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Inguinal Hernia
CHAPTER 58
INGUINAL HERNIA Magdalene A. Brooke, MD, Gregory P. Victorino, MD, FACS
1. Groin hernia refers to which three hernias? Direct and indirect inguinal hernias and femoral hernias. 2. Francois Poupart, a French surgeon and anatomist (1616–1708), described a ligament that bears his name. What is the anatomic name of the Poupart ligament? Inguinal ligament, which is a key element in most groin hernia repairs. 3. Franz K. Hesselbach, a German surgeon and anatomist (1759–1816), described a triangle that is the common site of direct hernias. What are the anatomic margins of Hesselbach’s triangle? The triangle is defined inferiorly by the inguinal ligament, superiorly by the inferior epigastric vessels, and medially by the rectus fascia. The transversalis fascia forms the floor of the triangle. The original description used Cooper’s ligament as the inferior limit, but because of the common use of the anterior approach to hernias, the more apparent inguinal ligament was substituted as the inferior limit of the triangle. With the increasing use of preperitoneal approaches to hernia repair, Cooper’s ligament is again much more apparent and useful as an anatomic landmark. 4. Sir Astley Paston Cooper, an English surgeon and anatomist (1768–1841), described a ligament bearing his name. What is the anatomic name for the ligament and the proper name of Cooper’s ligament repair? The anatomic name of Cooper’s ligament is iliopectineal ligament. The Cooper’s ligament repair or McVay repair was popularized by Chester McVay (1911–1987). With Barry Aston, professor of anatomy at Northwestern University, McVay provided the modern description of the groin anatomy. 5. Antonio de Gimbernat, a Spanish surgeon and anatomist (1734–1816), had his interesting name attached to the lacunar ligament, which marks the medial margin of a groin area opening. What is the opening? What hernia protrudes into this opening? The opening is the femoral canal, which is defined medially by the lacunar ligament, anteriorly by the inguinal ligament, posteriorly by the pectineal fascia, and laterally by the femoral vein. A femoral hernia protrudes into the femoral canal. 6. Indirect inguinal hernia (particularly in children) and hydrocele are associated with which congenital abnormality? Persistence of an open processus vaginalis, in the case of a hernia, allows descent of bowel into the inguinal canal. With fluid accumulation, partial obstruction presents as a hydrocele of the spermatic cord. 7. What are the diagnostic criteria for hernia in an infant or child? • Inguinal, scrotal, or labial lump that may or may not be reducible • History of a lump seen by a healthcare provider • History of a lump seen by the mother • The silk sign (the feeling of rubbing together two surfaces of silk cloth when gently rubbing together the two surfaces of a hernia sac) • An incarceration sometimes felt on rectal examination 8. What can be done to reduce an incarcerated hernia? The four-point program is easier said than done, but it is worth the effort: a. Sedate the patient. b. Place the patient in the Trendelenburg position. c. Apply a cold pack (over petroleum gauze to avoid skin injury) in inguinal area. d. In the absence of spontaneous reduction—and if the patient is quiet—use gentle manipulation.
250
Inguinal Hernia 251 9. How often can incarceration be successfully reduced? What should be done next? About 80% of incarcerated hernias can be reduced in children; in adults, the percentage is lower. Despite the fact that 80%–90% of inguinal hernias occur in boys, most incarcerations occur in girls. The hernia should be repaired electively within a few days after incarceration. The 20% of hernias that are still incarcerated should be operated on immediately. 10. What is a Bassini repair? The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring (see Fig. 58.1). This classic procedure, introduced in 1887 at the Italian Society of Surgery in Genoa, revolutionized hernia repair. Until recently, it has been the standard of repair. After graduation from medical school and while fighting for Italian independence, Eduardo Bassini (1844– 1924) was bayoneted in the groin and, as a prisoner, was hospitalized for months with a fecal fistula.
Conjoined tendon
Iliopubic tract and/or Inguinal ligament
Fig. 58.1 The standard right inguinal hernia repair using the conjoined tendon and inguinal ligament.
