Inguinal Hernia

"If you don't have a hernia yet then you're not pulling your own weight!" George Steinbrenner

1. Inguinal Hernia Dr Rabia khanum PG General Surgery

2. Anatomy Of Inguinal Canal: The inguinal canal is about 4 cm in length extending between the internal and external inguinal rings containing spermatic cord in men and the round ligament of the uterus in women.

3. Boundaries of inguinal canal:

4. Fascial Coverings of spermatic cord The contents of the spermatic cord are mainly bound together by three fascial layers. They are all derived from anterior abdominal wall: External spermatic fascia – derived from deep subcutaneous fascia. and the aponeurosis of the oblique externe muscle. Cremaster muscle and fascia – derived from the internal oblique muscle and its fascial coverings. Internal spermatic fascia – derived from the transversalis fascia.

5. Contents of spermatic cord The spermatic cord has a number of important structures that run to and from the testis. Blood vessels: Testicular artery – branch of the aorta that arises just inferiorly to the renal arteries. Cremasteric artery and vein – supplies the cremasteric fascia and muscle. Artery to the vas deferens – branch of the inferior vesicle artery, which arises from the internal iliac. Pampiniform plexus of testicular veins – drains venous blood from the testes into the testicular vein. Nerves: Genital branch of the genitofemoral nerve – supplies the cremaster muscle. Autonomic nerves Other structures: Vas deferens – the duct that transports sperm from the epididymis to the ampulla (a dilated terminal part of the duct), ready for ejaculation. Processus vaginalis – projection of peritoneum that forms the pathway of descent for the testes during embryonic development. In the adult, it is fused shut. Lymph vessels – these drain into the para-aortic nodes, located in the lumbar region.

6. cremaster muscle : The cremaster muscle arises from the lowermost fibers of the internal oblique muscle and encompasses the spermatic cord in the inguinal canal. Cremasteric vessels are branches of the inferior epigastric vessels and pass through the posterior wall of the inguinal canal through their own foramen. These vessels supply the cremaster muscle and can be divided to expose the floor of the inguinal canal during hernia repair without damaging the testis.

7. Important structures of inguinal canal:

8. Deep inguinal ring The inferior crus of the deep inguinal ring is comprised of the iliopubic tract; the superior crus of the deep ring is formed by the transversus abdominis aponeurotic arch. The lateral border of the internal ring is connected to the transversus abdominis muscle, which forms a shutter mechanism to limit the development of an indirect hernia.

9. Iliopubic tract The iliopubic tractis a thickened part of transversalis fascia that originates from the anterior superior iliac spine laterally, stretches medially over the iliac muscles (iliopectineal arch) and attaches to the superior ramus of the pubis. This fibroelastic structure runs deep and parallel to theinguinal ligament with which it is only loosely connected. It forms the inferior margin of the internal inguinal ring and from an endoscopic perspective, the boundary between inguinal hernia (above) and femoral hernia (below)

10. Transversus Abdominis Aponeurotic Arch. The lower margin of the transversus abdominis arches along with the internal oblique muscle over the internal inguinal ring to form the transversus abdominis aponeurotic arch. It forms upper crus of deep inguinal ring.

11. Myopectineal orifice of Fruchaud : Fruchaud postulated that the anterior abdominal wall has an area that is inherently weak. Bounded above by the arch of tranversus abdominis, below by the coopers ligament (pectineal line of the superior pubic ramus), laterally by the iliopsoas muscle and medially by the lateral border of the rectus muscle.

12. This serves as the passage for blood vessels, nerves, lymphatics, muscles and tendons between the abdomen and the lower limb. This space is arbitrarily divided into upper and lower halves by inguinal ligament. This is the site for direct, indirect and femoral hernias. All the three can be repaired by a single piece of mesh by covering this orifice.

13. Posterior anatomy of inguinal canal: Three peritoneal ligaments are distinctive in the lower abdominal wall. The median ligament represents the obliterated urachus. The medial ligament represents the obliterated umbilical artery. The lateral ligament is a peritoneal fold containing the inferior epigastric vessels. (The inferior epigastric artery is a branch of external iliac artery).

14. Posterior anatomy of inguinal canal: The median ligament The medial ligament The lateral ligament The prominent peritoneal folds can be confused, and lead to disastrous consequences. The inferior epigastric artery can bleed briskly when injured. Dissection medial to the medial fold may injure the bladder.

