HERNIA

SURGERY BLOCK
2012

Abdominal Hernia
Dr. Mendoza
INTRODUCTION

HISTORY & EPIDEMIOLOGY

Hernia
Historical Perspective
15th century:
castration with wound cauterization or henia sac
debridement
recommended a truss
Hernia
Latin for rupture
an abnormal protrusion of an organ or tissue through a defect
in its surrounding walls.
Occur at sites where aponeurosis and fascia are not covered by
striated muscle
Protrusion of abdominal viscera thru the abdominal wall
Important features or COMPONENTS of a hernia
HERNIAL ORIFICE or Defect
Defect or Fascial opening
HERNIAL SAC
peritoneal protrusion
found at ANTEROMEDIAL side of the sprematic cord
Contents
hollow viscera:
intestines
bladder
omentum
ALL Hernias should be repaired at time of discovery
Epidemiology
Types of Hernia
EXTERNAL ABDOMINAL HERNIAS
Inguinal hernia
75% of all hernias
2/3 INDIRECT: MC
1/3 DIRECT
High incidence of bilaterality in children
Incisional hernia: 15-20%
Umbilical and epigastric: 10%
Femoral: 5%
MC in Females
highest rate of complications 15-20%
Scrotal enlargement
In children d/t INDIRECT Hernia
In adults d/t PANTALOON Hernia
Prevalence of hernia increases with age
Most serious complication
strangulation
1-3% of groin hernias
All hernias should be repaired at time of discovery
Etiology of Hernias
Congenital
Hydrocele vs. indirect hernia
Hydrocele

External Abdominal Hernias

(+) Transillumination
Patency rate of processus vaginalis
60% at 2mo
40% at 2yo
20% in adults
Connective tissue abnomalities
Malnutrition, Vitamin deficiency
Increased intra-abdominal pressure
COPD, dialysis, ascites, BPH
Chronic constipation
Strenuous labor

Terminology
REDUCIBLE HERNIA
can be replaced within surrounding musculature
Hernia that can be returned to the abdomen
IRREDUCIBLE or INCARCERATED HERNIA
Incarcerated Hernia that cannot be reduced into the
abdomen
STRANGULATED HERNIA
Incarcerated hernia w/ compromised blood supply to its
contents
occurs in hernia of small orifice and relatively voluminous
sacs
Clinical parameters for strangulation
Fever
Tachycardia
Exquisite tenderness
Erythema of overlying skin
Leukocytosis
Obstructive symptoms
COMPLETE OR EXTERNAL HERNIA
Sac & contents protrudes completely through the
abdominal wall
INCOMPETE HERNIA
Defect present without sac or contents protruding
completely through it
INTERPARIETAL HERNIA
sac contained within the abdominal wall
INTERNAL HERNIA
sac within the visceral cavity
INTERNAL ABDOMINAL HERNIAS can occur at
A: Paraduodenal
B: Foramen of Winslow
C: Intersigmoid
D: Pericecal
E: Transmesenteric
F: Retroanastomotic

Internal Abdominal Hernias

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HERNIA
PANTALOON HERNIA
direct and indirect components
indirect hernia component typically seen in elederly if
present
RICHTER'S HERNIA
contains antimesenteric portion of small bowel
the contents of the sac consist of only one side of the wall
of the intestine
SLIDING HERNIA
involves visceral retroperitonem of an organ (e.g.
bladder/ovary)

ANATOMY OF

Inguinal Region
Myopectinate Orifice of Fruchaud
Where majority of heniations occur
BOUNDARIES:
SUPERIOR: Transversus abdominis aponeurosis (TAA)
LATERAL: Iliopsoas muscle
INFERIOR: Pubic rami
MEDIAL: Rectus Abdominis muscle
VITAL STRUCTURES
Coopers Ligament
McVay approach

MYOPECTINEAL ORIFICE OF FRUCHARD

Anatomy of the Inguinal Region

INGUINAL LIGAMENT OF POUPART'S
Inferior edge of EXTERNAL OBLIQUE
Bisects myopectineal orifice
LACUNAR LIGAMENT OF GIMBERNAT
Triangular extension of the INGUINAL LIGAMENT before its
insertion upon the pubic tubercle
Medial border of femoral canal
CONJOINED TENDON
Only present in 5-10% of individuals
INTERNAL OBLIQUE fuses with Transversus Abdominis
Aponeurosis.
Lateral portion of rectus sheath
COOPER'S OR PECTINEAL LIGAMENT
formed by periosteum and fascia along the superior ramus
of the pubis
Joins IPT & lacunar ligament in their insertion to the pubis
Strong repair if this ligament is included in hernia repair
strong support structure in treatment of Femoral
Hernia
ILIOPUBIC TRACT
Between Coopers ligament & inguinal ligament
Innervation of the Abdominal & Inguinal Regiona
Iliohypogastric (T12,L1)
Ilioinguial (L1)
Genitofemoral (L1,L2)
Genital Branch
Femoral Branch
Lateral Femoral Cutaneous Nerve (L2, L3)

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Femoral Nerve IL2-L4)

