INGUINAL HERNIAMax Angelo G. Terrenal – Post Graduate Medical Intern – Veterans Memorial

Medical Center

WHAT IS AN INGUINAL HERNIA?

Protrusion of a peritoneal sac through a musculoaponeurotic barrier

Direct or Indirect

DIRECT INGUINAL HERNIA

Within the floor of Hesselbach’s triangle

Acquired defect from mechanical breakdown over the years

~1% Lifetime risk

INDIRECT INGUINAL HERNIA

Through the internal ring of inguinal canal

CongenitalPatent processus vaginalis

~5% Lifetime riskHigher risk of strangulation than direct

INDIRECT INGUINAL HERNIA

INCARCERATED STRANGULATED

Hernia which cannot be reduced

Incarcerated hernia with resulting ischemia

EPIDEMIOLOGYOne of the most common surgical procedures Incidence: ~5-10% lifetime75% of abdominal wall hernias

Male > Female Indirect > DirectRight > Left1/3 may develop a contralateral inguinal hernia

ETIOLOGYMultifactorialWeakness in abdominal wall musculature

PRESUMED CAUSES OF GROIN HERNIATIONCoughing Valsalva's maneuversChronic obstructive pulmonary disease

Ascites

Obesity Upright positionStraining Congenital connective tissue

disordersConstipation Defective collagen synthesisProstatism Previous right lower quadrant

incisionPregnancy Arterial aneurysmsBirthweight <1500 g Cigarette smokingFamily history of a hernia Heavy liftingPhysical exertion (?)

ANATOMYInguinal Hernia

ABDOMINAL WALL Skin Subcutaneous fat Scarpa’s fascia External oblique muscle Internal oblique muscle Transversus abdominis Transveralis fascia Preperitoneal fat Peritoneum

INGUINAL CANAL4-6 cm longAnteroinferior of pelvic basin

Cone-shapedBase superolateral margin

Apex Inferomedially

BOUNDARIES Anterior

external oblique aponeurosis Lateral

Internal oblique muscle Posterior

fusion of the transversalis fascia and transversus abdominus muscle,

Superior arch formed by the fibers of the

internal oblique muscle. Inferior

inguinal ligament

SPERMATIC CORDCremasteric muscle fibersVas deferensTesticular arteryTesticular pampiniform

venous plexusGenital branch of the

genitofemoral nerve+/- hernia sac

HESSELBACH’S TRIANGLE

Medial aspect of Rectus abdominis muscle

Inferior epigastric vessels

Inguinal ligament

POSTERIOR

MYOPECTINEAL ORIFICE OF FRUCHAUD Superior

Arch of IOM and TA Lateral

Iliopsoas muscle Medial

Lateral edge of RA and Pubic pectin

Iliopubic tract Spermatic cord Iliac vessels

TRIANGLE OF DOOM External iliac vessels Deep circumflex iliac vein Femoral nerve Genital branch of GF nerve

TRIANGLE OF PAINNerves Lateral femoral cutaneousFemoral branch of GF nerveFemoral nerve

CLASSIFICATIONInguinal Hernia

NYHUS CLASSIFICATION SYSTEM

Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults

Type II INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum

Type IIIA DIRECT HERNIA; size is not taken into account

Type IIIB

INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinal wall; INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in

this category because they are commonly associated with EXTENSION TO THE DIRECT SPACE; also includes PANTALOON HERNIAS

Type IIIC FEMORAL HERNIA

Type IV RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO INDIRECT, DIRECT, FEMORAL, AND MIXED, RESPECTIVELY

DIAGNOSIS

HISTORY Groin pain Extrainguinal symptoms

Change in bowel habits Urinary symptoms

Pressure on nerves Generalized pressure Local sharp pains Referred pain

Scrotum, testicle or inner thigh

Duration Progressiveness

PHYSICAL EXAMINATION Inspection

Standing Palpation

Inguinal Occlusion test

Direct Indirect

Cough Impulse

Manifested Controlled

Dorsum of finger Fingertip

DIFFERENTIAL DIAGNOSIS Malignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor Primary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle

Undescended testicle Femoral artery aneurysm or pseudoaneurysm

Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of Nuck (female)

Saphenous varix Psoas abscess Hematoma Ascites

IMAGINGInguinal Hernia

UltrasoundCT ScanMRI

MANAGEMENT

CONSERVATIVE MANAGEMENT

Aimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contents

Assuming a recumbent positionTruss, an elastic belt or brief

EMERGENT REPAIRIncarcerated herniasStrangulated herniasSliding hernias

INCARCERATED HERNIAReasons for incarceration large amount of intestinal contents within the hernia sac

dense and chronic adhesions of hernia contents to the sac

small neck of the hernia defect in relation to the sac contents

INCARCERATED HERNIAAn incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency

INCARCERATED HERNIAReduction should be attempted before definitive surgical intervention.

INCARCERATED HERNIAHernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.

TAXISThe patient is sedated and placed in a Trendelenburg position.

The hernia sac is grasped with both hands, elongated, and then milked back through the hernia defect.

Pressure applied to the most distal portion of the sac will cause the contents to mushroom and prevent reduction.

STRANGULATED HERNIAFemoral > Indirect > DirectFever, leukocytosis, and hemodynamic instability. The hernia bulge usually is very tender, warm, and may exhibit red discoloration.

Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressed

OPERATIVE TECHNIQUES

Inguinal hernia

ANTERIOR REPAIRNON PROSTHETIC

Inguinal hernia

OPEN APPROACH

OPEN APPROACH

BASSINI REPAIR Is frequently used for indirect

inguinal hernias and small direct hernias

The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

MCVAY REPAIR inguinal and femoral canal defects

The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally

SHOULDICE REPAIR

ANTERIOR REPAIRPROSTHETIC

Inguinal hernia

LICHTENSTEIN TENSION-FREE REPAIR

LAPAROSCOPIC HERNIA REPAIRTransabdominal Preperitoneal Procedure (TAPP)

Totally Extraperitoneal (TEP) Repair

Indications include bilateral inguinal hernia, recurring hernia, need for early recovery

RECURRENCEAround 1% for Shouldice repairMost recurrences are of the same type as the original hernia

Recurrence FactorsPatientTechnicalTissue

RECURRENCEPatient factors malnutrition, immunosuppression, diabetes, steroid use, and smoking.

Technical factors mesh size, prosthesis fixation, and technical proficiency of the surgeon.

Tissue factors wound infection, tissue ischemia, and increased tension within the surgical repair

COMPLICATIONSThe overall risk of complications of inguinal hernia repair is low.

Common ComplicationsPain, injury to the spermatic cord and testes, wound infection, seroma, hematoma, bladder injury, osteitis pubis, and urinary retention

EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT

INGUINAL HERNIA

EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA

PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES

1. What is the recommended treatment for inguinal hernia? Mesh repair, Laparoscopic or the Open2. If laparoscopic mesh repair is the preferred technique for inguinal hernias, what is the recommended laparoscopic technique? Transabdominal Preperitoneal or Total Extra Preperitoneal3. Is fixation of the mesh necessary in laparoscopic repair? No4. If open mesh repair, what is the recommended technique Lichtenstein, plug and mesh or Prolene Hernia System

EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA

PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES

5. What is the recommended treatment for recurrent inguinal hernia? Mesh repair, either laparoscopic or open method6. What is the recommended treatment for bilateral inguinal hernia? Mesh repair, either laparoscopic or open method7. Is antimicrobial prophylaxis recommended for elective groin hernia surgery? Not routinely recommended using mesh

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