Inguinal hernia

hernia

1. INGUINAL HERNIA

2. ANATOMY OF INGUINAL CANAL Oblique passage in the lower part of the anterior abdominal wall , situated just above the medial half of the inguinal ligament. Length and direction : About 4 cm(1.5 inches) long directed downwards , forwards, and medially. It extends from the deep inguinal ring to the superficial inguinal ring.

3. Superficial Inguinal Ring Opening in external oblique aponeurosis . It lies 1.25 cm above the pubic tubercle. Bounded by the superomedial and inferolateral crura . Normally it does not admit tip of little finger. DEEP INGUINAL RING U shaped condensation of fascia transversalis . 1.25 cm above inguinal ligament midway between pubic symphysis and anterior superior iliac spine(mid inguinal point ).

4. DEVELOPMENT It represents the passage of GUBERNACULUM through the abdominal wall. It extends from the caudal end of developing gonad(in the lumbar region) to the labioscrotal swelling. In the early life, the canal is very short. As the pelvis increases in width, the deep inguinal ring is shifted laterally and the adult dimension of canal is attained .

5. BOUNDARIES ANTERIOR WALL In its whole extent skin superficial fascia ext. oblique aponeurosis In its lateral one third Fleshy fibres of the internal oblique muscle ROOF Arched fibres of the internal oblique and transverses abdominis muscle. FLOOR Grooved upper surface of the inguinal ligament and at the medial end by the lacunar ligament.

6. POSTERIOR WALL In its whole extent fascia transversalis extra peritoneal tissue parietal peritoneum In its medial two thirds The conjoint tendon Reflected part of inguinal ligament In its lateral one third By interfoveolar ligament extending b/w lower border of transversus abdominis and sup ramus of pubis.

7. STRUCTURES PASSING THROUGH THE CANAL Spermatic cord in males and round ligament of uterus in females Ilioinguinal nerve

8. COVERINGS OF SPERMATIC CORD FROM WITHIN OUTWARDS Internal spermatic fascia: Fascia transversalis : covers the whole extent. Cremasteric fascia: Internal oblique and transversus abdominis muscle: covers below the level of these muscles. External spermatic fascia: E xt.oblique aponeurosis : covers below the superficial inguinal ring.

9. It is an osseo-myo-aponeurotic tunnel. It is through this tunnel all groin hernias occur. It is bounded : Medially by the lateral border of the rectus sheath. Above by the arched fi bres of internal oblique and transversus abdominis muscle. Laterally by the illiopsoas muscle. Below by the pectin pubis and fascia covering it Fruchaud’s Myopectineal Orifice

10. MECHANISM OF INGUINAL CANAL The presence of the inguinal canal is a cause of weakness of lower part of ant abdominal wall. This weakness is compensated by the following factors : Obliquity of the inguinal canal- Flap valve mechanism The sup inguinal ring is guarded-from behind by the conjoint tendon and by the reflected part of inguinal ligament The deep inguinal ring is guarded from the front by the fibres of internal oblique. Shutter mechanism of internal oblique-triple relatn of the muscle Contraction of the cremaster helps the spermatic cord to plug the sup inguinal ring( ball valve mech ). Contraction of the ext oblique results in the approximation of two crura ( slit valve mech ).

11. HERNIA DEFINITION Abnormal protrusion of a viscous or a part of viscous through an opening natural or artificial with a sac covering it PARTS OF HERNIA COVERING SAC CONTENT

12. COVERING LAYERS OF ABDOMINAL WALL SAC DIVERTICULUM OF PERITONEUM WITH MOUTH, NECK, BODY AND FUNDUS CONTENTS OMENTOCELE ENTEROCELE CYSTOCELE RICHTER′S HERNIA LITTRE′S HERNIA OVARY WITH FALLOPIAN TUBE

13. PARTS OF HERNIAL SAC

14. In enterocele First part is difficult to reduce but last part is easier. There will be gurgling sound on reduction . Resonant on percussion. Peristalsis is seen. Bowel sounds may be heard. In omentocele ( epiploecele ) First part is easier to reduce but last part is difficult. Has a doughy feeling. Dull on percussion. No peristalsis. Bowel sounds not heard.

