A hernia is defined as an abnormal protrusion of
an organ or tissue through a defect in its
more common in men and women but
much more common in men.
Comprises of :
The sac is a diverticulum of the peritoneum
with mouth, neck,body and fundus.
Hernias without neck and large mouth-
incisional hernia and direct hernia.
Hernias without sac – epigastric
hernia(protrusion extra peritoneal fat).
A canal 4cm long
located in the lower part of the anterior
abdominal wall above the groin,directed
downwards, medially and forward.
Deep inguinal ring to the superficial inguinal
Basic anatomy of the inguinal canal
Deep inguinal ring
U-shaped opening on the transversalis fascia 1.25cm
above and perpendicular to the mid inguinal
point(midway between the anterior superior iliac
spine and the pubic tubercle)
approximately 2–3 cm above the femoral artery pulse
in the groin
Superficial inguinal ring
opening on the `external oblique aponeurosis
herniation of the gubernaculum testis and the
processus vaginalis which makes it possible
for the testis and spermatic cord to pass from
the abdomen to the scrotum in males and the
round ligament in female.
aponeurosis of the external oblique, and
reinforced by the internal oblique muscle
transversalis fascia and conjoint tendon
by the internal oblique, transversus abdominis
and transversalis fascia.
inguinal ligament (a ‘rolled up’ portion of the
external oblique aponeurosis) and thickened
medially by the lacunar ligament.
The classic and memorable description of the
spermatic cord in the male are:
3 arteries: cremasteric, differential and testicular art.
3 nerves: ilioinguinal, the iliohypogastric
and the genital branch of the genitofemoral nerve
3 fascial layers: external spermatic, cremasteric,
and internal spermatic fascia.
3 other structures: pampiniform plexus, vas
deferens (ductus deferens), testicular lymphatics
Three types of classification
1.According to the extent of the hernia
a) bubonocele — when the hernia does not come out
of the superficial inguinal ring
(b) incomplete hernia— when it comes out through
the superficial inguinal ring but fails to reach the
bottom of the scrotum
(c) complete hernia — when it reaches the bottom of
A. ANATOMICAL TYPES
2.According to its site of exit-
(a)oblique (indirect) hernia
3.According to the contents of the hernia-
Omentum – omentocele-
Intestine – enterocele
Two loops of intestine in a manner of W -Maydl’s
Appendix – Amayand hernia
Meckel’s diverticulum – litter’s hernia
lateral because its origin is lateral to the
inferior epigastric vessels.
oblique as the hernia passes obliquely from
lateral to medial through the abdominal
Two forms of indirect inguinal hernia
(i) Congenital hernia
(ii) Acquired hernia
In neonates and young children
As the testis descends, a tube of peritoneum(funicular
process of peritoneum) is pulled with the testis and wraps
around it ultimately to form tunica vaginalis.
This peritoneal tube should obliterate, possibly under
hormonal control, but it commonly fails to fuse either in
part or totally. As a result, bowel within the peritoneal
cavity is able to pass inside the tube down towards the
In case of congenital hernia the whole process remains patent.
Thus a congenital hernia reaches the bottom of the scrotum
It may so happen that the funicular process remains patent up
to the top of the testis. So the hernia stops at the top of the
testis and is known as a congenital funicular hernia.
As the name suggests it does not protrude into a pre-
Clinically it can be differentiated from a congenital
hernia by the fact that it does not become complete
Acquired hernia progresses gradually.
more common above the age of 40.
It is a result of stretching and weakening of the
abdominal wall just medial to the inferior epigastric
There is a triangle referred to as Hasselbach’s triangle
laterally- the IE vessels
medially -lateral edge of rectus abdominis
below -pubic bone (the iliopubic tract)
This area is weak
Abdominal wall here consists of only transversalis fascia
covered by the external oblique aponeurosis.
A direct, medial hernia is more likely in elderly patients.
It is broadly based and therefore unlikely to strangulate.
The medially placed bladder can be pulled into a direct
This cystogram shows the urinary bladder, part of
which has descended into a left direct inguinal hernia
Due to weakening of the abdominal wall
lateral to the IE vessels.
Retroperitoneal fatty tissue is pushed downwards .
As more tissue enters the hernia- peritoneum is
pulled-creating a sac.
Sac has formed secondarily, distinguishing it from a
classic indirect hernia.
