Inguinal hernia and its management

A thorough presentation on inguinal hernia and its management

1. INGUINAL HERNIA AND ITS MANAGEMENT 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. ETIOLOGY Multifactorial 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 Skin Subcutaneous fasciae (Camper and Scarpa ) (superficial fascia) Innominate fascia (Gallaudet) External oblique aponeurosis , including the inguinal, lacunar , and reflected inguinal ligaments Spermatic cord Internal oblique muscle, Transversus abdominis muscle and aponeurosis , and the conjoined tendon. Anterior lamina of transversalis fascia Posterior lamina of transversalis fascia Preperitoneal connective tissue with fat 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.

15. BOUNDARIES OF THE RINGS External ring: Triangular opening of the a poneurosis 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.

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

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

18. COVERINGS OF THE SPERMATIC CORD

19. 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.

20. 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)

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

22. 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

23. 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.

24. 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

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

26. 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

27. 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

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

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

30. 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.

31. 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.

32. PREPERITONIAL SPACES

33. PREPERITONIAL SPACES

34. 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

35. 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

36. 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.

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

38. NYHUS CLASSIFICATION SYSTEM

39. MANAGEMENT OF INGUINAL HERNIA

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

41. 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.

42. 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 .

43. HERNIOGRAPHY Right sided Direct I nguinal H ernia Left sided Indirect I nguinal H ernia

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

45. 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

46. TRUSS

47. 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

48. PROCEDURES HERNIOTOMY HERNIORRHAPY HERNIOPLASTY

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

50. 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

51. HERNIOTOMY

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

53. HERNIORRHAPHY Herniotomy Approximation of conjoint tendon with inguinal ligament

54. Types of herniorrhaphy

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

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

57. 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)

58. EDUARDO BASSINI FATHER OF MODERN INGUINAL HERNIA REPAIR 1884

59. 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.

60. 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

61. 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

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

63. 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

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

65. 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.

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

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

68. 3 rd & 4 th The conjoint tendon and inguinal ligament is approximated by two layers of continuous suture . 5 th & 6 th 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.

69. 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.

70. 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

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

72. 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

73. Technique of the Operation

74. 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.

75. 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

76. 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

77. 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.

78. 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

79. 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

80. 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

81. 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

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

83. 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.

84. -Two 5-mm t rocars are placed in the midline.

85. 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.

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