1. Ellery Ivan E. Apolinario
Zamboanga City Medical Center
DEPARTMENT OF SURGERY

2. General Objective:
 To present a case of Indirect Inguinal Hernia
Specific Objectives:
To present a clinical picture of a patient with IIH
 To discuss the approach to a patient with IIH
 To discuss the management options of a patient
with IIH

3.  EV, a 55 year old
 Male
 Married
 Self-employed
 ZamboangaCity.

4. ChiefComplaint: Inguinoscrotal mass

5.  2 years PTA, onset of inguino scrotal mass on
the right, reducible, with no other associated
signs and symptoms.
 2 days PTA, inguinoscrotal mass noted but this
time associated with pain, dragging sensation
and a pain scale of 6/10 non-radiating and
irreducible.
 A few hours PTA, prompted consult at the ER for
persistence of symptoms hence admission.

6.  No previous surgery and no known allergy to
food and drugs

7. No known Heredo- familial diseases

8.  has a son and a wife
 Smoker
 Non-alcohol drinker
 A retired driver

9. General: (-) weight loss
Skin: (-) rashes, (-) itchiness, (-) changes of color
Head: (-) dizziness, (-) headache
Eyes: (-) redness, (-) visual changes, (-) blurring of vision
Ears: hearing good, (-) tinnitus, (-) vertigo
Nose: (-) nosebleed, (-) nasal congestion, (-) sinus trouble
Mouth andThroat: (-) dry lips, (-) bleeding gums
Neck: (-) neck pain, (-) stiffness, (-) swollen glands
Respiratory: (-) colds
Cardiovascular: (-) dyspnea, (-) orthopnea, (-) chest pain, (-)
palpitations
Gastrointestinal: (-) dysphagia, (-) heartburn, (-)
abdominal pain, (-) constipation, (-) diarrhea

10. Urinary: (-) oliguria, (-) flank pain
PeripheralVascular: (-) varicose veins, (-) leg cramps
Musculoskeletal system: (-) bone or joint pains and
muscle cramps (-) bipedal edema, (-) tremors or
involuntary movements
Neurologic system: memory good, (-) fainting, (-)
numbness and tingling, (-) weakness, paralysis
and loss of sensation,(-) involuntary
movements
Hematologic: (-) anemia, (-) easy bruising or bleeding
Endocrine system: (-) excessive sweating, hunger or
thirst, (-) polyuria, (-) heat or cold intolerance

11.  GENERAL SURVEY
Conscious, coherent, cooperative , NIRD
 VITAL SIGNS
Temperature - 36.2 C, Respiration - 22 bpm, Blood pressure - 100/ 60
mmHg and a Pulse Rate - 71 bpm.
 SKIN
No jaundice noted. No pallor.
 HEENT
Eyes: Anicteric sclerae. Conjunctivae is pink, , reactive to light.
Ears: (-) discharges,With good acuity to whispered voice.
Nose: No alar flaring. (-) discharges
Throat: Oral mucosa is pink, tongue midline.Tonsils (-) infection /
inflamed. Pharynx: (-) exudates
 NECK
Trachea midline. No palpable lymph nodes.

12.  THORAX AND LUNGS
Thorax are symmetrical. Clear breath sounds. No rales or wheezes
noted.
 CARDIOVASCULAR SYSTEM
AP, NRRR, distinct sounds with no heart murmurs.
 ABDOMEN
flat, soft, normoactive bowel sound, percussed and revealed a dull
sound, palpated with tenderness on hypogastric area, 6 x9 cm.
 RECTAL AND GENITALIA
No discharges/ulcers noted on genitalia, inguino-scrotal mass on
the right, no cyanosis noted, (-) transillumination, 6x7cm.

13.  EXTREMITIES Warm to touch, no edema, CRT < 2 secs.
 MUSCULOSKELETAL
No deformities and with good range of motion.
 NEUROLOGIC
Oriented to time and place, is conscious and has a stable gait.

14.  Indirect Inguinal Hernia Right, Incarcerated
 BASIS:
Hx of scrotal mass that was formerly
reducible
PE:
Irreducible scrotal mass with inguinal
component, no cyanosis noted. No
tachycardia. NABS.

