Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 6 Inguinal Hernia Lecture Notes
Inguinal hernia
Epidemiology
? Inguinal hernia repair is one of the most commonly performed operation.
? Approximately 75% of abdominal wall hernias occur in the groin.
? Of inguinal hernia repairs, 90% are performed in men and 10% in women.
? The incidence of inguinal hernias in males has a bimodal distribution.
? Before the first year of age
? After age 40
? Approximately 70% of femoral hernia repairs are performed in women;
however, inguinal hernias are five times more common than femoral hernias.
? The most common subtype of groin hernia in men and women is the indirect
inguinal hernia
Anatomy
? 4- to 6 cm-long
? Anterior portion of the pelvic
basin
? Spermatic cord:
? Three arteries
? Three veins
? Two nerves
? Pampiniform venous plexus
? Va s deferens
Anatomy
? Anterior
? External oblique aponeurosis
? Lateral
? Internal oblique muscle
? Posterior
? Transversalis fascia and transversus
abdominus muscle
? Superior
? Internal oblique muscle
? Inferior
? Inguinal ligament
Anatomy
? Anterior
? External oblique aponeurosis
? Lateral
? Internal oblique muscle
? Posterior
? Transversalis fascia and transversus
abdominus muscle
? Superior
? Internal oblique muscle
? Inferior
? inguinal ligament
Anatomy
Other structure :
? Iliopubic tract:
? An aponeurotic band
that begins at the
anterior superior iliac
spine and inserts into
Cooper's ligament from
above.
? lacunar ligament (ligament of
Gimbernat)
? Cooper's ligament (pectineal)
? Conjoined tendon
Anatomy
Other structure :
? Iliopubic tract:
An aponeurotic band
that begins at the
anterior superior iliac
spine and inserts into
Cooper's ligament from
above.
? lacunar ligament (ligament of
Gimbernat)
? Cooper's ligament (pectineal)
? Conjoined tendon
HESSELBACH'S
TRIANGLE
? Medial aspect of Rectus
abdominis muscle
? Inferior epigastric vessels
? Inguinal ligament
Subtypes
? Direct hernia
? Indirect hernia
? Femoral hernia
Direct hernia
Direct hernias protrude
medial to the inferior
epigastric vessels,
within Hesselbach's
triangle.
Indirect hernias
Indirect hernias
protrude lateral to the
inferior epigastric
vessels, through the
deep inguinal ring.
Femoral hernias
Femoral hernias
protrude through the
small and inflexible
femoral ring.
Etiology
? Acquired:
the best-characterized risk
factor is weakness in the
abdominal wal musculature
? Chronic obstructive
pulmonary disease: direct
? increase intra-abdominal
pressure
? decreased col agen fiber
density in hernia patients
Congenital
? The majority of pediatric hernias
? Patent processus vaginalis
(PPV)
? The high incidence of indirect
inguinal hernias in preterm
babies.
DIAGNOSIS
? History:
? Groin pain
? Extrainguinal symptoms such as a change in bowel habits or urinary symptoms
? Generalized pressure, localized sharp pain, and referred pain
? Pressure or heaviness in the groin , following prolonged activity
? Sharp pain tends to indicate an impinged nerve and may not be related to the
extent of physical activity performed by the patient.
? Neurogenic pain may be referred to the scrotum,testicle, or inner thigh.
? Hernias wil often increase in size and content over a protracted time.
? Patients wil often reduce the hernia by pushing the contents back into the
abdomen, thereby providing temporary relief.
Physical Examination
? Ideally, the patient should be examined in a standing position to
increase intra-abdominal pressure, with the groin and scrotum fully
exposed.
? Inspection: an abnormal bulge along the groin or within the scrotum
? Palpation: advancing the index finger through the scrotum toward the
external inguinal ring.
? Femoral hernias should be palpable below the inguinal ligament,
lateral to the pubic tubercle.
Imaging
? US:
? sensitivity of 86% and specificity of
77%
? CT :
? sensitivity of 80% and specificity of
65%
? MRI:
? Sensitivity of 95% and specificity of
96%
TREATMENT
? Surgical repair is the definitive treatment of inguinal hernias
1. Surgical
2. Conservative
Conservative Treatment
? When the patient's medical condition confers an unacceptable level of
operative risk, elective surgery should be deferred until the condition
resolves, and operations reserved for lifethreatening emergencies.
? A nonoperative strategy is safe for minimally symptomatic inguinal
hernia patients, and it does not increase the risk of developing hernia
complications.
Conservative Treatment
? Nonoperative inguinal hernia
treatment targets pain, pressure,
and protrusion of abdominal
contents in the symptomatic
patient population.
? Trusses externally
? not prevent complications
? Femoral inguinal hernia
SURGICAL REPAIR
? Al surgical repairs follow the same basic principles:
1. Reduction of the hernia content into the abdominal cavity.
2. Excision and closure of a peritoneal sac if present or replacing it deep
to the muscles
3. Re-approximation of the walls of the neck of the hernia if possible
4. Permanent reinforcement of the abdominal wall defect with sutures or
mesh.(i.e. Anatomical vs Prosthetic repair)
SHOULDICE REPAIR
LICHENSTEIN REPAIR i.e. MESH HERNIOPLASTY
Laparascopic hernia repair
1. Trans abdominal Preperitoneal Procedure (TAPP)
2. Totally Extraperitoneal (TEP) Repair
COMPLICATIONS
? Hernia Recurrence
? Pain
? Cord and Testes Injury
? Wound infection
? Seroma
? Hematoma
? Bladder injury
? Osteitis pubis
? Urinary retention
This post was last modified on 07 April 2022