domain
expansion is necessary in the face of high infection risk.
Generally, they have lower tensile strength and subsequent higher
rates of rupture than synthetic prostheses, and varying degrees of
tensile strength and tissue biocompatibility between them.
In ventral hernia repairs, xenograft material was associated with a
lower rate of recurrence than allograft material.
A review of biologic materials concluded that cross-linked graft
materials are more durable and less prone to failure than noncross-
linked grafts.
Diminished ability to remodel adversely affects rates of infection and
incorporation.
FIXATION TECHNIQUE
Suturing, stapling, and tacking prostheses entail tissue perforation,
which may cause inflammation, neurovascular injury, and chronic
pain development.
Improper prosthesis fixation may result in mesh migration, repair
failure, meshoma, pain, and hernia recurrence.
Mesh may be fixed with fibrin-derived glue, and self-gripping mesh
has been developed to minimize trauma to surrounding tissues and
to reduce the risk for entrapment neuropathy.
For hernias repaired via a strictly preperitoneal approach, prosthesis
fixation may not be necessary at all.
Fibrin glue fixation is a successful alternative to tack fixation in hernia
repair with a synthetic prosthesis.
o Recent studies comparing fibrin glue fixation and suture fixation
in open hernia repair show superior rates of chronic pain with
both Lichtenstein and plug and patch techniques
In TEP repairs, fixation of mesh may not be compulsory.
o A prospective randomized trial comparing fixation and no
fixation in TEP repairs found a significant increase in new pain
and equivalent recurrence rates in the fixation group several
months after repair HERNIA RECURRENCE
In the preperitoneal approach, the re-approximation of surrounding Develops pain, bulging, or a mass at the site of an inguinal hernia
tissues and physiologic intraabdominal pressure, hypothetically, repair, seroma, persistent cord lipoma, and hernia recurrence should
prevent mesh migration. be considered
o Due to higher theoretical risk of mesh migration, repair without Common medical issues associated with recurrence include
fixation is not recommended for anterior or transperitoneal malnutrition, immunosuppression, diabetes, steroid use, and
approaches. smoking
Technical causes of recurrence include improper mesh size, tissue
COMPLICATIONS ischemia, infection, and tension in the reconstruction
Most common complications: As with primary hernias, US, CT, or MRI can elucidate ambiguous
o Bleeding physical findings
o Seroma When a recurrent hernia is discovered and warrants re-operation, an
o wound infection approach through a virgin plane facilitates its dissection and
o urinary retention exposure
o Ileus Extensive dissection of the scarred field and mesh may result in
o injury to adjacent structures injury to cord structures, viscera, large blood vessels, and nerves
Complications specific to herniorrhaphy and hernioplasty: After an initial anterior approach, the posterior laparoscopic
o hernia recurrence approach will usually be easier and more effective than another
o chronic inguinal and pubic pain anterior dissection
o injury to the spermatic cord or testis Conversely, failed preperitoneal repairs should be approached using
an open anterior repair.
PAIN
Pain after inguinal hernia repair is classified into acute or chronic
manifestations of three mechanisms:
o Nociceptive (somatic)
o Neuropathic
o visceral pain
Nociceptive pain - most common.
o usually a result of ligamentous or muscular trauma and
inflammation
o reproduced with abdominal muscle contraction.
