Hernia (Latin, rupture; Greek, bud):Hernia (Latin, rupture; Greek, bud):

A protrusion of viscus through A protrusion of viscus through an opening in the wall of the cavity in an opening in the wall of the cavity in

which it is contained.which it is contained.

Hernial (H) orificeHernial (H) orifice

H sac: an outpouch of peritoneum.H sac: an outpouch of peritoneum.

External H: the sac protrudes completely External H: the sac protrudes completely through the abdominal wallthrough the abdominal wall

Internal H: the sac is within the visceral cavityInternal H: the sac is within the visceral cavity

Interparietal H: the sac is within the Interparietal H: the sac is within the abdominal wallabdominal wall

Reducible H: can be returned to the abdomenReducible H: can be returned to the abdomenIrreducible H: cannot.Irreducible H: cannot.Strangulated H: vascularity of the protruded Strangulated H: vascularity of the protruded

viscus is compromised, usually at neck.viscus is compromised, usually at neck.Incarcerated H: Irreducible H.Incarcerated H: Irreducible H.Richter’s H: the contents of the sac consist of Richter’s H: the contents of the sac consist of

only one side of the wall of the intestine.only one side of the wall of the intestine.  

Sites of HSites of H

Common: Groin, umbilicus, the linea alba, the Common: Groin, umbilicus, the linea alba, the semilunar line of Spieghel, the diaphragm, semilunar line of Spieghel, the diaphragm, and surgical incisionsand surgical incisions

Rare: Perineum, the superior lumbar triangle Rare: Perineum, the superior lumbar triangle of Grynfelt, the inferior lumbar triangle of of Grynfelt, the inferior lumbar triangle of Petit, and the obturator and sciatic foramen Petit, and the obturator and sciatic foramen of the pelvisof the pelvis

Symptoms and diagnosisSymptoms and diagnosis

Initial unawarenessInitial unawareness until the hernia is pointed until the hernia is pointed out to them.out to them.

Slow enlargementSlow enlargement to the point of irreducibility to the point of irreducibility and disfigurement, with the risk of and disfigurement, with the risk of strangulationstrangulation..

A wide variety of nonspecific discomforts A wide variety of nonspecific discomforts related to the contents of the sac and the related to the contents of the sac and the pressure by the sac on adjacent tissue.pressure by the sac on adjacent tissue.

Worse at the end of the dayWorse at the end of the day and and relieved at nightrelieved at night when the patient reclines and the hernia reduceswhen the patient reclines and the hernia reduces

Most hernias develop insidiously. But some are Most hernias develop insidiously. But some are precipitated by a single forceful muscular event.precipitated by a single forceful muscular event.

Easy to diagnosis:Easy to diagnosis:

Stand, strain or cough; not supineStand, strain or cough; not supine

DDX: hydrocele by transillumination or sonography.DDX: hydrocele by transillumination or sonography.

Indications for surgeryIndications for surgery

In general, all hernias should be repaired In general, all hernias should be repaired unless local or systemic conditions in the unless local or systemic conditions in the patient preclude a safe outcome.patient preclude a safe outcome.

Truss Truss

Groin HerniaGroin Hernia

The most common site for abdominal The most common site for abdominal herniation.herniation.

Male/female: 25:1Male/female: 25:1

Hernias arising above the abdominocrural Hernias arising above the abdominocrural crease are crease are inguinalinguinal (Latin, groin), and those (Latin, groin), and those arising below the crease are arising below the crease are femoralfemoral (Latin, (Latin, thigh) or crural (Latin, leg). thigh) or crural (Latin, leg).

Inguinal H: direct and indirectInguinal H: direct and indirect

In men, indirect H outnumbers In men, indirect H outnumbers direct H at a ratio of 2:1.direct H at a ratio of 2:1.

In women direct H are a rarity.In women direct H are a rarity.

Femoral HFemoral H

Femoral HerniaFemoral Hernia

A separate entityA separate entity

UncommonUncommon, 2.5% of all groin H., 2.5% of all groin H.