11. What is the recurrence rate with indirect and direct hernias that have been repaired with classic Bassini repair technique? Over a follow-up period of 50 years, the recurrence rate of adult indirect hernias is 5%–10%; of direct hernias, 15%–30%. 12. Describe a McVay hernia repair The line of interrupted sutures starts at the pubic tubercle and joins the tendinous arch of the transversus abdominis muscle to Cooper’s ligament up to the femoral canal. At this point, two or three transitional sutures are placed from Cooper’s ligament to the anterior femoral fascia, effectively closing the medial extreme of the femoral canal. The final set of sutures joins the transversus abdominis arch and the anterior femoral fascia. The stitches usually incorporate the inguinal ligament at the upper limit of the repair, the site of the new internal inguinal ring and cord structures. About 15 years ago, McVay described laying in a mesh patch and stitching it, at its periphery, to the same anatomic structures. This application of mesh closely resembles the Lichtenstein repair (see question 17), except that it uses Cooper’s ligament.
252 ABDOMINAL SURGERY 13. For what type of hernias is the McVay Cooper’s ligament repair most useful? Femoral and direct hernias. 14. What is the Shouldice repair? The Shouldice repair, popularized at the Shouldice Clinic near Toronto, imbricates or overlays the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures. The suture tract runs from the pubic tubercle to a new internal ring. Care is taken with the inferior epigastric vessels. The result is layered approximation of the conjoined tendon to the inguinal ligament tract. 15. What is the reported recurrence rate for the Shouldice repair? The recurrence rate is 1%, the lowest reported rate for nonmesh repairs of inguinal hernias in adults. 16. For what type of groin hernia is the Shouldice repair not appropriate? Femoral hernia. 17. Describe the Lichtenstein repair The Lichtenstein repair consists of a sutured patch of polypropylene mesh (Marlex, C.R. Bard, Inc., Covington, GA) that covers Hesselbach’s triangle and the indirect hernia area. It is considered a tension-free repair because the mesh is sutured in place without pulling ligaments or tissues together as in all other repairs. The mesh is divided at its upper end to wrap closely around the spermatic cord and its associated structures in the normal position of the internal inguinal canal (see Fig. 58.2). The Lichtenstein procedure is rapidly becoming the most widely used repair of adult inguinal hernia. The reported recurrence rate is <1%.
Conjoined tendon Iliopubic tract and/or Inguinal ligament
Marlex
Fig. 58.2 The Marlex mesh repair of a right inguinal hernia. Note that the same structures are used but not brought together; thus, the name of the tension-free repair.
18. For what groin area is the Lichtenstein repair not appropriate? Femoral hernia. 19. Which type of repair is acceptable for the femoral hernia? Several different repairs can be used. Mesh in the form of a plug can be inserted into the femoral canal and fixed in place. A McVay Cooper’s ligament repair can be done. A preperitoneal approach to the hernia can be used to suture or plug the defect. A suture repair or a sartorius facial flap applied from below the inguinal ligament in a femoral approach also may be used. The preperitoneal approach is increasingly used for complicated inguinal and femoral hernias.
Inguinal Hernia 253 20. What is the preperitoneal or Stoppa procedure? The preperitoneal or Stoppa procedure is a groin hernia repair on the internal side of the abdominal wall between the peritoneum and fascial surfaces that do not open into the peritoneal cavity. The anatomic landmarks are quite different and initially quite challenging to surgeons accustomed to the external abdominal wall approach. The technique is suited for recurrent hernias in which scarring and obliterated anatomy increase the risk of cord injury and recurrence. Other problems such as large hernias and femoral hernias are corrected with this approach. Conceptually, the laparoscopic hernia repair uses the same approach (see Fig. 58.3).
Ext. Oblique
Int. Oblique
Cremaster m. Inguinal ligament
Pubic tubercle Inguinal ligament
Inf. epigastric a. & v. Cooper’s ligament Urinary bladder
Testicular a. & v.
Testicular a. & v.
Vas deferens Iliac a. & v.
Vas deferens Preperitoneal
Intraperitoneal
Fig. 58.3 The different appearance and landmarks are seen in the anterior view (above) and the posterior view (below) of the inguinal-femoral area. In the posterior view, the importance of the inferior epigastric vessels, bladder, and Cooper’s ligament as anatomic landmarks is apparent.