15. Posterior anatomy of inguinal canal: Three structures important to consider Inferior epigastric vessels Vas deferens Spermatic vessels making inverted “Y”

16. Posterior anatomy of inguinal canal: Forming inverted y

17. Inguinal ligament: Inguinal ligament divide it into five triangles including Triangle of pain Triangle of doom(death) Triangle of indirect hernia Triangle of direct hernia ( hasel batch triangle) Triangle o0f femoral hernia

18. Triangles: Triangle of pain Triangle of doom(death) Triangle of indirect hernia Triangle of direct hernia (hasel batch triangle) Triangle 0f femoral hernia

19. Triangle of Doom

20. Triangle of pain: Femoral branch of the genitofemoral nerve Lateral branch of femoral nerve Femoral nerve.

21. Hesselbach’s triangle: Boundaries: superolateral border :The inferior epigastric vessels medial border: the rectus sheath inferior border: the inguinal ligament and pectineal ligament Direct hernias occur within Hesselbach’s triangle, whereas indirect inguinal hernias arise lateral to the triangle.

22. Space of Bogros? It is located between the posterior lamina of the transversalis fascia and peritoneum. It is a lateral extension of the retropubic space of Retzius . The space of Bogros is used for the location of prosthesis during the repair of inguinal hernia in laparoscopic surgery. It is the true preperitoneal space, known as avascular space of Bogros .

23. Nerves of the inguinal region:

24. Nerves to be considered during posterior approach include:

25. Nerves: iliohypogastric nerve ilioinguinal nerves genitofemoral nerve Lateral femoral cutaneous nerve Femoral nerve

26. Important Blood vessels in inguinal region The external iliac artery runs within the triangle of doom. The vein is posteromedial. Inferior epigastric artery is a key laparoscopic landmark. Laterally, it gives off the deep circumflex artery. along its course it gives off two branches: cremasteric branch. pubic branch.(The pubic branch courses and crosses the Coopers’s ligament to anastomose with a pubic branch of obturator artery).

27. The Circle of death: (corona mortis) The "corona mortis" is a common anatomical variant, an anastomosis between the obturator and branch of inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis. The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis .

28. Vessels likely to be injured in hernia surgery

29. Blood supply to the testis? Blood supply to the testis a. Testicular artery (major supply)—from aorta b. External spermatic artery—from inferior epigastric artery—also supply cremaster muscle c. Artery to vas deferens—from superior vesical artery. There is a rich collateral existing between these three vessels. In addition the vesical and prostatic branches communicate with the above. The scrotal vessels from internal and external pudendal vessels, freely communicate with vessels in the spermatic cord external to the superficial inguinal ring. Ligation of testicular artery alone at the deep ring may not lead to testicular atrophy provided collateral circulation is undisturbed.

30. Classification of groin hernia

31. Treatment options

32. Surgical options

33. Anterior Repairs: Rarely indicated, except for patients with simultaneous contamination or concomitant bowel resection, when placement of a mesh prosthesis may be contraindicated.

34. Iliopubic tract repair The iliopubic tract repair approximates the transversus abdominis aponeurotic arch to the iliopubic tract with the use of interrupted sutures. The repair begins at the pubic tubercle and extends laterally past the internal inguinal ring.

35. Shouldice repair : Shouldice operation which is the gold standard for prosthesis free repair. This is a four layer repair using non-absorbable monofilament suture material. The basic principle of Shouldice’s technique is the division of transversalis fascia obliquely, suturing of the lower leaf of transversalis fascia to the under surface of the upper leaf (first layer). Followed by the suturing of lower border of the upper leaf of transversalis fascia to the inguinal ligament (second layer). This is called imbrication of a double layer of transversalis fascia to the inguinal ligament. This is followed by a double layer of conjoint tendon—internal oblique muscle suturing to the inguinal ligament (third and fourth layers).

36. Bassini’s herniorrhaphy: This is the oldest technique of hernia repair After herniotomy the conjoint tendon is approximated to the inguinal ligament using interrupted polypropylene sutures (synthetic nonabsorbable).

37. Darn repair Darn repair is performed by darning a continuous nonabsorbable suture between the conjoined tendon and the inguinal ligament without approximating the two structures.

38. Tension-Free Anterior Inguinal Hernia Repair There are several options for placement of mesh during anterior inguinal herniorrhaphy, including Lichtenstein approach, Plug and patch technique, Sandwich technique, with both an anterior and preperitoneal piece of mesh.

