Download MBBS General Surgery PPT 6 Inguinal Hernia Lecture Notes

Inguinal hernia

Epidemiology
? Inguinal hernia repair is one of the most commonly performed operation.

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? 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.

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? Before the first year of age
? After age 40

? Approximately 70% of femoral hernia repairs are performed in women;

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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

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Anatomy
? 4- to 6 cm-long

? Anterior portion of the pelvic

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basin

? Spermatic cord:
? Three arteries
? Three veins

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? Two nerves
? Pampiniform venous plexus
? Va s deferens

Anatomy

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? Anterior

? External oblique aponeurosis

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? Lateral

? Internal oblique muscle

? Posterior

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? Transversalis fascia and transversus

abdominus muscle

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? Superior

? Internal oblique muscle

? Inferior

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? Inguinal ligament
Anatomy

? Anterior

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? External oblique aponeurosis

? Lateral

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? Internal oblique muscle

? Posterior

? Transversalis fascia and transversus

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abdominus muscle

? Superior

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? Internal oblique muscle

? Inferior

? inguinal ligament

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Anatomy
Other structure :
? Iliopubic tract:

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? An aponeurotic band

that begins at the

anterior superior iliac

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spine and inserts into

Cooper's ligament from

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above.

? lacunar ligament (ligament of

Gimbernat)

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? Cooper's ligament (pectineal)
? Conjoined tendon
Anatomy
Other structure :

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? Iliopubic tract:

An aponeurotic band

that begins at the

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anterior superior iliac

spine and inserts into

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Cooper's ligament from

above.

? lacunar ligament (ligament of

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Gimbernat)

? Cooper's ligament (pectineal)
? Conjoined tendon

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HESSELBACH'S

TRIANGLE
? Medial aspect of Rectus

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abdominis muscle

? Inferior epigastric vessels
? Inguinal ligament

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Subtypes

? Direct hernia
? Indirect hernia
? Femoral hernia

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Direct hernia

Direct hernias protrude

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medial to the inferior

epigastric vessels,

within Hesselbach's

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triangle.
Indirect hernias

Indirect hernias

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protrude lateral to the

inferior epigastric

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vessels, through the

deep inguinal ring.

Femoral hernias

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Femoral hernias

protrude through the

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small and inflexible

femoral ring.
Etiology
? Acquired:

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the best-characterized risk

factor is weakness in the

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abdominal wal musculature

? Chronic obstructive

pulmonary disease: direct

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? increase intra-abdominal

pressure

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? decreased col agen fiber

density in hernia patients

Congenital

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? The majority of pediatric hernias
? Patent processus vaginalis

(PPV)

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? The high incidence of indirect

inguinal hernias in preterm

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babies.
DIAGNOSIS

? History:

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? 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

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? 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.

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? 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.

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Physical Examination

? Ideally, the patient should be examined in a standing position to

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increase intra-abdominal pressure, with the groin and scrotum fully

exposed.

? Inspection: an abnormal bulge along the groin or within the scrotum

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? Palpation: advancing the index finger through the scrotum toward the

external inguinal ring.

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? Femoral hernias should be palpable below the inguinal ligament,

lateral to the pubic tubercle.
Imaging
? US:

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? sensitivity of 86% and specificity of

77%

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? CT :

? sensitivity of 80% and specificity of

65%

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? MRI:

? Sensitivity of 95% and specificity of

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96%
TREATMENT

? Surgical repair is the definitive treatment of inguinal hernias

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1. Surgical

2. Conservative

Conservative Treatment

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? When the patient's medical condition confers an unacceptable level of

operative risk, elective surgery should be deferred until the condition

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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

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complications.
Conservative Treatment

? Nonoperative inguinal hernia

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treatment targets pain, pressure,

and protrusion of abdominal

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contents in the symptomatic

patient population.

? Trusses externally

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? not prevent complications

? Femoral inguinal hernia

SURGICAL REPAIR

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? Al surgical repairs follow the same basic principles:

1. Reduction of the hernia content into the abdominal cavity.

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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

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4. Permanent reinforcement of the abdominal wall defect with sutures or

mesh.(i.e. Anatomical vs Prosthetic repair)
SHOULDICE REPAIR

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LICHENSTEIN REPAIR i.e. MESH HERNIOPLASTY

Laparascopic hernia repair
1. Trans abdominal Preperitoneal Procedure (TAPP)
2. Totally Extraperitoneal (TEP) Repair

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COMPLICATIONS
? Hernia Recurrence
? Pain
? Cord and Testes Injury
? Wound infection

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? Seroma
? Hematoma
? Bladder injury
? Osteitis pubis
? Urinary retention

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