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A case discussion on hernia. Useful for medical students. Primary reference: Schwartz Principles of Surgery.

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  1. 1. Omar Khayyam Ramos Macadato
  2. 2. Sir Astley Cooper Recommended a truss rather than surgery; only indication for surgery was strangulation Lucas-Championnière 1881 Performed high ligation of an indirect inguinal hernia sac at the internal ring Edoardo Bassini 1844–1924 dissection of the layers of the inguinal canal to the transversalis fascia & reconstruction of the floor of the inguinal canal in several layers Lotheissen, McVay, Halsted, Shouldice Described modifications of Bassini's repair to reduce the recurrence rate and to avoid complications
  3. 3. Lichtenstein 1986 Introduced tension-free repair by reconstructing floor of inguinal canal using mesh prosthetic material Gilbert 1989 Devised technique for sutureless repair of inguinal hernia using prosthesis through internal inguinal ring or for repair of posterior inguinal wall Rutkow 1993 Modified mesh-plug repair; plug and patch operation
  4. 4. Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed
  5. 5.  Skin and subcutaneous fat  External oblique abdominal muscle  Internal oblique abdominal muscle and transverse abdominal muscle  Transvers abdominal fascia  Fat out of peritoneum  Peritoneum Abdominal Wall
  6. 6. Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed
  7. 7. Muscle Origin Insertion External oblique  Inferior border of lower 8 ribs  Lateral lip of iliac crest  Aponeurosis ending in midline raphe (linea alba) Internal Oblique  Thoracolumbar fascia  iliac crest between origins of external and transversus  Lateral two-thirds of inguinal ligament  Aponeurosis to linea alba  Lower border of ribs 9-12 Transversus abdominis  Thoracolumbar fascia  medial lip of iliac crest  lateral one-third of inguinal ligament  Costal cartilages lower six ribs (ribs VII to XII)  Aponeurosis ending in linea alba  pubic crest and pectineal line Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed
  8. 8. Muscle Origin Insertion Rectus abdominis  Pubic crest  Pubic tubercle  Pubic symphysis  Costal cartilages of ribs V to VII  xiphoid process Pyramidalis  Front of pubis and pubic symphysis  Into linea alba Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed
  9. 9.  Inguinal ligament – formed by the lower border of the external oblique aponeurosis Other ligaments are also formed  lacunar ligament  pectineal (Cooper's) ligament Drake, et al: Gray’s Atlas of Anatomy, 2nd Ed
  10. 10. Inguinal ligament Deep inguinal ring Superficial inguinal ring Int. oblique m. Transversus abdominis Tranversalis fascia Ext. oblique m. Boundaries of the Inguinal Canal
  11. 11. Anatomy in Posterior Perspective
  12. 12. Schwartz’s Principles of Surgery 9th Edition MYOPECTINEAL ORIFICE OF FRUCHAUD
  13. 13. Hasselbach Triangle Right inferior epigastric left artery and vein HASSELBACH TRIANGLE Rectus abdominis muscle Inguinal ligament
  17. 17. Contents of the Inguinal Canal  Genital branch of the genitofemoral nerve  Ilioinguinal nerve  Spermatic cord (in men)  Round ligament (in women)
  18. 18. Contents of the Inguinal Canal
  19. 19. Contents of Spermatic Cord  Ductus deferens  Artery of the ductus deferens  Testicular artery  Pampiniform plexus of veins  Cremasteric artery and vein  Genital branch of the genitofemoral nerve  Sympathetic and visceral afferent nerve  Lymphatics  Remnants of the processus vaginalis
  20. 20. Spermatic Cord
