Classification of inguinal hernia

this chapter discuss the variant types of inguinal hernia

1. Classification of Inguinal Hernia
Effective groin hernia classifications serve an anatomic
blueprint for the dissection and functional evaluation of the canal and
its contents assist in determining the most appropriate repair for the
particular problem help correlate postoperative symptoms, duration
of convalescence, and degree of disability allow correlation of
postoperative results and long-term follow-up with the original
problem (Gilbert, 1989).
According to most authorities, an acceptable classification
scheme should serve as a blue print for understanding the inguinal
and femoral canals, aids in a more scientific appraisal of various
surgical repairs, assist in the evaluation of specific outcome measures
(i.e. complication rate, recurrence rate, return to normal daily
activities, socioeconomic factors, and technical difficulties), and
clearly differentiate anatomic problems when recounciling surgical
success and failure. As a communication tool, the routine use of well
recognized hernia classification scheme would make the retrieving
and reporting of treatment results more comprehensive, meaningful,
and reliable. On a practical level, an acceptable nomenclature would
assist health care planners to better understand the economic,
political and sociologic implications of performing one type of
herniorrhaphy more than other (Rutkow, 1995).
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Classification of Inguinal Hernia

2. Types and subtypes of inguinal hernias:
Inguinal hernias are further divided by anatomical location into
direct and indirect types. This differentiation is based on the location
of the actual hernia defect in relation to the inferior epigastric vessels.
The inferior epigastric vessels are continuous with the superior
epigastric vessels that originate from the internal mammary artery
cephalad and ultimately course caudally into the common femoral
artery and vein. These vascular structures make up the lateral axis of
Hesselbach's triangle, which includes the lateral border of the rectus
sheath as its medial border and the inguinal (Poupart's) ligament itself
as the inferior border. Hernias that develop lateral to the inferior
epigastric vessels are termed indirect inguinal hernias, and those that
develop medial to the vessels are direct inguinal hernias. In this way,
direct hernia defects are found within Hesselbach's triangle (Javid
and Brooks, 2007).
Types of indirect inguinal hernia:
1. Bubonocele. The hernia is limited to the inguinal canal.
2. Funicular. The processus vaginalis is closed just above the
epididymis. The contents of the sac can be felt separately from the
testis which lies below the hernia.
3. Complete (synonym: scrotal). A complete inguinal hernia is
rarely present at birth but is commonly encountered in infancy. It also
occurs in adolescence or adult life. The testis appears to lie within the
lower part of the hernia (Russel et al., 2004).
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Classification of Inguinal Hernia

3. Gilbert classification:
Hernias can be categorized into five classes (Gilbert, 1989).
Indirect:
Type 1: Snug internal ring, intact canal floor.
Type 2: One finger breadth internal ring, intact canal floor.
Type 3: Two finger breadth internal ring, defective canal floor
(scrotal and sliding hernias).
Direct:
Type 4: Entire canal floor defective, no peritoneal sac anterior
to canal floor, intact internal ring.
Type 5: Diverticulum defect admitting no more than one finger,
internal ring intact.
In 1993, Rutkow and Robbins expanded on Gilbert's
classification scheme.
• Type 6: was added to encompass those groin hernias
consisting of both indirect and direct components (pantaloon
hernias).
• Type 7: covers all femoral hernias.
As with any classification system, numerous variations and
combinations must be accounted for. Therefore, these variables (i.e.
primary versus recurrence, reducible versus incarcerated versus
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Classification of Inguinal Hernia

4. strangulated, sliding component, or lipoma) must be individually
noted in describing any hernia type (Rutkow and Robbins, 1993).
Nyhus classification:
In 1993, Nyhus introduced a classification scheme based on
strict anatomic criteria, focusing on the functional state of the internal
ring and posterior wall of inguinal canal. Terming this an
individualized approach, he proposed specific operations to go along
with each hernia type (Nyhus, 1993).
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Classification of Inguinal Hernia

5. Table (1): Nyhus classification:
Aachen classification:
The Aachen classification uses a grading system similar to the
Nyhus groups, but with an additional measurement incorporating size
of the hernial orifice (Schumpelick and Arlt, 1995).
• Grade 1 represents the normal diameter of the internal ring of
up to 1.5cm.
• Grade 2 Indirect and direct hernias with an orifice of 1.5 cm
to 3.0 cm are termed.
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Classification of Inguinal Hernia

