Sabiston Textbook of

Surgery, 18th Ed
Hernias

Erik Peltz, D.O.

December 9th, 2010

University of Colorado Health Science Center
Department of surgery

Background

Hernia: abnormal protrusion of an organ or

tissue through a defect in its surrounding walls.

Reducible: Contents can be replaced

Incarcerated: Cannot

Strangulated: Compromised blood supply

External vs Internal vs Interparietal

Richters hernia

Hernia:

Background

5% of patients will develop an abd wall hernia

75%
15 20%
10%
5%

inguinal region
incisional
umbilical and epigastric
femoral

Background

Groin hernias M:F 25:1

Femoral
F:M 10:1
Umbilical F:M 2:1

Indirect:Direct 2:1

Inguinal vs Femoral hernia ?

Inguinal are more common than femoral hernias in
both M, F

10% of females and 50% of males with femoral hernia will

develop and inguinal hernia

Background

Indirect Inguinal hernia Which side is more

common?
More common on right
Slower descent of right teste
Delayed atrophy of the right processus vaginalis

Femoral Hernia
More common of right
Tamponade of sigmoid colon protecting Left?
15 20% rate of incarceration.

Mandate operative repair when diagnoses

Anatomy

Anatomy

Inguinal Canal

Contains the spermatic cord / round ligament of the uterus

Spermatic cord

Cremasteric muscle inferior extension of internal oblique

Testicular artery (aorta), Veins (left renal, right IVC)
Genital branch genitofemoral nerve
Vas deferens
Lymphatics
Processus vaginalis

Hesselbachs triangle

Bounderies
Inferior Epigastrics

Rectus Sheath

Superior Lateral border

Medial border

Inguinal Ligament

Inferior border

direct Hernia

indirect Hernia

Associated Nerves

Iliohypogastric (L1) suprapubic / inguinal sensation

Ilioinguinal (L1) Inguinal / scrotal / proximal thigh

Beneath the interal obl. at the ASIS

Penetrate I.O. and course superior / medial

Beneath the interal obl. At the ASIS

Penetrates I.O. and courses superior / medial overlying cord

Genital branch (L1 L2), genitofemoral

Courses with the cremaster fibers in the spermatic cord

Cremaster motor
Scrotal sensation

Femoral Canal

Boundaries

Iliopubic tract anteriorly

Coopers ligament posteriorly
Femoral vein laterally

Differential Diagnosis

Inguinal hernia
Femoral hernia
Adenitis
Varicocele
Ectopic teste
Lipoma
Hematoma
Sebaceous cyst
Hidradenitis
Lymphoma

Metastatic neoplasm
Epididymitis
Testicular torsion
Vascular aneurysm /
Pseudoaneurysm

Diagnosis

Hx / PE

Supine and Standing

Valsalva
Invagination of scrotum to inspect canal
Inguinal adenopathy?
Hx CA?
Rectal Exam? Colonoscopy?
Bulge below inguinal ligament Femoral Hernia
Comorbidities: Pulmonary, Cirrhotics, renal failure /
dialysis, Constipation / GI / Colon CA?

Diagnosis

Imaging:

Ultrasound: sensitive and specific

CT
Laparoscopy

Non-operative management

Fitzgibbons et al., JAMA 2006

700 pts randomizes to non-op vs operative repair

25% non-op pts crossed over (pain / enlargement)

Incarceration with non-op 0.03%

No difference in operative outcome with watchful
waiting (SSI, OR time, Recurrence Rates)

Operative management

Tissue Repair

High recurrence rates largely replaced by mesh repairs

Remain useful / important in certain situation

Strangulated hernias / bowel resection / infection

Iliopubic Tract Repair

Shouldice
Bassini
McVay

Tissue Repair

Iliopubic Tract Repair

Approximates the
transversus abdominis /
conjoint tendon to the
iliopubic tract.

Tissue Repair

Bassini Repair

Single layer repair

T. Abdominis / IO /
conjoint tendon to the
inguinal ligament

Tissue Repair

Shouldice Repair

Multi-layer repair
T. Abdominis incised
Overlap T.A.
Free edge of T.A. Iliopubic
tract.
2nd deep layer of interal
oblique / T.Abdominis to
inguinal ligament
May incorporate relaxing
incision
Low recurrence rate for
tissue repair (2%)

McVay Tissue Repair

McVay Repair

Multi-layer
Very useful in incarcerated or strangulated femoral hernias.
Approximates Transversus Abdominis to Coopers Ligament
(postero-medial aspect of femoral canal)
Relaxing incision in posterior aspect of the anterior rectus
sheath then allows layered closure of internal oblique to
inguinal ligament tension free fashion.