  21. 21. Femoral Canal Inguinal lig. Femoral vein
  22. 22. TRIANGLE OF DOOM  Lateral Border: Spermatic cord vessels  Medial Border: Vas deferens  Posterior Border: Peritoneal edge  Contents:  External iliac vessels  Deep circumflex iliac vein  Femoral nerve  Genital branch of genitofemoral nerve
  23. 23. Schwartz’s Principles of Surgery 9th Edition
  24. 24. TRIANGLE OF PAIN  Superomedial Border: Gonadal vessels  Lateral Border: Reflected peritoneum  Inferolateral Border: Iliopubic tract  Contents:  Lateral femoral cutaneous nerve  Femoral branch of the genitofemoral nerve  Femoral nerve
  25. 25. Schwartz’s Principles of Surgery 9th Edition
  26. 26. CIRCLE OF DEATH  Common Iliac  Internal Iliac  Obturator  Aberrant Obturator  Inferior Epigastric  External Iliac
  28. 28. Deep Inguinal Ring Inguinal ligament Superficial Inguinal Ring Hasselbach Triangle Inguinal Canal Spermatic Cord Adductor longus Sartorius Femoral nerve Femoral artery Femoralvein Femoral ring Femoral Triangle Ductus deferens TRIANGLE OF DOOM Gonadal vessels Iliac artery and vein TRIANGLE OF PAIN Ant. Epigastric a. & v. ANATOMY 1 2 3 4 1. Femoral nerve 2. Femoral br. of genitofemoral nerve 3. Ant. femoral cutaneous nerve 4. Lat. femoral cutaneous nerve 1 2 1. Iliac vein 2. Iliac artery MYOPECTINEAL ORIFICE OF FRUCHAUD MYOPECTINEAL ORIFICE OF FRUCHAUD  SUPERIOR: Oblique muscles & Transversus abdominis  MEDIAL: Rectus muscle & sheath  LATERAL: Iliopsoas  INFERIORLY: Cooper’s ligament (Pecten pubis) CIRCLE OF DEATH Abberant Obturator artery & vein Obturator artery & vein 1. Common Iliac 2. Internal Iliac 3. Obturator 4. Aberrant Obturator 5. Inferior Epigastric 6. External Iliac
  29. 29. DEFINITION  Defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls  Abdominal wall hernias occur only at sites at which the aponeurosis and fascia are not covered by striated muscle
  30. 30. Primary Abdominal Wall Hernia
  31. 31.  Coughing  COPD  Obesity  Straining  Constipation  Prostatism  Pregnancy  Birthweight <1,500 g  Family history of a hernia  Valsalva maneuver  Ascites  Upright position  Congenital connective tissue disorder  Defective collagen synthesis  Previous right lower quadrant incision  Arterial aneurysms  Cigarette smoking  Heavy lifting  Physical exertion
  32. 32.  75% of all hernias occur in the inguinal region  Two-thirds are indirect, the remainder are direct inguinal hernias  The lifetime risk of inguinal hernia is 27% in men and 3% in women  In males: peaks before the first year of age and after age 40.  70% of femoral hernia repairs are performed in women  The most common subtype of groin hernia in men and women is the indirect inguinal hernia
  33. 33.  patent processus vaginalis  obliterated processus vaginalis  congenital structural malformations of the transversalis fascia and transversus abdominis aponeurosis  Denervation of the internal oblique muscle by adjacent incisions
  34. 34. PATHOPHYSIOLOGY CONGENITAL ACQUIRED Pediatric Adult Patency of the processus vaginalis Weak abdominal wall muscles  Family history  Low birth weight  COPD  chronic cough  Tissue weakness  Right lower quadrant incision  Straining 2° Prostatism  Valsalva maneuver  Hereditary collagen disorders HERNIA
  35. 35. • Testes develops near the kidneys 7 weeks after conception • Testes descends at the groin level about 12 weeks after conception • Testes descends into the scrotum at about 4-6 weeks after birth
  36. 36. Varying degrees of closure of the processus vaginalis • A. Closed PV. • B. Minimally patent PV. • C. Moderately patent PV. • D. Scrotal hernia.
