Gastro 44 Hernia - Inguinal hernia femoral hernia

Abnormal protusion of an organ or tissue through a defect in its surrounding walls

• anterior : Epigastric, umbilical, Paraumbilical, Spigelian
• Posterior : Lumber- Superior triangle/ Inferior triangle
• Pelvic: Obturator, Sciatic, Perineal
• Groin: inguinal, Femoral

• Direct Hernia
• Incisional Hernia

Epigastric Hernia

• The innominate fascia covers the external oblique and the spermatic cord as it emerges between the crura of the external ring.
• The external spermatic fascia covers the pubic and scrotal portion of the spermatic cord.
• The internal spermatic fascia covers the spermatic cord within the inguinal canal.

The internal inguinal ring is located 2 cm above the skin crease in the groin and midway between the pubic tubercle and the anterior superior iliac spine.

The inguinal ligament is formed by fibers of the external oblique aponeurosis that swing posterior and medial after they insert on the pubic bone. It is held together by epitendineum and is attached at the anterior superior iliac spine and at the pubic tubercle, where it fans out to become the lacunar ligament.

• The conjoined tendon, which exists in only 3% to 6% of patients, is a fused tendonous structure of the internal oblique and transversus abdominus muscles that reaches the pubic tubercle.
• The cremasteric fascia arises from the internal oblique muscle.

• Indirect - sac passes from the internal inguinal ring obliquely toward the external inguinal ring and ultimately into the scrotum
• Direct - the sac protrudes outward and forward and is medial to the internal inguinal ring and inferior epigastric vessels.
• Pantaloon-type hernia occurs when there is both an indirect and direct hernia component

• This is attributed to a delay in atrophy of the processus vaginalis after the normal slower descent of the right testis to the scrotum during fetal development.
• The predominance of right-sided femoral hernias is thought to be caused by the tamponading effect of the sigmoid colon on the left femoral canal

• Poupart ligament - inguinal ligament
• Lacunar ligament - fan-shaped medial expansion of the inguinal ligament, which inserts into the pubis and forms the medial border of the femoral space.
• The pectineal (Cooper) ligament - is an extension of the lacunar ligament that runs on the pectineal line of the pubic bone. This structure is posterior to the iliopubic tract and forms the posterior border of the femoral canal.

• The iliopubic tract is an aponeurotic band that is formed by the transversalis fascia and transversus abdominis aponeurosis and fascia.
• It runs parallel to the inguinal ligament from the iliopectineal arch to the superior ramus of the pubis. It is more easily visualized from the posterior view, but often is difficult to discern from the anterior approach. It varies considerably in its thickness, thus making its identification from either approach questionable.

• The inguinal canal is about 4 cm in length and is located just cephalad to the inguinal ligament.
• The canal extends between the internal (deep) inguinal and external (superficial) inguinal rings.
• The inguinal canal contains the spermatic cord in men and the round ligament of the uterus in women.

• Boundary
• Superficially by the external oblique aponeurosis.
• Superior wall - internal oblique and transversus abdominis musculoaponeuroses
• Inferior wall - inguinal ligament and lacunar ligament.
• Posterior wall, or floor of the inguinal canal - aponeurosis of the transversus abdominis muscle and transversalis fascia.

• Contents of inguinal canal - 
• - For Males - Spermatic cord (with the genital branch of the genitofemoral nerve) and the ilioinguinal nerve.
• - For females, the contents include the round ligament, genital branch of the genitofemoral nerve, and the ilioinguinal nerve

• Cremaster muscle fibers - arises from the lowermost fibers of the internal oblique muscle
• Testicular artery and accompanying veins
• Genital branch of the genitofemoral nerve
• Vas deferens
• Cremasteric vessels - inferior epigastric vessels
• Lymphatics, and
• Processus vaginalis.