McVay Tissue Repair

Lichtenstein

Mesh Repair

Tension is the pricinpal cause of recurrence

Tension Free Mesh Repair

Lichtenstein

Tension is the pricinpal cause of recurrence mesh placed to

reinforce the inguinal floor / Internal ring

May be sutured to conjoint / internal oblique and iliopubic tract

Results:
Several Randomized Controlled Trials
Recurrence 0% - 3.5%
Critics note short follow-up (1-3 yrs) in many of these
trials.
Rate is better than 5 15% reported for many primary tissue
repairs.

Preperitoneal Repair

Pre-peritoneal Repair

Involves initial incision 2cm cephalad to the internal

ring.
Dissection to the preperitoneal plane through the
anterior rectus muscles
Both primary and mesh repairs described.

Very useful open approach for:

Recurrent Hernias
Sliding Hernias
Stangulated Hernias
Femoral Hernias

Laparoscopic Inguinal Repair

Trans-abdominal Preperitoneal (TAPP)

Totally Extraperitoneal

Very useful for bilateral hernias / recurrence

Recurrence Rates from RCT 0 10%

Veterans Admin RCT
TEP vs Lichtenstein
Recurrence 10% vs 5%
Surgeon experience with technique questioned

Special Considerations

Sliding Hernia

Recurrent

Internal organ comprises a portion of the wall of the

hernia sac. (Colon or Bladder)
Careful identification before injury to organ
McVay, open preperitoneal, laparoscopic

Stangulated

Open preperitoneal
Allows single incision evaluation, resection and
repair of hernia

Complications

SSI

1 2% open, less with laparoscopic

No abx necessary for elective repair

Including placement of mesh

Abx for:

ASA > 3, comorbidities, strangulation, etc

Complications

Nerve Injury

Traction, electocautery, transection, entrapment

Ilioinguinal, Iliohypogastric, Genitofemoral
Lateral femoral cutaneous (laparoscopic)
Chronic pain has surpassed recurrence as the
leading postop complication (29 76%)

Complications

Ischemic Orchitis

Thrombosis of pampiniform plexus veins

Tender / swollen teste POD 2 5
Continues for 6 12 wks
Test atrophys

Complications

Recurrence:

1 3% tension free and laparoscopic repairs

Most commonly recur within 2 yrs

Shouldice has the lowest reported recurrence rate for tissue

repairs 2%

Umbilical Hernia

Congenital in infants

Most close by 2yoa. Repair if persist after 5yoa.

Adults acquired

Obesity, ascites, pregnancy, abdominal distension

Primary Repair vest over pants
10 30% recurrence rate
< 3 cm may primarily repair with interupted suture
> 3 cm mesh under lay, overlay, +/- primary closure

Epigastric Hernia

2 3 times more common in men

Often incarceration of preperitoneal fat

Pain

20% multiple
80% off of the midline
Repair similar to umbilical hernia

Surgical Site Infections

Causes and Risk Factors

Bacterias
Fault
BACTERIA
Surgeons
Fault
Remote
site infection
Patients
Fault
Long-term
care facility

(Microorganism)
LOCAL WOUND
(Local Wound
Factors)
Surgical
Technique
(Patient Factors)
Hematoma / seroma

PATIENT
Age
Immunosuppression

Recent hospitalization

Necrosis

Steroids

Duration of procedure

Sutures

Malignancy

Wound class

Drains

Obesity

ICU Patient

Foreign bodies

Diabetes / Glucose Control

Previous Abx

Malnutrition

Preoperative shaving

Comorbidities

Bacterial #, virulence, resistance

Transfusions
Cigarette
Oxygen Delivery
Temperature

Surgical Site Infections

Preventative Measures for SSI

Timing of action

Bacteria

Local

Patient

Preoperative

-Shorten Preop Stay

-Antiseptic Shower
-Hair Clippers
-Postpone Surgery or
treat remote infection
-Apporpriate Prophylaxis
-Bowel Prep?

Intraoperative

-Asepsis
-Antisepsis
-Control Spillage

-Supplemental O2 (80%)
-Intra-operative Warming
-Fluid Resuscitation
-Strict Glucose Control

Postoperative

-DSG 48 72 hrs
-Early Drain Removal
-Avoid Postop Bacteremia

-Early Enteral Nutrition

(EAST)
-Supplemental O2
-Strict Glucose Control
-Surveillence Programs

-Hair Clippers

-Optimize Nutrition
-Pre-operative Warming
-Strict Glucose Control
(80 110)
-Smoking Cessation

Bacterias Fault

Asepsis and Antisepsis Practices

Chlorhexidine Shower

No reduction in SSI. Do reduce bacterial colony count.

CDC recommendation
Cardiac, Vascular, Prosthetic Procedures

No shave
Germicidal Skin prep
Surgical scrub
Sterile technique

Gowns/masks/hats/gloves/OR FOOT TRAFFIC

Antimicrobial Prophylaxis

Enteral (Abx bowel prep)

Non-absorbable antibiotics to suppress both aerobic

and anaerobic intestinal bacteria.

