SURGICAL OPTIONS IN

THE MANAGEMENT OF
INGUINAL HERNIAS
Mohammed Al-Saffar

outlines

Definition
Epidemiology
Anatomy
Surgical management options

Hernia

A hernia is defined as an abnormal

protrusion of an organ or tissue through
a defect in its surrounding walls.

Groin hernia

Inguinal
Direct
Indirect

femoral

Epidemiology

Epidemiology

Predisposing factors

Epidemiology

Bimodal peak age : < 1 year then > 40

years
Right-sided groin hernias are more
common than those on the left.

Types of hernia - Condition

Inguinal Canal Anatomy

No disease of the human body,
belonging to the province of the
surgeon, requires in its treatment a
better combination of accurate,
anatomical knowledge with surgical skill
than Hernia in all its varieties.
Sir Astley Cooper, 1804

Inguinal Canal Anatomy

The inguinal canal is an oblique space

measuring 4 cm in length that lies above
the medial half of the inguinal ligament.

Inguinal canal has 4 walls : anterior,

posterior, roof, and floor

Important ligaments

Contents of the inguinal canal

Males : spermatic cord and ilioinguinal

nerve

Females : round ligament and the

ilioinguinal nerve

The spermatic cord

It consists of

Three coverings
Three arteries
Three other structures.
Nerves

The Spermatic Cord

Preperitoneal space

Space of Retzius
Space of Bogros
Inf. Epigastric
Vas deferens
the lateral
femoral
cutaneous nerve
the genitofemoral
nerve.

Management

Uncomplicated hernias require either :

No treatment
Support with a truss
Operative treatment

complicated hernias :

always require surgery, often urgently.

? Should we repair

Inguinal hernia :
should we repair ?

?Inguinal hernia : should we repair

Surgical approaches

For any hernia the surgical option

comprises 2 components :

Herniotomy
Herniorrhaphy or hernioplasty

It is either :

Open repair
Laparascopic repair

Surgery

Surgery aims to

Reduce the hernial contents

Excise the sac (herniotomy) in most cases
Repair and close the defect either by
herniorrhaphy or hernioplasty

Components of the hernia

Hernial Sac Dissection

Types of open repair

Repairing the floor of the inguinal canal :

Bassini repair
Shouldice repair
Tension free mesh repair

Bassini repair

The conjoined tendon is retracted upward

the aponeurosis of the transversus abdominis
muscle is approximated to the iliopubic tract
that lies adjacent to the inguinal ligament with
several interrupted 3-0 silk sutures.
The second layer of the repair involves suturing
the conjoined tendon to the inguinal ligament
with interrupted 2-0 silk sutures.
This suture line extends from the pubic tubercle
to the medial border of the internal ring.

Shouldice Repair

With a no. 15 scalpel an incision is made

in the transversalis fascia. This incision is
extended from the internal ring to the
pubic tubercle.

The repair involves placing four lines of

sutures.

Shouldice repair

The first suture line

is started at the pubic tubercle using 3-0

continuous polypropylene, and the white line is
approximated to the free edge of the inferior
transversalis fascial flap.

The 2nd suture line :

At the internal ring the suture is tied and then

continued medially by approximating the free
edge of the superior flap to the shelving edge of
the inguinal ligament. When the pubic tubercle
is reached, the suture is tied and divided.

Shouldice repair

The third suture line is started at the

level of the internal ring where the
conjoined tendon is approximated to the
inguinal ligament and tied when the
pubic tubercle is reached.
Using the same suture, the fourth suture
line attaches these same structures to
one another and is tied at the level of
the internal ring.

Shouldice repair

The cord is replaced within the inguinal

canal, and the external inguinal
aponeurosis is reapproximated with
continuous 2-0 absorbable sutures

Tension free repair

There are several options for placement

of mesh during anterior inguinal
herniorrhaphy, including

The Lichtenstein approach

The plug-and-patch technique
The sandwich technique with both an
anterior and preperitoneal piece of mesh.

Tension free repair

Tension free repair

Prolene hernial system

Comparison of open approachs

Recurrence rate PGY

Laparoscopic Repair

Indications for laparoscopic repair

Bilateral inguinal hernia

When the diagnosis of inguinal hernia is
uncertain
When the patient want to return to
normal physical life

Contraindications

The patient medical condition makes

general anesthesia more risky
Patient who have planned pelvic or
extraperitoneal operations (eg, radical
prostatectomy)
Patient who have had a recurrence from
a prior laparoscopic repair
Patient presented with strangulated
hernia

Advantages of laparoscopic

Less acute postoperative pain

Shorter convalescence
Earlier return to work

Disadvantages

increased risk of femoral nerve injury

and
Increased risk of spermatic cord damage
risk of developing intraperitoneal
adhesions with the TAPP
greater cost and duration of the
operation.

Laparoscopic Approaches

Laparoscopic repair is done by 2

approaches :
1.
2.

Transabdominal preperitoneal TAPP

Totally extraperitoneally TEP

Transabdominal Preperitoneal

The TAPP approach, first described by

Arregui and colleagues in 1992

It requires laparoscopic access into the

peritoneal cavity and placement of mesh
in the preperitoneal space after reducing
the hernia sac.

Totally extraperitoneally

The first TEP inguinal hernia repair was

described by McKernan and Laws
in1993.

This approach involves preperitoneal

dissection and mesh placement without
entering into the abdominal cavity.

The Mercedes Benz sign

Thank You

Complication

Urinary retention
Nerve injury
Testicular ischemia and atrophy
Injury to vas deferens
recurrence