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ABSITE Review:
Inguinal and Femoral
Hernias
Sybile Val M.D.
SUNY Downstate Medical Center
Department of Surgery
June 27, 2008
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Obj ti
Objectives
Correctly identify anatomical landmarks
intra-operatively
„ Differentiate
Diff
ti t between
b t
femoral
f
l and
d inguinal
i
i l
hernias
„ Understand different approaches at
surgical repair
„ Compare operative approaches
„
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Q
Questions
ti
1.
From which muscle layer
y is the inguinal
g
ligament
g
derived?
a.
b.
c.
d.
2.
Transversus abdominus
External oblique
Internal oblique
None of the above
What are the borders of the femoral canal?
a.
b.
c.
d
d.
External oblique, femoral vein, empty space
external oblique, femoral vein, empty space iliopubic tract and
f
femoral
l vein
i
iliopubic, cooper’s, femoral vein and junction of iliopubic and
cooper’s ligament
None of the above
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Q
Questions
ti
3
3.
A McVay repair
a.
b.
c.
d.
4
4.
May be used to repair femoral hernias
Entails suturing Poupart’s to the conjoined tendon
Is no longer performed
Does not require a relaxing incision
TAPP
a.
b.
c.
d.
Is contraindicated in the elderly
Requires traversing the peritoneal cavity
Is totally extraperitoneal
Has a low learning curve
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Q
Questions
ti
5
5.
The base of Hasselbach’s triangle is
a.
b.
c.
d.
Derived from the external oblique
Cooper’s ligament
There is no base
The inferior epigastric
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I t d ti
Introduction
„
In the US ~1 million abdominal wall hernia
p
y
repairs/year
… 750,000
– inguinal
… 25,000 - femoral
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I t d ti
Introduction
From latin word meaning rupture
„ Definition: Abnormal protrusion
„
… Occur
at sites where the aponeurosis and
fascia are not covered by striated muscle
Male preponderance (7:1)
„ Presentation:
„
… Groin
bulge/pain
… Right
g more common than left
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I t d ti
Introduction
„
Risk Factors:
… Age
… Obesity
Ob it
… COPD
… Chronic
constipation
… Straining
… Pregnancy
… Ascites
… Peritoneal dialysis
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I
Inguinal
i lH
Hernia
i
„
Indirect
… Most
common type
… Weakness in the
internal inguinal ring
… Associated with patent
processus vaginalis
i li
„
Direct
… Weakness
in the
transversalis fascia
… Due to “wear and tear”
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Abd i l W
Abdominal
Wallll A
Anatomy
t
„
Muscles
…
…
…
„
Nerves
…
…
„
External oblique
Internal oblique
Transversalis abdominus
Ilioinguinal
Genitofemoral
Blood supply
…
…
…
…
…
Superior epigastric
Inferior epigastric
Deep circumflex
Posterior intercostal
L b
Lumbar
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G i Anatomy
Groin
A t
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I
Inguinal
i lC
Canall
„
„
„
„
Allows passage b/w
abdomen and testes
Transmits ilioinguinal
nerve
Parallel to inguinal
ligament
Walls:
…
Anterior- external oblique
… Posterior – transversalis
fascia
… Inferior – inguinal ligament
… Superior – int oblique &
trans abd
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G i Anatomy
Groin
A t
„
Femoral Canal
…
Medial compartment
… Blind pouch
… Borders:
„
„
„
„
superiorly: iliopubic tract
inferiorly – cooper’s
ligament
laterally – femoral vein
medially
di ll – junction
j
ti off
iliopubic tract and cooper’s
ligament
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O
Operative
ti R
Repair
i
„
„
„
Indicated for all symptomatic hernias
Based on surgeon’s experience
May be:
… Via
anterior or posterior approach
… Primary:
Pi
„
„
„
Preferred in presence of contamination
Best choice in female patients
p
Accomplished using: Bassini, McVay or Shouldice technique
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O
Operative
ti R
Repair
i
… Prosthetic
Mesh Repair technique:
Onlay versus preperitoneal
„ Mesh bridges inguinal defect
„ Foreign body reaction incited
„ Common strategy entails:
„
Minimal tissue dissection
… Anchoring
g of mesh with interrupted
p
sutures
…
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O
Operative
ti R
Repair
i
… Laparoscopic
technique:
Based on reconstruction of weakened posterior
abdominal wall
„ Steep learning curve
„ Two approaches:
„
Totally extraperitoneal
… Transabdominal preperitoneal
… (Intraperitoneal Onlay Mesh)
…
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Hi t i l R
Historical
Review
i
„
Edoardo Bassini (1844-1924)
… Father
„
of modern hernia repair
Performed and published a novel anatomical
dissection (1884)
… Repair
empasized:
High ligation
„ Reconstruction of the inguinal
g
floor
„ Opening the transversalis fascia