• Inguinal ligament inferiorly
• Lateral margin of the rectus sheath medially
• Inferior epigastric vessels laterally

Type I - Indirect inguinal hernia: internal inguinal ring normal (e.g., pediatric hernia)

Type II - Indirect inguinal hernia: internal inguinal ring dilated but posterior inguinal wall intact; inferior deep epigastric vessels not displaced

• Type III - Posterior wall defect
• A. Direct inguinal hernia
• B. Indirect inguinal hernia: internal inguinal ring dilated, medially encroaching on or destroying the transversalis fascia of Hesselbach triangle (e.g., scrotal, sliding, or pantaloon hernia)
• C. Femoral hernia

Type IV - Recurrent hernia

• Anatomical dissection
• Tension free repair
• Placement of mesh

• 1. The iliopubic tract repair - approximates the transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures.
• 2. Shouldice repair 
• 3. Bassini repair 
• 4. Cooper ligament (McVay repair) repair

The original repair includes dissection of the spermatic cord, dissection of the hernia sac with high ligation, and extensive reconstruction of the floor of the inguinal canal.

After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal fat is bluntly dissected from the upper margin of the posterior side of the transversalis fascia to permit adequate tissue mobilization.

A triple-layer repair is then performed.

The internal oblique, transversus abdominis, and transversalis fascia are fixed to the shelving edge of the inguinal ligament and pubic periosteum with interrupted sutures.

The lateral aspect of the repair reinforces the medial border of the internal inguinal ring.

The Shouldice repair recapitulates principles of the Bassini repair, and its distribution of tension over several tissue layers results in lower recurrence rates.

During dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the mons pubis and labium majus in women.

With the posterior inguinal floor exposed, an incision in the transversalis fascia is made between the pubic tubercle and internal ring.

Care is taken to avoid injury to preperitoneal structures, which are bluntly dissected to mobilize the upper and lower fascial flaps.

At the pubic tubercle, the iliopubic tract is sutured to the lateral edge of the rectus sheath using a synthetic, nonabsorbable, monofilament suture.

This continuous suture progresses laterally, approximating the edge of the inferior transversalis flap to the posterior aspect of the superior flap.

At the internal inguinal ring, the suture continues back in the medial direction, approximating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament.

At the pubic tubercle, this suture is tied to the tail of the original stitch.

The next suture begins at the internal inguinal ring, and it continues medially, apposing the aponeuroses of the internal oblique and transversus abdominis to the external oblique aponeurotic fibers.

At the pubic tubercle, the suture doubles back through the same structures laterally toward the tightened internal ring.

The McVay repair addresses both inguinal and femoral ring defects.

This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated .

Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space.

The upper flap is mobilized by gentle blunt dissection of underlying tissue.

Cooper’s ligament is bluntly dissected to expose its surface.

A 2- to 4-cm relaxing incision is made in the anterior rectus sheath vertically from the pubic tubercle.

This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation.

Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is continued laterally along Cooper’s ligament to occlude the femoral ring.

Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament.

The transversalis is then sutured to the inguinal ligament laterally to the internal ring.

• ●Lichtenstein repair 
• ● Abrahamson nylon darn repair
• ●Bilayer mesh repair (sandwich technique) – Combined onlay and underlay (ie, bilayer) mesh placement (eg, Prolene hernia system)
• ●Preperitoneal mesh repair – Mesh placed behind transversalis fascia (eg, Nyhus, Rives, Stoppa, Read, Wants, Kugel repairs). This approach avoids mobilization of the spermatic cord and injury to the sensory nerves of the inguinal canal, which is particularly important for hernias previously repaired through an anterior approach.
• ●Plug and patch repair – Mesh plug through the defect, mesh onlay anterior to the transversalis fascia, a cone-shaped plug of polypropylene mesh that when inserted into the internal inguinal ring would deploy like an upside-down umbrella and occlude the hernia

The Lichtenstein technique expands the domain of the inguinal canal by reinforcing the inguinal floor with a prosthetic mesh, thereby minimizing tension in the repair.

Initial exposure and mobilization of cord structures is identical to other open approaches.

The inguinal canal is dissected to expose the shelving edge of the inguinal ligament, the pubic tubercle, and sufficient area for mesh.

