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Inguinal Hernia
R>L M > F (7-FOLD) In Men: Indirect >> Direct >>>>Femoral In Women Indirect > Femoral > Direct Femoral hernias account for fewer than 10% of all groin hernias
40% present as emergencies (i.e., with incarceration or strangulation) Mortality is higher for emergency repair than for elective repair
Natural History
RJ Fitzgibbons, A Giobbie-Hurder, JO Gibbs, Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA 2006 vol:295 page:285
Randomized, controlled trial from 2006, Minimally symptomatic inguinal hernia was addressed in a in which 364 men were assigned to 'watchful waiting' (WW) 356 men underwent routine operation. Only two patients in the WW group required emergency operations for strangulation over the follow-up period of 2 to 4.5 years. This result is about 1/5 of 1% for each year that the hernia remains unrepaired.
The two patients who required emergency operations recovered uneventfully.
At the conclusion of the study, functional status, as measured by quality-of-life instruments and pain scales, was identical in the two groups.
Postoperative complication rates were the same in patients who underwent immediate surgery as in those who were assigned to watchful waiting but had to cross over to surgical treatment.
Physiology / Pathophysiology
Inguinal Hernia
Either indirect or direct Indirect inguinal hernia
Passes through internal inguinal ring, traverses inguinal canal to external ring May extend into scrotum in males and labia majora in females Passes lateral to inferior epigastric vessels and has an oblique inferior course Considered a congenital defect and associated with a patent processus vaginalis 5x more common than direct inguinal hernias
Anatomy
Anterior Pelvis
Muscles:
External Oblique Most superficial
Course Inferiomedial
Inguinal Boundaries:
Superior Aponeurosis of Tansversus Abdominus (Falx Inguinalis)
Fuses with internal oblique aponeurosis to form conjoined tendon medially Medial portion attached on pectineal/ Coopers ligament Fuses anteriorly and inferior as the ileopubic tract
Forms shelving edge when traveling inferiorly and posteriorly cradling cord structures Inserts into inguinal ligament and travels posteriorly to ileopubic tract.
Canal Anatomy
Fascial Anatomy
Transversalis fascia
attached to the iliac crest laterally inserts on the pubic tubercle medially
crura of the deep inguinal ring, Continues into insert into Cooper's ligament (i.e., the pectineal ligament) a condensation of the periosteum .
Fascial Anatomy
Between the transversalis fascia and the peritoneum is the preperitoneal space.
In the midline behind the pubis - The space of Retzius; Laterally - The space of Bogros. The preperitoneal many of the inguinal hernia repairs are performed in this area. Within the preperitoneal space:
inferior epigastric vessels deep inferior epigastric vein iliopubic vein retropubic vein internal spermatic vessels vas deferens
Inguinal Anatomy
Inguinal Canal
Passage through anterior abdominal wall Conveys spermatic cord in males and round ligament in females Formed embryologically by evagination of processus vaginalis through anterior abdominal wall
Inguinal Anatomy
Inguinal Nerves
Types of Repair
Marcy Repair
Children and young adults Concern about the longterm prosthetic material. High ligation of the sac and narrowing of the internal ring. Displacing the cord structures laterally allows the placement of sutures through the muscular and fascial layers
Bassini Repair
Reconstruction of the inguinal floor by opening the transversalis fascia from the internal inguinal ring to the pubic tubercle, thereby exposing the preperitoneal fat, Bluntly dissected undersurface of the superior flap of the transversalis fascia 'triple layer' approximation The layer of transversalis fascia and the transversus abdominis is sutured, with the internal oblique muscle, to the reflected inguinal ligament
Bassini Repair
Reconstruction of the inguinal floor by opening the transversalis fascia from the internal inguinal ring to the pubic tubercle, thereby exposing the preperitoneal fat, Bluntly dissected undersurface of the superior flap of the transversalis fascia 'triple layer' approximation The layer of transversalis fascia and the transversus abdominis is sutured, with the internal oblique muscle, to the reflected inguinal ligament
Shouldice Repair
2 layers A continuous running suture reapproximates the inguinal floor A second layer is started near the internal ring, approximating the internal oblique muscle and the transversus abdominis to a band of external oblique aponeurosis superficial and parallel to Poupart's ligament This suture line ends at the pubic crest. A fourth suture line may be added
Shouldice Repair
2 layers A continuous running suture reapproximates the inguinal floor A second layer is started near the internal ring, approximating the internal oblique muscle and the transversus abdominis to a band of external oblique aponeurosis superficial and parallel to Poupart's ligament This suture line ends at the pubic crest. A fourth suture line may be added
Shouldice Repair
Shouldice Repair
McVay Repair
Similar to the Bassini repair, Except that it uses Cooper's ligament instead of the inguinal ligament Interrupted sutures are placed from the pubic tubercle laterally along Cooper's ligament, progressively narrowing the femoral ring Treatment of Femoral Hernia The last stitch in Cooper's ligament is known as a transition stitch and includes the inguinal ligament. Relaxing Incision
McVay Repair
Lichtenstein Repair
Femoral Anatomy
Femoral Hernia
Begins posterior to medial portion of inguinal ligament Traverses femoral canal to fossa ovalis Herniated contents are below inguinal ligament, lateral to pubic tubercle and medial to femoral vessels More common in older women
Femoral Anatomy
Below the iliopubic tract Iliopectineal arch separates the vascular compartment (femoral vessels) from the neuromuscular compartment (iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous nerve) Vascular compartment
3 subcompartments:
(1) the lateral, containing the femoral artery and the femoral branch of the genitofemoral nerve; (2) the middle, containing the femoral vein; (3) the medial, which is the cone-shaped cul-de-sac known as the femoral canal.
