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HERNIAS
Historical Perspective

15th century - Castration
with wound cauterization
or hernia sac
debridement

recommended a truss
Father of Modern Inguinal Hernia
Repair
EDUARDO BASSINI
Hernia

Latin for rupture

an abnormal protrusion of an organ or tissue
through a defect in its surrounding walls

Occur at sites where aponeurosis and fascia are
not covered by striated muscle
Which of the following statements is/are true
regarding incidence of the abdominal wall hernia?
A.
B.
C.
D.
E.
Two-thrirds of all inguinal hernias are
classified as indirect.
Femoral hernias are more common in females
than in males.
Direct hernias are common in females.
Hernias generally occur with equal frequency
in males and females
Premature babies have a 10% incidence of
having inguinal hernia.
Epidemiology


700,000 hernia repairs year
Inguinal hernias -75% of all hernias




2/3 Indirect, remainder are direct
Incisional hernias – 15 to 20%
Umbilical and epigastric – 10%
Femoral – 5%
Epidemiology


Prevelance of hernias increases with age
Most serious complication – strangulation


1 to 3% of groin hernias
Femoral – highest rate of complications 15% to
20%

recommended all be repaired at time of discovery
Abdominal Wall
Anatomy
Anatomy




Inguinal ligament
(Poupart’s) – inferior edge
of external oblique
Lacunar ligament –
triangular extension of the
inguinal ligament before
its insertion upon the pubic
tubercle
conjoined tendon (5-10%)Internal oblique fuses with
transversus abdominis
aponeurosis
Cooper’s Ligament formed by the periosteum
and fascia along the
superior ramus of the pubis.
Inguinal Canal

Between deep and superficial
inguinal rings

Boundaries




Superifical – external oblique
aponeurosis
Superior – internal and
transversus
Inferior – shelving edge of
inguinal ligament and lacunar
ligament
Posterior (floor) –
transversalis fascia and
aponeurosis of transversus
abdominis muscle
Inguinal Canal


Contains the spermatic
cord and round ligament
of the uterus
Spermatic cord





Cremasteric muscle fibers
Testicular vessels
Genital branch of
genitofemoral nerve
Vas deferens
Cremasteric vessels
Components of Hesselbach’s triangle include which
of the following anatomic landmarks?
A.
B.
C.
D.
E.
Pectineal ligament
Lateral border of the rectus sheath
Cooper’s ligament
Inguinal ligament
Inferior epigastric vessels
Terminology

Reducible – can be replaced within
surrounding musculature

Incarcerated – cannot be reduced

Strangulated – compromised blood supply to
its contents
Sends sensory branches to the inner thigh and
medial aspect of the scrotum
A.
B.
C.
D.
Ileoinguinal nerve
Genitofemoral nerve
Both
Neither
A sliding inguinal hernia on the left side is likely to
involve which of the following?
A.
B.
C.
D.
E.
Jejunum composing the posterior wall of the
sac
Ovary and fallopian tube in a female infant
Omentum
Sigmoid colon composing the posterior wall of
the sac
Cecum composing the anteromedial wall of
the sac
Terminology






Pantaloon – direct and indirect components
Richter’s – contains antimesenteric portion of small
bowel
Sliding – involves visceral peritoneum of an organ ,
i.e. bladder, ovary
Littre’s – hernia contains Meckel’s diverticulum
Petit – hernia at inferior lumbar triangle
Grynfelt – hernia at superior lumbar triangle
Groin Hernias



Indirect
Direct
Femoral
Inguinal Hernia

Classified as congenital vs. acquired

commonly thought that repeated increases in
intra-abdominal pressure contribute to hernia
formation

collagen formation and structure deteriorates
with age, and thus hernia formation is more
common in the older individual.
Clinical Presentation





Groin bulge
Often asymptomatic
Dull feeling of discomfort or heaviness in the
groin
Focal pain – raise suspicion for incarceration or
strangulation
Symptoms of bowel obstruction
Inguinal hernia
Male inguinal hernia
Female inguinal hernia
Diagnosis