Blood Vessels of the Inguinal Regiona
External Iliac Artery & Vein
Testicular Artery & Vein
Deferential Artery
Inguinal Canal
Space traversed by cord between deep/ internal and
superficial/external inguinal rings
Deep ring from peritoneal cavity
BOUNDARIES:
SUPERFICIAL
external oblique aponeurosis
SUPERIOR (roof)
internal oblique
transversus abdominis
INFERIOR
shelving edge of inguinal ligament & lacunar
ligament
POSTERIOR (floor)
transversalis fascia
aponeurosis of transversus abdominis muscle
CONTENTS
MALES: Spermatic Cord
Composed of: (CVCGT)
Cremasteric muscle fibers
Vas deferens
Cremasteric vessels
Gential branch of the genitofemoral nerve
Testicular artery & vein
FEMALES: Round Ligament of the Uterus
Abdominal Wall in the Groin
9 LAYERS
Skin
Campers fascia
Scarpas fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis muscle
Transversalis fascia
Pre-peritoneal fat
Peritoneum

Layer Of Abdomial Structures That Continuous To The Scrotum

ABDOMINAL WALL
SERMATIC CORD
SKIN
Scrotum
CAMPERS & SCARPAS FASCIA
Superficial Spermatic Fascia
EXTENAL OBLIQUE MM
External Spermatic Fascia
INTERNAL OBLIQUE MM
Cremasteric muscle
TRANSVERSUS ABDOMINIS MM
NONE
TRANSVERSALIS FASCIA
Internal Spermatic Fascia
PRE-PERITONEAL FAT
Scrotal Fat Layer
Processus vaginalis or Canal of
PERITONEUM
Tuck

HERNIA
GROIN HERNIA

INGUINAL

Hernia
Groin Hernia
Incidence
INGUINAL HERNIA
75% of all hernias
rd
2/3 INDIRECT
rd
2/3 DIRECT
Male:Female= 7:1
Lifetime risk of developing a hernia
M= 5%, F= 1%
Right-sided in 84%; 25% bilateral
Most serious complication
Strangulation
1-3% of groin hernias
Most common surgical disease in males
60% indirect
36% direct
4% femoral
Most common groin hernia in BOTH sex
Indirect Inguinal Hernia
Femoral hernia
3x more in women
Highest rate of complication 15-20%
ALL hernias should be repaired at time of discovery
Classified as congenital vs acquired
Commonly thought that repeated in intra-abdominal
pressure contribute to hernia formation
Collagen formation and strucure deteriorates with age
hernia formation is more common in the older indiviual
REDUCIBILITY
Reducible
Incarcerated
Strangulated
CLINICAL Parameters for STRANGULATION
Fever & Tachycardia
Exquisite tenderness
Erythema of overlying skin
Leukocytosis
Obstructive symptoms
Diagnosis of Inguinal Hernia
HISTORY & PHYSICAL EXAM
GOLD Standard
best way to determine the presence or absence of an
inguinal hernia
74.5% sensitive and 96.3% specific
examine the patient in
standing
supine positions
CAN distinguish
direct vs indirect Inguinal Hernia
difficult to distinguish w/ exam alone
Inguinal vs Femoral hernia
PROCEDURE
examiner place the tip of the index finger at the most
dependent part of the scrotum and direct it into the
external inguinal ring.
patient is then asked to strain.
indirect hernia
will push against the fingertip
direct hernia
will push against the pulp of the finger
apply pressure over the mid-inguinal point
midway between the anterior superior iliac spine
and the pubic tubercle, and just above the
inguinal ligament
apply with the fingertip
INDIRECT HERNIA
will control hernia and prevent it from
protruding when the patient strains

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DIRECT HERNIA
not be affected with this maneuver
RADIOLOGIC INVESTIGATION
Considered in when theres suspicion of OBSTRUCTION
PLAIN X-ray: Herniography
suspected hernia but clinical dx unclear
precedure done under FLOUROSCOPY following
injection of contrast medium
frontal and oblique radiographs are taken with and
without increased intra abdominal pressure
ULTRASONOGRAPHY
MRI
CT
Hernias are visualized as abnormal ballooning of the
anteroposterior diameter of the inguinal canal
simultaneous protrusion of fat or bowel within the inguinal
canal
LAPAROSCOPY
Differential Diagnosis of Inguinal Hernia
Femoral Hernia
Lymphadenopathy
Testicular masses
Hydrocele
(+) transillumination
MC Differential for inguinal hernia
Orchitis
Ectopic testicle
Lipoma of the cord

Clinical Presentation of Inguinal Hernia

Groin Bulge
often asymptomatic
dull feeling of discomfort or heaviness
FOCAL PAIN
raise suspicion for incaceration or strangulation
Symptoms of bowel obstruction

HERNIA

SURGERY BLOCK
2012

Hesselbachs Triangle
BOUNDARIES
MEDIAL:
Rectus Abdominis
LATERAL
Iferior Epigastric Artery
INFERIOR
Inguinal Ligament of Poupart
CLINICAL SIGNIFICANCE
Helps identify type of Inguinal Hernia
MEDIAL to Inferior Epigastric
Direct Hernia
LATERAL to Inferior Epigastric
Indirect Hernia

Types of Inguinal Hernia

DIRECT INGUINAL HERNIA
Medial to the Inferior Epigastric Artery and within
Hesselbachs Triangle
ACQUIRED weakness in the inguinal floor
2 MAJOR FACTORS in the Development of DIRECT Inguinal
Hernia
increased intra-abdominal pressure associated with a
variety of conditions listed in Table 36-2.
relative weakness of the posterior inguinal wall.
CAUSES
abnormally high-lying arch of the main body
of the transversus abdominis muscle above
the superior ramus limited insertion of
the transversus abdominis muscle onto the
pubis
weakness of the iliopubic tract
limited insertion of the iliopubic tract
aponeurosis into Cooper's ligament