Neomycin + Erythromycin at 19, 18 and 9 hours before

surgery. (Nichols Prep)

Effect of Preoperative Neomycin-Erythromycin Intestinal

Preparation on the Incidence of Infectious Complications
Following Colon Surgery. Nichols, RL et al. Ann Surg. 1973;
178(4): 453-462.

Meta-analyses have recently shown no benefit

over IV Abx and when combined with mechanical
prep there is a trend towards increased anastomotic
leaks.

Antimicrobial Prophylaxis

Intravenous

Clean Cases

Not indicated for low-risk, straightforward clean

procedures with no obvious bacterial contamination or
insertion of a foreign body.

All others: Abx appropriate to anticipated flora

should be given within one hour of incision and redosed at 1 2 half lives for longer cases.

Antimicrobial Prophylaxis

Intravenous

No anticipated entry into colon / distal small bowel

Ancef
Clindamycin (cephalosporin allergy)

Potential SB / Colon
Must cover for obligate anaerobic bacteria (Bacteroides)
Cefotetan, Cefoxitin (shorter T )

Antimicrobial Prophylaxis

Intravenous

Concern for MRSA (IVDA, Institutionalized, NH,

recent hospitalization)

Vanc

Patients Allergic to Cephalosporins with planned

bowel surgery
Aminoglycoside or Flouroquinolone + Clinda or Flagyl
Aztreonam + Clinda or Flagyl
Zosyn, Ertapenem, etc

Antimicrobial Prophylaxis

Common flora

Biliary Tract: Chronic Cholecystitis: < 1% SSI

Gram Negative
Klebsiella
Escherichia coli
Enterobacter
Pseudomonas
Citrobacter
Proteus

Open Chole
Ancef

Gram Positive
Enterococcus
Streptococcus

Lap Chole
Low risk NONE
High risk Ancef

Anaerobes
Bacteroides
Clostridium

Open Biliary
Unasyn,
Carbepenems,
Cipro +Flagyl,
Cefotetan,
Cefotaxime,
Ceftriaxone

Fungi
Candida

ERCP
Low risk None
High risk
Unasyn,
Carbepenems,
Cipro +Flagyl,
Cefepime

Antimicrobial Prophylaxis

Common flora

Appendicitis:
Aerobic /
Facultative
Anaerobes
Escherichia coli
Viridans strep
Pseudomonas
Group D strep
Enterococcus

Anaerobic

Bacteroides fragilis
Bacteroides spp
Peptostreptococcus
Bilophila
Lactobacillus
Fusobacterium

Must cover aerobic and anaerobic bacteria

Cefoxitin, Cefotetan
Levo + Flagyl
Zosyn ?, Ertapenem ?

Antimicrobial Prophylaxis

Common flora

Colon:
Bacteria make up to 90% of the dry weight of feces.
109 Organisms/ml feces

Aerobic
Escherichia coli
Enterococcus
Proteus
Streptococcus
Pseudomonas

Anaerobic
Bacteroides fragilis
Peptostreptococcus
Bilophila
Lactobacillus
Fusobacterium

Must cover aerobic and anaerobic bacteria

Cefoxitin, Cefotetan
Levo + Flagyl
Zosyn ?, Ertapenem ?

Surgeons Fault
Surgical Technique

Complications happen because you want

them to happen
Surgical Technique
Careful Tissue Handling

Monofilament Sutures

Ensure Adequate Blood Supply

Absorbable Sutures

Adequate Hemostasis

Closed Suction Drains to prevent

seroma / hematoma

Debriedment of Necrotic Tissue

Removal of Foreign Bodies

Avoid Open Drains (penrose)

Surgical Technique

Wound Closure

Delayed Primary Closure:

Heavily contaminated wounds or wounds with

Targeting closure of
devitalized tissue.

wound at point of
optimal macrophage
Allows for the body to developnumbers
adequate
inflammatory /
/ activity

cellular response to potential pathogens

Phagocytic cells progressively increase in number at the wound

edges to a peak at approximately day 5.
Capillary budding
Closure can be accomplished even with high bacterial counts.

Patients Fault

Malnutrition

Pre-op TPN / Enteral Feeds

Early post-op Enteral Feeds

Tobacco
Pre / Intra / Post-op Warming
Glucose Control
Adequate resuscitation / CO / O2 deliver?

Specific Surgical Infections

Specific Surgical Infections

Non-Necrotizing Soft Tissue Infections

Cellulitis: Erythema, Warmth, Induration, Pain

Acute inflammatory response
Small vessel engorgement / stasis
Endothelial leakage / interstitial edema
PMN infilitrate

Should

resolve with appropriate Abx coverage

Abscess: All of the above +

Sequelae of necrotic tissue, ischemia, pus
Fluctuance

Drainage

/ debriedment for local control

Specific Surgical Infections

Non-Necrotizing Soft Tissue Infections

Abscess:
Head and Neck: S. aureus +/- Strep
Axilla: Gram Negative component
Below Waist: Mixed aerobic and anaerobic gram neg.

