Hernia

Dr. Nachmany

Lecture Subjects

• Anatomy – Inguinal & Femoral canals

• Clinical aspects of hernia

• Repair of Inguinofemoral Hernia:– Open – Rrhaphy; Tension free. – Laparoscopic

Anatomy, Embryology & Physiology

The Inguinal Canal

Anatomy

• Extends from the deep (fascia transversalis) to the superficial inguinal ring (ext. oblique)

• Parallel and above the inguinal ligament

• Walls of the Inguinal Canal:– Anterior – Posterior– Superior– Inferior

Walls of the Inguinal Canal

• Anterior wall - Aponeurosis of Ext. oblique – Reinforced in its lateral third by origin of the Int.

oblique• strongest where it lies opposite the weakest part of the

posterior wall (deep ring)

Walls of the Inguinal Canal

• Posterior wall - Fascia transversalis – Reinforced in its medial third by the conjoint

tendon• Strongest where it lies opposite the weakest part of the

anterior wall (superficial ring)

• Inferior (floor) - Rolled-under inferior edge of aponeurosis of the Ext. oblique (→the inguinal lig.)

• Superior (roof) - Arching lowest fibers of the Int. oblique and transversus abdominis muscles

Walls of the Inguinal Canal – Cont.

Deep Inguinal Ring

• ½ inch above the ligament

• Midway between ASIS and the Symphysis

• Lateral to the inferior epigastric vessels

• Margins of ring give origin to the internal spermatic fascia

Superficial Inguinal Ring • Triangular defect in the aponeurosis of the

external oblique

• Immediately above and medial to the pubic tubercle

• Margins give origin to the external spermatic fascia

• Physical Exam

Physiology and Mechanics

Physiology

• Inguinal canal - a passage through the lower abdominal wall

• Males - to and from the testis

• Females - round ligament of the uterus to the labium major

• Both sexes – Ilio-inguinal nerve

Mechanics of the inguinal Canal

• A potential weakness

• A design to lessen weakness:– Oblique passage → weakest areas lying some

distance apart– Anterior reinforcement by Int. oblique in front

of deep ring– Posterior reinforcement by Conjoint tendon

behind superficial ring

• On coughing/straining (defecation, parturition etc.) → Int. oblique and transversus abdominis muscles contract → flattening the roof → canal is virtually closed

Mechanics of the inguinal Canal – Cont.

Embryology

• Processus Vaginalis

• Spermatic Fasciae

• Gubernaculum

Embryology of the Inguinal Canal – Processus Vaginalis

• Prior to testicular/ovarian descent a peritoneal diverticulum called the processus vaginalis is formed

Embryology - Processus Vaginalis and creation of Spermatic fasciae

• The processus vaginalis passes through the layers of the abdominal wall and acquires a tubular covering from each layer:– Fascia transversalis - Internal spermatic fascia – Lower part of Int. oblique muscle - it takes some of

its lowest fibers (Cremaster muscle & Fascia)– Aponeurosis of the external oblique – Ext. spermatic

fascia

Spermatic Cord

• Forms at the level of the Deep ring

• It is covered with three concentric layers of fascia derived from the layers of the anterior abdominal wall

Embryology oriented anatomy of spermatic fasciae

• Extends from the lower pole of the developing gonad to the labioscrotal swelling

• In the male the testis descends during the 7th and 8th months of fetal life

Embryology - Gubernaculum

• The stimulus for the descent is testosterone, secreted by the fetal testes

• The testis follows the gubernaculum and descends behind the processus vaginalis

• Pulls down its duct, blood vessels, nerves and lymphatics

• In the female - extends from the uterus into the developing labium major

• Persists as the round ligament

Embryology - Gubernaculum

Herniae of the Myopectineal orifice

• A hernia - protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall

• Consists of:– Sac– Contents of the sac– Coverings of the sac

• Complications:– Incarceration– Strangulation– Bowel obstruction

Common Abdominal herniae are• Inguinal:

– Indirect – Direct

• Femoral• Umbilical:

– Congenital– Acquired

• Epigastric• Separation of the rectiabdominis• Diaphragmatic:

– Sliding– Paraesophageal

• Incisional (POVH)

Indirect Inguinal Hernia

• The most common form of hernia• 20 times more common in males • one-third are bilateral • more common on the right • Congenital in origin • Hernial sac is the remains of the processus

vaginalis• The sac enters the inguinal canal through the deep

inguinal ring lateral to the inferior epigastric vessels

Direct Inguinal Hernia

• About 15 percent of all inguinal hernias

• Majority is bilateral

• The sac bulges directly anteriorly through the posterior wall of the inguinal canal

• Medial to the inferior epigastric vessels

• A disease of old men with weak abdominal muscles.