Physical Exam
74.5% sensitive and
96.3% specific
examine the patient in
the standing and supine
positions
difficult to distinguish
direct and indirect on
exam on alone
Diagnosis

Radiologic Investigations

Herniography
Suspected hernia, but clinical dx unclear
 Procedure done under flouroscopy following injection of
contrast medium
 Frontal and oblique radiographs are taken with and
without increased intra-abdominal pressure

Ultrasonography
 MRI
 CT

Herniography
Left indirect inguinal
hernia
Right direct inguinal hernia
Direct Inguinal Hernia
Direct Inguinal Hernia

Medial to the inferior
epigastric artery and vein,
and within Hesselbach's
triangle

acquired weakness in the
inguinal floor
Indirect Inguinal hernia

Abdominal contents protrude through internal inguinal
ring
Indirect Inguinal Hernia



Accepted hypothesis:
incomplete or defective
obliteration of the
processus vaginalis during
the fetal period
remnant layer of
peritoneum forms a sac
at the internal ring
more frequently on the
right
Femoral




More common in females
Up to 40% present as
emergencies with hernia
incarceration or strangulation
Passes medial to the femoral
vessels and nerve in the
femoral canal through the
empty space
Inguinal ligament forms the
superior border
Femoral

palpation of the femoral canal just below the
inguinal ligament in the upper thigh

NAVELS
Which of the following statements is/are true
regarding direct inguinal hernias?
A.
B.
C.
D.
E.
The most likely cause is destruction of connective
tissue resulting form physical stress.
Direct hernias should be repaired promptly because
of the risk of incarceration.
A direct hernia may be a sliding hernia involving a
portion of the bladder wall.
A direct hernia may pass through the external inguinal
ring.
Colon carcinoma is a known cause of direct inguinal
hernias.
Treatment

Non-Operative
Observation
 Trusses can provide symptomatic relief


Hernia control in ~30% of patients
Operative






Bassini
Shouldice
McVay
Lichtenstein
Preperitoneal
Laparoscopic

Bassini (early 20th Century)


Shouldice (1930s)


Transversus abdominis to Thompson’s ligament and
internal oblique musculoaponeurotic arches or
conjoined tendon to the inguinal ligament
Multilayer imbricated repair of the posterior wall of the
inguinal canal
McVay (1948)

Edge of the transversus abdominis aponeurosis to
Cooper’s ligament; incorporate Cooper’s ligament and
the iliopubic tract (transition suture)
BASSINI
MCVAY
SHOULDICE
Lichtenstein

First pure prosthestic, tension-free repair to
achieve low recurrence rates
Prosthetic Repair

Polypropylene mesh most common and
preferred


allows for a fibrotic reaction to occur between the
inguinal floor and the posterior surface of the mesh,
thereby forming scar and strengthening the closure
of the hernia defect
Polytetrafluoroethylene (PTFE) mesh

often used for repair of ventral or incision hernias in
which the fibrotic reaction with the underlying
serosal surface of the bowel is best avoided




Prospective study
Danish Hernia database
of over 13,000 hernia
repairs
Compared re-operations
for recurrent hernia
Results: After 5 years
significantly lower (1/4
less) recurrence with
mesh vs. sutured repair
Laparoscopic
The cause of neuropathic postherniorrhaphy
inguinodynia includes which of the following?
A.
B.
C.
D.
E.
Formation of scar tissue
Transection of the ilioinguinal, iliohypogastric,
or the genitofemoral nerves
Suture entrapment of nerves
Staple entrapment of nerves
Periosteal reaction
Surgical Complications
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