254 ABDOMINAL SURGERY 21. Where are the spaces of Retzius and Bogros? Why are they increasingly important? Retzius’ space is between the pubis and the urinary bladder. Bogros’ space is between the peritoneum and the fascia and muscle planes on the posterior aspect of the abdominal wall below the umbilicus and down to Cooper’s ligament. Laterally, the space goes to the iliac spines. In either the open Stoppa procedure or the laparoscopic preperitoneal repair, the spaces of Retzius and Bogros are developed for mesh placement and surgical exposure. 22. How tight around the spermatic cord should a surgically fashioned, internal inguinal ring be? About 5 mm, which is less than a fingertip and more than a forceps tip. 23. What is the common fascial defect of larger indirect and all direct inguinal hernias? Weakness or attenuation of the transversalis fascia. 24. On examination, the femoral hernia may be confused with what other inguinal hernia? The femoral hernia may be confused with a direct inguinal hernia because of the tendency of the femoral hernia to present at the lateral edge of the inguinal ligament. 25. What is the difference between an incarcerated and a strangulated hernia? • Incarcerated: Structures in the hernia sac still have a good blood supply but are stuck in the sac because of adhesions or a narrow neck of the hernia sac. • Strangulated: Herniated structures, such as bowel or omentum, have lost their blood supply because of anatomic constriction at the neck of the hernia. The herniated, ischemic tissue is, therefore, in various stages of gangrenous changes. Strangulated hernias are surgical emergencies. 26. Do all hernias require urgent repair? No. Acute incarceration or strangulation of abdominal contents in a hernia is a surgical emergency. Patients with chronic discomfort benefit from elective repair. However, recent data on men with asymptomatic or minimally symptomatic hernias indicates it may be safe to wait to operate until symptoms worsen. As with any surgical procedure, an individual’s risk factors and baseline function need to be considered along with the risk of an operative or nonoperative approach. In the case of hernias, only a small percentage of asymptomatic patients for whom elective repair is deferred will develop acute hernia incarceration at some time in the future. Of note, in athletes, operative repair has been shown to improve quality of life and return to athletics in comparison with conservative treatment. 27. What operation is done for an uncomplicated indirect infant hernia? High ligation of the hernia sac. 28. What operation is done for an uncomplicated indirect hernia in young adults? The appropriate operation consists of high ligation and possibly one or two stitches in the transversalis fascia to tighten the internal ring. This is the basic Marcy technique, developed by Henry Orlando Marcy (1837–1924); it is smaller and more anatomically focused than the Bassini repair. 29. What operation is done for an uncomplicated but sizable direct hernia in elderly adults? Traditionally, the Bassini or McVay repair was chosen. More recently, because of the low recurrence rate, the Shouldice or Lichtenstein repair is favored. 30. What organ systems should be reviewed with particular care in the workup of patients with hernia (especially elderly patients with recent onset of hernia)? The gastrointestinal, urinary, and pulmonary systems should be reviewed with particular care. One is looking for causes of chronic strain or sudden forces that may have induced the hernia. Straining during defecation or urination, unusual coughing, or difficulty with breathing, if corrected, may be of great value to the patient and reduce the chance of recurrent hernia. 31. What is a sliding hernia? A sliding hernia is formed when a retroperitoneal organ protrudes (herniates) outside the abdominal cavity in such a manner that the organ itself and the overlying peritoneal surface constitute a side of the hernia sac.
Inguinal Hernia 255 32. What organs can be found in sliding hernias? • Colon • Cecum • Appendix • Bladder • Fallopian tubes • Uterus (rare) • Ovary 33. What are common operative and postoperative complications of hernia repairs? Intraoperative complications: • Injury to the spermatic cord, especially in children. • Injury to the spermatic vessels, resulting in atrophy or acute necrosis of testes. • Injury to the ilioinguinal nerve, genitofemoral nerve, and lateral femoral cutaneous nerve (the lateral femoral cutaneous nerve is uniquely vulnerable in laparoscopic and properitoneal procedures). • Injury to the femoral vessels. Postoperative complications: • Infection: High risk in children with diaper rash and patients with bowel injury or necrosis. • Hematoma: Should resolve in time. • Nerve injury: The nerve is not always divided and, with time, may improve. If pain persists, try lidocaine block for both diagnosis and treatment. If a nerve block is not successful, one may consider reexploration to free the nerve from scar or to excise a postsurgical neuroma. • Recurrence of the hernia. • Direct hernias often recur at the pubic tubercle. Indirect hernias recur at the internal ring. The cause is usually related to poorly placed or insufficient stitches. Other possible causes include infection, poor tissue, poor collagen formation, or too much tension at the surgical suture line. A single line of repair under moderate tension fails in a significant number of patients, regardless of adequacy of repair or healing process. Tension is almost always bad in surgery.
