A thorough presentation on inguinal hernia and its management

1. I N G U I N A L H E R N I A
A N D I T S
M A N A G E M E N T
PRESENTED BY
JAYDEEP MALAKAR

2. HERNIA
DEFINITION
• A hernia is an abnormal protrusion of any
viscus or a part of a viscus from its proper
anatomical cavity through an opening, either
artificial or natural, with a sac covering it.
• Also defined as an area of weakness or
disruption of the fibromuscular tissues of the
body wall.

3. INGUINAL HERNIA
• An inguinal hernia is a protrusion of the
abdominal cavity contents through
the inguinal canal.
• Direct or Indirect

4. DIRECT INGUINAL HERNIA
• Occurs within the
Hesselbach’s triangle
• Acquired defect from
Mechanical
breakdown
over the years.

5. INDIRECT INGUINAL HERNIA
• Occurs through the
internal ring of inguinal
canal.
• Higher risk of
strangulation than direct

6. INCARCERATED STRANGULATED
• Hernia which cannot be
reduced
• Incarcerated hernia with
resulting ischemia

7. ETIOLOGYMultifactorial
Weakness of Abdominal Musculature Increased Intraabdominal Pressures
Patent processus vaginalis Chronic Cough, COPD
Patent canal of Nuck in females Obesity
Connective tissue Disorders (EDS, PBS) Chronic Constipation, Straining.
Advancing age Enlarged Prostate with straining at micturation.
Chronic Diseases Pregnancy
Defective Collagen synthesis Cirrhosis with ascites
Previous Right lower quadrant incision Intra abdominal tumours.
Cigarette Smoking

8. ANATOMY

9. DEVELOPMENT

10. LAYERS OF THE ABDOMINAL WALL IN THE INGUINAL REGION
1. Skin
2. Subcutaneous fasciae (Camper and Scarpa)
(superficial fascia)
3. Innominate fascia (Gallaudet)
4. External oblique aponeurosis, including the
inguinal, lacunar, and reflected inguinal
ligaments
5. Spermatic cord
6. Internal oblique muscle, Transversus
abdominis muscle and aponeurosis, and the
conjoined tendon.
7. Anterior lamina of transversalis fascia
8. Posterior lamina of transversalis fascia
9. Preperitoneal connective tissue with fat
10. Peritoneum

11. BLOOD SUPPLY OF THE INGUINAL AREA
Three superficial branches of the femoral
artery supply the abdominal wall below the
umbilicus
SUPERFICIAL CIRCUMFLEX ILIAC ARTERY
SUPERFICIAL EPIGASTRIC ARTERY
SUPERFICIAL EXTERNAL PUDENDAL ARTERY

12. NERVE DISTRIBUTION IN THE ABDOMEN AND
GROIN
Umbilicus = T10
The cutaneous branches of the lumbar plexus include
Iliohypogastric, T12,L1
Ilioinguinal, T12,L1
Genitofemoral, L1,2,3
lateral femoral-cutaneous, and
obturator nerves.

13. MID-INGUINAL POINT AND MIDPOINT OF THE INGUINAL LIGAMENT
• Mid-inguinal point
– Halfway between the PUBIC
SYMPHYSIS and the ASIS.
– The femoral pulse can be palpated
here.
• Midpoint of the inguinal ligament
– Halfway between the PUBIC
TUBERCLE and the ASIS(the two
attachments of the inguinal
ligament).
– The opening to the inguinal canal is
located just above this point.

14. INGUINAL CANAL
The inguinal canal in the
adult is an oblique rift in the
lower part of the anterior
abdominal wall.
4 cm in length.
2 to 4 cm above the inguinal
ligament, between the
opening of the external
(superficial) and internal
(deep inguinal rings.

16. BOUNDARIES OF THE RINGS
External ring:
Triangular opening of the aponeurosis of the external oblique,
Base is pubic crest with the margins formed by two crura, superior (medial) and
inferior (lateral).
The superior crura is formed by the aponeurosis of the external oblique itself; the
inferior crura is formed by the inguinal ligament.
Internal ring:
The boundaries of this ring, is an inverted “V” or “U” shaped normal defect in the
transversalis fascia.
The arms of the “U” anterior and posterior, are a special thickening of the transversalis
fascia, forming a sling.
The inferior border is formed by another thickening of the transversalis fascia – the
iliopubic tract.