Occasionally, both lateral and medial hernias are present in
the same patient.
small portion of the antimesenteric wall of the intestine is
Congenital direct hernia
through a rigid circular orifice in the conjoined tendon
Clinically hernia may be of five types-
1. Reducible hernia—contents can be returned
into the abdominal cavity, but the sac remains
in its position.
2. Irreducible hernia contents cannot be
returned to the abdomen.
not suggest any other complication.
B. CLINICAL TYPES
causes of irreducibility are
(i) adhesion of its contents to each other
(ii) adhesion of its contents with the sac
(iii) adhesion of one part of the sac to the other part
(iv) sliding hernia
(v) very large scrotal hernia (scrotal abdomen)
Often confused with strangulated hernia by the
Clinically a strangulated hernia is also irreducible,
but it is extremely tender and tense and the
overlying skin may be red.
These signs are absent in a pure irreducible hernia.
3. Obstructed or incarcerated hernia
Due to occlusion of the lumen of the bowel.
No interference with the blood supply
4. Strangulated hernia
irreducibility+obstruction+arrest of blood supply to
No impulse on coughing
Tense and tender
Features of acute intestinal obstruction.
5. Inflamed hernia
very rare condition
Mimic a strangulated hernia.
when its content such as an appendix, a salpinx or a
Meckel's diverticulum becomes inflamed.
local signs of inflammation-skin becomes red and
oedematous and the swelling becomes painful,
tender and swollen.
The only differentiating feature from a strangulated
hernia is that this hernia is not tense and is not
associated with intestinal obstruction.
Casten,Halverson and McVay, Zollinger, Ponka, Gilbert
The European Hernia Society has recently suggested a
primary or recurrent (P or R);
lateral, medial or femoral (L, M or F);
defect size in fingerbreadths assumed to be 1.5 cm
A primary, indirect, inguinal hernia with a 3-cm defect
size would be PL2.
presenting as intermittent swellings,
lying above and lateral to the pubic tubercle
associated cough impulse.
Often the hernia will reduce on lying and reappear on
Diagnosis of an inguinal hernia
Rupture of sac – trauma, pressure necrosis
Fistula formation – Richter's hernia
Hydrocele of sac
Extension of intra abdominal inflammation
Extension of intra abdominal tumour.
Torsion of omentum
MANAGEMENT OF INGUINAL
High Test Sensitivity (>90%)
High Test Specificity
CT&MRIof the abdomen and pelvis may be useful
laparoscopy can be diagnostic and therapeutic for
particularly challenging cases.
A herniogram involves the injection of contrast into the
peritoneal cavity followed by screening which shows the
presence of a sac or asymmetrical bulging of the inguinal
Non operative Treatment-with the use of a truss
Truss is a mechanical appliance ,belt with a pad
applied to groin after spontaneous or manual
reduction of hernia.
purpose is to maintain reduction and to prevent
Separation of sac from cord srtuctures
Reducing the content
Transfixation and ligation of sac
Excise the redundant sac
Tightening of the internal inguinal ring around the
Use prolene 2.o
Heniotomy +reconstruction of the posterior wall of
the inguinal canal.
Anterior repairs are the most common operative
approach-Tension-free repairs are now standard.
Older tissue types of repair are rarely indicated
for patients with simultaneous contamination or
concomitant bowel resection, when placement of a
mesh prosthesis may be contraindicated
make a transversely oriented linear or slightly
curvilinear incision above the inguinal ligament and a
fingerbreadth below the internal inguinal ring.
Dissection is continued through the subcutaneous
tissues and Scarpa fascia.
The external oblique fascia and external inguinal ring
are identified. The external oblique fascia is incised
through the superficial inguinal ring to expose the
The genital branch of the genitofemoral nerve
and the ilioinguinal and iliohypogastric nerves
are identified and avoided or mobilized to
prevent transection and entrapment.
The cremaster muscle of the mobilized spermatic
cord is separated parallel to its fibers from the
underlying cord structures.
The cremaster artery and vein, which join the
cremaster muscle near the inguinal ring, can usually
be avoided but may need to be cauterized or ligated
When an indirect hernia is present, the hernia sac is
located deep to the cremaster muscle and anterior
and superior to the spermatic cord structures.
Incising the cremaster muscle in a longitudinal
direction and dividing it circumferentially near the
internal inguinal ring help expose the indirect hernia
The hernia sac is carefully separated from adjacent
cord structures and dissected to the level of the
internal inguinal ring.
