Groin hernia 4th year
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This document discusses groin hernias, including their definition, anatomy, types, and treatment methods. It notes that inguinal hernias are most common, occurring in 96% of cases, and are more frequent in males. The two main types are indirect hernias, which pass through the internal ring, and direct hernias, which occur through Hesselbach's triangle. Treatment has evolved from early cauterization and debridement to modern tension-free repairs using synthetic mesh, which have significantly lower recurrence rates than open suture repairs. Laparoscopic techniques are increasingly utilized but remain more complex and costly.
Groin hernia 4th year
- 2. Definition Abnormal protrusion of a peritoneal lined sac thru the musculoaponeurotic covering of the abdomen
- 3. Introduction In US 96% are inguinal, 4% femoral 20% bilateral Most common in both sexes indirect. Femoral hernias more common in elderly females Male to female ratio in 9:1 for inguinal hernias, 1:3 for femoral hernias
- 4. Myopectineal Orifice of Fruchaud The MPO is bordered: Above by the arching fibers of the internal oblique and transversus abdominus Muscles, Medially (towards the center or to the right) by the Rectus Abdominus Muscle and its fascial Rectus Sheath Inferiorly by Coopers Ligament, and Laterally by the Ileopsoas Muscle Running diagonally thru the MPO is the inguinal ligament
- 5. Myopectineal Orifice of Fruchaud
- 6. Anatomy 4cm in length 2-4 cm cephalad to inguinal ligament Extends between superficial and deep rings Contains spermatic cord or round ligament
- 7. Anatomy Bounded superficially by external oblique Cephalad by conjoint tendon Inferior border is inguinal ligament Floor is transversalis fascia
- 8. Layers Skin, subcutaneous, campers, scarpa, external spermatic fascia, cremaster,, int spermatic fascia , preperitoneal tissues, peritoneum
- 9. Anatomy Broadly classified as indirect and direct depending on relationship to epigastric vessels. Hesselbach’s triangle is inferior epigastric artery laterally, lateral border of rectus medially, inguinal ligament inferiorly.
- 10. Anatomy An indirect hernia passes lateral to Hesselbach’s triangle. A direct hernia passes thru Hesselbach’s triangle. Indirect hernia has a congenital component, from processus vaginalis. The processus is supposed to obliterate after descent of testes.
- 12. Indirect Inguinal hernia Abdominal contents protrude through internal inguinal ring
- 13. Indirect Hernia
- 14. Indirect Inguinal Hernia Accepted hypothesis: incomplete or defective obliteration of the processus vaginalis during the fetal period remnant layer of peritoneum forms a sac at the internal ring more frequently on the right
- 15. 15
- 16. Direct Hernia
- 18. Direct Inguinal Hernia Medial to the inferior epigastric artery and vein, and within Hesselbach's triangle acquired weakness in the inguinal floor
- 19. Anatomy Direct hernias are usually not congenital. Acquired by the development of tissue deficiencies of the transversalis fascia. Development of femoral hernia less understood. Can result from increased intraabdominal pressure. The sac then migrates down the femoral vessels into thigh.
- 20. Anatomy Inguinal ligament (Poupart’s) – inferior edge of external oblique Lacunar ligament – triangular extension of the inguinal ligament before its insertion upon the pubic tubercle conjoined tendon (5-10%)- Internal oblique fuses with transversus abdominis aponeurosis Cooper’s Ligament - formed by the periosteum and fascia along the superior ramus of the pubis.
- 21. Inguinal hernia Male inguinal hernia Female inguinal hernia
- 22. Nyhus Classification I indirect, internal ring normal (kids) II indirect, dilated internal ring III posterior wall defects, direct inguinal hernia, dilated internal ring, massive scrotal, sliding, femoral hernia IV recurrent hernia
- 23. Terminology Reducible – can be replaced within surrounding musculature Incarcerated – cannot be reduced Strangulated – compromised blood supply to its contents
- 24. 24 Hernia complications Bowel obstruction: usually not partial, look at groin Irreducibility . Strangulation: serious, life-threatening Inflammation.