INGUINAL HERNIA

TYPE

Indirect
Inguinal
Hernia

Direct
Inguinal
Hernia

INDIRECT INGUINAL HERNIA

Abdominal contents protrude through Internal Inguinal
Ring.
Accepted hypothesis
Incomplete or defective obliteration of Processus
Vaginalis during the fetal period

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Remnant alyer of peritoneum forms a sac in the

internal ring
more frequently on the RIGHT
if a left hernia is initially seen, explore also the right
side
intra-abdominal pressure
Could further stretch and weaken the internal ring
susceptipility of intra-abdominal organs to herniate
through the orifice
By itself, could not actually cause an indirect inguinal
hernia.
patent processus vaginalis
can be found at autopsy without clinical evidence of a
hernia
there are patients with an obliterated processus
vaginalis who have an abdominal wall defect lateral to
the epigastric vessels
congenital structural malformations of the transversalis
fascia and transversus abdominis aponeurosis
can alter the strength and size of the internal inguinal
ring.
Denervation of the internal oblique muscle by adjacent
incisions (e.g., appendectomy)
a/w eventual development of indirect inguinal hernia
lipoma of the cord
Excessive fatty tissue involving the cord or round
ligament encountered
implies a neoplastic process
consists of normal fatty tissue
fatty tissue can easily be separated from the cord
structures and reduced into the preperitoneal space
en masse, as if it were a tumor
important from a clinical standpoint for the following
reasons:
(1) cause hernia-type symptoms, but with less
frequency than indirect hernias with a peritoneal
sac
(2) difficult to distinguish at physical examination
from an indirect hernia with a peritoneal sac
(3) it can be responsible for an unsatisfactory
result because of an unchanged physical
examination
after
elective
inguinal
herniorrhaphy, especially when a preperitoneal
repair is utilized.
was classified as an indirect hernia.
contents of the indirect hernia
preperitoneal fat
come from the preperitoneal space
rather than the abdominal cavity

DESCRIPTION

protrudes through the

inguinal ring and is
ultimately the result of
the failure of embryonic
closure of the internal
inguinal ring after the
testicle passes through it
enters through a weak
point in the fascia of the
abdominal wall
(Hesselbach triangle)

RELATION
TO
Inferior
Epigastric
A.

Covered
by
Internal
Spermatic
Fascia

Usual
Onset

LATERAL

YES

Congenital

MEDIAL

NO

Adult

SLIDING INGUINAL HERNIA

part of the sac is the wall of a viscus
8% of all groin hernias
incidence is age related
rarely found in < 30 years of age
increases to 20% after the age of 70
RIGHT Sliding Hernia
cecum, ascending colon, or appendix are most
commonly involved
LEFT Sliding Hernia
sigmoid colon is involved

HERNIA
uterus, fallopian tube, ovary, ureter, and bladder can be
involved on either side
sliding component
usually found on the posterolateral side of the
internal ring.
it is not necessary to resect hernia sacs, and that simple
reduction into the preperitoneal space is sufficient.
eliminates the primary danger associated with sliding
hernias
injury to the viscus during high ligation and sac
excision
NYHUS CLASSIFICATION SYSTEM
TYPE

DESCRIPTION

Type I

Type II
TYPE III
IIIA

IIIB

IIIC
Type IV
IVA
IVB
IVC
IVD

PATENT PROCESSUS VAGINALIS, 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 canal; does
not extend to the scrotum
POSTERIOR WALL DEFECTS
DIRECT HERNIA; size is not taken into account
Indirect hernia that has enlarged enough to encroach
upon the posterior inguinal wall; INDIRECT SLIDING OR
SCROTAL HERNIAS w/c are commonly a/w extension to
the direct space; PANTALOON hernias; MASSIVE
Scrotal Hernias
FEMORAL HERNIA
RECURRENT HERNIA
Recurrent DIRECT Hernia
Recurrent INDIRECT Hernia
Recurrent FEMORAL Hernia
COMBINED

can provide symptomatic relief

external device to help contain hernia w/o surgery
mechanical appliance consisting of a belt with a pad
that is applied to the groin after spontaneous or
manual reduction of a hernia
hernia control in 30% of patients
GOAL
maintain reduction
prevent enlargement
OPERATIVE
Must be TENSION free
To prevent recurrence
Hernia Surgical Approaches
ANTERIOR REPAIR
POSTERIOR OR PREPERITONEAL REPAIR
MARCY
OPEN APPROACH
HALSTED 1
GPRVS
BASSINI OR HALSTEAD 2
LAPAROSCOPIC APPROACH
FERGUSSON ANDREW
IPOM
SHOULDICE
TAPP
MCVAY-ANSON
TEP
LICTENSTEIN
MESH PLUG
ANTERIOR Surgical Approaches
ANTERIOR REPAIR
DESCRIPTION
MARCY
Tightening of INTERNAL INGUINAL Ring
HALSTED 1
TAA to IL
BASSINI OR HALSTEAD 2
TAA to IL
FERGUSSON ANDREW
TAA to ILJ + EO Imbrocation
SHOULDICE
TAA to IL + TF to TF
TAA to Coopers Ligament to tighten
MCVAY-ANSON
FEMORAL ring
LICTENSTEIN
1st TENSION free approach, use MESH
MESH PLUG
ROLLED or CONICAl MESH