The femoral canal is normally a 1 to 2 cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis. normally contains preperitoneal fat, connective tissue, and lymph nodes (including Cloquet's node at the femoral ring)
The femoral ring is bordered by the superior pubic ramus inferiorly, the femoral vein laterally, and the iliopubic tract (with its curved insertion onto the pubic ramus) anteriorly and medially. A femoral hernia exists when the blind end of the femoral canal becomes an opening (the femoral orifice) through which a peritoneal sac can protrude.
Femoral Anatomy
Ventral Hernia
Fascial Anatomy
Linea alba
Raphe of the flat abdominal muscles
Rectus sheath
Invests
Rectus abdominis muscles Epigastric vessels
Aponeuroses of external oblique, internal oblique and transversus abdominis muscles Internal oblique aponeurosis splits:
Upper abdominal wall:
Anterior portion and joins external oblique aponeurosis to form anterior rectus sheath Posterior portion joins transversus abdominis aponeurosis to form posterior rectus sheath
Fascial Anatomy
Upper midline incisions are associated with the highest incidence of ventral hernia formation Transverse or oblique incisions with the lowest. Most incisional hernias are detected within 1 year of surgery Male-to-female incidence ratio is 1:1, Early evisceration is more common in males.
Incisional hernia
Risk factors for (Re/O)ccurrence:
Male sex, age, obesity, jaundice, underlying disease process, wound infection, abdominal distension, pulmonary diseases
Timeline
Prior to 1960s
Primary repair wit natural materials Transposition of tissue
1959 - Advent of synthetic material Polyproplene suture and mesh Materials and positions for mesh closure 1983 PTFE used for mesh closure 1980s Rives and Stoppa separately described Subfascial/ pre-peritoneal placement of mesh 1990 Ramirez, described a method to close incisional hernia defects by separating the muscle planes of the abdominal wall termed, component separation.
Luijendijk et al.
at 3-years, regardless of hernia size, mesh repair was statistically superior to suture repair (43% vs. 24%) in the recurrence of midline abdominal incisional hernias.(21)
Burger et al.
Follow-up work by documented a 10-year cumulative recurrence rate of 63% for suture repair and 32% for underlay mesh repairs of first time midline incisional hernia defects <6cm. (22)
Composite synthetic materials have been develop specifically to prevent visceral injury and adhesion formation. Wiliams et al., demonstrated that the Rives-Stoppa method, could be accomplished intra-peritoneally.
Specifically, they performed open incisional hernia repairs using an intraperitoneal mesh underlay. In their study, the repairs were completed with a variety materials designed to limit visceral erosion including ePTFE, coated polyester, coated polypropylene, and biologic meshes.