  37. 37. Hernia Types
  38. 38. Femoral Hernia
  39. 39. Indirect Inguinal Hernia
  40. 40. Direct Inguinal Hernia
  41. 41. Clinical classification  Reducible hernia  Irreducible hernia
  42. 42. Sliding hernia
  43. 43. Incarcerated hernia Strangulated hernia
  44. 44. Other types of hernia  Romberg's hernia or saddle bag hernia  ipsilateral, concurrent direct and indirect inguinal hernias PANTALOON HERNIA
  45. 45.  hernias develop on both the right and the left sides of the groin  commonly congenital  associated with age and straining in elderly men BILATERAL HERNIA
  46. 46.  Hernia through an incisional site INCISIONAL HERNIA
  47. 47.  hernia through the spigelian fascia SPIGELIAN HERNIA
  48. 48. Other types of hernia Hernias Littre’s hernia Hernia involving a Meckel’s diverticulum Petersen’s hernia Seen after bariatric gastric bypass; Petit’s hernia hernia through Petit’s triangle (inferior lumbar triangle) Grynfeltt’s hernia Hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle) Richter’s hernia Incarcerated or strangulated hernia involving only one sidewall of the bowel Amyand’s hernia Hernia sac containing a ruptured appendix
  49. 49. Pathological anatomy
  53. 53. COUGH IMPULSE •Visible & Palpable cough impulse. •Reappear on straining, standing or coughing
  54. 54. INVAGINATION TEST  Felt on the pulp: direct hernia  Felt on the tip: indirect hernia
  55. 55. THREE FINGER TEST / ZIEMAN’S TECHNIQUE  Index finger: deep inguinal ring (indirect hernia)  Middle finger: superficial ing. Ring (direct hernia)  Ring finger: saphenous opening (femoral hernia)
  56. 56. RING OCCLUSION TEST  (-) ring occlusion test: bulging of the hernia: INDIRECT HERNIA  (+) ring occlusion test: no bulging of the hernia: DIRECT HERNIA
  58. 58. NYHUS CLASSIFICATION SYSTEM 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
  59. 59. Emergent repair • Incarcerated hernias • Strangulated hernias • Sliding hernias
  60. 60. INCARCERATED HERNIA  An incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency  Reduction should be attempted before definitive surgical intervention.  Hernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.
  61. 61. How to reduce an incarcerated hernia in the ER Apply ice to incarcerated hernia Sedate the patient Use the Trendelenburg position for inguinal hernias Apply steady gentle manual pressure Admit and observe for signs of necrotic bowel after reduction Perform surgical herniorrhaphy ASAP
  62. 62. Treatment Approach on Strangulated Hernia Rapid IVF resuscitation & Electrolyte replacement Antibiotics GI decompression: NGT insertion Urgent surgery
  63. 63. Surgical Approach Surgery Viable bowel Reduced Nonviable bowel more bowel is pulled Viable bowel is transected End-to-end anastomosis Groin approach not possible Explore laparoscopy/laparotomy
  64. 64. INGUINAL HERNIA REPAIR Open Anterior, Nonprosthetic  Marcy Repair  Bassini Repair  Moloney Darn Repair  Shouldice Repair  McVay Cooper's Ligament Repair Schwartz’s Principles of Surgery 8th Edition
  65. 65. MARCY REPAIR  simplest nonprosthetic repair performed today  main indication is in Nyhus type I  The essential features: high ligation of the hernia sac plus narrowing of the internal ring Schwartz’s Principles of Surgery 8th Edition
  66. 66. BASSINI REPAIR  Sutures approximate reflection of inguinal ligament (Poupart’s) to the transversus abdominis aponeurosis/conjoint tendon  Major Components:  Division of the external oblique aponeurosis  Division of the cremaster muscle  Division of the floor or posterior wall of the inguinal canal  High ligation of an indirect sac  Reconstruction of the posterior wall Schwartz’sPrinciplesofSurgery9thEdition
  67. 67. SHOULDICE REPAIR  Initial approach similar to Bassini:  2 continuous sutures:  Iliopubic tract  rectus sheath inf. Trans. Flap  sup. Flap int. inguinal ring  back to superior flap  tie at pubic tub.  Int ing ring  apo. of int. obl. & trans. abd.  ext. obl.  tie at pubic tub.  distribution of tension over several tissue layers results in lower recurrence rates Schwartz’s Principles of Surgery 10th Edition
  68. 68. MCVAY COOPERS LIGAMENT REPAIR  addresses both inguinal and femoral ring defects • Indications: • femoral hernias • Prosthetic material is contraindicated • Similar to Bassini except: Cooper’s ligament sutured to transversus abdominis aponeurosis/conjoint tendon Schwartz’s Principles of Surgery 10th Edition
  69. 69. PROSTHETIC INGUINAL HERNIA REPAIR  Open Anterior, Prosthetic  Lichtenstein Tension-Free Hernioplasty  Mesh Plug and Patch Schwartz’s Principles of Surgery 9th Edition
  70. 70. LICHTENSTEIN TENSION-FREE HERNIOPLASTY Expands the domain of the inguinal canal by reinforcing the inguinal floor with a prosthetic mesh Schwartz’s Principles of Surgery 10th Edition
  71. 71. PLUG AND PATCH TECHNIQUE  Modification of the Lichtenstein repair; developed by Gilbert and later popularized by Rutkow and Robbins  Indirect: plug is placed alongside the spermatic cord through the internal ring  Direct: sac is reduced, and the plug is sutured to Cooper’s ligament, the inguinal ligament, and the internal oblique aponeurosis
  72. 72. PROLENE HERNIA SYSTEM  provides reinforcement to the anterior and posterior aspects of the abdominal wall  The advantage of the preperitoneal mesh position:  increased intra-abdominal pressure pushes the mesh into closer apposition to the abdominal wall.  The overlay flap reinforces the inguinal floor similar to a tension-free repair.