17. STRUCTURES PASSING
THROUGH THE CANAL
Males
Spermatic Cord
Ilioinguinal Nerve.
Females
Round Ligament of
the Uterus
Ilioinguinal Nerve.

18. CONSTITUENTS OF THE SPERMATIC CORD
Ductus
Deferens
3 Arteries
Testicular
artery,
Cremesteric
artery
Artery to
the ductus
deferens
The
pampini-
form plexus
of veins
3 Nerves
*Genital
branch of
genito-
femoral
nerve
*Sympatheti
c nerves and
*Visceral
afferent
nerve fibres
Lymph
vessels from
testis
3 Arteries, 3 Nerves and 3 Other Things

19. COVERINGS OF THE SPERMATIC CORD

20. CONJOINED AREA
The conjoined tendon is the
fusion of lower fibers of the
internal oblique aponeurosis
with aponeurosis of the
transversus abdominis
inserting into the pubic
tubercle and superior ramus
of the pubis.

21. The Lacunar ligament
connects the inguinal
ligament to the Coopers
ligament where they both
insert near the pubic
tubercle.
The Cooper’s Ligament is an
extension of the Lacunar
ligament that runs on the
pectineal line of the pubis
bone.
LACUNAR LIGAMENT AND COOPER’S LIGAMENT
(GIMBERNAT’S LIGAMENT) (PECTINEAL LIGAMENT)

22. LIGAMENT OF HENLE (FALX INGUINALIS)
 It is the lateral vertical expansion of the rectus sheath that
inserts on the pecten pubis.

23.  It is an aponeurotic band formed
by the condensation of the
anterior layer of fascia
transversalis, blended with the
transversus abdominis ap.
 It courses from the ASIS to the
Pubis Tubercle.
 Runs Parallel to the Inguinal
Ligament.
 It is attached to the Pubic Ramus
as the Cooper’s Ligament.
ILIO PUBIC TRACT

24. HESSELBACH’S TRIANGLE
• Hesselbach’s (Inguinal) Triangle - site for direct hernias.
• Medially - Lateral border of rectus abdominis.
• Laterally - Inferior epigastric vessels. Inferiorly - Inguinal ligament
superior
pubic
ligament.

26. The two inguinal rings do not lie
opposite to each other. Therefore,
when the intraabdominal pressure
rises the anterior and posterior walls
of the canal are approximated, thus
obliterating the passage. This is
known as the flap valve mechanism.
OBLIQUITY OF THE INGUINAL CANAL
DEFENSE MECHANISMS OF INGUINAL CANAL

27. BALL VALVE MECHANISM
Contraction of the cremaster helps the spermatic cord to plug the
superficial inguinal ring

28. Contraction of the external oblique
results in approximation of the two
crura of the superficial inguinal
ring .
The integrity of the superficial
inguinal ring is greatly increased by
the intercrural fibres.
SLIT VALVE MECHANISM

29. This muscle has a triple relation
to the inguinal canal. It forms
the anterior wall, the roof, and
the posterior wall of the canal.
When it contracts the roof is
approximated to the floor, like a
shutter
SHUTTER MECHANISM
OF THE INTERNAL
OBLIQUE

30. Increased estrogen action and decreased testosterone
action leads to inguinal hernia formation.
HORMONES

31. The laparoscopic anatomy of the inguinal area based on
Myopectineal orifice of Fruchaud.
Osseo – Myo – Aponeurotic Tunnel.
LAPAROSCOPIC ANATOMY

32. MYOPECTINEAL ORIFICE
Medially - Lateral Border Rectus Muscle.
Superiorly - Transversus Abdominus And
Internal Oblique
Laterally - Iliopsoas Muscle.
Inferiorly - Cooper Ligament.
Anteriorly - Inguinal Ligament,
Posteriorly - Iliopubic Tract.

33. THE MYOPECTINEAL ORIFICE.
The myopectineal orifice (MPO) is the site of
indirect, direct, femoral and some interstitial
hernias, and it has become the focus of
many recent advances in hernia surgery.
Inguinal Ligament divided this tunnel into
Upper and Lower Halves.
Inguinal Hernias – Upper Half
Femoral Hernia – Lower Half.