Femoral Hernia

• The femoral sheath - a protrusion of the fascial envelope lining the abdominal walls

• Surrounds the femoral vessels & lymphatics for 1 inch below the inguinal ligament

• The femoral canal, the compartment for the lymphatics, occupies the medial part of the sheath.

• Its upper opening is the femoral ring:– Anterior -Inguinal ligament– Posterior - Pectineal ligament and the pubis– Medial - sharp free edge of the Lacunar ligament– Lateral - Femoral vein

• The femoral septum, which is a condensation of extraperitoneal tissue, plugs the opening

• The femoral vein is separated from it by a fibrous septum

The Femoral Canal

Femoral Hernia

• Much more common in women• The sac passes down the canal, pushing the

septum• On the lower end, it forms a swelling in the upper

thigh• With further expansion the sac may turn upward

to cross the inguinal ligament• The neck always lies below and lateral to the

pubic tubercle

Surgical Repair of Hernia

Classification• Those that close all or part of the myopectineal

orifice• Anterior Vs. Posterior• Repair by suturing the tissues at boundaries:

– Bassini– Shouldice– Cooper (McVay)

• Those that cover the orifice with prosthetic mesh:– Lichtenstein– Plug and patch– Laparoscopic

Anterior Repairs• Dissection and hernia reduction is the same:• incision 2 to 3 cm above and parallel to the

inguinal ligament• Dissection through the subcutaneous tissues and

Scarpa’s fascia• The external oblique fascia and external ring is

identified• The external oblique fascia is incised to expose the

inguinal canal• The ilioinguinal and iliohypogastric nerves should

be preserved

Open Repair – Cont.

• The spermatic cord is mobilized at the pubic tubercle

• The Cremaster muscle is divided and separated from the cord

• The hernia sac is dissected from adjacent cord structures

• The sac should be opened and examined for visceral contents if it is large

• Neck of the sac is ligated at the level of the internal ring

Herniorrhaphy

• Bassini

• Shouldice

• McVay (Coopers ligament repair)

• Ileopubic tract

The Bassini repair

• Suturing the conjoined tendon to the inguinal ligament

• was the most popular repair before the tension-free repairs

The Shouldice repair

• Multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique:– 1st suture line - transversus abdominis aponeurotic arch

to the iliopubic tract– 2nd line - internal oblique and transversus abdominis

muscles and aponeuroses (Conjoint) to the inguinal ligament

– 3rd line - Conjoint to Ext. oblique– 4th line - Conjoint to Ext. oblique

1st posterior suture - Transversus abdominis to Iliopubic tract

1st posterior suture - Transversus abdominis to Iliopubic tract (Cont.)

2nd posterior suture – Int. oblique and transversus abdominis to inguinal ligament

3rd posterior suture - Conjoint to Ext. oblique

4th posterior suture - Conjoint to Ext. oblique

Relaxing incision

Cooper Ligament (McVay) Repair

• For correction of all the Myopectineal orifice:– Direct inguinal hernias– Large indirect hernias– Recurrent inguinal hernias– Femoral hernias

• Transversus abdominis aponeurosis to Cooper’s ligament

• Lateral to the medial aspect of the femoral canal , the transversus abdominis aponeurosis is secured to the iliopubic tract

• An important principle - relaxing incision

Lichtenstein Repair

• Tension is the principal cause of recurrence

• Synthetic mesh prosthesis to bridge the defect– Inferior suture line - Shelving edge of the

inguinal (Poupart’s) ligament– Superior line – Conjoint muscle & tendon

Posterior Repairs

• Open Repair:– Stoppa

– Laparoscopic • Trans Abdominal Pre-Peritoneal (TAPP)

• Total Extra Peritoneal (TEP)

Preperitoneal Anatomy

What’s that?

…and that?

Danger areas

The approach to the preperitoneal space

Arcuate line (3)

TEP

TAPP

Direct Hernia

Indirect Hernia

Trans-abdominal approach to the preperitoneal space

Dissection of indirect hernia

TAPP

Post Op. Complications