1. Hernia
Dr. Nachmany

2. Lecture Subjects Anatomy – Inguinal & Femoral canals
Clinical aspects of hernia
Repair of Inguinofemoral Hernia:
Open – Rrhaphy; Tension free.
Laparoscopic

3. Anatomy, Embryology & Physiology
The Inguinal Canal
Anatomy, Embryology & Physiology

4. Anatomy
Extends from the deep (fascia transversalis) to the superficial inguinal ring (ext. oblique)
Parallel and above the inguinal ligament
Walls of the Inguinal Canal:
Anterior
Posterior
Superior
Inferior

5. Walls of the Inguinal Canal
Anterior wall - Aponeurosis of Ext. oblique
Reinforced in its lateral third by origin of the Int. oblique
strongest where it lies opposite the weakest part of the posterior wall (deep ring)

6. Walls of the Inguinal Canal
Posterior wall - Fascia transversalis
Reinforced in its medial third by the conjoint tendon
Strongest where it lies opposite the weakest part of the anterior wall (superficial ring)

7. Walls of the Inguinal Canal – Cont.
Inferior (floor) - Rolled-under inferior edge of aponeurosis of the Ext. oblique (→the inguinal lig.)
Superior (roof) - Arching lowest fibers of the Int. oblique and transversus abdominis muscles

8. Deep Inguinal Ring ½ inch above the ligament
Midway between ASIS and the Symphysis
Lateral to the inferior epigastric vessels
Margins of ring give origin to the internal spermatic fascia

9. Superficial Inguinal Ring
Triangular defect in the aponeurosis of the external oblique
Immediately above and medial to the pubic tubercle
Margins give origin to the external spermatic fascia
Physical Exam

10. Physiology and Mechanics

11. Physiology Inguinal canal - a passage through the lower abdominal wall
Males - to and from the testis
Females - round ligament of the uterus to the labium major
Both sexes – Ilio-inguinal nerve

12. Mechanics of the inguinal Canal
A potential weakness
A design to lessen weakness:
Oblique passage → weakest areas lying some distance apart
Anterior reinforcement by Int. oblique in front of deep ring
Posterior reinforcement by Conjoint tendon behind superficial ring

13. Mechanics of the inguinal Canal – Cont.
On coughing/straining (defecation, parturition etc.) → Int. oblique and transversus abdominis muscles contract → flattening the roof → canal is virtually closed

14. Processus Vaginalis Spermatic Fasciae Gubernaculum
Embryology
Processus Vaginalis
Spermatic Fasciae
Gubernaculum

15. Embryology of the Inguinal Canal – Processus Vaginalis
Prior to testicular/ovarian descent a peritoneal diverticulum called the processus vaginalis is formed

16. Embryology - Processus Vaginalis and creation of Spermatic fasciae
The processus vaginalis passes through the layers of the abdominal wall and acquires a tubular covering from each layer:
Fascia transversalis - Internal spermatic fascia
Lower part of Int. oblique muscle - it takes some of its lowest fibers (Cremaster muscle & Fascia)
Aponeurosis of the external oblique – Ext. spermatic fascia

17. Spermatic Cord Forms at the level of the Deep ring
It is covered with three concentric layers of fascia derived from the layers of the anterior abdominal wall

18. Embryology oriented anatomy of spermatic fasciae

19. Embryology - Gubernaculum
Extends from the lower pole of the developing gonad to the labioscrotal swelling
In the male the testis descends during the 7th and 8th months of fetal life

20. Embryology - Gubernaculum
The stimulus for the descent is testosterone, secreted by the fetal testes
The testis follows the gubernaculum and descends behind the processus vaginalis
Pulls down its duct, blood vessels, nerves and lymphatics
In the female - extends from the uterus into the developing labium major
Persists as the round ligament

22. Herniae of the Myopectineal orifice

24. A hernia - protrusion of part of the abdominal contents beyond the normal confines of the abdominal wall
Consists of:
Sac
Contents of the sac
Coverings of the sac
Complications:
Incarceration
Strangulation
Bowel obstruction

25. Common Abdominal herniae are
Inguinal:
Indirect
Direct
Femoral
Umbilical:
Congenital
Acquired
Epigastric
Separation of the rectiabdominis
Diaphragmatic:
Sliding
Paraesophageal
Incisional (POVH)

26. Indirect Inguinal Hernia
The most common form of hernia
20 times more common in males
one-third are bilateral
more common on the right
Congenital in origin
Hernial sac is the remains of the processus vaginalis
The sac enters the inguinal canal through the deep inguinal ring lateral to the inferior epigastric vessels

27. Direct Inguinal Hernia
About 15 percent of all inguinal hernias
Majority is bilateral
The sac bulges directly anteriorly through the posterior wall of the inguinal canal
Medial to the inferior epigastric vessels
A disease of old men with weak abdominal muscles.