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Recurrence
Infection
Neuralgia
Bladder injury
Testicular injury
Vas Deferens injury
Other Hernias
Which of the following is/are true statements
regarding umbilical hernias?
A.
B.
C.
D.
E.
They are embryonic equivalent of a small
omphalocele
Repair in infants is usually deferred until
approximately 4 years of age
Repair in adults is usually indicated
The “vest-over-pants” type of repair is stronger than
simple approximation of fascial margins
They are most common in Caucasian infants
Umbilical
Incidence
 Reported ~10%
 several times greater in Black children
 more common in premature children all races
 Most close spontaneously by age 2 or 3
 Acquired rather than congenital in adults
 Female to male ratio 3:1
Epigastric





midline junction of the
aponeuroses (linea alba)
between the xiphoid process
and umbilicus
Paraumbilical hernia epigastric hernia that borders
the umbilicus
Estimated frequency 3-5%
More common in Males 3:1
20% may be multiple
Epigastric

Clinical

Often asymptomatic, incidental finding
If symptomatic, vague abdominal pain above the umbilicus exacerbated
by standing or coughing; relieved in supine position
Severe pain secondary to incarceration/strangulation of preperitoneal fat
(often no peritoneal sac) or omentum
Exam: palpate small, soft, reducible mass superior to the umbilicus

RARE to have strangulated bowel




Tx

Excise fat and sac, close primarily
An 82-year-old previously healthy woman has a 12-hour history of severe epigastric
pain associated with nausea and vomiting. She has had no previous abdominal
operations. Her WBC count is 21,000/cu mm. The plain films and abdominal CT
shown are obtained.
Which of the following best describes
this patient’s diagnosis?
A.
B.
C.
D.
E.
Pain in the medial thigh and knee is
uncommonly associated with this condition
It is unusual in women
It is unusual in elderly patients
It is seldom associated with intestinal necrosis
It is usually unilateral
Obturator






Rare form of hernia
Protrusion of intra-abdominal
contents through obturator
foramen
F:M ratio 6:1
The obturator foramen is formed
by the ischial and pubic rami
obturator vessels and nerve lie
posterolateral to the hernia sac in
the canal
Small bowel is the most likely
intraabdominal organ to be
found in an obturator hernia
Obturator

4 cardinal signs :
intestinal obstruction (80%)
 Howship-Romberg sign (50%) –History of repeated
episodes of bowel obstruction that resolve quickly and
without intervention
 Palpable mass (20%)


Tx: Sugical Repair
Spigelian Hernia

occurs along the semilunar
line, which traverses a
vertical space along the
lateral rectus border

where more than 90% of
spigelian hernias are found
Spigelian Hernia

Clinical




Swelling in middle to
lower abdomen lateral to
rectus muscle
Usually reducible
Up to 20% present with
incarceration
Tx: surgical


Mesh not required
Recurrence is uncommon
Lumbar

Acquired lumbar hernias –


Contains to anatomic
triangles, inferior and
superior lumbar triangles




back or flank trauma,
poliomyelitis, back surgery, and
the use of the iliac crest as a
donor site for bone grafts
Grynfelt’s
Petit’s
Strangulation is rare
Soft swelling in lower
posterior abdomen
Sciatic





Via greater or lesser sciatic
notch
greater sciatic notch is
traversed by the piriformis
muscle, and hernia sacs can
protrude either superior or
inferior to this muscle
suprapiriform defect 60%
Infrapiriform 30%
subspinous (through the
lesser sciatic foramen) 10%
Which of the following hernias is most likely to recur
after primary repair?
A.
B.
C.
D.
E.
Epigastric hernia
Spigelian hernia
Indirect hernia
Femoral hernia
Incisional hernia
Ventral wall (Incisional)




Highest incidence in midline and
transverse incisions
Up to20% after laparotomy
1/3 present in 5-10 years
postoperatively
Risk factors


obesity, DM, ascites, steroids,
smoking malnutrition, wound
infection
Technical aspects of wound closure


Type of incision
Excessive tension (prone to fascial
disruption)
Which of the following hernias represent an
incarceration of a limited portion of small bowel?
A.
B.
C.
D.
E.
Spigelian hernia
Grynfelt’s hernia
Petit’s hernia
Richter’s hernia
Littre’s hernia