15. CLASSIFICATION OF HERNIA CLINICAL Reducible Irreducible Obstructed Inflamed Strangulated CONGENITAL/ACQUIRED ACCORDING TO CONTENTS OMENTOCELE ENTEROCELE CYSTOCELE RICHTER′S HERNIA LITTRE′S HERNIA - Meckel’s diverticulum MAYDL’S HERNIA SLIDING HERNIA

16. Richter’s hernia Richter’s hernia is a hernia in which the sac contains only a portion of the circumference of the intestine (usually small intestine). It usually complicates femoral and, rarely, obturator hernias. Sliding hernia Here posterior wall of the sac is not only formed by the parietal peritoneum, but also by sigmoid colon with its mesentery on left side; caecum on right side and often with portion of the bladder. Maydl’s hernia (Hernia-in-W) Here a loop of bowel in the form of ‘W’ lies in the hernial sac and the centre portion of the ‘W’ loop is strangulated and lies within the abdominal cavity .

17. Based on sites

18. INGUINAL HERNIA CLASSIFICATION Anatomical classification Indirect hernia It come out through the internal ring along with the cord .Sac is lat. to the inf epigastric artery. Direct hernia It occurs through the Hasselbach’s triangle . Sac is medial to the inf. epigastric artery.

19. GILBERT’S CLASSIFICATION Type 1 Indirect inguinal hernia(IIH)-tight deep ring Type 2 IIH deep ring admit 1 finger but less than 2 finger breadth Type 3 IIH deep ring more than 2 finger breadth Type 4 Direct hernia –entire posterior wall is defective Type 5 direct hernia-punched out hole/defect in transversalis fascia Type 6 Pantaloon/double hernia Type 7 Femoral hernia Type 6 & 7 are Robbin’s modification

20. NYHUS CLASSIFICATION Type I-indirect hernia with normal deep ring Type II-indirect hernia with dilated deep ring without impengement on the floor of the inguinal canal Type III-post wall defect direct pantaloon hernia femoral hernia Type IV –recurrent hernia

21. indirect inguinal hernia Direct inguinal hernia Can occur in any age from childhood to adult. Occurs in a pre-existing sac. Protrusion through the deep ring; herniation occurs later Pyriform /oval in shape; descends obliquely and downwards. Can become complete by descend down in to scrotum. Sac is anterolateral to cord. Commonly u/l but can be b/l . Sac should be opened in surgery . Common in elderly Always acquired Herniation through posterior wall of the inguinal canal Globular/round in shape; descends directly forward bulge. Descent down in to scrotum is rare Sac is posterior to the cord. Commonly b/l . It is not necessarily opened.

22. According to the extent - indirect IH Incomplete Bubonocele -sac is confined to the inguinal canal Funiclar -here the sac crosses the sup inguinal ring but does not reach the bottom of the scrotum Complete Sac descend to the bottom of the scrotum

23. PRECIPITATING CAUSES STRAINING CHRONIC CONSTIPATION RESPIRATORY CAUSES SMOKING OBESITY ASCITES PREVIOUS SURGERY LIKE APPENDICECTOMY URINARY PROBLEMS LIKE BPH , URETHRAL STRICTURE MULTIPLE PREGNANCIES

24. Old appendicectomy scar with direct inguinal hernia. It is due to injury to ilioinguinal nerve during appendicectomy .