  73. 73. LAPAROSCOPIC APPROACH Transabdominal Preperitoneal Procedure  Useful for bilateral hernias, large hernia defects, and scarring from previous lower abdominal surgery
  74. 74. LAPAROSCOPIC APPROACH Totally Extraperitoneal Procedure  Advantage: access to the preperitoneal space without intraperitoneal infiltration  minimizes the risk of injury to intra-abdominal organs and port site herniation through an iatrogenic defect in the abdominal wall
  75. 75. POST- OPERATIVE COMPLICATIONS • Pain • Cord and Testis Injury • Wound Infection • Seroma • Hematoma • Bladder Injury • Osteitis Pubis • Urinary Retention Schwartz’s Principles of Surgery 9th Edition
  76. 76. Evidence-based CPG on the management of adult inguinal hernia
  77. 77. 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 Open 2. If laparoscopic mesh repair is the preferred technique for inguinal hernias, what is the recommended laparoscopic technique? • Transabdominal Preperitoneal or Total Extra Preperitoneal 3. Is fixation of the mesh necessary in laparoscopic repair? • No 4. If open mesh repair, what is the recommended technique • Lichtenstein, plug and mesh or Prolene Hernia System
  78. 78. 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 method 6. What is the recommended treatment for bilateral inguinal hernia? • Mesh repair, either laparoscopic or open method 7. Is antimicrobial prophylaxis recommended for elective groin hernia surgery? • Not routinely recommended using mesh
  79. 79. REFERENCES • Brunicardi, F. 2010. Schwartz's Principles of Surgery 10th Edition. McGraw-Hill Professional Publisher. pp 1495-1516. • Drake, R., V. Wayne, A.W.M. Mitchell. 2005. Gray’s Atlas of Anatomy. 1st Edition. Churchill Livingstone. pp 1-648. • Drake, R., V. Wayne, A.W.M. Mitchell. 2010. Gray’s Anatomy for Students. 2nd Edition. Churchill Livingstone. pp 1-1136. • Netter, F.H. 2014. Atlas of Human Anatomy: Including Student Consult Interactive Ancillaries and Guides, 6th Edition. Netter Basic Science. Saunders. pp 1-640. • Townsend, C.M. Jr. 2012. Sabiston Textbook of Surgery, 19th Edition. Saunders Publisher. pp 1-2152. • Zollinger, R.M. Jr., and E. Ellison. 2010. Zollinger’s Atlas of Surgical Operations. McGraw-Hill Medical. pp 412-426. • Lawrence, P.F., R. M. Bell, and M. T. Dayton. 2006. Essentials of General Surgery Lippincott Williams and Wilkins. pp 1-613. • Bendavid, R. 2001. Abdominal Wall Hernias: Principles and Managements. Springer Science and Business Media. pp 1-792.
  80. 80. REFERENCES Internet Sources • Medscape/hernia • • Journals: • Evidence-Based Clinical Practice Guidelines on the Management of Adult Inguinal Hernia: Primary Inguinal Hernia, Recurrent Inguinal Hernia and Bilateral Inguinal Hernia. Philippine Journal of Surgical Specialties. 2007
  81. 81. fin Thank you!