15. Rule in Rule out
1. Hydrocele -scrotal mass (-) soft fullness within the
hemiscrotum
(-) transillumination
Usually presents with painless
scrotal mass
2. Testicular tumor - scrotal mass
- age of the patient
(-) Painless swelling or nodule
of one testicle
(-) mass/nodule exclusively
within the testis
(-) Unilateral or bilateral lower
extremity swelling may be
present
(-) lymphadenopathy
(-) weight loss

16. Rule in Rule out
3.Epidydimitis - scrotal mass (-) acute scrotal pain
(-) epididymal pain and inflammation
(-) Dysuria, frequency and/or urgency
(-) Fever and chills
(-) preceded by Urethral discharge
(-)Tenderness and induration in the
epididymal tail
4. Orchitis - scrotal mass (-) testicular pain and swelling
(-) Associated systemic symptoms:
(Fatigue, Malaise, Myalgias
Fever and chills, Nausea, Headache)
(-) Testicular enlargement
(-)Tenderness
(-) edematous scrotal skin
(-) discharges

17. Rule in Rule out
5. Testicular Torsion - scrotal mass (-) Peak incidence occurs in
adolescents aged 13 years
(-) acute-onset scrotal
discomfort which may occur
at rest or may relate to
sports or physical activities

18.  Admitted
 Secure consent
 NPO
 IVF D5lr 1 L at 40 gtts/ min
 Labs: cbc, platelet, blood typing
 Chest xray and 12 lead ECG for CP evaluation
 Meds: Cefoxitin 2 gm IVTT ANST 1 hour before
induction
 For emergency Hernioplasty right mesh inguinal
 Notify OR/ Anesthesiologist
 Insert FBC and attach to urine bag collector
 Insert NGT

19.  CBC
-hgb 152
-hct 0.45
-rbc 4.64
-wbc 19.7
-plt 284
-bt O+

20. Subjective Objective Assessment Plan
Pain at surgical site Vital Signs:
BP- 100/80
T- 37
RR-19
O2 Sat- 97%
PR – 68
(-) discharges on
surgical site
(-) hx of febriles
episodes for the
past 24 hours
S/P Hernioplasty
right with mesh
inguinal; iih right
with incarcerated
bowel
DAT
Hydration
Cont. cefoxitin
Cont. pressure
dressing
Advise ambulation

21.  MGH with home meds of:
 1. Cefuroxime 500mg BID x 7 days
 2. Celecoxib 200mg BID PRN pain
 3. MV tab OD

22. Indirect Inguinal Hernia Right with incarcerated
small bowel;
Hernioplasty Right with Inguinal Mesh

23. Hernia- is the protrusion of an organ or the
fascia of an organ through the wall of the
cavity that normally contains it.

24.  Types of Hernia - Location

25. follows the tract through the inguinal canal.This
results from a persistent process vaginalis.
The inguinal canal begins in the intra-abdominal
cavity at the internal inguinal ring, located
approximately midway between the pubic symphysis
and the anterior iliac spine.The canal courses down
along the inguinal ligament to the external
ring, located medial to the inferior epigastric
arteries, subcutaneously and slightly above the pubic
tubercle. Contents of this hernia then follow the tract
of the testicle down into the scrotal sac.[

26.  A direct inguinal hernia usually occurs due to
a defect or weakness in the transversalis
fascia area of the Hesselbach triangle.The
triangle is defined inferiorly by the inguinal
ligament, laterally by the inferior epigastric
arteries, and medially by the conjoined
tendon.

27.  follows the tract below the inguinal ligament
through the femoral canal.The canal lies
medial to the femoral vein and lateral to the
lacunar (Gimbernat) ligament. Because
femoral hernias protrude through such a
small defined space, they frequently become
incarcerated or strangulated.

28.  Reducible hernia:This term refers to the ability to return
the contents of the hernia into the abdominal cavity,
either spontaneously or manually.
 Incarcerated hernia:An incarcerated hernia is no longer
reducible.The vascular supply of the bowel is not
compromised; however, bowel obstruction is common.
 Strangulated hernia:A strangulated hernia occurs when
the vascular supply of the bowel is compromised
secondary to incarceration of hernia contents.

29.  Approximately 75% of all hernias occur in the
groin; two thirds of these hernias are indirect
and one third direct.[2]
 Indirect inguinal hernias are the most
common hernias in both men and women; a
right-sided predominance exists.
 Femoral hernias (although rare) occur almost
exclusively in women because of the
differences in the pelvic anatomy.

30. Any condition that increases the pressure in the
intra- abdominal cavity may contribute to the
formation of a hernia, including the following:
 Marked obesity
 Heavy lifting
 Coughing
 Straining with defecation or urination
 Ascites
 Peritoneal dialysis
 Ventriculoperitoneal shunt
 Chronic obstructive pulmonary disease (COPD)
 Family history of hernias[16]

31. Borders of the triangle:
1. Inguinal ligament - forms the inferior margin
2. Edge of rectus abdominis - medial border
3. Inferior epigastric vessels - superior or lateral border

32. Inguinal canal
 Approx. 4 to 6 cm long
 situated in the anteroinferior portion of the
pelvic basin
 Shaped like a cone
 begins intra-abdominally on the deep aspect of
the abdominal wall, where the spermatic cord
passes through a hiatus in the transversalis
fascia (in females, this is the round ligament)
 This hiatus is termed the deep or internal inguinal
ring