Occasionally in women, especially in multiparous Occasionally in women, especially in multiparous elderly women.elderly women.

Rarely in menRarely in men..

An irreducible mass about the size of a walnut at the An irreducible mass about the size of a walnut at the medial base of Scarpa’s femoral triangle.medial base of Scarpa’s femoral triangle.

DDX: enlarged lymph node and synovial cyst.DDX: enlarged lymph node and synovial cyst.

Indirect inguinal and femoral H are Indirect inguinal and femoral H are twice as twice as common on the rightcommon on the right as on the left. as on the left.

Delay in the atrophy of the processus Delay in the atrophy of the processus vaginalis that follows the normally slower vaginalis that follows the normally slower descent to the scrotum of the right testis. In descent to the scrotum of the right testis. In femoral H, sigmoid colon’s tamponading femoral H, sigmoid colon’s tamponading the left femoral canal.the left femoral canal.

EpidemiologyEpidemiology

Estimated incidence is 3 to 4 % of the male Estimated incidence is 3 to 4 % of the male population.population.

Strangulation occurs in Strangulation occurs in 1.3 to 3.0 %1.3 to 3.0 % of groin of groin H.H.

Most strangulated H are Most strangulated H are indirectindirect inguinal H, inguinal H, but the but the femoralfemoral H has the highest rate of H has the highest rate of strangulation (5 to 20%) of all H.strangulation (5 to 20%) of all H.

Anatomy of Groin HAnatomy of Groin HSliding HSliding H: retroperitoneal organs such as the sigmoid : retroperitoneal organs such as the sigmoid

colon, cecum, ureters, and urinary bladder may colon, cecum, ureters, and urinary bladder may slide into an indirect sac. They thereby become a slide into an indirect sac. They thereby become a part of the wall of the sac and are susceptible to part of the wall of the sac and are susceptible to injury during hernioplasty. These sliding H often injury during hernioplasty. These sliding H often are are large and partially irreduciblelarge and partially irreducible..

An indirect H sac is actually a dilated persistent An indirect H sac is actually a dilated persistent processus vaginalis.processus vaginalis.

Direct inguinal H sacs originate through the floor of Direct inguinal H sacs originate through the floor of the inguinal canal, that is Hesselback’s triangle. the inguinal canal, that is Hesselback’s triangle.

EtiologyEtiology

Congenital or acquiredCongenital or acquired

A family history of groin H is usually strongly A family history of groin H is usually strongly positive.positive.

A patent processus vaginalis is found in 80% of A patent processus vaginalis is found in 80% of newborns and in 50% of 1-year-olds. Closure newborns and in 50% of 1-year-olds. Closure continues until the age of 2 years. The incidence continues until the age of 2 years. The incidence of a patent processus vaginalis in adults is 20%. of a patent processus vaginalis in adults is 20%. Having the potential for a hernia does not mean Having the potential for a hernia does not mean that a hernia will develop. that a hernia will develop.

Other factorsOther factors must be present to cause failure of the must be present to cause failure of the transversalis fascia.transversalis fascia.

Erect stanceErect stance of human beings. of human beings.Muscle deficiencyMuscle deficiencyDestruction of connective tissueDestruction of connective tissue: fracture of the : fracture of the

elastic fibers and alterations in the structure, elastic fibers and alterations in the structure, quantity, and metabolism of collagen.quantity, and metabolism of collagen.

Abdominal distentionAbdominal distention and and chronic increase in chronic increase in intraabdominal pressureintraabdominal pressure from ascites and from ascites and peritoneal dialysis.peritoneal dialysis.

Basics of groin hernioplastyBasics of groin hernioplasty

Anterior approach Anterior approach

Posterior approachPosterior approach

Synthetic mesh prostheses currently play a Synthetic mesh prostheses currently play a major role. major role.

Bassini, Shoudice, McVay, etc.Bassini, Shoudice, McVay, etc.