- 25. Epidemiology Prevelance of hernias increases with age Most serious complication – strangulation 1 to 3% of groin hernias Femoral – highest rate of complications 15% to 20% recommended all be repaired at time of discovery
- 26. Treatment
- 27. 27
- 28. 28 History 1st century: Surgical treatment 15th century: Castration with wound cauterization or hernia sac debridement with secondary healing Early 18th century: Sir Astley Cooper: recommended truss > surgery, only in strangulation
- 29. History 1881: French surgeon, Lucas- Championni re: high ligation of indirectѐ inguinal hernia 1844-1924: Edoardo Bassini (father of modern inguinal hernia surgery): high ligation and reconstruction of inguinal floor
- 30. Father of Modern Inguinal Hernia Repair EDUARDO BASSINI
- 31. Surgical Techniques Open anterior repair (Bassini, McVay, Shouldice). Tension-free repair with mesh(Liechtenstein, Rutkow)
- 32. Posterior repair Open : Nyhus Laparoscopic
- 33. Open anterior repair Herniotomy Herniorrhaphy (repair) Hernioplasty .
- 34. 34 Herniotomy Patent processus vaginalis ligated at origin at internal ring (high ligation) Nyhus type I Children
- 35. 35 Herniorrhaphy Nyhus type II and III High ligation + reinforced area of weakness with patient’s own tissue Bassini, Shouldice, McVay
- 36. 36 Bassini repair Transversus abdominis aponeurosis + transversalis fascia inguinal ligament with nonabsorbable interrupted sutures
- 37. 37 Shouldice repair 4 rows of suture
- 38. 38 McVay repair Inguinal and femoral hernias, Transversus abdominis aponeurosis + transversalis fascia Cooper’s ligament + iliopubic tract
- 39. 39 Hernioplasty High ligation, inverted sac + reinforce defect with synthetic material Tension-free Lichtenstein Recurrent rate 0.1%
- 40. Tension-Free Repair Same initial approach as anterior repair Instead of sewing fascial layers together to repair defect, a prosthetic mesh onlay used Simple to learn, easy to perform, suited for local anesthesia, excellent results with recurrence less than 4%.
- 43. Techniques Coined by Liechtenstein in 1989 Central feature is polypropylene mesh over unrepaired floor. Gilbert repair uses a cone shaped plug placed thru deep ring. Slit placed in mesh for cord structures
- 44. Techniques Suturing the mesh to the inguinal ligament is not important. Fixing the mesh to the rectus sheath 1- 1.5cm medial and superior to the pubic tubercle is very important. Should have a surplus of mesh over inguinal ligament, the medial suture ensures surplus mesh inferiorly
- 45. Open Posterior Repair Divide the layers of the abdominal wall superior to the internal ring, enter preperitoneal space. Dissection continues behind and deep to the entire inguinal region. Suture tension problems.
- 46. Laparoscopic Procedures Increasingly popular, controversial Early in the development, hernias were repaired by placing very large mesh over entire inguinal region on top of the peritoneum. Was abandoned because of contact with bowel. Today, most performed TEP or TAPP
- 48. Laparoscopic Mesh Repair Note: Viewed from inside the pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.
- 49. Laparoscopic Procedures The argued advantage of these procedures was less pain and disability, faster return to work. Great for bilateral hernia, with no increase in morbidity. For recurrent hernia Disadvantages are cost, time.
- 50. Recurrence Type of repair Recurrence McVay 9% Shouldice 7-11% Liechtenstein 0-4% Laparoscopic 0-1%
Editor's Notes
- #15: -through which intra-abdominal contents may herniate -where descent of the gonads occurs later during fetal development.)
- #21: This structure is posterior to the iliopubic tract and forms the posterior border of the femoral canal
- #24: (more in large hernias that have small necks obstructing arterial flow and/or venous drainage)
- #26: (increases with age)
- #31: Bassini revolutionized the surgical repair of the groin hernia with his novel anatomical dissection and low recurrence rates – first operation in 1884