CONTROVERSIES 34. What are some of the anatomic issues related to inguinal hernias? At issue is the iliopubic tract, which is central to the Anson/McVay anatomic description of the inguinal area and featured in the McVay Cooper’s ligament repair. Although the McVay repair is used in England, the iliopubic tract is not referred to or described in English anatomic texts. The term conjoined tendon, although commonly used, is considered by many to be anatomically inaccurate and misleading. The internal oblique and transversus abdominis muscles that make up the conjoined tendon are obvious and can be used surgically either alone or together. The tendinous edge of the transversus abdominis muscle and the tendinous edge of the internal oblique muscle start at their insertion on the pubic tubercle and course laterally and superiorly to the medial edge of the internal ring. At this point, the tendinous elements diminish, leaving only muscle tissues, and continue laterally and superiorly to their origins. Whether the lacunar ligament or the iliopubic tract defines the medial border of the femoral canal is controversial. The compromise position is that the iliopubic tract is the border, whereas in the normal unstretched state, the lacunar ligament (Gimbernat’s ligament) is the border in the presence of hernia (stretched state). At surgery, it is enough to say that a palpable, visible curved ligament is present and used in some femoral repairs. 35. How long should the patient avoid heavy lifting after a hernia repair? The standard advice for decades has been 4–6 weeks. However, recent data shows no increase in recurrence rate related to early resumption of normal activities. There is no evidence to support such a long convalescent period. Recent guidelines recommend that patients should self-limit their activity as required by their postoperative pain, and that they should be reassured that physical activity does not appear to cause hernia recurrence. 36. What are the typical indications for laparoscopic repair? Hernias that are bilateral or recurrent.
256 ABDOMINAL SURGERY 37. Is laparoscopic repair appropriate for initial, unilateral inguinal hernia? Recent studies show no significant difference between laparoscopic and open repair in terms of major complications, including hernia recurrence. In addition, laparoscopic repair has the benefit of shorter recovery time, and less postoperative pain. It is important, however, to recognize that laparoscopic repair has a very gradual learning curve. The literature supports use of laparoscopic, primary, unilateral hernia repair depending on the volume of the center and surgeon’s experience.
K EY POIN T S: T Y P E S O F I N G UI N A L H E R N I A R EPA I R 1. The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring. 2. The McVay repair is most useful for femoral and direct hernias. 3. The Shouldice repair imbricates the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures (not appropriate for femoral hernias). 4. The Lichtenstein repair consists of a sutured patch of polyprolene mesh that covers Hesselbach’s triangle and the indirect hernia sac.
Bibliography 1. Avisse C, Delattre JF. The inguinal rings. Surg Clin North Am. 2000;80(1):49–69. 2. Avisse C, Delattre JF. The inguinofemoral area from a laparoscopic standpoint. History, anatomy, and surgical applications. Surg Clin North Am. 2000;80(1):35–48. 3. Bendavid R, Howarth D. Transversalis fascia rediscovered. Surg Clin North Am. 2000;80(1):25–33. 4. EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg. 2002;235(3):322–332. 5. Bittner R, Montgomery MA, Arregui E, et al. Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society). Surg Endosc. 2015;29(2):289–321. 6. Fitzgibbons RJ, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508–515. 7. Kockerling F, Stechemesser B. TEP versus Lichtenstein: which technique is better for the repair of primary unilateral inguinal hernias in men? Surg Endosc. 2016;30(8):3304–3313. 8. Miserez M, Peeters E, Aufenacker T, et al. Update with level 1 studies of the European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia. 2014;18(2):151–163. 9. O’Reilly EA, Burke JP, O’Connell PR. A meta-analysis of surgical morbidity and recurrence after laparoscopic and open repair of primary unilateral inguinal hernia. Ann Surg. 2012;255(5):846–853. 10. Stroupe KT, Manheim LM, Luo P, et al. Minimally symptomatic inguinal hernias: a cost-effectiveness analysis. J Am Coll Surg. 2006;203(4):458–468.