Variants of Inguinal Hernia

RICHTERs HERNIA
Partial circumferance on small bowel in hernial sac
Only the ANTIMESENTERIC BORDER of the small intestine
is incarcerated in the deep inguinal ring, therefore
intestinal obstruction may be absent, but gangrene of the
bowel wall may occur.
More common in premature infants
Present with intestinal obstruction
No hernia may be palpable/visible
LITTRE'S HERNIA
hernia contains Meckel's diverticulum
PETTIT HERNIA
hernia at inferior lumbar triangle
GRYNFELTT HERNIA
hernia at superior lumbar triangle
AMYANDS HERNIA
content of the hernial sac is the vermiform appendix
Management of Inguinal Hernia
NON-OPERATIVE (Historical Approach)
Only Appilcable in ASYMPTOMATIC or minimally
symptomatic hernias that does not require immediate
repair
All hernias must eventually be repaired
Elective vs Emergent repair
Observation
Taxis
En masse Reduction
manual manipulation required to reduce viscera
entrapped in a hernial sac
patient Acute TRENDELENBURG position
if its incarcerated, also put cold compress to decrease
edema
Hernia trusses

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Progressive Pneumoperitoneum
Done in successive sessions in preparation for
hernia surgery for patients with "loss of domain."
The viscera protrude outside the confines of
the abdominal cavity to the extent that
replacement followed by hernia repair
might cause respiratory embarrassment
and/or an abdominal compartment
syndrome.
OBJECTIVE
to stretch the abdominal wall preoperatively,
increasing the amount of room in the peritoneal
cavity.
decision to use pneumoperitoneum is most
commonly based on a CT scan, which allows
determination of the degree of domain loss
Anterior Inguinal Herniorrhapies
Bassini-Shouldice (1930)
Multilayer imbricated repair of the posterior wall
of the inguinal canal
OPEN Anterior PURE tissue repair
Done when MESH is not available
Use relaxing incisions
divides the anterior rectus sheath,
extending from the pubic tubercle
superiorly for a variable distance
Some surgeons "hockey stick" the incision
laterally at the superior extent.
rectus muscle itself is strong enough to
prevent future incisional herniation.
Allows various components of the
abdominal wall to displace laterally and
inferiorly
TYPES
MARCY
closure of internal ring, type I and II
TYPE I
abnormal inguinal floor w/
NORMAL inguinal ring
just ligate the sac
seen in children

HERNIA

TYPE II
MAIN INDICATION
Nyhus Type I Indirect Inguinal
Hernias
internal ring is normal.
appropriate for
children and young adults in
whom concern remains about the
long-term effects of prosthetic
material.
ESSENTIAL FEATURES
high ligation of the hernia sac
narrowing of the internal ring by
approximating the transversus
abdominis muscle medial to the
cord.
Displaces the cord structures
laterally allowing the placement
of sutures through the muscular
and fascial layers

BASSINI repair

MARCY repair

BASSINI
POPULAR
SIMPLEST REPAIR to perform
approx TAA w/ II, IPT; type II and III
COMPONENTS
Division of the external oblique
aponeurosis over the inguinal canal
through the external ring
Division of the cremaster muscle
lengthwise followed by resection,
while simultaneously exposing the
floor of the inguinal canal
to more accurately assess for a
direct inguinal hernia
Division of the floor or posterior wall
of the inguinal canal for its full length.
ensures adequate examination of
the femoral ring from above
surgeon is less likely to use the
transversalis fascia alone for
reconstruction, as it is the
WEAKEST LAYER of the posterior
wall.
High ligation of an indirect sac
Bassini's "Triple Layer"
Reconstruction of the posterior wall by
suturing the
transversalis fascia
transversus abdominis muscle,
internal oblique muscle
suture all 3 structures MEDIALLY to the
inguinal ligament laterally, and the
iliopubic tract.

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MALONEY DARN
LONG NYLON SUTURE is repeatedly passed
between the tissues to create a weave that
similar to a mesh.
INITIAL LAYER
consists of a continuous nylon suture
to oppose the usual elements of the
abdominal wall medially (transversalis
fascia and the transversus abdominis,
rectus, and internal oblique muscles)
to the inguinal ligament.
first suture is continued into the
muscle about the cord, weaving in and
out to form reinforcement around the
cord
finally tied to the inguinal ligament on
the lateral side of the cord
SECOND LAYER
sutures made parallel or in a crisscross
fashion, plicating well into the inguinal
ligament below.
external oblique is closed over the cord
structures.
RATIONALE of the darn procedure
form a meshwork of nonabsorbable
suture that is well tolerated by the
tissues.
interstices fill with fibrous connective
tissue, producing a BUTTRESS across
the weakened area of the inguinal
canal

MALONEY DARN repair

SHOULDICE
GOLD STANDARD for Anterior Tissue Repair
1.1% recurrence rate
similar w/ Bassini but using continuous
suturing (imbrication)
COMPONENTS
importance placed upon freeing the
cord from its surrounding adhesions,
resection of the cremaster muscle
high dissection of the hernia sac
division of the transversalis fascia.
CONTINUOUS
NONABSORBABLE
SUTURE is used to repair the floor.
Use monofilament steel wire.