The mesh is a 7 × 15 cm rectangle with a rounded medial edge, and it must be large enough to extend 2 to 3 cm superior to Hesselbach’s triangle.

The lateral portion of the mesh is split such that the superior tail comprises two thirds of its width, and the inferior tail comprises the remaining one third.

The medial edge of the mesh is affixed to the anterior rectus sheath such that it overlaps the pubic tubercle by 1.5 to 2 cm.

This refinement to the original Lichtenstein technique minimizes medial recurrence  For fixation of the inferior margin of the mesh, a permanent, synthetic, monofilament suture is used, taking care to avoid placing sutures directly into the periosteum of the pubic tubercle.

Fixation is continued along the shelving edge of the inguinal ligament from medial to lateral, ending at the internal ring.

The upper tail of the mesh is then fixed to the internal oblique aponeurosis and the medial edge to the rectus sheathusing a synthetic, absorbable suture.

• The principle of Abrahamson nylon darn repair is to reinforce the posterior wall of the inguinal canal with the muscle of the musculoaponeurotic arch along with a simple lattice of monofilament suture under no tension on which fibrous tissue develops.
• The hernial sac is dealt with. The repair begins by suturing the medial edge of rectus sheath and the musculoaponeurotic arch (conjoint tendon) to the posterior portion of the inguinal ligament and to the iliopubic tract with a continuous suture of 2-0 polypropylene. If the conjoined tendon and inguinal ligament cannot be apposed without tension then approximation is not forced and a gap is left between the inguinal ligament or the upper elements of repair. The gap is bridged by a number of layers of the polypropylene suture.
• The first bite is to take over the most medial fiber of inguinal ligament over the pubic tubercle and then through the medial edge of the rectus sheath. The suture is then taken laterally taking bites below to the inguinal ligament and above to rectus sheath medially and laterally to the conjoint tendon and more laterally muscular part of transversus abdominis and internal oblique, upto the deep inguinal ring. The suture is not tied tightly, but kept loose and the suture is then continued medially taking bites of the same structures and ending up at the most medial end of inguinal ligament and rectus sheath.

• Mayo’s repair involves tackling of hernial sac in the usual way.
• The repair is done by double breasting of rectus sheath whereby one flap of rectus sheath overlaps the other. 
• It usually causes tension on the suture line and there is 50% chance of recurrence following Mayo’s repair.

A large mesh prosthesis into the preperitoneal space, particularly useful for large, recurrent, or bilateral hernias.

The mesh may be placed in the preperitoneal space by either a midline abdominal incision orPfannensteil incision. Unilateral mesh placement may also be done by an inguinal incision.

The totally extra-peritoneal repair (TEP) uses exactly the same principles as the Stoppa repair, however it is performed laparoscopically

This operation is also known as giant prosthetic reinforcement of the visceral sac (GPRVS).

When the deep ring is patulous, the fascia transversalis is plicated by suture narrowing thedeep ring.

• The basic defect in congenital hernia is the failure of obliteration of processus vaginalis. The inguinal canal structure and mechanism remain intact.
• The inguinal canal donot develop and superficial and deep inguinal rings lie close to each other. By 2 years the deep ring moves laterally and proper inguinal canal can be identified.

• Useful for the repair of recurrent inguinal hernias, sliding hernias,femoral hernias, and some strangulated hernias.
• A transverse skin incision is made 2 cm above the internal inguinal ring and is directed to the medial border of the rectus sheath.
• The preperitoneal tissues are retracted cephalad to visualize the posterior inguinal wall and the site of herniation.
• The inferior epigastric artery and veins are generally beneath the midportion of the posterior rectus sheath and usually do not need to be divided.
• This approach avoids mobilization of the spermatic cord and injury to the sensory nerves of the inguinal canal, which is particularly important for hernias previously repaired through an anterior approach.
• The transversalis fascia and transversus abdominis aponeurosis are identified and sutured to the iliopubic tract with permanent sutures.
• Femoral hernias repaired by this approach require closure of the femoral canal by securing the repair to Cooper ligament.
• A mesh prosthesis is frequently used to obliterate the defect in the femoral canal, particularly with large hernias.