The sac is opened and examined for visceral contents
if it is large; however, this step is unnecessary in small
The sac can be mobilized and placed within the
preperitoneal space, or the neck of the sac can be
ligated at the level of the internal ring and any excess
If a large hernia sac is present, it can be divided with
use of electrocautery to facilitate ligation.
It is not necessary to excise the distal portion of the
If the sac is broad based, it may be easier to displace it
into the peritoneal cavity rather than to ligate it.
Direct hernia sacs protrude through the floor of the
inguinal canal and can be reduced below the
transversalis fascia before repair.
A “lipoma” of the cord actually represents
retroperitoneal fat that has herniated through the
deep inguinal ring; this should be suture ligated and
Not done nowadays- because of high recurrence
Available options for tissue repair
Approximates the transversus abdominis aponeurotic
arch to the iliopubic tract with the use of interrupted
The repair begins at the pubic tubercle and extends
laterally past the internal inguinal ring.
Iliopubic tract repair
A multilayer imbricated repair of the posterior
wall of the inguinal canal with a continuous
running suture technique.
The initial suture line secures the transversus
abdominis aponeurotic arch to the iliopubic
The internal oblique and transversus abdominis
muscles and aponeuroses are sutured to the inguinal
The Shouldice repair is associated with a very low
recurrence rate and a high degree of patient
satisfaction in highly selected patients.
By suturing the transversus abdominis and internal
oblique musculoaponeurotic arches or conjoined
tendon (when present) to the inguinal ligament.
This once popular technique is the basic approach to
nonanatomic hernia repairs .
most popular type of repair done before the advent
of tension-free repairs.
Also known as Cooper ligament repair.
has traditionally been popular for the correction of
direct inguinal hernias, large indirect hernias, recurrent
hernias, and femoral hernias.
Interrupted nonabsorbable sutures are used to
approximate the edge of the transversus abdominis
aponeurosis to Cooper ligament(extension of lacunar
The McVay repair
suited for strangulated femoral hernias because it
provides obliteration of the femoral space without
the use of mesh.
Dominant method of inguinal hernia repair
Tension in a repair is the principal cause of
Current practices in hernia management-synthetic
mesh to bridge the defect a concept-by
Tension-free anterior repair
Anterior inguinal herniorrhaphy
plug and patch technique
sandwich technique, with both an anterior and
preperitoneal piece of mesh.
Tension-free anterior repair
nonabsorbable mesh is fashioned to fit the
A slit is cut into the distal lateral edge of the
mesh to accommodate the spermatic cord.
nonabsorbable suture - to secure the mesh
beginning at the pubic tubercle and running a length
of suture in both directions toward the superior
aspect above the internal inguinal ring to the level of
the tails of the mesh.
The mesh is sutured to the aponeurotic tissue
overlying the pubic tubercle medially, continuing
superiorly along the transversus abdominis or
The inferolateral edge of the mesh is sutured to the iliopubic
tract or inguinal ligament
Tails created by the slit are sutured together around the
spermatic cord-forming a new internal inguinal ring.
It is important to protect the nerves from as they are passed
through this newly fashioned internal inguinal ring.
Adapting the principles of tension-free repair.
By Gilbert .
A cone-shaped plug of polypropylene mesh into the
internal inguinal ring - act like an upside-down
umbrella and occlude the hernia.
plug is fixed to the surrounding tissues and held in
place by an additional overlying mesh patch
Plug and patch repair
This patch may not need to be secured by sutures.
An extension of Lichtenstein’s original mesh repair,
has now become the most commonly performed
primary anterior inguinal hernia repair.
Can be done without suture by some experienced
Most secure plug and patch -nonabsorbable suture.
A bilayered device, with three polypropylene
An underlay patch provides a posterior repair similar
to that of the laparoscopic approach
An onlay patch covers the posterior inguinal floor.
using a self-expanding polypropylene patch.
A pocket is created in the preperitoneal space
A preformed mesh patch is inserted into the hernia defect,
which expands to cover the direct, indirect, and femoral
The patch lies parallel to the inguinal ligament.
can remain without suture fixation, or a tacking suture .
A subumbilical midline incision.
large mesh prosthesis into the preperitoneal space.
space that extends into the prevesical space, beyond
the obturator foramen, and posterolateral to the
distributing the natural intra-abdominal pressure
across a broad area to retain the mesh in a proper
Useful for large, recurrent, or bilateral hernias.
Open preperitoneal approach is useful for
Recurrent inguinal hernias
Some strangulated hernias.