25. COVERINGS INDIRECT HERNIA Extra peritoneal tissue Internal spermatic fascia Cremastric fascia External spermatic fascia Skin DIRECT HERNIA Extra peritoneal tissue Fascia transversalis Conjoint tendon External spermatic fascia Skin

26. CLINICAL FEATURES More common in males(20:1) Pat. presents with dragging pain and swelling in the groin which is better seen while coughing and standing. Contents are either small bowel, ,large bowel, omentum or its combination. Usually reducible but can go for irreducibility ,inflammation, obstruction or strangulation. Other symptoms –colicky abd . pain, vomiting, abd . distention and constipation. Should ask h/o chronic bronchitis, frequency or urgency of micturation,enlargment of prostate Past history Any past surgical history: Appendicectomy Previous h/o hernia repair on the same or opp. side

27. Local examination S hould be exposed from umbilicus up to the mid thigh. Examine first in standing position then in the supine position. INSPECTION Swelling- size and shape position and extent visible peristalsis Skin over the swelling Impulse on coughing Position of the penis

28. PALPATION Temp. t enderness Position and extent Get above the swelling(scrotal & inguino scrotal swelling) The root of scrotum is held between the thumb infront and other fingers behind in an attempt to reach above swelling. Inguinoscrotal Hernia –cannot get above the swelling Consistency(doughy & granular omentum elastic-intestine) Relation of the swelling to the testis and sprmatic cord Impulse on coughing( Zieman’s technique ): Three finger test

29. Fig. 18.23: Zieman’s test: Index finger on deep ring; middle finger on superficial ring and ring finger over saphenous opening—are placed after reducing the content. Patient is asked to cough and impulse is felt in finger corresponding to the existing hernia.

30. Reducibility-taxis A method of reducing hernia. H ere pt is asked to flex the thigh of the affected side and to adduct and rotate it internally .The fundus of the sac is gently held with one hand and pressure is applied to squeeze contents while other hand will guide the contents through supf . ring. Invagination test D one after reduction of hernia. Using little finger skin of the scrotum is invaginated from bottom up to pubic tubercle. T he finger is then rotated and pushed up into the supf ing ring.the pt is asked to cough and if the impulse felt on the pulp of finger –direct ; if on tip- indirect. Ring occlusion test D one after reduction of hernia This is a confirmatory test to differentiate an IIH from DIH A Thumb is pressed on the deep ing ring (1/2 inch above mid-inguinal point).Ask the pt to stand. the pt is asked to cough . A direct hernia will show a bulge medial to the occluding finger but an indirect hernia will not.

31. PERCUSSION Resonant- enterocele Dull- omentocele AUSCULTATION Peristaltic sound Examine the testis , epididymis and spermatic cord Examine the other side Examine the tone of abdominal muscles –head or leg rising test or by valsalva maneouvre MALGAIGNE BULGINGS -it indicate pure tone of oblique muscles PRE-PROSATE ENLARGMENT

32. DIFFERENTIAL DIAGNOSIS Hydrocele Undescended testes Femoral hernia Lipoma of cord Inguinal lymph node enlargement Groin abscess

33. INVESTIGATIONS Usual pre op investigations Chest X-Ray USG abdomen

34. COMPLICATIONS OF HERNIA Irreducibility Obstruction Strangulation Inflammation Incarceration

35. TREATMENT INDIRECT HERNIA Always surgery IN INFANTS: Herniotomy IN ADULTS: Herniotomy [excision of hernial sac]+ Herniorrhaphy / Hernioplasty [strengthening of the posterior wall of inguinal canal either by repair or mesh]

36. REPAIR MAY BE:

37. REPAIR CAN ALSO BE:

38. HERNIOTOMY Anesthesia-spinal or GA After cleaning and draping, skin is incised-1.25 cm above and parellel to the medial 2/3 of inguinal ligament. Sup fascia(camper’s and scarpa’s fascia)are incised. Ext oblique aponeurosis is incised. Visualize the inguinal ligament. Illio inguinal nerve is safeguarded. Cremasteric muscle is opened, cord structures are dissected. Sac which is ant and lat to the cord is identified and its pearly white in colour .

