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Hernia and Hernia Repair
Steven Roy Hofstetter, MD., FACS,
Chief of Surgical Services
Department of Surgery,
New York University School of Medicine,
Schwartz Health Care Center 6
6C 530 First Avenue
New York 10016
Hernia
Hernia is derived from the Latin for "rupture" and is the protrusion of an
organ or part of an organ or other structure through the wall of the cavity
normally containing it.
Sir Percivall Pott described hernias in 1756 as:
"The disease which makes the subject of the following tract, is one in
which mankind are, on many accounts, much interested. No age, sex,
rank, or condition of life, is exempted from it; the rich, the poor, the lazy,
and the laborious, are equally liable to it; it produces certain inconvenience
to all who are afflicted by it...
It sometimes puts the life of the patient in such hazard, as to require one of
the most delicate operations in surgery; and it has in all times, from the
most ancient down to the present, rendered those who labor under it
subject to the most iniquitous frauds and impositions."
Common Types of Hernias
Inguinal Hernia
Inguinal Canal
The inguinal canal in the anterior abdominal wall stretches from the deep
inguinal ring to the superficial inguinal ring. The spermatic cord traverses
the inguinal canal in men. The round ligament traverses the inguinal canal
in women.
Anterior wall of the canal: Aponeurosis of external oblique muscle,
aponeurosis of internal oblique muscle for the lateral third of the canal, and
the superficial inguinal ring for the medial third of the canal.
Posterior wall of the canal: Transversalis fascia, conjoint tendon at the
medial third of the canal, and the deep inguinal ring at the lateral third of
the canal.
Superior wall of the canal: Internal oblique muscle and the transversus
abdominis muscle.
Inferior wall of the canal: Inguinal ligament, lacunar ligament at the
medial third of the canal and iliopublic tract at the lateral third of the canal.
Anatomical types of Inguinal Hernia
Direct versus Indirect Inguinal hernias
Indirect hernias are hernias that enter the canal via the deep inguinal
ring. The hernia traverses the entire length of the inguinal canal. The
neck of the inguinal sac lies lateral to the deep epigastric artery.
Direct hernias are hernias that enter the inguinal canal directly via a gap
or defect in transversalis fascia, the floor of Hesselbach's Triangle. The
boundaries of the triangle are: medial boundary is the lateral border of the
rectus abdominis muscle, the lateral boundary is deep epigastric artery,
and the lower boundary is the inguinal ligament.
Incidence: Inguinal hernias are found in 5% of male population, and
represent 86% of hernia cases. It occurs 5 times more often in males and
females.
Anatomical types of Inguinal Hernia
Incomplete versus Complete hernias
Incomplete hernias (bubonocele) are hernias that do not pass beyond
the superficial inguinal ring of the inguinal canal.
Complete hernias descend into the scrotum.
Surgical Anatomy
Hesselbach's Triangle is defined as
follows:
Laterally: The Inferior Epigastric
artery and vein
Medially: The Rectus Sheath
Inferiorly: The Inguinal Ligament
Posteriorly: Transversalis Fascia
Direct versus Indirect hernias:
Hernias medial to the epigastric
vessels that enter the inguinal canal
via Hesselbach's Triangle are Direct
Hernias. Hernias that enter the canal
via the internal (deep) inguinal ring,
are Indirect Hernias.
Indirect Inguinal
Hernias
Hernias that enter the
canal via the internal
(deep) inguinal ring, are
Indirect Hernias.
Direct Inguinal Hernia
Incidence: 25% of hernia cases
The hernia contents enter the inguinal canal directly via a gap or
defect in transversalis fascia, the floor of Hesselbach's Triangle.
These hernias are generally considered to be acquired, and may be
associated with heavy lifting, straining due to constipation, coughing,
or prostatic enlargement.
Right sided hernias are more
frequent than left sided ones.
Bilateral Hernia
Simultaneous Right and Left Inguinal Hernia
Common in children and elderly men
If a left inguinal hernia is present, there is a 25% risk of an
occult right inguinal hernia
Both hernias may be repaired with one surgical procedure
History
Age: Indirect hernia is usually seen in younger adults. A direct hernia is
common after the age of 40.
Pain: Patient complains of patient during the early stages when the hernia
is forming. The pain is intensified by straining. Pain ceases when the hernia
is fully formed. Funiculitis (inflammation of the spermatic cord) can be
intensely painful. When the hernia gets strangulated, pain is felt not only at
the site of the hernia, but all over the abdomen as well, possibly due to drag
on the omentum or mesentry.
Swelling: A direct hernia is seen as a spherical swelling that tends not to
extend to the scrotum, whereas an indirect inguinal hernia is pyriform in
shape and extends to the scrotum. In a complete hernia, the swelling
extends from the inner part of the inguinal ligament down to bottom of the
scrotum (in the congenital type) or stops above the testis (funicular type).