• Medially - vas deferens
• Laterally - vessels of the spermatic cord
• Posterior border - Peritoneal edge 

Contents - external iliac vessels, deep circumflex iliac vein, femoral nerve, and genital branch of the genitofemoral nerve

• Lateral border - reflected peritoneum
• Inferolateral border - iliopubic tract
• Superomedial border - gonadal vessels 

• Contents - lateral femoral cutaneous, femoral branch of the genitofemoral, and femoral nerves.

Aberrant branch of the obturator artery arising from the inferior epigastric or external iliac artery, crossing the pectineal ligament, and anastomosing with the obturator artery; this vessel can encircle the neck of a hernial sac. 

• The myopectineal orifice (MPO) is the site of indirect, direct, femoral and some interstitial hernias, and it has become the focus of many recent advances in hernia surgery
• The MPO is divided anteriorly by the inguinal ligament, and posteriorly by the iliopubic tract.

• Boundaries:
• Medially - lateral border of the rectus muscle
• Superiorly - arching fibers of the transversus abdominus and the internal oblique muscles
• Laterally - iliopsoas muscle 
• Inferiorly - Cooper ligament.

• The MPO is perforated in its superior pane by the spermatic cord, and through its inferior pane by the femoral vessels.
• The MPO is protected only by the combined lamina of the aponeurosis of the transversus abdominus and the transversalis fascia.

• Totally extraperitoneal (TEP)
• Transabdominal preperitoneal (TAPP)
• Intraperitoneal onlay mesh (IPOM) repair

• Bilateral hernia
• Recurrent hernia after open anterior repair
• Concomittent other laparoscopic procedures like Lap prostatectomy

• Preperitoneal space is accessed after initially entering the peritoneal cavity.
• The transabdominal approach confers the advantage of an intraperitoneal perspective, which is useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery.
• The working space is larger

• Dissection begins in the preperitoneal space using a balloon dissector.
• The advantage of the TEP repair is the access to the preperitoneal space is quicker without intraperitoneal infiltration. Consequently, this approach minimizes the risk of injury to intra-abdominal organs and port site herniation through an iatrogenic defect in the abdominal wall.
• However, the use of dissection balloons is costly, the working space is more limited, and it may not be possible to create a working space if the patient has had a prior preperitoneal operation.Also, if a large tear in the peritoneum is created during a TEP approach, the potential working space can become obliterated, necessitating conversion to a TAPP approach.

• In contrast to TAPP and TEP, the IPOM procedure permits the posterior approach without preperitoneal dissection.
• It is an attractive procedure in cases where the anterior approach is unfeasible, in recurrent hernias that are refractory to other approaches, or where extensive preperitoneal scarring would make TEP or TAPP challenging.

• Tacks are placed above the iliopubic tract to avoid injury to the lateral cutaneous nerve of the thigh and the femoral branch of the genitofemoral nerve. Femoral branch of the genitofemoral nerve and lateral femoral cutaneous nerve, which are located lateral to and below the iliopubic tract.
• During this fixation, the surgeon palpates the end of the tacker from the abdominal surface to ensure its proper angle and to stabilize the pelvis

• Femoral canal is a tunnel about 1.25cm long and 1.25 cm wide at its base.
• This is the most medial compartment of the femoral sheath.
• This extends from femoral ring above to the saphenous opening below.

• Boundaries of femoral ring:
• Anteriorly - Iliopubic tract
• Posteriorly - Cooper ligament
• Laterally - femoral vein
• Medially – Lacunar ligament

• Content of femoral canal
• - Deep inguinal lymph node (Cloquet’s lymph node)
• - Lympahtics and
• - Loose areolar tissue.

• Lockwood's infra-inguinal,
• Lotheissen's trans-inguinal and
• McEvedy's high approach.

• The patient is asked to adduct the thigh against  resistance. The tendon of the adductor longus is palpated at the upper medial aspect of the thigh.
• Trace the adductor longus tendon upwards, it reaches up to a bony point, that is pubic tubercle.