SURGICAL OPTIONS IN THE MANAGEMENT OF INGUINAL HERNIAS
Mohammed Al-Saffar
outlines
Definition Epidemiology Anatomy Surgical management options
Hernia
A hernia is defined as an abnormal protrusion of an organ or tissue through a defect in its surrounding walls.
Groin hernia Inguinal
Direct Indirect
femoral
Epidemiology
Epidemiology
Predisposing factors
Epidemiology
Bimodal peak age : < 1 year then > 40 years
Right-sided groin hernias are more common than those on the left.
Types of hernia - Condition
Inguinal Canal Anatomy
No disease of the human body, belonging to the province of the
surgeon, requires in its treatment a better combination of accurate,
anatomical knowledge with surgical skill than Hernia in all its varieties.
Sir Astley Cooper, 1804
Inguinal Canal Anatomy
The inguinal canal is an oblique space measuring 4 cm in length that lies above the medial half of the inguinal ligament.
Inguinal canal has 4 walls : anterior, posterior, roof, and floor
Important ligaments
Contents of the inguinal canal
Males : spermatic cord and ilioinguinal nerve
Females : round ligament and the ilioinguinal nerve
The spermatic cord
It consists of Three coverings Three arteries Three other structures. Nerves
The Spermatic Cord
Preperitoneal space
Space of Retzius Space of Bogros Inf. Epigastric Vas deferens the lateral
femoral cutaneous nerve
the genitofemoral nerve.
Management
Uncomplicated hernias require either : No treatment Support with a truss Operative treatment
complicated hernias : always require surgery, often urgently.
Should we repair ?
Inguinal hernia : should we repair ?
Inguinal hernia : should we repair?
Surgical approaches
For any hernia the surgical option comprises 2 components : Herniotomy Herniorrhaphy or hernioplasty
It is either : Open repair Laparascopic repair
Surgery
Surgery aims to Reduce the hernial contents Excise the sac (herniotomy) in most cases Repair and close the defect either by
herniorrhaphy or hernioplasty
Components of the hernia
Hernial Sac Dissection
Types of open repair
Repairing the floor of the inguinal canal : Bassini repair Shouldice repair Tension free mesh repair
Bassini repair
The conjoined tendon is retracted upward the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract that lies adjacent to the inguinal ligament with several interrupted 3-0 silk sutures.
The second layer of the repair involves suturing the conjoined tendon to the inguinal ligament with interrupted 2-0 silk sutures.
This suture line extends from the pubic tubercle to the medial border of the internal ring.
Shouldice Repair
With a no. 15 scalpel an incision is made in the transversalis fascia. This incision is extended from the internal ring to the pubic tubercle.
The repair involves placing four lines of sutures.
Shouldice repair
The first suture line is started at the pubic tubercle using 3-0
continuous polypropylene, and the white line is approximated to the free edge of the inferior transversalis fascial flap.
The 2nd suture line : At the internal ring the suture is tied and then
continued medially by approximating the free edge of the superior flap to the shelving edge of the inguinal ligament. When the pubic tubercle is reached, the suture is tied and divided.
Shouldice repair
The third suture line is started at the level of the internal ring where the conjoined tendon is approximated to the inguinal ligament and tied when the pubic tubercle is reached.
Using the same suture, the fourth suture line attaches these same structures to one another and is tied at the level of the internal ring.
Shouldice repair
The cord is replaced within the inguinal canal, and the external inguinal aponeurosis is reapproximated with continuous 2-0 absorbable sutures
Tension – free repair
There are several options for placement of mesh during anterior inguinal herniorrhaphy, including The Lichtenstein approach The plug-and-patch technique The sandwich technique with both an
anterior and preperitoneal piece of mesh.
Tension – free repair
Tension – free repair
Prolene hernial system
Comparison of open approachs
Recurrence rate “ PGY“
Laparoscopic Repair
Indications for laparoscopic repair
Bilateral inguinal hernia When the diagnosis of inguinal hernia is
uncertain When the patient want to return to
normal physical life
Contraindications
The patient medical condition makes general anesthesia more risky
Patient who have planned pelvic or extraperitoneal operations (eg, radical prostatectomy)
Patient who have had a recurrence from a prior laparoscopic repair
Patient presented with strangulated hernia
Advantages of laparoscopic
Less acute postoperative pain Shorter convalescence Earlier return to work
Disadvantages
increased risk of femoral nerve injury and
Increased risk of spermatic cord damage risk of developing intraperitoneal
adhesions with the TAPP greater cost and duration of the
operation.
Laparoscopic Approaches
Laparoscopic repair is done by 2 approaches :1. Transabdominal preperitoneal “TAPP”2. Totally extraperitoneally “TEP”
Transabdominal Preperitoneal
The TAPP approach, first described by Arregui and colleagues in 1992
It requires laparoscopic access into the peritoneal cavity and placement of mesh in the preperitoneal space after reducing the hernia sac.
Totally extraperitoneally
The first TEP inguinal hernia repair was described by McKernan and Laws in1993.
This approach involves preperitoneal dissection and mesh placement without entering into the abdominal cavity.
The Mercedes Benz sign
Thank You
Complication
Urinary retention Nerve injury Testicular ischemia and atrophy Injury to vas deferens recurrence