inguinal hernia repair surgery- dr valeria simone, southlake general surgery
TRANSCRIPT
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Inguinal
Hernia
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Incidence
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Approximately 700,000 hernia repairs are performed as an outpatient procedure each year
Approximately 75%of all hernias occur in the inguinal region
Approximately 50%of hernias are indirect inguinal hernias
A vast majority occur in males
Hernias more commonly occur on the right side
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The Anatomy
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Historical Hernias
Herniashave been documented throughout history with varying successat either reduction or repair.
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Trusses & Techniques
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Anatomic Considerations
• The inguinal region must be understood with regard
to its three-dimensional configuration
• A knowledge of the convergence of tissue
planesisessential
• If repairing the hernia laparoscopica lly, theanatomy must be well understood from theperitoneal surface outward
• There is a considerable amount of anatomic
variability with regard to:
o Size and location of the hernia
o Degree of adipose tissue
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Pelvic & Inguinal Anatomy
Both the ilioinguinal nerve and the genitofemoral nerve traverse the usual hernia-repair operative field. The femoral vein also runs just deep to the inguinal floor laterally.
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Myopectineal Orifice of Fruchaud
The MPO isbordered:• Above by the arching fibersof the internal
oblique and transversus abdominus Muscles,• Medially by the Rectus AbdominusMusc le
and its fascial RectusSheath• Inferiorly by Coopers Ligament, and• Laterally by the IleopsoasMuscle
• Running diagonally thru the MPO is the inguinal ligament
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Myopectineal Orifice of Fruchaud
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Hesselbach's triangle
Boundaries:
Medial:
Rectusabdominismuscle
medially,
Inferiorly:
Inguinal ligament
Laterally:
Inf. Epigastrics
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Diagnosis
• The patient usually presents (forgroin hernia)with the complaint of a bulge in the inguinalregion
• They may describe minor pain or vague discomfort associated with the bulge
• Extreme pain usually represents incarceration with intestinal vascular compromise
• Paresthesiasmay be present if inguinal nervesare compressed
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Diagnosis
Physical examo The patient should be standing and facing the
examiner
o Visual inspection may reveal a lossof symmetry in the inguinal area or bulge
o Having the patient perform valsalva’smaneuver or cough may accentuate the bulge
o A fingertip is then placed in the inguinal canal;Valsalva maneuver is repeated
o Differentiation between indirect and direct hernias at the time of examination is not essential
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Nyhus Classification
• Type I:Indirect inguinal hernia Internal inguinal ring normal (simple pediatric hernia)
• Type II:Indirect inguinal hernia
Internal inguinal ring dilated but posterior inguinal wall intact (inferior deep epigastric vesselsnot displaced)
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Inguinal Hernia
• Indirect inguinal hernia
o Isa congenital lesion
o Occurswhen bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalis
o If the processusvaginalisdoes not remain patent an indirect hernia cannot develop
o Most common type of hernia
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Indirect Hernia Route
Note:
The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.
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Inguinal Hernia
• Direct inguinal hernia
o Proceedsdirectly through theposterior inguinal wall
o Direct hernias protrude medial to the inferior epigastric vessels andare not associated with theprocessusvaginalis
o They are generally believed tobe acquired lesions
o Usually occur in older males as a resultof pressure and tension on the musclesand fascia
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Direct Hernia Route
Note:
The hernia sac passes directly through Hesselbach's triangle and may disrupt the floorof the inguinal canal.
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Specific Surgical Procedures
• Lichenstein (Tension Free) Repair
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McVay (Cooper’s Ligament) Repair
Halstead’sRepair
• Shouldice (Canadian) Repair
• Laproscopic Hernia Repair
• Bassini Repair
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Bassini Repair
o Is frequently used for indirect inguinal hernias and small direct hernias
o The conjoined tendon of the transversus abdominisand the internal oblique muscles issutured to the inguinal ligament
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Laparoscopic Hernia Repair
o Early attempts resulted inexceptionally high reoccurrencerates
oCurrent techniques include
• Transabdominal preperitoneal repair(TAPP)
• Totally extraperitoneal approach(TEPA)
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Laparoscopic Mesh Repair
Note:
Viewed from inside the pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.
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Laparoscopic Mesh Repair
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