HERNIAS

DEFINITION

• A hernia is defined as an abnormal protrusion, bulge or projection of an organ through the wall
that contains it
• They can be classified based on:
– Anatomical location
– Etiology – congenital vs acquired
– Clinical presentation - Uncomplicated vs complicated
CLASSIFICATION LOCATION
• Ventral
– Spigelian – defect through Spigelian aponeurosis
– Epigastric – defect in midline of abdomen between xiphoid and
umbilicus
– Umbilical - more common in females
– Parastomal – incisional hernia from deliberately exteriorized bowel
• Groin
– Inguinal
• Direct – through Hesselbach’s triangle
• Indirect – through inguinal canal
– Femoral
• Pelvic
– Obturator – fibroosseous membrane, loss of adductor reflex, pain on
extension
– Sciatic – greater vs less sciatic foramen
– Perineal - occurs in multiparous women
• Lumbar
– Grynfeltt – superior lumbar triangle
– Petit – inferior lumbar triangle
 GROIN HERNIA ETIOLOGY
A) Congenital
– Males – patency of the processus vaginalis
– Females – widened canal of Nuck
B) Acquired
i) Weakened connective tissue – in born errors
of metabolism collagen synthesis
ii) Glucocorticoids
iii) Chronically increased intra-abdominal pressure
iv) Pectineus muscle atrophy (femoral hernia)
MECHANISM

1. Loss of mechanical integrity of abdominal wall muscles

2. Intra-abdominal pressure > abdominal wall pressure
3. Increased wall tension will cause rupture through the weakest point

Laplace Law – wall tension is greatest at point of largest radius and thinnest
walls
RISK FACTORS
• Obesity
• Pregnancy
• Smoking
• Extensive physical activity
• Ascites
• Chronic liver disease
• Inborn errors of metabolism
• Male
• Age
• Chronic steroid use
ANATOMY
• The groin is a naturally weak point in the abdominal wall – referred to as the myopectineal
orifice of Fruchaud
• Medially it is bordered by the conjoined tendon and rectus abdominis, laterally by the ilopsoas
and caudally by the superior ramus of os pubis
• The area covered by transversalis fascia is split into two by the inguinal ligament

• 1. Indirect hernia – enters the internal inguinal ring lateral to the inferior epigastric
artery and exits via the external ring
• 2. Direct inguinal hernia – protrudes medial to inferior epigastric vessels within
Hasselbach’s triangle
• Femoral hernia – inferior to inguinal ligament protrude through femoral ring medial to
neurovasculature
 EXAMINATION
• Groin lump
• Dull pain or discomfort exacerbated by straining
• Cough impulse - distinct “silky” impulse felt during Valsalva manoeuvre

• Incarcerated/strangulated hernias = irreducible hernia  trapped sac contents  oedema

compromised blood flood  ischaemia/necrosis  non-viable bowel up to 3% of the time
– Typically febrile, vomiting
– In such cases it is not advisable to attempt reducing hernia
– Generally not peritonitic unless there is rupture of necrotic bowel through hernia sac
INVESTIGATION
• Usually hx and physical exam will
suffice
• However in cases where dx is not
apparent (i.e. occult hernia or to
exclude other differentials)
ultrasound is the initial
recommended diagnostic modality
• CT/MRI can help differentiate
femoral from inguinal hernias
• Diagnostic laproscopy is gold
standard
• Herniography unnecessarily invasive
TREAMTENT

• Watchful waiting if asymptomatic + optimization of medical risk factors

• Laparoscopic repair
• Open repair

• Indications: depends on severity of symptoms, ability to manually reduce hernia and location of
hernia
• Contraindications (relatively few): 4 week post partum, active groin infection or systemic sepsis
CHOICE OF REPAIR CONSIDERATIONS
• Previous surgeries – adhesions render
preperitoneal space inaccessible
• Complicated hernia - mesh is contraindicated
• Ascites
• Patients that cannot tolerate GA
• Bilateral inguinal hernias – both sides can be
repaired laproscopically with a single mesh
• Cosmesis
• Recurrent hernia – optimally performed in
previously undissected plane
• Open is more cost effective – operating time,
equipment, length of stay and complications
LAPROSCOPIC TECHNIQUES
TEP – Totally extraperitoneal

Steps:
1. Extra peritoneal exposure
2. Blunt dissection of pre-peritoneal plane
3. Identification of epigastric vessels
4. Balloon dissector + insufflate space
5. Dissection of retro-pubic space
6. Mobilise sac back into peritoneal cavity
7. Mesh deployment
LAPAROSCOPIC TECHNIQUES
• TAAP – Transabdominal preperitoneal

Steps:
1. Access peritoneal cavity via hasson port at
umbilicus
2. Insufflate abdomen
3. Incise peritoneum from lateral edge of median
umbilical ligament (or single transverse from ASIS
if bilateral)
4. Develop peritoneal flap in avascular plane
5. Mobilise flat to expose cord structure
6. Reduce hernia
7. Mesh deployment in preperitoneal plane
8. Reposition inferior peritoneal flap + close
peritoneum
OPEN TECHNIQUES
Choice of repair open mesh: Choice of non-mesh open repair:
• Lichtenstein – mesh onlay anterior to • Shouldice repair
transversalis facia • McVay repair
• Bilayer mesh repair – combined onlay and • Bassini repair
underlay
• Preperitoneal mesh – mesh behind
transversalis fascia
• Plug and patch – mesh plug through defect,
onlay anterior to transversalis fascia
 LITCHTENSTEIN TECHNIQUE (OPEN)
• Primary open technique recommended by European
Hernia Society

Steps:
1. Incise skin above inguinal canal
2. Sharply dissect subcut tissue from ext ob to
expose external ring
3. Dissect spermatic cord from underlying
transversalis fascia
4. Taylor mesh to hernia
5. Suture inferior margin of mesh to shelving edge of
inguinal ligament
6. Suture superior mesh to rectus sheath medially
and internal oblique laterally
7. Slit lateral aspect of mesh to encircle spermatic
cord
8. Suture leaves of mesh together forming a neo-
internal ring
VENTRAL HERNIA REPAIR
• Perioperative risk assessment for patient
selection - stratify patients in terms of risk of
recurrence and wound complications
• Smoking – minimum 4-8 weeks smoking
cessation
• Obesity BMI <50
• Diabetes HbA1c <8%
• Although high risk scores does not exclude
patient from surgery, medical optimization of
risk factors is recommended
VENTRAL HERNIA REPAIR
• Mesh vs non-mesh – depends on size, type of hernia
• Open vs laproscopic
• Mesh material
– Synthetic
• Causes significant adhesions to serosal surface and organs
– Biologic – derived from human/animal tissue
• More susceptible to infection