29. Femoral Hernia
The femoral sheath - a protrusion of the fascial envelope lining the abdominal walls
Surrounds the femoral vessels & lymphatics for 1 inch below the inguinal ligament

30. The Femoral Canal
The femoral canal, the compartment for the lymphatics, occupies the medial part of the sheath.
Its upper opening is the femoral ring:
Anterior -Inguinal ligament
Posterior - Pectineal ligament and the pubis
Medial - sharp free edge of the Lacunar ligament
Lateral - Femoral vein
The femoral septum, which is a condensation of extraperitoneal tissue, plugs the opening
The femoral vein is separated from it by a fibrous septum

31. Femoral Hernia Much more common in women
The sac passes down the canal, pushing the septum
On the lower end, it forms a swelling in the upper thigh
With further expansion the sac may turn upward to cross the inguinal ligament
The neck always lies below and lateral to the pubic tubercle

32. Surgical Repair of Hernia

33. Classification
Those that close all or part of the myopectineal orifice
Anterior Vs. Posterior
Repair by suturing the tissues at boundaries:
Bassini
Shouldice
Cooper (McVay)
Those that cover the orifice with prosthetic mesh:
Lichtenstein
Plug and patch
Laparoscopic

34. Anterior Repairs Dissection and hernia reduction is the same:
incision 2 to 3 cm above and parallel to the inguinal ligament
Dissection through the subcutaneous tissues and Scarpa’s fascia
The external oblique fascia and external ring is identified
The external oblique fascia is incised to expose the inguinal canal
The ilioinguinal and iliohypogastric nerves should be preserved

35. Open Repair – Cont.
The spermatic cord is mobilized at the pubic tubercle
The Cremaster muscle is divided and separated from the cord
The hernia sac is dissected from adjacent cord structures
The sac should be opened and examined for visceral contents if it is large
Neck of the sac is ligated at the level of the internal ring

37. Herniorrhaphy Bassini Shouldice McVay (Coopers ligament repair)
Ileopubic tract

38. The Bassini repair
Suturing the conjoined tendon to the inguinal ligament
was the most popular repair before the tension-free repairs

40. The Shouldice repair
Multilayer imbricated repair of the posterior wall of the inguinal canal with a continuous running suture technique:
1st suture line - transversus abdominis aponeurotic arch to the iliopubic tract
2nd line - internal oblique and transversus abdominis muscles and aponeuroses (Conjoint) to the inguinal ligament
3rd line - Conjoint to Ext. oblique
4th line - Conjoint to Ext. oblique

41. 1st posterior suture - Transversus abdominis to Iliopubic tract

42. 1st posterior suture - Transversus abdominis to Iliopubic tract (Cont

43. 2nd posterior suture – Int
2nd posterior suture – Int. oblique and transversus abdominis to inguinal ligament

44. 3rd posterior suture - Conjoint to Ext. oblique

45. 4th posterior suture - Conjoint to Ext. oblique

46. Relaxing incision

47. Cooper Ligament (McVay) Repair
For correction of all the Myopectineal orifice:
Direct inguinal hernias
Large indirect hernias
Recurrent inguinal hernias
Femoral hernias

48. Transversus abdominis aponeurosis to Cooper’s ligament

49. Lateral to the medial aspect of the femoral canal , the transversus abdominis aponeurosis is secured to the iliopubic tract
An important principle - relaxing incision

50. Lichtenstein Repair Tension is the principal cause of recurrence
Synthetic mesh prosthesis to bridge the defect
Inferior suture line - Shelving edge of the inguinal (Poupart’s) ligament
Superior line – Conjoint muscle & tendon

52. Posterior Repairs Open Repair: Stoppa Laparoscopic
Trans Abdominal Pre-Peritoneal (TAPP)
Total Extra Peritoneal (TEP)

53. Preperitoneal Anatomy

54. What’s that?

55. …and that?

56. Danger areas

57. The approach to the preperitoneal space

58. Arcuate line (3)

62. TEP

63. TAPP

64. Direct Hernia

65. Indirect Hernia

66. Trans-abdominal approach to the preperitoneal space

67. Dissection of indirect hernia

68. TAPP

69. Post Op. Complications