1.
MANAGEMENT OF INGUINAL
HERNIA
Dr Rojan Adhikari
FCPS Resident

2.
Father of Modern Inguinal
Hernia Repair - 1884
EDUARDO BASSINI

3.
Investigation
• USG abdomen and pelvis
 defines defect and content
I n old age – BPH, size and to calculate
post voidalurine (>100ml significant)
To find anymass

4.
Investigation
• CT scan – helpful in complex incisional hernia
determining the number and size of muscle
defects, identifying the content as well as intra
abdominal pathology
• MRI -- helpful in diagnosing sportsman’s groin
where pain is the presenting feature and to
distinguish occult hernia from orthopedic
injury

5.
Investigation
• Laparoscopy – useful to identify occult
contralateral hernia

6.
Investigation
• HERNIOGRAPHY
• Suspected hernia, but clinical diagnosis
unclear
• Procedure done under flouroscopy following
injection of contrast medium in peritoneum
• Frontal and oblique radiographs are taken
with and without increased intra-abdominal
pressure

7.
Herniography
Right direct inguinal hernia
Left indirect inguinal
hernia

8.
Investigation
ROUTINE
• Complete blood count
• Coagulation profile PT/INR
• Urine Routine
• Blood sugar
• Renal function test
• Blood grouping/typing
• ECG and Chest X-ray

9.
Historical Perspective
15th century -
Castration with
wound
cauterization or
hernial sac
debridement

10.
Principle of hernia repair
• Reduction of hernia content into the abdominal
cavity with removal of any non-viable tissue and
bowel repair if necessary,
• Excision and closure of a peritoneal sac if present
or replacing it deep to the muscle,
• Reapproximation of the walls of the neck of the
hernia if possible,
• Permanent reinforcement of the abdominal wall
defect with suture or mesh, anatomical repair
• Tension free

11.
Treating precipitating factors
• Chronic Bronchitis / Bronchial asthma
• BPH
• Uretheral stricture
• Chronic Constipation

12.
TRUSS
• Not curative
• Hernia should be reducible
• Contraindicated in case of irreducible
hernia, undesended testis, associated
huge hydrocele

13.
TRUSS

14.
TRUSS

15.
SURGERIES FOR HERNIA
HERNIOTOMY
HERNIORRHAPY
HERNIOPLASTY

16.
INDICATIONS OF HERNIOTOMY
• Congenital hernia
• Congenital hydrocoele (patent processus
vaginalis)
•All paediatric age group & young adults

17.
INDICATIONS OF HERNIORRHAPHY
•Young adults with good muscle tone
•Weak posterior wall
•Dilated internal ring

18.
INDICATIONS OF HERNIOPLASTY
• Old age with poor muscle tone
• Direct hernia
• Huge indirect complete hernia

19.
INDICATION OF LAPAROSCOPIC
HERNIA REPAIR
• Recurent hernia : avoid scar tissue and
visualizes occult hernia
• Bilateral hernia: decrease pain and early
mobilization
• Obese and athletic patient: diagnostic and
therapetic

20.
HERNIOTOMY
•Opening up the inguinal canal
•Separation of sac from cord structures
•Reducing the content
•Transfixation and high ligation of sac
•Excision of sac

21.
herniotomy

22.
herniotomy

23.
HERNIORRHAPHY
• Herniotomy
• Approximation of conjoint tendon with
inguinal ligament

24.
Types of herniorrhaphy

25.
BASSINI’S REPAIR
• Opening the fascia transversalis from pubictubercle
to deep ring
• Approximation with interrupted stitches
• Approximation of conjoint tendon & upperleaf of
fascia transversalis with inguinal ligament & lower
leaf of fascia transversalis

26.
MODIFIED BASSINI
• Approximation with continuous
interlocking stitch with prolene
• Sutures are placed between the conjoint tendon
above and the inguinal ligament below, extending
from the pubic tubercle to the deep inguinal ring.

27.
SHOULDICE TECHNIQUE
• Additional strength is given to the
posterior wall by “DOUBLE BREASTING”
the fascia transversalis
• Lower flap of fascia is sutured to posterior
part of upper flap and upper flap is sutured
to inguinal ligament.
• Best among all anatomical repairs
(Herniorrhaphy) d/t Least recurrence

28.
LYTLE’S REPAIR
• Narrowing of the deep ring by placing
interrupted sutures over the medial side of the
ring to the transversalis fascia

29.
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 downward

30.
Darning
• Continuous interventing network of
nonabsorbable sutures are placed between
conjoint and inguinal ligament to give good
support to posterior wall of inguinal hernia

31.
McVay Operation
• Interrupted suture is aplied between
transversalis fascia to copper’s ligament
starting from pubic tubercle medially towards
femoral sheath and later continued as suture
repair between transversalis fascia and
iliopubic tract laterally upto entrance of cord
• Covers all three groin defects- indirect, direct,
and femoral.