34. PREPERITONIAL SPACES

35. PREPERITONIAL SPACES

37. Staples / Tacking to be
avoided.
Bounded by :
Ductus Deferens
medially
Spermatic Vessels
laterally.
Peritoneal Edge
Posteriorly
Avoid injury to the
external iliac vessels
and femoral nerve.
TRIANGLE OF DOOM

38. Aberrant
obturator artery
is an occasional
branch of
inferior
epigastric artery
travel across
Cooper’s
Ligament which
during fixation
of mesh can
cause torrential
haemorrhage.
CIRCLE OF DEATH
CORONA MORTIS

39. TRIANGLE OF PAIN
Staples / Tacking to be
avoided.
Bounded by :
Spermatic Vessels
medially
Iliopubic tract laterally
Reflected Peritoneum below.
Avoid injury to the femoral
branch of the
genitofemoral nerve or
the lateral cutaneous
nerve of thigh.

40. PARTS OF A HERNIA
Sac has a :
•Mouth
•Neck
•Body
•Fundus
•Covering
•Sac
•Content

41. NYHUS CLASSIFICATION SYSTEM

42. MANAGEMENT OF INGUINAL HERNIA

43. ROUTINE INVESTIGATIONS
• Complete Blood Count
• Random Blood Sugar
• Kidney and Liver Function Tests along with Serum
Electrolytes.
•Blood grouping/typing

44. SPECIFIC INVESTIGATIONS
• Ultrasound abdomen and pelvis.
- Defines the defect and content.
- In Old Age – BPH and to calculate the
PVRU (>100 ml is significant)
- To find any mass.

45. SPECIFIC INVESTIGATIONS
• CT Scan –Identifying the content as well as any intra-
abdominal pathology.
• MRI –Sportsman’s groin where pain is the presenting
feature and to distinguish occult hernia from
orthoapedic injury.
• Laparoscopy – useful to identify occult
contralateral hernia.
• Herniography.

46. HERNIOGRAPHY
Right sided Direct Inguinal Hernia Left sided Indirect Inguinal Hernia

47. TREATING PRECIPITATING FACTORS
• Chronic Bronchitis / Bronchial asthma
• BPH
• Uretheral stricture
• Chronic Constipation
MANAGEMENT
CONSERVATIVE
TAXIS TRUSS

48. TRUSS
• Not curative
•Indications : Elderly Patients with reducible hernia, not fit for
surgery.
• Contraindications :
irreducible hernia,
undesended testis,
associated huge hydrocele
•ABSOLUTE CONTRAINDICATIONS : Femoral and Sliding Hernia

49. TRUSS

50. PRINCIPLES OF HERNIA REPAIR
• Reduction of hernia content into the abdominal cavity.
• Excision and closure of a peritoneal sac.
• Reapproximation of the walls of the neck of the hernia.
• Permanent reinforcement of the abdominal wall defect with
suture or mesh, anatomical repair.
• Tension free

51. PROCEDURES
HERNIOTOMY
HERNIORRHAPY
HERNIOPLASTY

52. HERNIOTOMY
• Congenital hernia
• Congenital hydrocoele (patent processus
vaginalis)
• All paediatric age group & young adults
INDICATIONS

53. HERNIOTOMY
PROCEDURE
•Opening up the inguinal canal
•Separation of sac from cord structures
•Reducing the content
•Transfixation and high ligation of sac
•Excision of sac

54. HERNIOTOMY

55. INDICATIONS OF HERNIORRHAPHY
• Young adults with good muscle tone
• Weak posterior wall
• Dilated internal ring

56. HERNIORRHAPHY
Herniotomy
Approximation of conjoint tendon with
inguinal ligament

57. Types of herniorrhaphy

58. INDICATIONS OF HERNIOPLASTY
• Old age with poor muscle tone
• Direct hernia
• Huge indirect complete hernia

59. INDICATIONS OF LAPAROSCOPIC
HERNIA REPAIR
• Recurrent hernia.
• Bilateral hernia.
• Obese and athletic patient.

60. SUMMARY OF METHODS OF HERNIA REPAIR
Open Repair
– Anterior Repairs, Nonprosthetic
 Bassini’s repair
 Shouldice Repair
 McVay Repair
– Anterior Repairs, Prosthetic
• Lichtenstein tension free
Hernioplasty
• Gilbert’s Patch and Plug
• Read-Rives
• Kugel
• Nyhus-Condon
• Wantz, Stoppa, and Rives
Laparoscopic methods:
Transabdominal preperitoneal (TAPP)
Intraperitoneal Onlay mesh (IPOM)
Totally extraperitoneal (TEP)

