1. Hernia
Abnormal protrusion of an organ or tissue, through a defect in its surrounding walls
Various sites of the body
Most commonly abdominal wall hernia

2. Hernia External – protrudes through all layers of abdominal wall
Internal – protrusion of the intestine through a defect within peritoneal cavity

3. Abdominal wall hernias
Groin
Inguinal
Femoral
Anterior
Umbilical
Epigastric
Spigelian
Pelvic
Obturator
Perineal
Posterior
Lumbar
Superior triangle
Inferior triangle

4. Hernia
Reducible – content can be replaced within the surrounding musculature
Irreductible or incarcerated – cannot be reduced
Strangulated – compromised blood supply - complications

5. Hernia strangulation Large hernia – small orificies
Small neck obstructs blood flow, venous drainage or both
Adhesions between content and peritoneum – obstruction and strangulation of the intestine

6. Hernia – incidence 600.000/y hernia repairs in US
Most common operation performed by general surgeons
5% of population will develope abdominal wall hernia

7. Hernia incidence 75% of all hernias occur in the inguinal region
2/3 – indirect hernias
Men – 25 times more likely to have groin hernia then woman
Female – femoral and umbilical hernias more often then inguinal (10/1 and 2/1 respectively)

8. Hernia incidence
Both inguinal indirect and femoral – more commonly on the right side
Delay in atrophy of right processus vaginalis peritonei
Slower decent of thr right testis to the scrotum
Tamponading effect of sigmoid colon on the left femoral canal

9. Hernia – inguinal canal
4 cm lenght, 2 – 4 cm up to inguinla ligament
Extends between internal (deep) and external (superficial) inguinal ring
Contain spermatic cord or round ligament of the uterus

10. Hernia – inguinal canal
Spermatic cord
Cremasteric muscle fibres
Testicular artery
Pampiniform plexus
Genital branch of genitofemoral nerve
Vas deferens
Cremasteric vessels
Lymphatics
Processus vaginalis

11. Hernia – inguinal canal
Superficial – external oblique aponeurosis
Upper (cephalad) – intermnal oblique and transversus muscle
Inferior – inguinal and lacunar ligament
Posterior – transversalis fascia

12. Hernia – diagnosis Bulge in the inguinal region
Pain or discomfort (groin hernias are not extremely painful)
Paresthesias (compression or irritation of inguinal nerves)

13. Hernia – differential diagnosis
Inguinal hernia
Femoral hernia
Hydrocele
Inguinal adenitis
Varicocele
Ectopic testes
Lipoma
Hematoma

14. Hernia – differential diagnosis
Psoas abscess
Femoral adenitis
Lymphoma
Metastatic nepolasm
Epididymitis
Testicular torsion
Femoral artery aneurysm or pseudoaneurysm
Hydradenitis of inguinal apocrine glands

15. Hernia – physical examination
Both supine and standing position
Visual and palpative inspection for mass in inguinal region
Ask patient to cough or perform Valsalva maneuver
Fingertip OVER inguinal canal
Finally fingertip into inguinal canal – small hernia

16. Hernia – physical examination
PROBLEM – bulge of the groin described by the patient not demonstrated during examination???
Ask patient to stand for a period of time
Repeat examination (sometimes another visit)

17. Hernia – examination
USG – high degree of sensitivity and specificity in detection of occult direct, undirect and femoral hernias
CT – abdomen and pelvis – to diagnose unusual hernias or atypical groin masses

18. Hernia – nonoperative management
Opertaion recomended on discovery!!!
Progressive enlargement and weakening
Potential for incarceration and strangulation
Exclusions:
Short life expectancy patients
Significant comorbid ilnesses
Minimal symptoms

19. Hernia – nonoperative management
Trusses – provide symtomatic relief
Correct measurement and fitting are the key
Hernia control in 30% patients
Complications:
Testicular atrophy
Ilioinguinal or femoral neuritis
Hernia incarceration

20. Hernia – nonoperative management
NOT RECOMMENDED IN FEMORAL HERNIAS!!!
High incidence of complications, particulary strangulation

21. Hernia – operative repair
Anterior repairs:
Most common technique
Tension – free techniqes are standard
Older types – indicated for small hernias

22. Hernia – operative repair

23. Hernia – operative repair

24. Hernia – operative repair

25. Hernia – operative repair

26. Hernia – operative repair

27. Hernia – operative repair

28. Hernia – operative repair

29. Hernia – operative repair

30. Hernia – Bassini repair

31. Hernia – Bassini repair

32. Hernia – Bassini repair

33. Hernia – Bassini repair

34. Hernia – Halstead repair

35. Hernia – Shouldice repair

36. Hernia – Lichtenstein repair

37. Hernia – Lichtenstein repair

38. Hernia – Lichtenstein repair

39. Hernia – Lichtenstein repair

40. Hernia – other methods Girard Kirschner Marcy Mc Arthur Mc Vay Wolfer
Zimmerman

41. Hernia – laparoscopic management
Minimal invasive ???
Tension – free mesh repair
Less pain
Quicker recovery
Better visualisation of anatomy
Fixing all hernia defects
Decreased surgical site infections

42. Hernia – laparoscopic management
Complication rate – less then 10%
Reccurrence rate 0 – 3%

43. Hernia – laparoscopic management
TAPP – transabdominal preperitoneal approach
TEP – total extraperitoneal approach – without entering peritoneal cavity

44. Hernia – laparoscopic management
Infraumbilical incision
Dissecting baloon inflated under vision
Created space is insuflated, aditional trocars are placed
Reduction of hernia (hernias)
Traction
Large sac shoud be cautered to inguinal ring

45. Hernia – laparoscopic management
10x15 cm mesh inserted through a trocar and unfolded
Mesh should cover direct, indirect and femoral area
It’s secured with a tacking stapler

46. Hernia – femoral canal Superficial – inguinal ligament
Lateral – femoral vein
Posterior – Cooper’s ligament

47. Hernia – femoral canal

48. Femoral hernia

49. Femoral hernia - diagnosis
Mass or bulge occursbelow inguinal ligament
If it’s over inguinal ligament – it still could be femoral hernia (hernia sac is ascending)
It’s usually more painful then inguinal

50. Femoral hernia - repair
Dissection and removal of hernia sac
Obliteration of the femoral canal defect
Cooper’s method
Mesh
In case of strangulation, hernia sac content should always be examined for viability

51. Femoral hernia - repair

52. Femoral hernia - repair

53. Femoral hernia - repair

54. Hernia – special problems
Sliding hernia
Internal organ comprises a portion of the hernia sac
Mostly indirect inguinal hernias
Bowel (sigmoid) or urinary bladder
DANGER – recognize visceral component of hernia sac during operation, to avoid damage of the organ)

55. Hernia – special problems
Recurrent hernias
Challenging
Higher incidence of secondary recurrence
Placing of the mesh required for succes
Recurrences after anterior mesh repairs require posterior approach and placement of second prothesis

56. Hernia – special problems
Strangulated hernias
Hernia sac content must be visualised for viability
Constricting ring can be incised to reduce tension
Sometimes it’s necessery to resect strangulated intestine

57. Hernia – postopertaive complications
Wound infection – 0,58%
Haematoma – 0,43%
Pulmonary embolus – 0,07%
Haemorrhage – 0,02%
Ischemic orchitis – 0,61%
Testicular atrophy – 0,34%