HERNIA
SHOULDICE Repair:
CONTINUOUS Imbrication Sutures

distributes tension evenly

prevents defects that could
potentially
occur
between
interrupted sutures, resulting in a
recurrence.
repair is started at the pubic tubercle by
approximating the iliopubic tract laterally to
the undersurface of the lateral edge of the
rectus muscle.
suture continued laterally to approximate
iliopubic tract to medial flap of transversalis
fascia, internal oblique and transversus
abdominis muscles
4 suture lines are developed from the
medial flap.
running suture is continued to the internal
ring where the lateral stump of the
cremaster muscle is picked up, forming a
new internal ring.
direction of the suture is REVERSED BACK
towards the pubic tubercle, approximating
the medial edge of the internal oblique and
transversus abdominis muscle to Poupart's
ligament and the wire is tied to itself
After the stump of the cremaster muscle is
picked up, the suture is reversed back
toward the pubic tubercle, approximating
the internal oblique and transversus
muscles to the inguinal ligament.
Two more suture lines are created suturing
the internal oblique and transversus
muscles medially to a pseudoinguinal
ligament developed from superficial fibers
of the inferior flap of the external oblique
aponeurosis parallel to the true ligament
OPEN Anterior PROSTHETIC repair
LINCHTENSTEIN TENSION FREE Hernioplasty
First pure prosthetic tension free repair w/
low recurrence rates.
1st TRUE Tension Free Repair
similar to Bassini repair.
The ilioinguinal nerve, external spermatic
vessels, & genital branch of genitofemoral
nerve all remain with the cord structures.
INDICATION
INDIRECT HERNIAS
DIRECT HERNIAS
Mesh prosthesis is positioned over the
inguinal floor.
Rounded medial end
secured to the anterior rectus
sheath medial to the pubic
tubercle
nonabsorbable or long-acting absorbable
suture is used w/ wide overlap of the pubic
tubercle
PREVENTS pubic tubercle recurrences
w/c are commonly seen with other
operations.

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LICHTENSTEIN Repair:
Running Locking Sutures

MEDIAL BORDER of the prosthesis has been sutured to the ANTERIOR

RECTUS SHEATH 2 cm medial to the PUBIC TUBERCLE. The same suture is
continued in a running locking fashion to secure the inferior edge of the
prosthesis to the inguinal ligament. A 2nd suture approximates the inferior
surface of the superior tail to the inferior surface of the inferior tail and
the inguinal ligament after the prosthesis was split laterally to
accommodate the cord structures. Repair relies entirely on the overlying
prosthesis. EOA = external oblique aponeurosis; P = prosthesis; HD =
hernia defect

The suture is continued in a RUNNING

LOCKING FASHION laterally, securing
the prosthesis to either side of the
pubic tubercle (not into it), and then
the shelving edge of the inguinal
ligament.
suture is tied at the internal ring
PROSTHETIC REPAIR MESH
Polypropylene mesh
MOST COMMON and preferred
Allow for a FIBROTIC REACTION to occur
between the inguinal floor and the posterior
surface of the mesh scar formation
strengthening the closure of the hernia defect
Polytetraflouroehtylene (PTFE) mesh
used to repair of ventral or incision hernias in
which the fibrotic reaction with the underlying
serosal surface of the bowel is best avoided.
Preperitoneal Approach
Nyhus Posterior Approach
Laparoscopic
Parietal peritoneum incised first until groin is exposed
from the inside
Mesh covers the myopectineal orifice
ANTERIOR APPROACH RECURRENCE RATES
ANTERIOR REPAIR
RECURRENCE
MARCY
10%
HALSTED 1
10%
BASSINI OR HALSTEAD 2
10%
FERGUSSON ANDREW
10%
SHOULDICE
0-1%
MCVAY-ANSON
10%
LICTENSTEIN
0-1%
MESH PLUG
0-1%

Prospective study
Danish hernia database of over 13000 hernia repairs
compared reoperations for recurrent hernia
Results After 5 years significantly lower (1/4 less
recurrence with mesh vs sutured repair)
Hence, Mesh has almost ZERO recurrence
Surgical Complications
Recurrence
MC complication
Infection
Hernia is classified as Class I: CLEAN WOUND
Other classes
Class II: Clean Contaminated
Neuralgia

HERNIA
Injury to genitofemoral nerve in triangle of PAIN
Bladder injury
Testicular injury
Vas Deferens injury

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McVAY Repair:
INTERRUPTED Sutures

FEMORAL

Hernia
Femoral Hernia
more common in females
wide pelvis in females diameter of femoral ring
40% present as emergencies with hernia incarceration or
stranglation
passes medial to the femoral vessels and nerve in the femoral
canal through the empty space
inguinal ligament forms the superior border
Palpation of the femoral canal just below inguinal ligament in
the upper thigh
FEMORAL TRIANGLE
Boundaries
SUPERIOR:
Inguinal Ligament
LATERAL
Sartorius Muscle
MEDIAL
Adductor Longus Muscle
Content: NAVEL
N: femoral nerve
A: femoral artery
V: femoral vein

E: empty space, site of hernia

L: lymphatics of cloquet
MANAGEMENT
Anterior True Tissue Repair
McVAY COOPERs LIGAMENT REPAIR
Hard to perform
cooper ligament -TAA; types II, III, IV
similar to the Bassini repair, except that Cooper's
ligament instead of the inguinal ligament is used
for the medial portion of the repair
edge of the transversus abdominis
aponeurosis to cooper's ligament
incorporate cooper's ligament and the
iliopubic tract (transition suture)
INDICATIONS
treatment of a femoral hernia with specific
contraindications to the use of mesh (e.g.,
infection).