61. EDUARDO BASSINI
FATHER OF MODERN INGUINAL HERNIA REPAIR 1884

62. BASSINI: THE FATHER OF MODERN DAY HERNIA SURGERY
• Bassini's aggressive approach was to perform "a radical cure of
inguinal hernia," (the title of his presentation to the Italian Surgical
Society in Genoa, in 1887).
• He reported only 8 failures in 206 hernia repairs during a 3-year
period.
•Before his work, failure rates ranged between 30% and 40% in the
first postoperative year and almost 100% after 4 years.

63. Bassini opened the fascia transversalis from
the pubic tubercle to the deep ring and
reconstructed the canal's posterior wall in 3
layers.
He approximated the
internal oblique,
transversus abdominus and
transversalis fascia
to the shelving edge of the inguinal ligament
with interrupted sutures.
He then placed the cord against that newly
constructed wall and closed the external
oblique aponeurosis over it, thereby reforming
the external inguinal ring

64. The posterior wall is not opened.
Sutures are placed between the
conjoint tendon
above and the inguinal ligament
below, extending
from the pubic tubercle to the
deep inguinal ring.
Continuous interlocking stitch
with prolene.
MODIFIED BASSINI

65. The external oblique
aponeurosis is closed under
the spermatic cord.
HALSTED OPERATION

66. The Cooper ligament repair (McVay repair) is the only
anterior herniorrhaphy that repairs all of the hernia
defects that occur in the groin.
Transversus abdominis aponeurosis and the underlying
transversalis fascia are sutured onto the Cooper
ligament from the pubic tubercle to the medial margin
of the femoral ring laterally and later continued
between TA and Ilio pubic tract till deep ring.
Requires relaxing incisions.
COOPER LIGAMENT REPAIR OF GROIN HERNIAS

67. RELAXING INCISION.
Required for most tissue repairs to reduce
tension on suture line

68. Tanner Slide Operation
• Reduces the tension in the repair area
• Relaxing incision is given over the lower rectus sheath so that conjoined
tendon is allowed to slide downwards.

70. Canadian Surgeon Edward Earl Shouldice
contributed substantially to hernia surgery
in the second half of the 20th century.
It applies the principle of an imbricated
posterior wall closure with continuous
monofilament suture.
SHOULDICE REPAIR.

71. After Herniotomy,
Transversalis fascia is incised along the line of
the wound from deep ring to pubic tubercle.
1st
Lower flap of the transversalis fascia is sutured
to the posterior part of the upper flap.
2nd
Upper flap is sutured to the inguinal ligament.
It causes double breasting of transversalis
fascia.

72. 3rd & 4th
The conjoint tendon and inguinal
ligament is approximated by two
layers of continuous suture.
5th & 6th
External oblique aponeurosis is
sutured in two layers in front of the
cord.
Hence, Shouldice repair is a six-
layered procedure.
Suture material used is fine steel
wire 34 Gauge.

73. DESARDA TECHNIQUE
Upper leaf of External
Oblique Aponeurosis
is sutured to the
inguinal ligament.
The EO Aponeurosis
is then divided
superiorly creating a
live external oblique
tissue flap
reconstruction.

74. Bathtub drawing.
Water pressure in the
tub holds the stopper
in the drain
In Stoppa's approach,
the mesh is held in
place by intra-
abdominal pressure,
an
application of Pascal's
principle

75. STOPPA PROCEDURE.
The entire peritoneal bag is
wrapped with a mesh graft.
Expanding intra-abdominal
pressure
holds the graft in place without
suture fixation

76. • Protease-antiprotease imbalance has a role in the pathogenesis of groin hernias and the causes of their surgical
failure.
• Evidence suggests that adult male inguinal hernias are associated with altered collagen type l to type III ratio.
• To use this already defective tissue, especially under tension, is a violation of the most basic principles of
surgery.
• In the tension-free hernioplasty, instead of suturing anatomic structures that are not in apposition, the entire
inguinal floor is reinforced by insertion of a sheet of mesh. The prosthesis that is placed between the
transversalis fascia and the external oblique aponeurosis extends well beyond the Hesselbach triangle.
LICHTENSTEIN TENSION-FREE HERNIOPLASTY