39. Dissection usually starts from the fundus and extented towards the neck which is identified by extra peritoneal fat Finger is passed to release any adhesions Sac is twisted and transfixed using absorbable suture and is excised distally

40. BASSININI ´S HERNIORRHAPHY Strengthening of posterior wall of inguinal canal by approximation of conjoint tendon to inguinal ligament. Monofilament non-absorbable suture material . Commonly used suture material is either polypropylene[blue] or poly ethylene[black] Always interrupted sutures .

41. Fig. 18.36: Modified Bassini’s repair It is approximation of inguinal ligament to conjoint tendon using interrupted non absorbable monofilament sutures.

42. Complications of H erniorrhaphy Haemorrhage Haematoma , seroma Infection—1-5% Haematocele Post- herniorrhaphy hydrocele , lymphocele Hyperaesthesia over the medial side of inguinal canal due to injury to iliiohypogastric nerve—neuralgia (15%) Recurrence—10-15% Osteitis pubis Injury to urinary bladder/bowel Testicular atrophy, penile oedema rarely can occur

43. SHOULDICE REPAIR Multilayered Repair

44. SIX LAYERS: First two layers – trasversalis fascia Next two layers – conjoint tendon & ing ligmt Last two layers – external oblique aponeurosis SUTURE MATERIAL: Fine steel wire of 34 gauge. OR Polypropylene / polyethylene

45. Lytle’s Repair Often internal ring is narrowed by placing interrupted sutures over the medial side of the ring to the transversalis fascia using either thread or silk (To narrow the ring and push the cord laterally).

46. Tanner Slide Operation To reduce the tension in the repair area, relaxing incision is placed over the lower rectus sheath so that conjoined tendon is allowed to slide downward

47. HERNIOPLASTY Strengthening of posterior inguinal wall in case of inguinal hernia or in any large hernia with weak abdominal wall using a supportive material. This allows and supports good fibroblast proliferation. MATERIALS USED: Synthetic: Prolene mesh, Dacron mesh, Morlex mesh, mersiline sheath. Biological: Tensor fascia lata , temporal fascia and skin. Not well accepted.

48. INDICATIONS: Direct hernia Recurrent hernia Incisional hernia Old age Hernia with weak abdominal muscle tone. Sliding hernia COMPLICATIONS: Infection Mesh extrusion Foreign body reaction Mesh inguinodynia – hyperaesthesia and pain along the distribution of ilioinguinal or iliohypogasrtric nerve Mesh erosion into bowel ,bladder or vessels.

49. PRINCIPLE: Size of mesh should be bigger than size of defect. Mesh should be fixed above and below to conjoint tendon and inguinal ligament or abdominal wall using interrupted non absorbable sutures. Absolute hemostasis and control of infection. TYPES OF MESH REPAIR: On lay repair Lichtenstein tension free onlay mesh repair In lay repair Under lay repair Gilbert patch and plug repair / Gilbert’s PHS repair(on lay + sub lay) Nyhus preperitoneal mesh repair. Kugel groin hernia mesh repair Modified Rives preperitoneal mesh repair TEP TAPP

50. Fig. 18.43: Hernioplasty : Mesh repair—Lichtenstein’s method (done under local anaesthesia ). Mesh is fixed inferiorly to lacunar & inguinal ligaments, medially to overlap rectus sheath & fixed to fascia over the pubic bone Laterally an artificial deep ring is created by crossing of both upper and lower leaf of mesh, superiorly it is fixed to conjoint tendon.

51. Direct hernia-Treatment Surgery The principles of repair of direct hernias are the same as those of an indirect hernia ,with the exception that the hernia sac is not opened. This reconstruction of the posterior wall of the inguinal canal should be undertaken by the Shouldice repair or by using a mesh implant according to the Lichtenstein technique. Ideally hernioplasty (mesh repair) is done.

52. LAPAROSCOPIC HERNIORRHAPHY TAPP approach In large indirect hernia or irreducible inguinal hernia. 10 umbilical port for laproscope 5mm ports-each side on pararectal point above the level of umbilicus Contents of hernia reduced,sac dissected in preperitoneal plane Vas, gonadal vessels, pubic bone, inferior epigastric vessels identified Prolene mesh placed in preperitoneal space & fixed to pubic bone using tacks. Peritoneum closed with continuous prolene sutures.