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INTERRUPTED SUTURES beginning at the

pubic tubercle and continuing laterally
along Cooper's ligament progressively
narrow the femoral ring
last stitch to Cooper's ligament is known as
a TRANSITION STITCH and includes the
inguinal ligament.
two purposes
complete the narrowing of the
femoral ring by approximating the
inguinal ligament to Cooper's
ligament as well as the medial
tissue
provide a smooth transition or
step-up to the inguinal ligament
over the femoral vessel so that
the repair can be continued
laterally, identically to the Bassini
repair.
RELAXING INCISION should always be used
given the considerable tension required to
span such a large distance.
Drawbacks
result in more pain than other
herniorrhaphies
predisposes to recurrence

Preperitoneal Spaces
TRIANGLE OF DOOM
BOUNDARIES
MEDIAL
vas deferens
LATERAL
spermatic vessels
Testicular Artery & Vein
INFERIOR
external iliac vessels
CONTENT
External Iliac Artery And Vein
deep circumflex iliac vein
genital branch of genitofemoral nerve
femoral nerve.
hidden by fascia
Staple should not be applied in this triangle otherwise;
chances of mortality are there if these great vessels are
injured
MOST important structure
Arteria corona mortis
Obturator vessels
External Iliac Vessels
TRIANGLE OF PAIN
BOUNDARIES
MEDIAL
Testicular Artery & Vein
BASE
iliopubic tract

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Estimated frequency 3-5%

More common in males 3:1
20% may be multiple
often asymptomatic incidental findhing
if symptomatic
vague abdominal pain above the umbilicus
exacerbated by standing or coughing
relieved in supine position
severe pain secondary to incarceration/strangulation of
the peritoneal fat (often no peritoneal sac) or omentum
Exam:
palpate small, soft, reducible mass superior to the
umbilicus
Rare to have a strangulated bowel
Treatment:
Excise fat and sac, close primarily

INFERIOR
inferior edge of skin incision.
CONTENTS
Genitofemoral Nerve
lateral femoral cutaneous nerve
femoral nerve
staple in this area should be less because nerve
entrapment can cause Neuralgia.
SPACE OF RETZIUS
Space between the pubic bone & the urinary bladders
anterior & lateral walls
SPACE OF BOGROS
Extension of the space of Retzius laterally beyond the
urinary bladder wall
represents the retroinguinal preperitoneum
BOUNDARIES
ANTERIOR
transversalis fascia
MEDIAL
umbilico vesical fascia
transversalis fascia
peritoneum situated just behind the epigastrics
LATERALLY
pelvis wall
iliacus muscle
INFERIORLY
psoas muscle
external iliac vessels
femoral nerve
SUPERIORLY
Bogrosspace is in free continuity with the
lumbar retroperitoneum.
continuity explains the inferior expansion of
perirenal abcesses appearing in the groin.
CIRCLE OF DEATH:
AKA: Corona Mortis
refers to vascular ring form by the anastomosis of an
aberrant artery with the normal obturator artery arising
from a branch of the internal iliac artery.
At the time of laparoscopic hernia this vessel is torn both
end of vessel can bleed profusely, because both arise from
a major artery.
The surgeon should remember these anatomic landmarks
and the point of mesh fixation should be selected
superiorly, laterally and medially
OTHER HERNIAS

VENTRAL HERNIAS

Hernia
Epigastric Hernia
Protrusion of preperitoneal fat and peritoneum though the
decussating fibers of the rectus sheath in the midline (linea
alba) between the xiphoid process and the umbilicus
MIDLINE aponeurosis NOT intact
PARAUMBILICAL HERNIA
epigastric hernia that borders the umbilicus

9 Schwartzs Principle of Surgery 8th edition

Umbilical Hernia
Incidence reported -10%
Frequently in women.
femal to male ratio 3:1
Obesity and repeated pregnancies are common precursors
Strangulation of the colon and omentum is fairly common
In infant
Several times greater in black children
more common in premature children in all races
it closes spontaneously if
defect is < 1.5 cm
before 2 or 3 yo
repair is needed if
defect is > 2.0 cm
still present at > 2 years of age
MANAGEMENT
Non-Operative
most close spontaneously by acquired rather than
congenital in adults
Operative
Mayo Hernioplasty (vest-over pants)
use of prosthesis (mesh)
Polytetraflouroethylene (PTFE) mesh
Oburator Hernia
(+) Howship-Rhomberg Sign
Pressure on the obturator nerve causes pain on the region
of the hip & knee and inner aspect of thigh
rare form of hernia
protrusion of intra abdomnial contents through obturator
foramen
F:M ration 6:1
the foramen is formed by the ischeial and pubic rami
obturatorrvessels and nerve lie posterolateral to he hernia sac
in the canal
Small bowel is the most likely intraabdominal organ to be
found in the obturator hernia
Treatment: prosthesis
Spigelian Hernia
occurs along the semilunar line, which traverses a vertical space
along the lateral rectus border
occuring usually at sub-umbilical portion of Spiegels semilunar
and through Spieghels fascia
fused aponeurosis of the internal oblique and transverse
abdominis fascia
Below the arcuate line, the fascia of the two above
muscles are more parallel and does not crisscross)
> 90% of spigelian hernias are found
uncommon hernia of the anterior abdominal wall.
occur lateral to the rectus abdominis through a defect in the
linea semilunaris,
aponeuroses of the internal oblique and transversus
abdominis muscles.
typically present as bowel loops projecting laterally through the
abdominal wall.
difficult to palpate when they extend between the internal and
external oblique muscles.