A transverse skin incision 2 cm above the internal
inguinal ring and is directed to the medial border of
the rectus sheath.
The muscles of the anterior abdominal wall are
preperitoneal space is identified
The transversalis fascia and transversus abdominis
aponeurosis are identified and sutured to the
iliopubic tract with permanent sutures.
A mesh prosthesis is frequently used to obliterate
Method of tension-free mesh repair based on a
The most popular techniques are-
Totally extraperitoneal (TEP)
Transabdominal preperitoneal (TAPP)
main difference between these two techniques is the
sequence of gaining access to the preperitoneal
TEP approach, the dissection begins in the
preperitoneal space using a balloon dissector.
TAPP repair, the preperitoneal space is accessed after
initially entering the peritoneal cavity.
Merits of TEP
preperitoneal dissection is quicker.
potential risk for intraperitoneal visceral damage is minimized.
De-merits of TEP
Use of dissection balloons is costly.
May not be possible to create a working space if the patient
has had a prior preperitoneal operation.
If a large tear in the peritoneum is created during a
TEP,potential working space can become obliterated,
necessitating conversion to a TAPP approach.
Laparoscopic mesh surgery, as compared to open mesh surgery
•Quicker recovery •Needs surgeon highly
•Less pain during first days Longer operating time
such as infections, bleeding
Increased recurrence of
primary hernias if
surgeon not experienced
•Less risk of chronic pain
Merits of TAPP
The transabdominal approach allows identification of
the groin anatomy.
larger working space of the peritoneal cavity .
No absolute contraindications to laparoscopic
inguinal hernia repair , except
Inability to tolerate GA.
prior lower abdominal surgeries-adhesions.
radical retropubic prostatectomy - preperitoneal
space previously dissected-
Anterior rectus sheath is incised
Ipsilateral rectus abdominis muscle is retracted
Create a space beneath the rectus.
A dissecting balloon is inserted deep to the posterior
rectus sheath, advanced to the pubic symphysis, and
inflated under direct laparoscopic vision.
30-degree laparoscope provides the best
visualization of the inguinal region.
inferior epigastric vessels are identified along the
lower portion of the rectus muscle and serve as a
Care must be taken to avoid injury to
femoral branch of the genitofemoral nerve and
lateral femoral cutaneous nerve- which are located
lateral to and below the iliopubic tract
Lateral dissection is carried out to the anterior
superior iliac spine. Finally, the spermatic cord is
infraumbilical incision -gain access to the peritoneal
Two 5-mm ports -lateral to the inferior epigastric
vessels at the level of the umbilicus.
A peritoneal flap is created high on the anterior
abdominal wall, extending from the median umbilical
fold to the anterior superior iliac spine.
Rest is similar to a TEP procedure
direct hernia- preperitoneal fat
Reduced by traction if not already reduced by balloon
expansion of the peritoneal space.
Small indirect hernia sac is mobilized from the cord
structures and reduced into the peritoneal cavity.
large sac -difficult to reduce
So, the sac is divided with cautery near the internal
inguinal ring, leaving the distal sac in situ.
The proximal peritoneal sac is closed with a loop
ligature to prevent pneumoperitoneum.
After reduction- piece of polypropylene mesh is
inserted through a trocar and unfolded.
It covers the direct, indirect, and femoral spaces and
rests over the cord structures
mesh is carefully secured with a tacking stapler to
Cooper ligament from the pubic tubercle to the
external iliac vein.
Anteriorly to the posterior rectus musculature and
transversus abdominis aponeurotic arch at least 2 cm
above the hernia defect.
laterally to the iliopubic tract.
The mesh extends beyond the pubic symphysis and
below the spermatic cord and peritoneum.
Tacks are not placed inferior to the iliopubic tract
beyond the external iliac artery.
Staples placed in this area may injure the femoral
branch of the genitofemoral nerve or lateral femoral
Staples are also avoided in - triangle of doom
bounded by the ductus deferens medially
spermatic vessels laterally,
avoid injury to the external iliac vessels and femoral
TRIANGLE OF DOOM
External iliac vessels
Deep circumflex iliac vein
Genital branch of GF nerve
Lateral femoral cutaneous
Femoral branch of GF nerve
TRIANGLE OF PAIN`
Injury to the Vas Deferens and Viscera
Urinary tract infection
Surgical site infection
Complications After Open and Lap
Inguinal Hernia Repair
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