INGUINAL HERNIA Magdalene A. Brooke, MD, Gregory P. Victorino, MD, FACS
1. Groin hernia refers to which three hernias? Direct and indirect inguinal hernias and femoral hernias. 2. Francois Poupart, a French surgeon and anatomist (1616–1708), described a ligament that bears his name. What is the anatomic name of the Poupart ligament? Inguinal ligament, which is a key element in most groin hernia repairs. 3. Franz K. Hesselbach, a German surgeon and anatomist (1759–1816), described a triangle that is the common site of direct hernias. What are the anatomic margins of Hesselbach’s triangle? The triangle is defined inferiorly by the inguinal ligament, superiorly by the inferior epigastric vessels, and medially by the rectus fascia. The transversalis fascia forms the floor of the triangle. The original description used Cooper’s ligament as the inferior limit, but because of the common use of the anterior approach to hernias, the more apparent inguinal ligament was substituted as the inferior limit of the triangle. With the increasing use of preperitoneal approaches to hernia repair, Cooper’s ligament is again much more apparent and useful as an anatomic landmark. 4. Sir Astley Paston Cooper, an English surgeon and anatomist (1768–1841), described a ligament bearing his name. What is the anatomic name for the ligament and the proper name of Cooper’s ligament repair? The anatomic name of Cooper’s ligament is iliopectineal ligament. The Cooper’s ligament repair or McVay repair was popularized by Chester McVay (1911–1987). With Barry Aston, professor of anatomy at Northwestern University, McVay provided the modern description of the groin anatomy. 5. Antonio de Gimbernat, a Spanish surgeon and anatomist (1734–1816), had his interesting name attached to the lacunar ligament, which marks the medial margin of a groin area opening. What is the opening? What hernia protrudes into this opening? The opening is the femoral canal, which is defined medially by the lacunar ligament, anteriorly by the inguinal ligament, posteriorly by the pectineal fascia, and laterally by the femoral vein. A femoral hernia protrudes into the femoral canal. 6. Indirect inguinal hernia (particularly in children) and hydrocele are associated with which congenital abnormality? Persistence of an open processus vaginalis, in the case of a hernia, allows descent of bowel into the inguinal canal. With fluid accumulation, partial obstruction presents as a hydrocele of the spermatic cord. 7. What are the diagnostic criteria for hernia in an infant or child? • Inguinal, scrotal, or labial lump that may or may not be reducible • History of a lump seen by a healthcare provider • History of a lump seen by the mother • The silk sign (the feeling of rubbing together two surfaces of silk cloth when gently rubbing together the two surfaces of a hernia sac) • An incarceration sometimes felt on rectal examination 8. What can be done to reduce an incarcerated hernia? The four-point program is easier said than done, but it is worth the effort: a. Sedate the patient. b. Place the patient in the Trendelenburg position. c. Apply a cold pack (over petroleum gauze to avoid skin injury) in inguinal area. d. In the absence of spontaneous reduction—and if the patient is quiet—use gentle manipulation.
250
Inguinal Hernia 251 9. How often can incarceration be successfully reduced? What should be done next? About 80% of incarcerated hernias can be reduced in children; in adults, the percentage is lower. Despite the fact that 80%–90% of inguinal hernias occur in boys, most incarcerations occur in girls. The hernia should be repaired electively within a few days after incarceration. The 20% of hernias that are still incarcerated should be operated on immediately. 10. What is a Bassini repair? The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring (see Fig. 58.1). This classic procedure, introduced in 1887 at the Italian Society of Surgery in Genoa, revolutionized hernia repair. Until recently, it has been the standard of repair. After graduation from medical school and while fighting for Italian independence, Eduardo Bassini (1844– 1924) was bayoneted in the groin and, as a prisoner, was hospitalized for months with a fecal fistula.
Conjoined tendon
Iliopubic tract and/or Inguinal ligament
Fig. 58.1 The standard right inguinal hernia repair using the conjoined tendon and inguinal ligament.
11. What is the recurrence rate with indirect and direct hernias that have been repaired with classic Bassini repair technique? Over a follow-up period of 50 years, the recurrence rate of adult indirect hernias is 5%–10%; of direct hernias, 15%–30%. 12. Describe a McVay hernia repair The line of interrupted sutures starts at the pubic tubercle and joins the tendinous arch of the transversus abdominis muscle to Cooper’s ligament up to the femoral canal. At this point, two or three transitional sutures are placed from Cooper’s ligament to the anterior femoral fascia, effectively closing the medial extreme of the femoral canal. The final set of sutures joins the transversus abdominis arch and the anterior femoral fascia. The stitches usually incorporate the inguinal ligament at the upper limit of the repair, the site of the new internal inguinal ring and cord structures. About 15 years ago, McVay described laying in a mesh patch and stitching it, at its periphery, to the same anatomic structures. This application of mesh closely resembles the Lichtenstein repair (see question 17), except that it uses Cooper’s ligament.