33. Spermatic cord
 consists of three arteries, three veins, and
two nerves
 it contains the pampiniform venous plexus
anteriorly and the vas deferens
posteriorly, with connective tissue and
remnant of the processus vaginalis

34.  Arteries: testicular artery, deferential
artery, cremasteric artery
 Nerves: nerve to cremaster (genital branch of
the genitofemoral nerve), testicular nerves
(sympathetic nerves)
 Vas deferens (ductus deferens)
 Pampiniform plexus
 Lymphatic vessels
 Tunica vaginalis (remains of the processus
vaginalis)

35. Inguinal ligament - spans the anterior superior iliac spine to the pubic bone
Cooper's ligament - seen as the lateral extension of the lacunar ligament, which is the
fanning out of the inguinal ligament as it joins the pubic tubercle
Iliopubic tract - originates and inserts in a similar fashion to the inguinal ligament

36. Inguinal ligament (Poupart's ligament)
 is comprised of the inferior fibers of the external oblique
aponeurosis.
 stretches from the anterior superior iliac spine to the
pubic tubercle
 serves an important purpose as a readily identifiable
boundary of the inguinal canal, as well as a sturdy
structure used in various hernia repairs.
Cooper's ligament (Pectineal ligament)
 lateral portion of the lacunar ligament that is fused to the
periosteum of the pubic tubercle
 may include fibers from the transversus
abdominus, iliopubic tract, internal oblique, and rectus
abdominus

37. Iliopubic tract
 often is confused with the inguinal ligament secondary
to common origin and insertion points.
 forms on the deep side of the inferior margin of the
transversus abdominus and transversalis fascia.
Inguinal ligament
 is on the superficial side of the musculoaponeurotic
layer
 The shelving edge of the inguinal ligament is a structure
that more or less connects the iliopubic tract to the
inguinal ligament.

38. Nyhus Classification System
Type I Indirect hernia; internal abdominal ring normal; typically in infants, children,
small adults
Type II Indirect hernia; internal ring enlarged without impingement on the floor of
the inguinal canal; does not extend to the scrotum
Type IIIA Direct hernia; size is not taken into account
Type IIIB Indirect hernia that has enlarged enough to encroach upon the posterior
inguinal wall; indirect sliding or scrotal hernias are usually placed in this
category because they are commonly associated with extension to the
direct space; also includes pantaloon hernias
Type IIIC Femoral hernia
Type IV Recurrent hernia; modifiersA–D are sometimes added, which correspond to
indirect, direct, femoral, and mixed, respectively
• assesses not only the location and size of the defect, but also the integrity of the inguinal
ring and inguinal floor
• most widely used classifications
• is limited by its subjectivity in assessment of distortion of the inguinal ring and posterior
floor, especially laparoscopically.

39. Gilbert Classification System
Type 1 Small, indirect
Type 2 Medium, indirect
Type 3 Large, indirect
Type 4 Entire floor, direct
Type 5 Diverticular, direct
Type 6 Combined (Pantaloon)
Type 7 Femoral
• requires intraoperative assessment
Type 1 - have a small internal ring
Type 2 - have a moderately dilated internal ring, < 4 cm
Type 3 - have a ring that is greater than 4 cm
Type 4 - involved complete disruption of the inguinal floor
Type 5 – no more than 2 cm, without complete weakness

40. ANTERIOR REPAIRS, NONPROSTHETIC
BASSINI REPAIR
• Recurrence rate - 8.6 %
• importance of the Bassini repair lies in the paradigm shift it
promoted, which included dissection of the spermatic
cord, dissection of the hernia sac with high ligation, and
extensive reconstruction of the floor of the inguinal canal
• A triple-layer repair is then performed to restore integrity to the
floor

41. A. The transversalis fascia is opened from the internal inguinal ring to the pubic tubercle
exposing the preperitoneal fat.
B. Reconstruction of the posterior wall by suturing the transversalis fascia (TF), the
transversus abdominis muscle (TA), and the internal oblique muscle (IO) (Bassini's famous
"triple layer") medially to the inguinal ligament (IL) laterally.
BASSINI REPAIR

42. SHOULDICE REPAIR
• principles of the Bassini repair were revitalized, resulting in superior
recurrence rates (6%)
• its success rates are equivalent to that of tension-free repairs in
many studies comparing the two approaches
• involve extensive dissection and reconstruction of inguinal canal
anatomy
• The use of a continuous suture in multiple layers resulted in the dual
advantage of distributing tension over several layers and preventing
subsequent herniation between interrupted sutures

43. • Original descriptions of the Shouldice technique involved the use of a
stainless steel wire
• modern modifications have resulted in the use of a synthetic
nonabsorbable suture
• Care is taken to avoid injury to any preperitoneal structures, and
these are bluntly dissected to mobilize the upper and lower fascial
flaps.