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usually occur in patients with:

Increased intraabdominal pressure
heavy labor
urinary retention,
COPD or gastric outlet obstruction
Multiparous women
patients with recent significant weight loss.
Clinical findings include
focal tenderness or a mass along the linea semilunaris.
Bowel incarceration and strangulation are common
Clinical
Swelling in the middle abdomen lateral to the rectus
muscle
usually reducible
up to 20% present with incarceration
difficult to diagnose because it is usually interparietal
Tx: surgical
Mesh not required
Recurrence is uncommon
Ventral Wall (Incisional) Hernia
Highes incidence in midline and transverse incisions
Up to 20% after laparotomy
1/3 present in 5-19 years post operatively
Risk Factors
Obesity
DM
Ascites
Steroid
Malnutrition
wound infection
integrity of the abdominal wall intra-abdominal
pressure disturbances:
respiratory dysfunction
edema of the mesentery
stasis in the splanchnic venous system and IVC
difficulty with micturition and bowel movement
Spontaneous ulceration of the skin
Eventration Disease
Technical aspects of wound closure
Type of incision
Excessive tension prone to fascial disruption
Parastomal Hernia
Fluctuant mass lateral to an ostomy
PARACOLOSTOMY HERNIAS
are more common than periileostomy hernia
Likely to occur through the semilunar line than through the
rectus sheath
Treatment:
moving the stoma to a new location
Leslie procedure
use of prosthetic repair

LATERAL-DORSAL LOCATED

Hernia
Lumbar hernia
acquired lumbar hernias
back or flank trauma
poliomyelitis
back surgery
use of iliac crest as a donor site for bone grafts
kidney incision
2 lumbar spaces
Grynfeltt-Lesshaft Triangle
Superior triangle
Petit Triangles.
Inferior triangle
rare in occurrance
typically seen on the left side.
more common among men.
Clinically, they present as a soft-tissue flank bulge with
discomfort and/or muscle weakness.

10 Schwartzs Principle of Surgery 8th edition

may consist of bowel, omentum, kidney, spleen, or stomach,

best characterized by CT.
Contain 2 anatomic triangles
Inferior TRIANGLE OF Petit
ANTERIOR: External Obique
POSTERIOR: Latissimus
INFERIOR: Iliac Crest
FLOOR: Internal Oblique
Superior Lumbar Triangle Of Grynfelt
LATERAL: internal oblique
MEDIAL: Sacrospinalis
BASE: 12th rib
COVER: Latissimus dorsi
Strangulation is rare
soft swelling in lower posterior abdomen
Treatment:
prosthesis/myoaponeurotic flap
CONGENITAL LUMBAR HERNIA
Clinical features:
presence of a large reducible mass in the flank or
lumbar region

HERNIA
Q&A
1.

Boundaries of hesselbachs triangle except:

a. Superolaterally by the superficial epigastric vessels
b. Inferomedially by the pouparts ligament
c. None
2. The most common incarcerated structure in groin hernia
a. Jejunum
b. Omentum
c. Ileum
d. Sigmoid
3. What structure forms the roof of the inguinal canal
a. External oblique aponeurosis
b. Rectus abdominis
c. TAA
d. Transversalis fascia
4. This structure forms the floor of the inguinal canal
a. External oblique aponeurosis
b. Rectus abdominis
c. Transversalis fascia
d. TAA
5. Anatomical difference in abdominal hernia seen in pediatric
patient is true:
a. Widening of the external ring
b. Absence of Hasselbachs triangle
c. Thickened campers fascia
d. Shortened inguinal canal
e. None of the above
6. More common in women, then in men
a. Indirect hernia
b. Direct hernia
c. Femoral hernia
d. AOTA
7. Outpouch of peritoneum
e. Hernial sac
f. Hernial orifice
g. Both of the above
h. None of the above
8. Most common site for abdominal herniation:
i.
umbilicus
j.
Linea alba
k. Groin
l.
Peritoneum
9. Manual manipulation required to reduce viscera in trapped in a
hernial sac
m. Tautaumeraze
n. Taxis
o. Both of the above
p. None of the above
10. Signs and symptoms of hernia
a. Discomfort produced is relieved at the end of the day
b. Discomfort is worst at night when patient reclines
c. Hernial sac reduces when patient coughs
d. Hernial sac transmits a palpable impulse with patient
strain
11. A 39 year old was seen at the ER because of vomiting and
abdominal distention. 150/90 mmhg, 103/min, 26/min. PE:
distended abdomen, hypoactive bowel sounds, tenderness
hypogastric area, (+) 4x4 cm mass, tender, R inguinal area.
Rectal = unremarkable. Management include, EXCEPT:
a. hydration with crystalloids
b. trendelenberg, sedation and reduce inguinal mass
c. emergency surgery
d. plain abdominal film and NGT
e. none
12. A 65 yo male dx to have groin hernia was being operated, the
surgeon noticed that the epigastric vessels were displaced
medially and weakness of the floor. This type of hernia is:
a. direct
b. indirect
c. pantaloon
d. femoral

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13. This type of hernial repair involves imbrications of transversalis