o Treatment consists of rest, nonsteroidal anti-inflammatory
drugs (NSAIDs), and reassurance
In evaluating the various available techniques, other salient signifiers o Place no restriction on patient function
of outcome include complication rates, operative duration, hospital o Simple and inexpensive to manufacture
stay, and quality of life. o Common brand names:
Among tissue repairs, the Shouldice operation is the most commonly Marlex (Davol, Cranston, RI)
performed technique, and it is most frequently executed at Prolene (Ethicon, Somerville, NJ)
specialized centers. ProLite (Covidien, Norwalk, Conn)
In experienced hands, the overall recurrence rate for the Shouldice
repair is about 1%. SPORTS HERNIA
o Although it is an elegant procedure, its meticulous nature Occult hernias
requires significant technical expertise to achieve favorable Sportmans hernia or athletic pubalgia
outcomes, and it is associated with longer operative duration Commonly seen in athletes that perform repetitive kicking, or
and longer hospital stay. turning, as in hockey, soccer, and football
Hernia recurrence is drastically reduced as a result of the o Which results in a weakness or tearing of the posterior
Lichtenstein tension-free repair inguinal wall
Compared with open elective tissue-based repairs, mesh repair is A similar abrupt motion in a non-athlete also may lead to this
associated with fewer recurrences (OR 0.37, CI 0.260.51) and with condition
shorter hospital stay and faster return to usual activities. In a multi- Presentation:
institutional series, 3019 inguinal hernias were repaired using the o May be acute, but more often, the deep groin pain
Lichtenstein technique, with an overall recurrence rate of 0.2%. o Presents in an insidious manner
Among other tension-free repairs, the Lichtenstein technique o Gradually worsening with increasing activity
remains the most commonly performed procedure worldwide. o Pain is aggravated by movements and sudden increases in
The Stoppa technique results in longer operative duration than the intra-abdominal pressure from coughing or sneezing
Lichtenstein technique. with an overall recurrence rate of 0.2%. o Present with tenderness to palpation over the pubic bone
Among other tension-free repairs, the Lichtenstein technique and inguinal canal
remains the most commonly performed procedure worldwide. Initial treatment of a sports hernia is conservative
The Stoppa technique results in longer operative duration than the o Rest
Lichtenstein technique. o NSAIDs
o Nevertheless, postoperative acute pain, chronic pain, and o Deep tissue massage
recurrence rates are similar between the two methods. o Physiotherapy
Perhaps the most compelling advantage of the Lichtenstein o Should the pain return upon gradual return to normal
technique is that non expert surgeons rapidly achieve similar activities after 6 to 8 weeks of conservative management,
outcomes to their expert counterparts. surgical exploration is necessary
Guidelines issued by the European Hernia Society recommend the Inguinal Exploration
Lichtenstein repair for adults with either unilateral or bilateral inguinal Fully assess the internal and external oblique
hernias as the preferred open technique. musculature and aponeuroses, inguinal rings,
Compared to open approaches, laparoscopic primary inguinal hernia ligaments and tendons, and pubic tubercle
repair produces equivalent recurrence rates and improved recovery Repair of the posterior floor by open laparoscopic
time, pain prevention, and return to normal activities. approach is
Because laparoscopic surgery requires specialized instruments and currently an effective strategy
longer operative times, its cost is higher than conventional open
repair; however, the potential financial benefit of shorter recovery PEDIATRIC HERNIA
and decreased pain may offset these costs in the long term. 0.8 and 44% incidence
Perhaps the most salient difference between open and laparoscopic With 10-fold increased incidence in boys vs. girls
techniques is the number of cases needed to develop technical Right-sided hernias are more common than left-sided hernias
proficiency. Approximately 10% of hernias presenting as bilateral
The frequency with which the above inguinal hernia repair Differential diagnosis
techniques are performed reinforces the importance of broad Undescended testes
experience. Testicular mass
Repair and 4.9% in those undergoing open repair, and the outcomes Varioceles
of laparoscopic repairs improved after each surgeon performed at Hydrocoeles
least 250 cases. o Hydrocoeles that present at birth do not necessarily
More recently, Lal and colleagues found that surgeons sustained a increase the likelihood that a PPV is present and will
decrease from 9% to 2.9% in postoperative recurrences after resolve on their own
performing 100 TEP operations. o Hydroceoeles that present following birth may be more
Other studies also suggest surgeons develop proficiency in these likely associated with a PPV that will not spontaneously
laparoscopic techniques after performing 30 to 100 cases; however, close
this estimate has decreased precipitously since laparoscopic Must be treated emergently
technique was first introduced. Open approach using a groin incision over the internal ring
In TAPP repair, the risk of intra-abdominal injury is higher than in Dilated internal ring can be repaired using the Marcy techniqu
TEP repair.
A Cochrane systematic review found that rates of port-site hernias Transcribers Note:
and visceral injuries were higher for the TAPP technique, whereas 1. Thanks sa notes from our 2B classmates and
TEP may be associated with a higher rate of conversion to an
sa 2C
alternative approach; however, neither finding was sufficiently
2. We do hope na natulungan kayo ng mga
compelling to recommend one technique over the other. ginawa naming transcriptions and pasensya
po sa mga minor errors
ADDITIONAL (SOURCE, 9TH ED./LECTURE)
3. Konting linggo na lang, kapit lang, magiging
MESH CHOICE
3rd years na tayo. #claimingit
Ideal mesh should be
o Easy to handle
o Provide adequate strength -FIN-
o Inert
o Resist contraction
o Avoid infection