„
…
Preparation for deep repair in three layer repair
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B
Bassini
i iR
Repair
i
„
„
Opening of inguinal
floor
Suture Poupart’s
ligament:
…
lateral border of
internal oblique or
conjoint tendon
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Sh ldi R
Shouldice
Repair
i
„
„
„
Complete dissection
& reconstruction of
inguinal floor
Imbricated layered
repair
i
Four layers
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M V R
McVay
Repair
i
„
„
„
Suturing transversus
abdominus to
Cooper’s ligament
Transition stitch in
f
femoral
l sheath
h th
Relaxing incision in
external
t
l oblique
bli
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Li ht
Lichtenstein
t i Repair
R
i
„
„
„
Gold standard by ACS
Transversalis fascia is not
opened
Fi key
Five
k elements:
l
t
…
…
…
…
…
Large sheet of mesh
Cross tails
Secure to rectus, int
oblique and inguinal
ligament
Keep mesh relaxed
Protect nerves
PK Amid Groin hernia repair – open technique. World J Surg 29;10461051 2005
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Gilb t “plug
Gilbert
“ l and
d mesh”
h” Repair
R
i
„
„
„
Originally described
by Lichtenstein
Modified to include
indirect hernias
Rutkow and Robbins
included direct
h i
hernias
PK Amid Groin hernia repair – open technique. World J Surg 29;10461051 2005
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O
Open
Preperitoneal
P
it
lM
Mesh
hR
Repair
i
„
Approaches
… Trans-inguinal
… Paramedian
… Lower
midline
… Pfannensteil
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O
Open
Preperitoneal
P
it
lM
Mesh
hR
Repair
i
„
Associated with
injuries to:
… Bladder
… Bowel
… Vascular
V
l
„
Recurrence rate
compared to in front
of TF are the same
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PHS S
System
t
Repair
R
i
„
„
Combines
Lichtenstein and
preperitoneal repair
2 layers:
… Deep
… Superficial
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L
Laparoscopic
i H
Hernia
i R
Repair
i
„
Transabdominal
preperitoneal (TAPP)
…
Mesh along anterior
abdominal
bd i l wallll
… Identify
„
„
…
Median & medial umbilical
ligament
g
Lateral umbilical fold
Parietal peritoneum incised
and reflected
… Mesh placed b/
b/w
peritoneum and
tranversalis fascia
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L
Laparoscopic
i H
Hernia
i R
Repair
i
„
Totally extraperitoneal
… Repair
via posterior approach
… Entirely w/in preperitoneal space
… Mesh positioned deep to hernia defect
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F
Femoral
l Hernia
H i R
Repair
i
„
Low Groin Approach
… Lichtenstein
„
Inguinal Approach
… McVay
„
technique
repair
Preperitoneal
Approach
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C
Complications
li ti
„
„
„
„
Recurrence
Postherniorrhaphy
p y
pain
Ischemic orchitis
Testicular atrophy
„
„
„
„
Hemorrhage
Osteitis p
pubis
Infection
Prosthesis-related
complication
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Q
Questions
ti
off th
the h
hour…
1.
2.
3.
Is there a superior open repair
q
technique?
Is laparoscopic repair superior to open
repair?
Chronic pain, is it avoidable?
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Open vs. Open
SS Awad et al. Improved
p
outcomes with the p
prolene hernia system
y
mesh
compared to the time-honored Lichtenstein onlay mesh repair for inguinal
hernia repair. Am J of Surgery 2007;193:697-701
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Li ht
Lichtenstein
t i vs. PHS
„
Lichtenstein
… Gold
standard
… Low learning curve
„
PHS system
… Combines
benefits of
anterior and posterior
repair
… Only open repair to
cover myopectineal
ti
l
orifice
SS Awad et al. Improved outcomes with the prolene hernia system mesh
compared to the time-honored Lichtenstein onlay mesh repair for inguinal
hernia repair. Am J of Surgery 2007;193:697-701
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Li ht
Lichtenstein
t i vs. PHS
„
Retrospective study with 622 pts
… 321
– PHS repair
… 302 – LMR
Follow up was 20 months
„ Assessed:
„
… Difference
in operating time
… Complications
… Recurrence
SS Awad et al. Improved outcomes with the prolene hernia system mesh
compared to the time-honored Lichtenstein onlay mesh repair for inguinal
hernia repair. Am J of Surgery 2007;193:697-701
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Li ht
Lichtenstein
t i vs. PHS
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Li ht
Lichtenstein
t i vs. PHS
„
Conclusion:
… PHS
was superior to LMR due to:
Lower recurrence rates
„ Decreased complications
„ Less p
post operative
p
p
pain
„ Earlier return to normal activity
„
SS Awad et al. Improved
p
outcomes with the p
prolene hernia system
y
mesh
compared to the time-honored Lichtenstein onlay mesh repair for inguinal
hernia repair. Am J of Surgery 2007;193:697-701