Physical Signs
Skin over swelling: Check for inflammation (redness, edema), scars
reflecting previous surgery.
Impulse on coughing: Ask the patient to cough. The increase in intraabdominal pressure forces more contents (omentum or intestine) into the
sac. A momentary bulge is noticed at the superficial inguinal ring with the
act of coughing.
Consistency on palpation: Hernias containing omentum (omentocele or
epiplocele) feel granular and doughy. Hernias containing intestine
(enterocele) feel elastic. Strangulated hernias feel tense and tender. A
varicocele has a “bag of worms” feel.
Reducibility: Application of pressure at the lower edge of the swelling
towards the inguinal canal should reduce the hernia. A hernia that cannot
be reduced (irreducibility, incarceration) may develop because of adhesions
of contents to each other or to the sac or strangulation.
Sliding Hernia
Seen in 3% of hernia procedures.
Great care must be taken to avoid visceral damage during the repair.
Pantaloon Hernia
Direct and indirect hernias co-existing on same side of the
groin. The hernia is named pantaloon because the two
hernia sacs are divided by epigastric vessels, and so they
look like a pair of pants from the 17th century. Patients
with pantaloon hernias are at risk of developing recurrent
hernias. Patients who have this type of hernia may feel
pain or a bulge in the groin area. If left untreated, the
hernia may become strangulated, which could lead to
bowel obstruction.
Hoquet maneuver: May be best approached by ligating
the inferior epigastric vessels to convert the direct and
indirect components to a single sac.
Richter's Hernia
It is named after German surgeon
August Gottlieb Richter (1742-1812).
A hernia involving only one sidewall of
the bowel, which can result in bowel
strangulation leading to perforation
through ischemia without causing
intestinal obstruction or any of its
warning signs.
Antimesenteric border only of the small
intestine is incarcerated in the deep
inguinal ring, therefore intestinal
obstruction may be absent, but
gangrene of the bowel wall may occur.
Strangulated Hernia
Pressure on the hernial contents, usually intestine, may compromise
blood supply and cause ischemia, necrosis and gangrene. This
complication may have a 12-13% mortality, and will require removal of a
portion of intestine.
Bulge below inguinal ligament,
female, age 80
Strangulated small intestine
Surgical Treatment of
Inguinal Hernia
Tension-Free Hernioplasty
Suture permanent polypropylene mesh to strong tissues in the groin to close the
gap in the inguinal canal.
The mesh is inserted in the pre-peritoneal space, to afford the strongest
mechanical advantage.
The mesh is soaked in an antibiotic solution prior to implantation, and prophylactic
antibiotics are administered intravenously to reduce the risk of infection.
After surgery, patients are fully ambulatory, and the sole restriction is to avoid very
heavy lifting for 30 days.
Modern, water-proof dressings allow the patient to bathe.
A prescription for pain medication is given, and patients are encouraged to
gradually return to full activities as tolerated.
Sutures used for
Tension-Free Hernioplasty
Mesh used for Tension-Free
Hernioplasty
Microscopic view of mesh
Steps in
Tension-Free Hernioplasty
Direct Hernia Sac Exposed
Steps in
Tension-Free Hernioplasty
Hernia Sac Removed
Steps in
Tension-Free Hernioplasty
Pre-peritoneal Space Exposed by Opening
Transversalis Fascia
Steps in
Tension-Free Hernioplasty
Mesh Anchored at Pubis (near retractor)
Steps in
Tension-Free Hernioplasty
"Wings" of Mesh placed Posterior to Cord to re-enforce internal ring
Steps in
Tension-Free Hernioplasty
Completed Tension-free Repair
Bassini Repair
Sutures the conjoined tendon to the inguinal ligament,
which slides the patient’s own muscles together to cover the
hole in the abdominal wall and repair the hernia.
Incision closed with a simple interrupted suture pattern.
Recovery is slower than with Tension-free Hernioplasty due
to more swelling at the operative site.
3-30% recurrence rate.
Bassini
Repair
Shouldice Repair
•Developed during World War II by Dr. E. E. Shouldice, a
Canadian surgeon, this technique is widely used as a non-mesh
option for hernia repair.
•Two permanent, continuous back-and-forth sutures are used to
close the hole in the abdomen wall.
•By sliding four layers of tissue together, this technique is
considered a more secure closure of the hole in the abdominal
wall than the single-layer Bassini repair. In addition, the
Shouldice technique uses the deepest layers of muscle while
the Bassini repair uses more superficial layers.
•High success rate and low rate of recurrence.
•Tension in the closure of the incision can lead to swelling and
patient discomfort lasting several weeks.
Shouldice Repair
Laparoscopic Hernia Repair
Less invasive than an open approach.
