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Hernia
Dr. Nachmany
Lecture Subjects
• Anatomy – Inguinal & Femoral canals
• Clinical aspects of hernia
• Repair of Inguinofemoral Hernia:
– Open – Rrhaphy; Tension free.
– Laparoscopic
The Inguinal Canal
Anatomy, Embryology & Physiology
Anatomy
• Extends from the deep (fascia transversalis) to
the superficial inguinal ring (ext. oblique)
• Parallel and above the inguinal ligament
• Walls of the Inguinal Canal:
–
–
–
–
Anterior
Posterior
Superior
Inferior
Walls of the Inguinal Canal
• Anterior wall - Aponeurosis of Ext. oblique
– Reinforced in its lateral third by origin of the Int.
oblique
• strongest where it lies opposite the weakest part of the
posterior wall (deep ring)
Walls of the Inguinal Canal
• Posterior wall - Fascia transversalis
– Reinforced in its medial third by the conjoint
tendon
• Strongest where it lies opposite the weakest part of the
anterior wall (superficial ring)
Walls of the Inguinal Canal – Cont.
• Inferior (floor) - Rolled-under inferior edge
of aponeurosis of the Ext. oblique (→the
inguinal lig.)
• Superior (roof) - Arching lowest fibers of
the Int. oblique and transversus abdominis
muscles
Deep Inguinal Ring
•
•
•
•
½ inch above the ligament
Midway between ASIS and the Symphysis
Lateral to the inferior epigastric vessels
Margins of ring give origin to the internal
spermatic fascia
Superficial Inguinal Ring
• Triangular defect in the aponeurosis of the
external oblique
• Immediately above and medial to the pubic
tubercle
• Margins give origin to the external
spermatic fascia
• Physical Exam
Physiology and Mechanics
Physiology
• Inguinal canal - a passage through the lower
abdominal wall
• Males - to and from the testis
• Females - round ligament of the uterus to the labium
major
• Both sexes – Ilio-inguinal nerve
Mechanics of the inguinal Canal
• A potential weakness
• A design to lessen weakness:
– Oblique passage → weakest areas lying some
distance apart
– Anterior reinforcement by Int. oblique in front
of deep ring
– Posterior reinforcement by Conjoint tendon
behind superficial ring
Mechanics of the inguinal Canal –
Cont.
• On coughing/straining
(defecation, parturition etc.) →
Int. oblique and transversus
abdominis muscles contract →
flattening the roof → canal is
virtually closed
Embryology
• Processus Vaginalis
• Spermatic Fasciae
• Gubernaculum
Embryology of the Inguinal Canal –
Processus Vaginalis
• Prior to testicular/ovarian descent a
peritoneal diverticulum called the processus
vaginalis is formed
Embryology - Processus Vaginalis
and creation of Spermatic fasciae
• The processus vaginalis passes through the layers
of the abdominal wall and acquires a tubular
covering from each layer:
– Fascia transversalis - Internal spermatic fascia
– Lower part of Int. oblique muscle - it takes some of
its lowest fibers (Cremaster muscle & Fascia)
– Aponeurosis of the external oblique – Ext. spermatic
fascia
Spermatic Cord
• Forms at the level of the Deep ring
• It is covered with three concentric layers of
fascia derived from the layers of the anterior
abdominal wall
Embryology oriented anatomy of
spermatic fasciae
Embryology - Gubernaculum
• Extends from the lower pole of the
developing gonad to the labioscrotal
swelling
• In the male the testis descends during the 7th
and 8th months of fetal life
Embryology - Gubernaculum
• The stimulus for the descent is testosterone,
secreted by the fetal testes
• The testis follows the gubernaculum and descends
behind the processus vaginalis
• Pulls down its duct, blood vessels, nerves and
lymphatics
• In the female - extends from the uterus into the
developing labium major
• Persists as the round ligament
Herniae of the Myopectineal
orifice
• A hernia - protrusion of part of the
abdominal contents beyond the normal
confines of the abdominal wall
• Consists of:
– Sac
– Contents of the sac
– Coverings of the sac
• Complications:
– Incarceration
– Strangulation
– Bowel obstruction
Common Abdominal herniae are
• Inguinal:
– Indirect
– Direct
• Femoral
• Umbilical:
– Congenital
– Acquired
• Epigastric
• Separation of the rectiabdominis
• Diaphragmatic:
– Sliding
– Paraesophageal
• Incisional (POVH)
Indirect Inguinal Hernia
•
•
•
•
•
•
The most common form of hernia
20 times more common in males
one-third are bilateral
more common on the right
Congenital in origin
Hernial sac is the remains of the processus
vaginalis
• The sac enters the inguinal canal through the deep
inguinal ring lateral to the inferior epigastric
vessels
Direct Inguinal Hernia
• About 15 percent of all inguinal hernias
• Majority is bilateral
• The sac bulges directly anteriorly through
the posterior wall of the inguinal canal
• Medial to the inferior epigastric vessels
• A disease of old men with weak abdominal
muscles.