32.
HERNIOPLASTY
•Herniotomy
• Strenthening of the posterior wall of
inguinal canal with autologous tissue or
foreign material
• Use of PROLENE MESH to bridge the gap
between inguinal ligament and conjoint
tendon

33.
Types of hernioplasty

34.
LICHTENSTEIN’S TENSION FREE
• Prolene mesh 15 X 10 cm size is taken &
fixed in the inguinal ligament
• First bite periosteum of pubic tubercle &
fix the mesh to a point beyond the deep
ring
• Fix the mesh with inguinal ligament &
conjoint tendon using 1’0 or 2’0 prolene
without tension

35.
LICHTENSTEIN’S TENSION FREE
• Used in all types of inguinal hernia
• Least recurrence rates

36.
Mesh can be used..
• To bridge a defect: simply fixed over the defect
as tension free patch
• To plug a defect: a plug of mesh is pushed into
the defect
• Ta augment a repair: the defect is closed with
sutures and the mesh added for
reinforcement.

37.
Types of Mesh
Synthetic mesh
• polymer of polypropylene, polyester or
polytetrafluroethylene (PTFE)
• Non absorbable and provoke little tissue
reaction
• Hydrophobic nature and monofilament
microstructure of polypropylene impede
bacterial ingrowth

38.
Types of Mesh
Biological mesh
• Sheets of sterilized, decellularised, non-
immunogenic connective tissue
• Provide a scaffold to encourage neovascular
ingrowth and new collagen deposition.
• Host enzymes eventually break down the
biological implant which is replaced and
remodelled with fibrous tissue
• It is expensive

39.
Types of Mesh
Absorbable mesh
• Also synthetic absorbable meshes, such as
those made from polyglycolic acid fibres
• Used in temporary abdominal closure and to
buttress sutured repairs
• No role in hernia repair as they absorb and
induce minimal collagen deposition

40.
Types of Mesh
Tissue separating mesh
• Intraperitoneal use
• Different surfaces, one being sticky and
another slippery
• Adherence and host tissue in growth is
required on the parietal side of the mesh
• Bowel side needs to prevent adhesion to the
bowel

41.
Positioning of Mesh
• Onlay – just outside of the muscle in the
subcutaneous space
• Inlay – with in the defect, only applies to mesh
plugs in small defects
• Sublay – between fascial layers in the
abdominal wall, intraparietal
• Immediately extraperitoneally, against muscle
or fascia (also sublay)
• intraperitoneally

42.
Laparoscopic mesh repair
TAPP–Transabdominal Preperitoneal
Procedure
TEP–Total Extraperitoneal Procedure

43.
TEP Repair
• More popular then TAPP
• Through subumbilical incision (10mm)
extraperitoneal space is reached
• After CO2 insufflation, another 5mm port created
4 cm below the 1st port in the midline, 3rd port on
same line or RIF
• Disssection is carried downwards carefully, then
medially upto pubic tubercle, iliopectneal line,
laterally to iliac vessels and inferior epigastric
vessels

44.
TEP Repair
• Once adequate space is dissected 15x15cm
mesh is placed and spread.
• Mesh may be sutured to iliopectinal ligament
• Displacement of mesh is not seen
• Another side can be done on single setting

45.
TAPP Repair
• Used in large indirect or irreducible inguinal
hernia
• Ports created
• Content of hernia is reduced
• Hernial sac dissected in preperitoneal plane
after making horizental incision at the upper
part of the sac opening,

46.
TAPP Repair
• Once sac is dissected and excised prolene
mesh of 15x10cm sized or smaller is placed in
preperitoneal space
• It is fixed with pubic bone using tacks.
Peritonem is closed with continous prolene
suture

47.
CONCLUSION
Laparoscopic and Lichtenstein open mesh repairs were
associated with good long term results and a low
incidence of recurrence, but laparoscopic repair caused
less groin pain and permanent paraesthesia than
Lichtenstein mesh repair.

48.
CONCLUSION
• The intraoperative and general postoperative
complication rates as well as the reoperation
rate for complications show no significant
difference between TEP and TAPP.
• The higher postoperative complication rate for
TAPP, which could be managed conservatively,
is partly explained by larger defect sizes, more
scrotal hernias and older age.

49.
CONCLUSION
TEP and TAPP improved clinical outcomes
compared with OHR, but the network meta-
analysis showed that TEP and TAPP efficacy is
equivalent. TAPP was associated with a slightly
longer hospital stay compared with TEP.

50.
Complication- Intra operative
• Injury to blood vessles (inferior epigastric
& femoral)
•Injury to bowel & bladder
• Injury to ilioinguinal & iliohypogastric
nerves
•Injury to cord structures

51.
Complication - Immediate post operative
•Urine retention
•Hematoma
•Infection
•Periosteitis of pubic tubercle
•Post herniorrhaphy hydrocele

52.
Complication -Late complications
• Recurrence
• Testicular atrophy if testicular artery is
damaged
• Obstruction

53.
Complication- Laparoscopic Hernia Repair
• Vascular Injuries
•Visceral Injuries
•Trocar Site Complications
•Bowel Obstructions
•Hypercarbia syndrome
•Abdomen Compartment Syndrome

54.
References
• Bailey and Love’s Short Practice of
Surgery
• Sabiston Textbook of Surgery
• SRB manual of Surgery
• UpToDate
• Medscape
• Pubmed online

55.
THANK YOU