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Open vs. Laparoscopic
Neumayer L, Giobbie-Hurder A, jonasson O, et al. Veterans Affairs Cooperative
Studies Program 456 Investigators. Open mesh versus laparoscopic mesh repair
of inguinal hernia. N Engl J Med 2004; 350:1819-27
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The data shows
shows…
„
Laparoscopic approach gaining popularity
…
…
Prelim recurrence rates ranged from 3-10%
Benefits included
„
„
…
Subsided enthusiasm due to:
„
„
„
„
„
Less Pain
Quicker return to activity
High cost
Steep
p learning
g curve
Serious complications
Need for general anesthesia
TAPP versus TEP:
…
TEP preferred because:
„
„
„
„
Wide exposure
Avoids abdominal entry
Associated with decrease post-op pain
Faster post-operative recovery
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Open versus Laparoscopic
„
Goal:
… Examine
perioperative outcomes and complications in
both TEP and open mesh repair
„
345 patients
… 198
… 147
„
„
– open mesh repair
– TEP repair
Follow
F
ll
up: th
three months
th
Compared:
… Operative time
… Complications
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 2004;18:221-227
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Open versus Laparoscopic
„
Results:
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 18;221-227, 2004
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Open versus Laparoscopic
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 18;221-227, 2004
www.downstatesurgery.org
Open versus Laparoscopic
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 18;221-227, 2004
www.downstatesurgery.org
Open versus Laparoscopic
„
Results:
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 2004;1:221-227
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Open versus Laparoscopic
„
Conclusion:
… TEP
repairs can be performed efficiently and
without major complications
… Operative times are shorter in the hands of
experienced surgeons
… TEP associated with lower rate of postoperative
p
numbness and p
prolonged
g g
groin p
pain
ER Winslow, LM Brunt Perioperative outcomes and complications of open vs
laparoscopic extraperitoneal inguinal hernia repair in a mature surgical practice.
Surg Endosc 2004;18:221-227
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Open versus Laparoscopic
Prospective, randomized controlled trial
Prospective
„ Conducted b/w 1996-1997
„ Follow up: 7.3 years
„ 168 patients:
p
„
… 81
– TEP
… 87 - Lichtenstein
Hallen et al
al. Laparoscopic extraperitoneal inguinal hernia repair versus open
mesh repair:long term follow-up of a randomized controlled trial. SURGERY
2008;143:313-317
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O
Open
versus Laparoscopic
L
i
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O
Open
versus Laparoscopic
L
i
„
Conclusion:
… Long
term cure of hernia in patient with lap or
open hernia
ope
e a repair
epa is
se
excellent
ce e
… Individualized hernia repair yields best results
and is most cost effective
… TEP is an excellent method for individuals in a
working population who require short
convalescence
… TEP advantageous in recurrent hernias
Hallen et al. Laparoscopic extraperitoneal inguinal hernia repair versus open
mesh repair:long term follow-up of a randomized controlled trial. SURGERY
2008143:313-317
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Ch i G
Chronic
Groin
i P
Pain
i
Potentially incapacitating complication
„ Cause not clear: ? Nerve Entrapment
„
… Ilioinguinal
… Iliohypogastric
… Genital
„
branch of genitofemoral
Routine
R
ti preservation
ti and
d division
di i i have
h
been advocated
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Prophylactic Ilioinguinal
Neurectomy in Open Hernia Repair
„
Double blinded randomized controlled trial
100 patients b/w 18-80yoa
… 50: whole ilioinguinal nerve excised
… 50: nerve preserved
Pi
Primary
outcome:
t
iincidence
id
off chronic
h i pain
i att 6
months
Secondaryy outcome: incidence of g
groin numbness
„
Follow up: 6 months
„
„
„
WL Mui et al “Prohylactic ilioinguinal neurctomy in open inguinal hernia repair”
Annals of Surgery 244;1, 2006
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Prophylactic Ilioinguinal
Neurectomy in Open Hernia Repair
„
Results:
… No
significant difference in:
incidence of pain at 6 months
„ Incidence of groin numbness and sensation
change
„ Quality of life
„
WL Mui et al “Prohylactic ilioinguinal neurctomy in open inguinal hernia repair”
Annals of Surgery 244;1, 2006
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C
Conclusion
l i
Lichtenstein
Li
ht
t i continues
ti
to
t be
b standard
t d d
although PHS and laparoscopic techniques
are gaining acceptance
„ Surgeon experience is key to providing
good hernia repair
„ Learning curve in laparoscopic hernia repair
is steep however in hands of experienced
surgeons outcome comparable to open
repair
„