53. TEP repair using laproscope Through subumbilical incision 10mm extraperitoneal space is reached. After CO2 insufflation - 5mm port 4cm below first,-5mm in same line Dissection carried out downward then medially upto pubic tubercle, iliopectineal ligament, laterally to iliac vessels,& inferior epigastric vessels. Mesh placed & sutured to iliopectineal ligament

54. Ports used for TEP and for TAPP Port incisions in TEP

55. COMPLICATIONS IN TEP Cord or vas injury Inadvertent opening of the sac or peritoneum and creation of pneumoperitoneum . Injury to major structures like iliac vessels. Displacement of mesh or erosion into structures like bladder. Nerve injury Seroma / hematoma Infection Recurrence

56. ADvantages Approach is totally extraperitoneal Small incision Proper placement of mesh in preperitoneal space Peritoneal cavity is intact and not opened CONTRAINDICATIONS Obstructed/strangulated hernia Ascites Bleeding disorders

57. COMPLICATIONS OF OPEN HERNIA SURGERY Infection Groin pain Ischemic orchitis Injury to vas Injury to viscera Recurrence Hydrocele Seroma Hematoma Inguinodynia Dysejaculation

58. CONSERVATIVE MEASURES Conservative measures should be avoided in hernia as much as possible TAXIS –Trial reduction Truss : a rat tailed sprung truss with a perineal band to prevent the truss from slipping away Hernia truss : It is used only when patient is not fit for surgery. It may precipitate strangulation. Before placing truss, contents of the hernia should be reduced completely a properly fitting truss must control the hernia when the patient stands with leg apart, stoops & cough violently.

59. RECURRENT HERNIA Recurrence: within 3 years – early ; after 3 years – late PREDISPOSING FACTORS: PREOPERATIVE smoking chronic cough constipation old age anemia hypoproteinaemia straining increased intra abdominal pressure ascites

60. OPERATIVE tension in the sutures weak anterior abdominal wall POSTOPERATIVE Infection Hematoma Straining Recurrence rate : Bassini’s repair - 10% Shouldice repair - 1% Hernioplasty - 1 – 3% Other methods - 1 – 5% More likely to go in for strangulation. TREATMENT: Treat the cause and later hernioplasty . TEP/TAPP is better.

61. STRANGULATED HERNIA Most serious Complication of hernia. Most common in IIH A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contents ischaemic . PATHOLOGY Obstruction ↓ Initially venous return is impaired ↓ Congestion of the bowel ↓ Further dilatation of the bowel which becomes purple coloured ↓

62. Fluid collects in the sac ↓ Eventually arterial blood supply is impaired ↓ Bowel becomes dark, brownish black coloured with flabby and friable wall ↓ Bacteria migrate transerosally and multiply in fluid of the sac ↓ Perforation occurs at the site of constriction ring ↓ peritonitis

63. Clinical Features of Strangulated Hernia Sudden severe pain, initially over a pre-existing hernia which later becomes generalized over the abdomen. Persistent vomiting, constipation and distension of the abdomen. Hernia is tense, severely tender, irreducible and without any expansile impulse on coughing. Rebound tenderness is diagnostic. Features of toxicity and dehydration & shock Electrolyte imbalance. Abdominal distension with guarding and rigidity. Oliguria 3% in incidence. In strangulated omentum features of obstruction are not present (i.e. vomiting, constipation)

64. Investigations Plain X-ray abdomen in erect posture shows multiple air-fluid levels. Serum electrolytes. Blood urea and serumc reatinine . Total count is increased. U/S abdomen. Treatment of Strangulated Hernia The patient is admitted. Ryle’s tube aspiration. Intravenous fluids to correct dehydration and electrolyte imbalance. Antibiotics. Catheterisation to maintain adequate urine output. Emergency surgery

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