6. • Grade 3 hernias are those with an orifice of more than 3cm.
"C" (for combined) is added in combined hernias and the total
diameter of the two defects is calculated.
"L" (for lateral) is added in indirect types.
"M (for medial) is added in direct types."F (for femoral) is
added in femoral types.
Bendavid classification:
In 1993, Bendavid proposed the type, staging and dimension
(TSD) classification scheme.
In the TSD classification plan, the "T" refers to type of hernia ,
the "S" refers to the stage of progress the "D" refers to the diameter
of the hernial defect at the level of the abdominal wall, recorded in
centimeters (Rutkow and Robbins, 1993).
• Type 1: Anterolateral (indirect):
Stage l: Extends from the deep inguinal ring to the superficial
ring.
Stage2: Goes beyond the superficial ring but not into the
scrotum.
Stage3: Reaches into the scrotum.
• Type 2: Anteromedial (direct):
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Classification of Inguinal Hernia

7. Stage 1: Remains within the confines of the inguinal canal.
Stage 2: Goes beyond the superficial ring but not into the
scrotum.
Stage 3: Reaches into the scrotum.
• Type 3: Posteromedial (femoral):
Stage 1: Occupies a portion of the distance between the femoral
vein and the lacunar ligament.
Stage 2: Goes the entire distance between the femoral vein and
the lacunar ligament.
Stage 3: Extends from the femoral vein to the pubic tubercle
(recurrences, destruction of lacunar ligament.).
• Type 4: Posterolateral (prevascular):
Stage 1: Located medial to the femoral vein.
Stage 2: Located at the level of the femoral vessels.
Stage 3: Located lateral to the femoral vessels.
• Type 5: Anteroposterior (inguinofemoral):
Stage 1: Has lifted or destroyed a portion of the inguinal
ligament between pubic crest and the femoral vein
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Classification of Inguinal Hernia

8. Stage 2: Has lifted or destroyed the inguinal ligament from the
pubic crest to the femoral vein.
Stage3: Has destroyed the inguinal ligament from the pubic
crest to a point lateral to the femoral vein.
Stoppa classification:
Under the guiding influence of Stoppa, more than 10 years of
discussion resulted in the latest groin hernia classification scheme.
This nomenclature is partially derived from the Nyhus classification,
with special attention given to so-called "aggravating factors
(Stoppa, 1998).
Among these factors are:
Local aggravating factors, including those related to the
complexity of the hernia (i.e., recurrence, size, or sliding component).
General aggravating factors, including those related to the
patient (i.e., activity, age, collagen deficiencies, constipation, obesity,
prostatic or bladder pathology, or pulmonary disease).
A final group of aggravating factors involves special
surgical situations (i.e., risk for infection or technical difficulties) and
any other unfavorable component that would modify management of
the patient (Stoppa, 1998).
• Type 1: An indirect hernia with a normal internal ring,
measuring less than 2 cm.
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Classification of Inguinal Hernia

9. • Type 2: An indirect hernia (and can include type 1 hernias
that have aggravating factors) but with an internal ring greater than 2
cm in diameter.
• Type 3: Indirect, direct inguinal and femoral hernias
associated with a weakened inguinal floor or type 2 hernias
complicated by an aggravating factor.
• Type 4: Recurrent hernias or any type 3s complicated with
aggravating factors
• Type 4, Rl represents a first time recurrence of a small
indirect hernia in non obese patients.
• Type 4, R2 consists of a first time recurrence of a small,
direct hernia in a suprapubic location in non obese individuals.
• Type 4, R3 consists of all other cases, including bilateral
recurrent hernias, femoral recurrent hernias, groin eventrations,
multiple recurrent hernias, recurrent hernial orifices of large size,
strangulated recurrent hernias, and any type 3s associated with an
aggravating factor.
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Classification of Inguinal Hernia

10. • Type 2: An indirect hernia (and can include type 1 hernias
that have aggravating factors) but with an internal ring greater than 2
cm in diameter.
• Type 3: Indirect, direct inguinal and femoral hernias
associated with a weakened inguinal floor or type 2 hernias
complicated by an aggravating factor.
• Type 4: Recurrent hernias or any type 3s complicated with
aggravating factors
• Type 4, Rl represents a first time recurrence of a small
indirect hernia in non obese patients.
• Type 4, R2 consists of a first time recurrence of a small,
direct hernia in a suprapubic location in non obese individuals.
• Type 4, R3 consists of all other cases, including bilateral
recurrent hernias, femoral recurrent hernias, groin eventrations,
multiple recurrent hernias, recurrent hernial orifices of large size,
strangulated recurrent hernias, and any type 3s associated with an
aggravating factor.
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Classification of Inguinal Hernia