Femoral Hernia
• The femoral sheath - a protrusion of the
fascial envelope lining the abdominal walls
• Surrounds the femoral vessels & lymphatics
for 1 inch below the inguinal ligament
The Femoral Canal
• The femoral canal, the compartment for the
lymphatics, occupies the medial part of the sheath.
• Its upper opening is the femoral ring:
–
–
–
–
Anterior -Inguinal ligament
Posterior - Pectineal ligament and the pubis
Medial - sharp free edge of the Lacunar ligament
Lateral - Femoral vein
• The femoral septum, which is a condensation of
extraperitoneal tissue, plugs the opening
• The femoral vein is separated from it by a fibrous
septum
Femoral Hernia
• Much more common in women
• The sac passes down the canal, pushing the
septum
• On the lower end, it forms a swelling in the upper
thigh
• With further expansion the sac may turn upward to
cross the inguinal ligament
• The neck always lies below and lateral to the
pubic tubercle
Surgical Repair of Hernia
Classification
• Those that close all or part of the myopectineal
orifice
• Anterior Vs. Posterior
• Repair by suturing the tissues at boundaries:
– Bassini
– Shouldice
– Cooper (McVay)
• Those that cover the orifice with prosthetic mesh:
– Lichtenstein
– Plug and patch
– Laparoscopic
Anterior Repairs
• Dissection and hernia reduction is the same:
• incision 2 to 3 cm above and parallel to the
inguinal ligament
• Dissection through the subcutaneous tissues and
Scarpa’s fascia
• The external oblique fascia and external ring is
identified
• The external oblique fascia is incised to expose the
inguinal canal
• The ilioinguinal and iliohypogastric nerves should
be preserved
Open Repair – Cont.
• The spermatic cord is mobilized at the pubic
tubercle
• The Cremaster muscle is divided and separated
from the cord
• The hernia sac is dissected from adjacent cord
structures
• The sac should be opened and examined for
visceral contents if it is large
• Neck of the sac is ligated at the level of the
internal ring
Herniorrhaphy
•
•
•
•
Bassini
Shouldice
McVay (Coopers ligament repair)
Ileopubic tract
The Bassini repair
• Suturing the conjoined
tendon to the inguinal
ligament
• was the most popular repair
before the tension-free
repairs
The Shouldice repair
• Multilayer imbricated repair of the posterior wall
of the inguinal canal with a continuous running
suture technique:
– 1st suture line - transversus abdominis aponeurotic arch
to the iliopubic tract
– 2nd line - internal oblique and transversus abdominis
muscles and aponeuroses (Conjoint) to the inguinal
ligament
– 3rd line - Conjoint to Ext. oblique
– 4th line - Conjoint to Ext. oblique
1st posterior suture - Transversus
abdominis to Iliopubic tract
1st posterior suture - Transversus
abdominis to Iliopubic tract (Cont.)
2nd posterior suture – Int. oblique and
transversus abdominis to inguinal ligament
3rd posterior suture - Conjoint to
Ext. oblique
4th posterior suture - Conjoint to
Ext. oblique
Relaxing incision
Cooper Ligament (McVay) Repair
• For correction of all the Myopectineal
orifice:
–
–
–
–
Direct inguinal hernias
Large indirect hernias
Recurrent inguinal hernias
Femoral hernias
• Transversus abdominis aponeurosis to
Cooper’s ligament
• Lateral to the medial aspect of the femoral
canal , the transversus abdominis
aponeurosis is secured to the iliopubic tract
• An important principle - relaxing incision
Lichtenstein Repair
• Tension is the principal cause of recurrence
• Synthetic mesh prosthesis to bridge the
defect
– Inferior suture line - Shelving edge of the
inguinal (Poupart’s) ligament
– Superior line – Conjoint muscle & tendon
Posterior Repairs
• Open Repair:
– Stoppa
– Laparoscopic
• Trans Abdominal Pre-Peritoneal (TAPP)
• Total Extra Peritoneal (TEP)
Preperitoneal Anatomy
What’s that?
…and that?
Danger areas
The approach to the preperitoneal
space
Arcuate line (3)
TEP
TAPP
Direct Hernia
Indirect Hernia
Trans-abdominal approach to the
preperitoneal space
Dissection of indirect hernia
TAPP
Post Op. Complications