77. Technique of the Operation

78.  Use of a large sheet of mesh (3-6
inches, standard shape, resembling
the tracing of a footprint)
 Crossing the tails of the mesh
behind the spermatic cord to avoid
recurrence lateral to the internal
ring.
 Secure the upper edge of the mesh
to the rectus sheath and internal
oblique aponeurosis with two
interrupted sutures, and the lower
edge of the mesh to the inguinal
ligament with one continuous suture
to prevent folding and movement of
the mesh in the mobile area of the
groin.

79. Performed using a transabdominal approach.
Advantages
 Shorter learning curve
 Familiar laparoscopic access technique
 Visualize intra-abdominal organs to potentially identify
occult diseases
Disadvantages
 Theoretical increased rate of injury to intra-abdominal
organs
 Require general anesthesia
 Increased operative time
LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL INGUINAL
HERNIA REPAIR

80.  Indications
 Same as for conventional hernioplasty
 Specially in recurrent hernias
 Contraindications
 Cannot tolerate capnoperitoneum (severe cardiopathies/
neuropathies)
 Strangulated & perforated inguinal hernia with intercurrent sepsis
 Severe ascites
 Recurrent hernia following prior lap treatment
 < 15 years (pediatric)
 Pregnancy, after second trimester
 Severe clotting disorders

81. SURGICAL TECHNIQUE
Placement of trocars-
– 12mm Hasson trocar through
umbilical scar/ infraumbilical,
– 2 accessory 5mm trocars on pt’s
right and left flanks respectively.
The peritoneum approximately 2 to 3
cm over the hernia defect is grasped
and retracted in toward the
abdominal cavity.

82.  Dissection of lower peritoneal
flap laterally on the space of
Bogros, medially over space of
Retzius, and centrally over hernia
and its sac.
 The sac is then divided, and the
distal portion is left open, similar
to the approach to a large
indirect sac in an open inguinal
hernia repair

83.  Mesh placement- A sheet
of mesh (6x4.5 inches),
tailored to the dissected
inguinal area is
introduced through the
12-mm camera port.
 Insertion of the mesh is
facilitated by rolling

84. • The mesh is then unfolded and
positioned so that it overlaps
Cooper’s ligament posterior
medially and the internal ring
laterally.
• Superiorly, the mesh should
extend well above the hernia
defect.
• The mesh must then be secured
to prevent migration using 10 to
12-mm stapler through the
umbilical port.
• Closure of peritoneum

85. Major difference - approach to the preperitoneal
space.
TEP does not violate the peritoneal cavity and hence
reduces the risk of bowel and bladder injury.
An intact peritoneum decreases the chance that mesh
will be in contact with the bowel, reducing the risk of
adhesions, fistula formation, and bowel obstruction.
TOTALLY EXTRA PERITONEAL INGUINAL HERNIA REPAIR

86. TECHNIQUE
Incision- 2- cm transverse infraumbilical incision is made extending from the midline to the side
opposite the hernia.

87. A dissecting balloon trocar is then passed
inferiorly until in comes into contact with the
symphysis pubis.
The laparoscope is passed through the trocar
and the balloon is inflated under direct
visualization.
A low-pressure pneumopreperitoneum is
created.

88. -Two 5-mm trocars are placed
in the midline.

92. LAPAROSCOPIC INTRAPERITONEAL ONLAY MESH TECHNIQUE
• Advantage is its simplicity (in that the repair is
accomplished by placing a prosthesis over the
hernia defect intraabdominally, avoiding a
groin dissection).
• Its disadvantage is the potential for
complications because the prosthesis is in
contact with the intra-abdominal viscera.

93. DIFFICULTIES AND COMPLICATIONS
1. Difficulty in dissecting the indirect sac – Cord / Vas Injury.
2. Inadvertent opening of sac/peritoneum (in TEP) and creation of
pneumoperitoneum.
3. Injuries to major vessels (iliac) 0.5-1%
4. Displacement of the mesh or erosion to nearby structures like
Bladder.
5. Nerve injury
6. Seroma/Haematoma.
7. Infection.
8. Recurrence.