Hernia and Hernia Repair

Steven Roy Hofstetter, MD., FACS, Chief of Surgical ServicesDepartment of Surgery,

New York University School of Medicine, Schwartz Health Care Center 6

6C 530 First Avenue New York 10016

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."

Hernia

Common Types of Hernias

Inguinal Hernia

Inguinal CanalThe 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 veinMedially: The Rectus SheathInferiorly: The Inguinal LigamentPosteriorly: 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.

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.

Direct Inguinal Hernia

Right sided hernias are more frequent than left sided ones.

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

Bilateral Hernia

HistoryAge: 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 SignsSkin over swelling: Check for inflammation (redness, edema), scars reflecting previous surgery.

Impulse on coughing: Ask the patient to cough. The increase in intra-abdominal 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.

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.

Pantaloon Hernia

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

Bulge below inguinal ligament, female, age 80

Strangulated small intestine

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.

Surgical Treatment of Inguinal Hernia

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.

Tension-Free Hernioplasty

Sutures used for Tension-Free Hernioplasty

Microscopic view of mesh

Mesh used for Tension-Free Hernioplasty

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

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

Bassini 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

Shouldice Repair

Laparoscopic Hernia RepairLess 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 10-mm 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.

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%)*

Laparoscopic Hernia Repair

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%)

Complications of Hernioplasty

Other types of 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 life-threatening 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

Femoral Hernias

• Linea alba defect in upper midline

• 5% of hernias

• Repair by resection of fat and primary facial closure

Epigastric 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.

Umbilical 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

Incisional HerniaDouble Layered Marlex Mesh Repair

Incisional HerniaCompleted repair

• 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

Spigelian Hernia

Plain Abdominal x-ray showing intestinal obstruction in a patient with a Spigelian Hernia.

CAT Scan of abdomen demonstrating an incarcerated Left Spigelian Hernia. Note air above fascia on patient's left.

Spigelian Hernia

• External oblique, iliac crest, Lattissimus dorsi • Acquired (55%) trauma or renal surgery • Congenital    - Superior (Grynfelt-Lesshaft triangle)      - Inferior (Petit's hernia)

Lumbar 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

Obturator Hernia

• Complication of abdominal-perineal resection

• Has a distinct sac, i.e. not a rectocele (pelvic floor relaxation)

• Most common in females

Perineal Hernia

• Gluteal hernia via greater sciatic notch

• Presents with sciatica

• Repair by abdominal or gluteal approach

Sciatic Hernia

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 out-patient 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.

Summary