Classical hernioplasty has three parts: Classical hernioplasty has three parts: dissection of the inguinal canal, repair of dissection of the inguinal canal, repair of the myopectineal orifice, and closure of the the myopectineal orifice, and closure of the inguinal canal.inguinal canal.

The management of hernia sac: indirect, The management of hernia sac: indirect, direct, slidingdirect, sliding

Insufficient repair of the deep ring is the Insufficient repair of the deep ring is the principal cause of indirect recurrence.principal cause of indirect recurrence.

In In womenwomen, simple ring closure is the , simple ring closure is the hernioplasty of choice with indirect inguinal hernioplasty of choice with indirect inguinal H.H.

  

Prosthetic materialProsthetic material

Marlex, Prolene, Trelex: knitted monofilament Marlex, Prolene, Trelex: knitted monofilament fibers of polypropylene (fibers of polypropylene ( 聚丙烯聚丙烯 ))

Surgipro: knitted, branded strands of Surgipro: knitted, branded strands of polypropylenepolypropylene

Mersilene: polyester (Mersilene: polyester ( 聚酯聚酯 )) Dacron (Dacron (達克達克龍龍 ))

Gore-Tex: polytetrafluoroethylene (PTFE): Gore-Tex: polytetrafluoroethylene (PTFE): encapsulation; The tendency of intestine to encapsulation; The tendency of intestine to adhere to Gore-Tex is minimal. adhere to Gore-Tex is minimal.

Polyester and polypropylene permanent Polyester and polypropylene permanent prostheses should never contact abdominal prostheses should never contact abdominal viscera directly.viscera directly.

Infections and synthetic nonabsorbable Infections and synthetic nonabsorbable prostheses prostheses

Anterior prosthetic groin hernioplastyAnterior prosthetic groin hernioplastyTension-free hernioplasty, LichtensteinTension-free hernioplasty, Lichtenstein

The prosthesis is implanted without a formal The prosthesis is implanted without a formal repair, thereby obviating tension.repair, thereby obviating tension.8x16 cm patch8x16 cm patch

Posterior (Properitoneal) prosthetic groin Posterior (Properitoneal) prosthetic groin hernioplastyhernioplastyStoppa procedure- Giant prosthetic reinforcement Stoppa procedure- Giant prosthetic reinforcement of the visceral sac of the visceral sac

Laparoscopic repair Laparoscopic repair

Anterior view Posterior view

Bassini hernioplasty

Femoral hernia Repair

ComplicationsComplications

Ischemic orchitis and testicular atrophyIschemic orchitis and testicular atrophy

Thrombosis of the spermatic cord.Thrombosis of the spermatic cord.

NeuralgiaNeuralgia

Injury of sensory nerve (neuroma)Injury of sensory nerve (neuroma)

Constricting scar tissueConstricting scar tissue

Adjacent inflammatory granuloma Adjacent inflammatory granuloma

The prevention of nerve injury is important The prevention of nerve injury is important since the treatment of neuralgic since the treatment of neuralgic complications is often unsuccessful. complications is often unsuccessful. Division (usually with ligation) of the Division (usually with ligation) of the genital branch of the genitofemoral nerve is genital branch of the genitofemoral nerve is routine. Most nerves require ligature to routine. Most nerves require ligature to control bleeding. The ligature may also control bleeding. The ligature may also confine neuroma formation to within the confine neuroma formation to within the neurilemma. neurilemma.

RecurrencesRecurrences

1 to 3 % in a 10-year follow-up.1 to 3 % in a 10-year follow-up.

Caused by excessive tension on the repair, Caused by excessive tension on the repair, deficient tissues, inadequate hernioplasty, deficient tissues, inadequate hernioplasty, overlooked hernias.overlooked hernias.

Recurrent hernias require a prosthesis for Recurrent hernias require a prosthesis for successful repair. successful repair.

Umbilical herniaUmbilical hernia

Epigastric herniaEpigastric hernia

Spigelian herniaSpigelian hernia

Lumbar herniaLumbar hernia

Pelvic herniaPelvic hernia

Parastomal herniaParastomal hernia

Incisional hernia Incisional hernia