Questions
Question 1
The Shelving portion of the inguinal ligament used for open inguinal hernia repair:
A) is formed from the external oblique aponeurosis B) Arises from the transversalis fascia C) Inserts directly on to creamasteric fascia D) represents the superior border of the iliopubic tract E) is usually sutured to the transversus aponeurosis arch (flax inguinalis), which lies inferior to it , to complete a primary open repair
Question 1
The Shelving portion of the inguinal ligament used for open inguinal hernia repair:
A) is formed from the external oblique aponeurosis
B) Arises from the transversalis fascia C) Inserts directly on to creamasteric fascia D) represents the superior border of the iliopubic tract E) is usually sutured to the transversus aponeurosis arch (flax inguinalis), which lies inferior to it , to complete a primary open repair
Question 1
The Shelving portion of the inguinal ligament used for open inguinal hernia repair:
A) is formed from the external oblique aponeurosis B) Arises from the transversalis fascia C) Inserts directly on to creamasteric fascia D) represents the superior border of the iliopubic tract E) is usually sutured to the transversus aponeurosis arch (flax inguinalis), which lies inferior to it , to complete a primary open repair
Question 2
Which is true of the anatomy of the Abdominal Wall:
A) The origin of the external oblique muscle is the 5 lowest ribs B) Embryologic origin of the Rectus Abdominus is the ectoderm C) The Majority of the neurovascular structures that supply the abdominal wall lie between the external and internal oblique muscles D) An abdominal hernia requires a defect in transversus abdominus E) Lymphatic Drainage of the abdominal wall above the umbilicus goes to the ipselateral axillary lymph nodes.
Question 2
Which is true of the anatomy of the Abdominal Wall:
A) The origin of the external oblique muscle is the 5 lowest ribs B) Embryologic origin of the Rectus Abdominus is the ectoderm C) The Majority of the neurovascular structures that supply the abdominal wall lie between the external and internal oblique muscles D) An abdominal hernia requires a defect in transversus abdominus E) Lymphatic Drainage of the abdominal wall above the umbilicus goes to the ipselateral axillary lymph nodes.
Question 2
Which is true of the anatomy of the Abdominal Wall:
A) The origin of the external oblique muscle is the 5 lowest ribs B) Embryologic origin of the Rectus Abdominus is the ectoderm C) The Majority of the neurovascular structures that supply the abdominal wall lie between the external and internal oblique muscles D) An abdominal hernia requires a defect in transversus abdominus E) Lymphatic Drainage of the abdominal wall above the umbilicus goes to the ipselateral axillary lymph nodes.
Question 3
Thirty years after having a right open inguinal hernia repair, a 67 year old man with hypertension presents with new onset bulge in his right groin. The bulge is apparent throughout the day and causes discomfort with valsalva. Five years ago, he had a radical retropubic prostatectomy and open cholecystectomy. On Exam, he has a moderately sized reducible right inguinal hernia. The most appropriate next step in management would be:
A) Open Primary Herniorrhapy B) Open Mesh Hernioplasty C) Transabdominal Preperitoneal (TAPP) repair D) Total Extraperitoneal (TEP) repair E) Watchful Waiting
Question 3
Thirty years after having a right open inguinal hernia repair, a 67 year old man with hypertension presents with new onset bulge in his right groin. The bulge is apparent throughout the day and causes discomfort with valsalva. Five years ago, he had a radical retropubic prostatectomy and open cholecystectomy. On Exam, he has a moderately sized reducible right inguinal hernia. The most appropriate next step in management would be:
A) Open Primary Herniorrhapy
Question 3 - SESAP
Question 4
A) systemic Corticosteroids B) Local injection of Corticosteroids C) Inguinal Exploration D) Laparotomy E) Pubic Ramus Plating
Question 4
C) Inguinal Exploration
D) Laparotomy E) Pubic Ramus Plating
Question 4 - SESAP
Question 5
Which statement about watchful waiting of inguinal hernia is true?
A) More Likely to limit physical activity due to pain B) More likely to encounter complications if subsequent repair is required C) Have a 10% chance of incarceration in 2 years time. D) More cost effective E) 20% require operative repair in 2 years
Question 5
Which statement about watchful waiting of inguinal hernia is true?
A) More Likely to limit physical activity due to pain B) More likely to encounter complications if subsequent repair is required C) Have a 10% chance of incarceration in 2 years time. D) More cost effective
Question 5
Question 6
Which of the following is true regarding patients with liver cirrhosis, ascites, and umbilical hernia.
A) They are best managed non-operatively B) Ascites is a contraindication to operative repair C) They have a low recurrence risk D) They may be categorized by MELD score to predict rate of failure E) Elective operation is recommended
Question 6
Which of the following is true regarding patients with liver cirrhosis, ascites, and umbilical hernia.
A) They are best managed non-operatively B) Ascites is a contraindication to operative repair C) They have a low recurrence risk D) They may be categorized by MELD score to predict rate of failure
Question 6
Prior Absite ?s
Prior Absite ?s