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Absence of clear local boundaries or palpable limit

Layer of necrotic tissue not walled off by
surrounding inflammation

Mortality

16% - 45%

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Overlying skin may look remarkably NORMAL

Rapidly progressive infection within the superficial
subcutaneous fascial planes.
Bounded by deep investing fascia.
Inflammation / edema / +/- sub-Q air / Tense / Tender
to palpation
Late signs are erythema / ecchymosis / cyanosis /
blisters secondary to perforating vessel thrombosis.

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Imaging:

CT, MRI: Inflammation (enhances on T2 imaging) /

edema within superficial tissues / Sub-Q gas ?
These modalities are sensitive but non-specific.
High index of suspicion to avoid delay in definitive
therapy Extensive fascial debriedment.

Specific Surgical Infections

Critical Care Medicine, 2004; 32(7): 1535 1541

Singapore

Retrospective Study
n = 89 pts admitted for Nec. Fasc.
n = 225 controls
Employed regression model to evaluate
various laboratory values at admission to
predict risk of Necrotizing Fasciitis.

Specific Surgical Infections

Specific Surgical Infections

Critical Care Medicine, 2004; 32(7): 1535 1541

Singapore

LRINEC Predictive Value

Risk Group
Low Risk
Moderate Risk
High Risk

LRINEC SCORE

PROBABILITY OF NEC.
FASC.

PREDICTIVE VALUE

LRINEC < 5

50%

LRINEC 6 7

50% - 75%

6; PPV 92% NPV 96%

LRINEC 8

>75%

8; PPV 93.4%

Specific Surgical Infections

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Finger Test
2 cm incision made down to deep fascia
+ Test

Lack of bleeding
Thrombosed vessels
Dishwater exudate
Lack of resistence to finger dissection

Frozen Section

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Necrotizing Soft Tissue Infections require emergent

wide excision of all clinically involved tissues.
Re-operation within 24 hours, or sooner
Systemic support for impending severe sepsis
Extremity involvement often requires amputation to
control local infection.

Abx coverage for common organisms

Specific Surgical Infections

Necrotizing Soft Tissue Infections

Variable (on admission)

# points

Heart rate > 110

Temp < 360 C

Creatinine > 1.5 mg/dl

Age > 50yr

WBC > 40

Hct > 50

Group Categories

# Points

Mortality Risk

02

6%

35

24%

88%

Anaya DA et al. Predicting mortality in necrotizing soft tissue infections.

Surg Infect. 2009; 10(6): 517 522

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

Mortality: 5 50%
Definitive therapy is NOT antibiotic management,
rather Operative or Interventional drainage.
a patient with fever and abdominal pain is not
given antibiotics without a plan leading to
surgery or other drainage procedure.
Administration of antibiotics in this setting before
diagnosis may obscure subsequent findings and
delay diagnosis and will certainly delay definitive
operative management.

Non-Surgical Causes of Acute Abdomen

Endocrine and Metabolic Causes
Uremia
Diabetic crisis
Addisonian crisis
Acute intermittent porphyria
Hereditary Mediterranean fever
Hematologic Causes
Sickle cell crisis
Acute leukemia
Other blood dyscrasias
Toxins and Drugs
Lead poisoning
Other heavy metal poisoning
Narcotic withdrawal
Black widow spider poisoning
Other

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

Does the Patient Need a Hole?

-Hx consistent with Surgical
Process?
-Peritonitis?
-Acidosis?
-Shock
-Non-op causes excluded

Yes
Emergent Operation
Source Control

Pancreatitis
Pyelonephritis
Salpingitis
Amebic Liver Abcess
Enteritis
SPB
Diverticulitis?
Cholangitis?

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

Does the Patient Need a Hole?

-Hx consistent with Surgical
Process?
-Peritonitis?
-Acidosis?
-Shock
-Non-op causes excluded

Yes

-Additional Labs
-Imaging
-Serial Exam
-Invasive Monitoring
-Percutaneous Drainage
-Other Intervention (ERCP, PTC,
Endoscopy)

No

Broad Spectrum
Antibiotics

Emergent Operation
Source Control

Does the Patient Need a Hole?

Specific Surgical Infections

Intra-abdominal and Retroperitoneal Infections

Abx
Cefoxitin, Cefotetan
Timentin
Ertapenem
Unasyn
Imipenem
Meropenem
Zosyn
Flagyl
Clinda
Vanc

Non-Surgical Infections

UTI #1 nosocomial post-op infection

Pneumonia 3rd most common
Central Lines
Sinusitis