39. The Lichtenstein Tension-free Hernioplasty The gold standard current hernia surgery is the Lichtenstein Tension-free Hernioplasty. Here approximately 16 × 8 cm size mesh (polypropylene)is placed anterior to the posterior wall after herniotomy and overlapping it generously in all directions including medially over the pubic tubercle and secured to the inguinal ligament and conjoined muscles

40. Plug and patch technique: Gilbert has reported using a cone-shaped plug of polypropylene mesh that when inserted into the internal inguinal ring, would deploy like an upside-down umbrella and occlude the hernia. This plug is sewn to the surrounding tissues and held in place by an additional overlying mesh patch. This so-called plug and patch repair, an extension of Lichtenstein’s original mesh repair, has now become the most commonly performed primary anterior inguinal hernia repair.

41. Sandwitch technique: In Lichtenstein repair, potential sites of herniation below the ligament are not covered. This is addressed when bilayer meshes are used. The onlay portion is placed as in Lichtenstein procedure while the sublay component is placed behind the fascia transversalis to cover all three hernia sites envisioned by Fruchaud .

42. Open Preperitoneal Repair The open preperitoneal approach is useful for the repair of recurrent inguinal hernias, sliding hernias, femoral hernias, and some strangulated hernias. A transverse skin incision is made 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 incised transversely and the preperitoneal space is identified The preperitoneal tissues are retracted cephalad to visualize the posterior inguinal wall and the site of herniation.

43. This approach avoids mobilization of the spermatic cord and injury to the sensory nerves of the inguinal canal, which is particularly important for hernias previously repaired through an anterior approach. If the peritoneum is incised, it is sutured closed to avoid the evisceration of intraperitoneal contents into the operative field. The transversalis fascia and transversus abdominis aponeurosis are identified and sutured to the iliopubic tract with permanent sutures.

44. laparoscopic hernia repair : Indications for laparoscopic hernia repair • Bilateral inguinal hernia • Recurrent hernia • Femoral hernia.

45. laparoscopic hernia repair :

46. Total extra peritoneal (TEP) repair:

47. Total extra peritoneal (TEP): In the TEP approach, an infraumbilical incision is used. The anterior rectus sheath is incised, the ipsilateral rectus abdominis muscle is retracted laterally, and blunt dissection is used to 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. After it is opened, the space is insufflated and additional trocars are placed. A 30-degree laparoscope provides the best visualization.

48. The inferior epigastric vessels are identified and serve as a useful landmark. Cooper’s ligament must be cleared from the pubic symphysis medially to the level of the external iliac vein. The iliopubic tract is also identifiednLateral dissection is carried out to the anterior superior iliac spine. Finally, the spermatic cord is skeletonized.

49. A direct hernia sac and associated preperitoneal fat are gently reduced by traction if not already reduced by balloon expansion. A small, indirect hernia sac is mobilized from the cord structures and reduced into the peritoneal cavity. A large sac may be difficult to reduce. In this case, the sac is divided with cautery near the internal inguinal ring, leaving the distal sac in situ, and the proximal peritoneal sac is closed with a loop ligature to prevent pneumoperitoneum from occurring. After all hernias are reduced, a 12-×14-cm piece of polypropylene mesh is inserted through a trocar and unfolded. It covers the direct, indirect, and femoral spaces. The mesh is carefully secured with a tacking stapler to Cooper’s 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, and laterally to the iliopubic tract. Tacks should not be placed below the ileopubic tract.

50. The concept of anatomical triangles described above are modeled to invite caution during laparoscopic procedures. Placement of staples or tacks in the triangle of doom jeopardizes the external iliac vessels with a consequence of troublesome bleeding. Laterally placed triangle of pain is nerve area where tacking of the mesh is to be avoided. As indicated the risk of disabling neuropathies due to injury to the femoral branch of the genitofemoral nerve, lateral femoral cutaneous nerve or the femoral nerve itself. As long as one can palpate the tip of the tacking device, these structures are not likely to be injured.

51. Transabdominal preperitoneal (TAPP): The transabdominal approach allows identification of the groin anatomy. The larger working space of the peritoneal cavity can make early experience with the laparoscopic approach easier. In the TAPP approach, an infraumbilical incision is used to gain access to the peritoneal cavity directly. Two 5-mm ports are placed lateral to the inferior epigastric vessels at the level of the umbilicus. The most important step after the initial recognition of landmarks is dissection of the preperitoneal space of Bogros after the peritoneal incision. Peritoneum is incised superior to the hernia sac with incision running from the medial umbilical ligament towards the anterior superior iliac spine.

52. A direct hernia presents at the medial umbilical fossa while the indirect hernia goes through the internal ring, the point of convergence of the vas deferens and spermatic vessels as highlighted above. Dissection medial to the medial umbilical ligament, when a large mesh needs to be placed, should be meticulous or avoided altogether as this step may endanger the urinary bladder. Rest of the procedure is similar to TEP.

53. Thank You __________________________________