1. Groin Hernias
Sameh Shehata

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.

11. Hesselbach’s Triangle

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

17. Direct Inguinal 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%