It uses three ports, or trochars, inserted into the area of the
surgery through which a TV camera and instruments are
placed to allow surgeons to visualize the anatomy, define the
hernia defect, and implant the mesh. Two 5-mm and one 10mm hole for the ports.
In the older Trans-Abdominal Pre-Peritoneal (TAPP)
procedure, the ports and mesh enter the abdominal cavity.
The newer Totally Extra-Peritoneal (TEP) technique, stays out
of the abdominal cavity and places the mesh in the same
anatomic space as in the tension-free repair.
Laparoscopic Hernia Repair
Techniques
- trans-abdominal pre-peritoneal (TAPP)
- totally extra-peritoneal (TEP)
Advantages
- less pain and more rapid return to work
- better for recurrent and bilateral hernias
Disadvantages
- cost
- learning curve; higher recurrence rate
- nerve irritation:
- genitofemoral nerve. (2%)
- Ileo-inguinal nerve. (1.1%)
- lateral femoral cutaneous nerve. (1.1%)*
Complications of Hernioplasty
Intra-operative
*Injury to vas deferens
*Injury to viscera (colon, bladder)
*Bleeding
Post-operative
*Testicular atrophy
*Recurrence
- Bassini (3-33%)
- Shouldice (0.8%)
- Laparoscopic repair (2-6%)
Other types of Hernias
Femoral Hernias
Femoral hernias are most often found in women and occur
at the upper thigh near the groin area. This type of hernia
has a high risk of incarcerating the small bowel, which can
then lead to a strangulated hernia and become a lifethreatening condition.
Patients who have a femoral hernia may feel a tender
bulge in the upper thigh, just under the groin area. Unless
a significant medical condition prevents it, all hernias
should be repaired with surgery.
Femoral
Hernias
Epigastric Hernia
• Linea alba defect in upper midline
• 5% of hernias
• Repair by resection of fat and primary facial closure
Umbilical Hernia
• Failure of closure of umbilical ring
• Common in males, and premature infants
• Acquired in adults with cirrhosis, obesity, ascites, malnutrition
• Repairs:
- Mayo "vest-over-pants"
- Primary mass closure
• Current trends in repair include mesh implantation into the pre-peritoneal
space to obtain a tension-free closure of the umbilical ring and remain
extra-peritoneal.
Incisional Hernia
•10% of cases; more common in females
• Unrecognized or late dehiscence
• Etiology:
•wound infection
•technical errors
•increased intra-abdominal pressure
•Multiple defects common; "button-hole"
•Risk of incarceration
•Repair:
- tension-free: Mesh implantation - Stoppa repair
- sutures should pass through normal fascia
• 24% recurrence with traditional primary closure methods
Incisional Hernia
Incisional Hernia
Incisional Hernia
Incisional Hernia
Double Layered Marlex Mesh Repair
Incisional Hernia
Completed repair
Spigelian Hernia
• Named for Adrian vander Spieghel: Flemish anatomist, (1578 1625).
• Spontaneous lateral ventral hernia below the umbilicus and
lateral to the rectus muscle, at junction of vertical semilunar line
and horizontal semicircular line 90% located 0 - 6 cm above
anterior superior iliac spine (Spigelian belt of Spagel).
• Characteristics:
- median age = 50 years
- more common in males than females
- more common on right side than left side
• Treatment: facial closure
Spigelian Hernia
Plain Abdominal x-ray showing intestinal obstruction in a patient with a
Spigelian Hernia.
Spigelian Hernia
CAT Scan of abdomen demonstrating an incarcerated Left Spigelian Hernia. Note air
above fascia on patient's left.
Lumbar Hernia
• External oblique, iliac crest, Lattissimus dorsi
• Acquired (55%) trauma or renal surgery
• Congenital
- Superior (Grynfelt-Lesshaft triangle)
- Inferior (Petit's hernia)
Obturator Hernia
• 0.1% of hernias, 0.2% of bowel obstructions
• Greater incidence in females than males ( 9:1)
• Frail women in 7th or 8th decade
• More common on right
• 20% bilateral
• Medial groin pain secondary to obturator nerve impingement
• Howship-Romberg sign (hip-knee pain)
• Repair via abdominal approach with mesh
• 25% mortality
Perineal Hernia
• Complication of abdominal-perineal resection
• Has a distinct sac, i.e. not a rectocele (pelvic floor relaxation)
• Most common in females
Sciatic Hernia
• Gluteal hernia via greater sciatic notch
• Presents with sciatica
• Repair by abdominal or gluteal approach
Summary
1. Hernias are the second most common cause of intestinal
obstruction, and a strangulated hernia is a life-threatening
condition.
2. Barring significant medical contradications.
All Hernias Should Be Repaired.
3. Tension-free Mesh Hernioplasty is a safe and effective outpatient technique of repairing an inguinal hernia in the setting
of a modern university medical center.
4. Following hernia repair, patients may return to full and
unrestricted activities.