Published on February 23, 2014
INGUINAL HERNIA Max 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 Congenital Patent processus vaginalis ~5% Lifetime risk Higher risk of strangulation than direct
INDIRECT INGUINAL HERNIA
INCARCERATED Hernia which cannot be reduced STRANGULATED Incarcerated hernia with resulting ischemia
EPIDEMIOLOGY One of the most common surgical procedures Incidence: ~5-10% lifetime 75% of abdominal wall hernias Male > Female Indirect > Direct Right > Left 1/3 may develop a contralateral inguinal hernia
ETIOLOGY Multifactorial Weakness in abdominal wall musculature PRESUMED CAUSES OF GROIN HERNIATION Coughing Valsalva's maneuvers Chronic obstructive pulmonary disease Ascites Obesity Upright position Straining Congenital connective tissue disorders Constipation Defective collagen synthesis Prostatism Previous right lower quadrant incision Pregnancy Arterial aneurysms Birthweight <1500 g Cigarette smoking Family history of a hernia Heavy lifting Physical exertion (?)
ANATOMY Inguinal Hernia
ABDOMINAL WALL Skin Subcutaneous fat Scarpa’s fascia External oblique muscle Internal oblique muscle Transversus abdominis Transveralis fascia Preperitoneal fat Peritoneum
INGUINAL CANAL 4-6 cm long Anteroinferior of pelvic basin Cone-shaped Base 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 CORD Cremasteric muscle fibers Vas deferens Testicular artery Testicular pampiniform venous plexus Genital branch of the genitofemoral nerve +/- hernia sac
HESSELBACH’S TRIANGLE Medial aspect of Rectus abdominis muscle Inferior epigastric vessels Inguinal ligament
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 PAIN Nerves Lateral femoral cutaneous Femoral branch of GF nerve Femoral nerve
CLASSIFICATION Inguinal Hernia
NYHUS CLASSIFICATION SYSTEM Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the inguinal Type II canal; does not extend to the scrotum DIRECT HERNIA; size is not taken into account Type IIIA 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 Type IIIB commonly associated with EXTENSION TO THE DIRECT SPACE; also includes PANTALOON HERNIAS FEMORAL HERNIA Type IIIC RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO INDIRECT, Type IV DIRECT, FEMORAL, AND MIXED, RESPECTIVELY
HISTORY Groin pain Duration Extrainguinal symptoms Change in bowel habits Urinary symptoms Progressiveness Pressure on nerves Generalized pressure Local sharp pains Referred pain Scrotum, testicle or inner thigh
PHYSICAL EXAMINATION Inspection Standing Palpation Inguinal Occlusion test Direct Cough Impulse Indirect 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
IMAGING Inguinal Hernia
Ultrasound CT Scan MRI
CONSERVATIVE MANAGEMENT Aimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contents Assuming a recumbent position Truss, an elastic belt or brief
EMERGENT REPAIR Incarcerated hernias Strangulated hernias Sliding hernias
INCARCERATED HERNIA Reasons 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 HERNIA An incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency
INCARCERATED HERNIA Reduction should be attempted before definitive surgical intervention.
INCARCERATED HERNIA Hernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.
TAXIS The 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 HERNIA Femoral > Indirect > Direct Fever, 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 REPAIR NON PROSTHETIC Inguinal hernia
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
ANTERIOR REPAIR PROSTHETIC Inguinal hernia
LICHTENSTEIN TENSIONFREE REPAIR
LAPAROSCOPIC HERNIA REPAIR Transabdominal Preperitoneal Procedure (TAPP) Totally Extraperitoneal (TEP) Repair Indications include bilateral inguinal hernia, recurring hernia, need for early recovery
RECURRENCE Around 1% for Shouldice repair Most recurrences are of the same type as the original hernia Recurrence Factors Patient Technical Tissue
RECURRENCE Patient 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
COMPLICATIONS The overall risk of complications of inguinal hernia repair is low. Common Complications Pain, 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 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
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
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