fascia, and approximating TAA with inguinal ligament
a. Bassini
b. Mcvay
c. Shouldice
d. Nyhus
e. Lichtenstein
14. A 4 yo was seen at OPD bec. Of inguinal mass, right. Based on
Nyhus classification this is:
a. type 1
b. type 2
c. type 3a
d. type 3b
e. type 3c
15. The most common cause of Nyhus type 4 occurring within 2
years is
a. suture material
b. tension in the floor
c. infection
d. none use of mesh
e. hematoma
16. The ff. is/are hernia repair using anterior approach, except:
a. Bassini
b. Mcvay
c. Lichtenstein
d. Shouldice
e. none
17. The hernia repair with least recurrence
a. Bassini
b. Mcvay
c. Lichtenstein
d. Shouldice
e. none
18. Contents of the spermatic cord include, except
a. genitofemoral nerve
b. pampiniform plexus
c. none
d. iliohypogastric nerve
e. vas deferens
19. True about hernia repair, except:
a. Bassini technic is a non anatomical repair for hernia
b. all are true
c. Mcvay technic use Coopers ligament instead of Pouparts
ligament
d. Laparoscopic hernia is a mesh repair done posteriorly
e. Nyhus technic use the iliopubic tract instead of inguinal
ligament
20. The space of Bogros is actually the:
a. subcutaneous layer
b. femoral canal
c. part of inguinal canal
d. hesselbachs triangle
e. preperitoneal area
21. 96. Boundaries of the Myopectineal orifice of FRUCHARD,
except
a. rectus abdomis m.
b. TAA
c. iliopsoas m
d. inguinal ligament
e. none
22. General principles in hernia repair include, except:
a. anatomical repair leads to least recurrence
b. dissect sac from spermatic cord
c. treat condition that inc. intrabdominal P. before repair
d. use of antibiotics
e. none
23. The most common location of the sac in groin hernias:
a. anterolateral to the cord
b. posteromedial to the cord
c. lateral to the cord
d. anteromedial to the cord
e. posterolateral to the cord
24. Differential diagnosis for hernia
a. hydrocoel
b. lipoma of the cord
c. testicular tumor
d. lymphadenopathy
e. all

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25. The most common complication of hernia repair:

a. wound infection
b. recurrence
c. orchitis
d. hematoma
e. SBO
26. Hernia Operation w/c transpose the cord above the external
oblique aponeurosis
a. Halsted 1 operation
b. Halsted 2 operation
c. Ferguson-Andrews operation
d. McVay
27. This procedure did not transpose the cord but added
imbrication of the aponeurosis of the external oblique muscle
in performing the closure
a. Halsted 1 operation
b. Halsted II operation
c. McVay repair
d. Bassini repair
28. Consists of tightening of an enlarged deep ring only
a. Halsted 1 operation
b. Halsted II operation
c. McVay repair
d. Marcy repair
29. Use of iliopectineal ligament to anchor the medial parietal wall
in the repair
a. McVay Cooper ligament repair
b. Ferguson-Andrews operation
c. Marcy Repair
d. Halsted 1 operation
30. Sites of herniation
a. Groin
b. Umbilicus
c. Surgical incison
d. All of the above

41. Boundaries of hesselbachs triangle, except:

a. superolaterally by the superficial epigastric vessels
b. inferomedially by the pouparts ligament
c. medially by the rectus abdominis
d. none
42. The most common incarcerated structure in groin hernia
a. jejunum
b. ileum
c. omentum
d. sigmoid
43. Which structure forms the roof of the inguinal canal:
a. external oblique Aponeurosis
b. TAA
c. Transversalis fascia
d. Rectus abdominis
e. Inguinal ligament
44. Which structure forms the floor of the inguinal canal:
a. external oblique Aponeurosis
b. TAA
c. Transversalis fascia
d. Rectus abdominis
e. Inguinal ligament
45. A 39 year old was seen at the ER because of vomiting and
abdominal distention. 150/90 mmhg, 103/min, 26/min. PE:
distended abdomen, hypoactive bowel sounds, tenderness
hypogastric area, (+) 4x4 cm mass, tender, R inguinal area.
Rectal = unremarkable. Management include, EXCEPT:
a. hydration with crystalloids
b. trendelenberg, sedation and reduce inguinal mass
c. emergency surgery
d. plain abdominal film and NGT
e. none

31. More common in women than male

a. Indirect hernia
b. Direct hernia
c. Femoral hernia
d. All of the above
32. Manual manipulation required to reduce entrapped bowels in a
hernial sac
a. Tomoprais
b. taxis
c. Both of the above
d. None of the above
33. Sign and symptoms of hernia
a. Discomfort produced is relieved at the end of the day
b. Discomfort worse at night when person reclines
c. Hernial reduces when patient coughs
d. Hernia transmits a palpabale impulse when patient strain
34. Diagnositic work-up for hernia
a. MRI
b. Herniogroaphy
c. Both of the above
d. None of the above
35. Most strangulated hernia are
a. Direct inguinal hernia
b. Indirect inguinal hernia
c. Umbilical hernia
d. None of the above
36. Congenital hernia
a. Communicating hydrocele
b. Non-communitating hydrocele
c. Both of the above
d. None of the above
37. Reducible hernia is when? Protruded viscus can be returned to
the abdomen
38. Irreducible hernia is when? Protruded viscus CANT be
returned to the abdomen
39. Strangulated hernia
40. Most common type of abdominal type of hernia
a. Umbilicus
b. linea alba
c. Groin
d. Peritoneum

46. This type of hernial repair involves imbrications of transversalis

fascia, and approximating TAA with inguinal ligament
a. Bassini
b. Mcvay
c. Shouldice
d. Nyhus
e. Lichtenstein
47. A 4 yo was seen at OPD bec. Of inguinal mass, right. Based on
Nyhus classification this is:
a. type 1
b. type 2
c. type 3a
d. type 3b
e. type 3c
48. The most common cause of Nyhus type 4 occurring within 2
years is
a. suture material
b. tension in the floor
c. infection
d. none use of mesh
e. hematoma
49. The ff. is/are hernia repair using anterior approach, except:
a. Bassini
b. Mcvay
c. Lichtenstein
d. Shouldice
e. none
50. The hernia repair with least recurrence
a. Bassini
b. Mcvay
c. Lichtenstein
d. Shouldice
e. none
51. Contents of the spermatic cord include, except
a. ilioinguinal nerve
b. pampiniform plexus
c. none
d. iliohypogastric nerve
e. vas deferens

12 Schwartzs Principle of Surgery 8th edition