44. THE SHOULDICE REPAIR
A. The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia
and the internal oblique and transverse abdominis muscles.
B. This is the second of the four suture lines. 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 will
eventually be created suturing the internal oblique and transversus muscles medially to an
artificially created "pseudo" inguinal ligament developed from superficial fibers of the
inferior flap of the external oblique aponeurosis parallel to the true ligament.

45. MCVAY (COOPER'S LIGAMENT) REPAIR
• advantage is the ability to address both inguinal and femoral canal defects
• Recurrence rate 11.2%
• Femoral hernias that are approached via a suprainguinal ligament approach, or
situations where the use of prosthetic material is contraindicated, are amenable to this
type of repair.
• Once the cord has been isolated, a transverse incision is performed through the
transversalis fascia, thereby entering the preperitoneal space.
• A small amount of dissection of the posterior aspect of the fascia is performed to allow
mobilization of the upper margin of the transversalis fascia.
• The floor of the inguinal canal is then reconstructed to restore its strength. Cooper's
ligament is identified medially, and it is bluntly dissected to expose its surface.The
upper margin of the transversalis fascia is then sutured to Cooper's ligament.The repair
is continued laterally along Cooper's ligament, occluding the femoral canal.

46. • An essential component of the procedure is the relaxing incision, which helps
reduce the considerable amount of tension that normally results.
• Before suturing the transversalis fascia to Cooper's and the inguinal ligament, an
incision in the anterior rectus sheath is made.
• The incision begins at the pubic tubercle and is extended superiorly for
approximately 2 to 4 cm.
• Potential consequences of the relaxing incision include increased postoperative
pain and less likely herniation at the anterior abdominal wall.
• Disadvantages of routinely performing the McVay Cooper's ligament repair include
elevated recurrence rates due to the tissue-based nature of the operation.
• Furthermore, the procedure requires extensive dissection and may result in injury
to the underlying femoral vessels.

47. MCVAY REPAIR

48. ANTERIOR REPAIRS, PROSTHETIC
• mesh herniorrhaphies were developed to circumvent the high
recurrence rates of tissue-based repairs and adhere to no-tension
principles of effective surgical repair.
• The addition of a mesh prosthesis effected a reconstruction of the
posterior inguinal canal, without placing tension on the floor
itself, hence a tension-free repair, as championed by Lichtenstein.

49. Medially, the prosthesis is sutured to the anterior rectus sheath 2 cm medial to the pubic
tubercle.
Laterally, a continuous suture is used to fix the prosthesis to the shelving edge of the inguinal
ligament.
The tails of the mesh are placed around the cord and secured with an interrupted suture.
LICHTENSTEINTENSION-FREE HERNIOPLASTY

50. PLUG AND PATCHTECHNIQUE
• modification of the Lichtenstein repair
• In addition to placement of the prosthesis in a similar fashion to the
Lichtenstein repair (i.e., the patch), the technique includes
placement of a prosthesis (i.e., the plug) through the internal ring
• Further modifications have involved shaping the plug into a flower
or umbrella configuration, with the apex pointed intra-abdominally,
in effect serving as a preperitoneal prosthesis.
• In this case, the plug is fixed to Cooper's and the inguinal ligament
inferiorly and the internal oblique aponeurosis superiorly.

51. A. Plug may be created from a flat piece of mesh, or a preformed, commercially available plug
is placed in the internal ring.
B. Final view of the repair following placement of the plug and patch.
A common modification is to use the flat mesh to overlap the plug, after it
is placed.
PLUG AND PATCHTECHNIQUE

52.  The definitive treatment of all hernias is surgical repair.
 is aimed at alleviating symptoms related to the inguinal
hernia, such as pain, pressure, and protrusion of abdominal
contents.
 Simple maneuvers include assuming a recumbent
position, which aids in self-reduction of the hernia.
 A truss, an elastic belt or brief that aims to keep the hernia
reduced, may also be worn; however, its use does not prevent
hernia progression or incarceration.
 A truss may provide relief in up to 65% of patients;
however, many will use it only intermittently as it does not
provide continuous control of the hernia and may actually lead
to an increased rate of hernia incarceration.

53.  conservative management is applied to asymptomatic or
minimally symptomatic inguinal hernias.
 One study has calculated the cumulative probability of developing
a strangulated hernia to be 2.8% at 3 months for an inguinal
hernia, and rising to 4.5% after 2 years.
 The figures were much higher for development of a strangulated
femoral hernia at 3 months and 2 years, 22 and 45%.

55.  Thank you!