252 ABDOMINAL SURGERY 13. For what type of hernias is the McVay Cooper’s ligament repair most useful? Femoral and direct hernias. 14. What is the Shouldice repair? The Shouldice repair, popularized at the Shouldice Clinic near Toronto, imbricates or overlays the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures. The suture tract runs from the pubic tubercle to a new internal ring. Care is taken with the inferior epigastric vessels. The result is layered approximation of the conjoined tendon to the inguinal ligament tract. 15. What is the reported recurrence rate for the Shouldice repair? The recurrence rate is 1%, the lowest reported rate for nonmesh repairs of inguinal hernias in adults. 16. For what type of groin hernia is the Shouldice repair not appropriate? Femoral hernia. 17. Describe the Lichtenstein repair The Lichtenstein repair consists of a sutured patch of polypropylene mesh (Marlex, C.R. Bard, Inc., Covington, GA) that covers Hesselbach’s triangle and the indirect hernia area. It is considered a tension-free repair because the mesh is sutured in place without pulling ligaments or tissues together as in all other repairs. The mesh is divided at its upper end to wrap closely around the spermatic cord and its associated structures in the normal position of the internal inguinal canal (see Fig. 58.2). The Lichtenstein procedure is rapidly becoming the most widely used repair of adult inguinal hernia. The reported recurrence rate is <1%.
Conjoined tendon Iliopubic tract and/or Inguinal ligament
Marlex
Fig. 58.2 The Marlex mesh repair of a right inguinal hernia. Note that the same structures are used but not brought together; thus, the name of the tension-free repair.
18. For what groin area is the Lichtenstein repair not appropriate? Femoral hernia. 19. Which type of repair is acceptable for the femoral hernia? Several different repairs can be used. Mesh in the form of a plug can be inserted into the femoral canal and fixed in place. A McVay Cooper’s ligament repair can be done. A preperitoneal approach to the hernia can be used to suture or plug the defect. A suture repair or a sartorius facial flap applied from below the inguinal ligament in a femoral approach also may be used. The preperitoneal approach is increasingly used for complicated inguinal and femoral hernias.
Inguinal Hernia 253 20. What is the preperitoneal or Stoppa procedure? The preperitoneal or Stoppa procedure is a groin hernia repair on the internal side of the abdominal wall between the peritoneum and fascial surfaces that do not open into the peritoneal cavity. The anatomic landmarks are quite different and initially quite challenging to surgeons accustomed to the external abdominal wall approach. The technique is suited for recurrent hernias in which scarring and obliterated anatomy increase the risk of cord injury and recurrence. Other problems such as large hernias and femoral hernias are corrected with this approach. Conceptually, the laparoscopic hernia repair uses the same approach (see Fig. 58.3).
Ext. Oblique
Int. Oblique
Cremaster m. Inguinal ligament
Pubic tubercle Inguinal ligament
Inf. epigastric a. & v. Cooper’s ligament Urinary bladder
Testicular a. & v.
Testicular a. & v.
Vas deferens Iliac a. & v.
Vas deferens Preperitoneal
Intraperitoneal
Fig. 58.3 The different appearance and landmarks are seen in the anterior view (above) and the posterior view (below) of the inguinal-femoral area. In the posterior view, the importance of the inferior epigastric vessels, bladder, and Cooper’s ligament as anatomic landmarks is apparent.
254 ABDOMINAL SURGERY 21. Where are the spaces of Retzius and Bogros? Why are they increasingly important? Retzius’ space is between the pubis and the urinary bladder. Bogros’ space is between the peritoneum and the fascia and muscle planes on the posterior aspect of the abdominal wall below the umbilicus and down to Cooper’s ligament. Laterally, the space goes to the iliac spines. In either the open Stoppa procedure or the laparoscopic preperitoneal repair, the spaces of Retzius and Bogros are developed for mesh placement and surgical exposure. 22. How tight around the spermatic cord should a surgically fashioned, internal inguinal ring be? About 5 mm, which is less than a fingertip and more than a forceps tip. 23. What is the common fascial defect of larger indirect and all direct inguinal hernias? Weakness or attenuation of the transversalis fascia. 24. On examination, the femoral hernia may be confused with what other inguinal hernia? The femoral hernia may be confused with a direct inguinal hernia because of the tendency of the femoral hernia to present at the lateral edge of the inguinal ligament. 25. What is the difference between an incarcerated and a strangulated hernia? • Incarcerated: Structures in the hernia sac still have a good blood supply but are stuck in the sac because of adhesions or a narrow neck of the hernia sac. • Strangulated: Herniated structures, such as bowel or omentum, have lost their blood supply because of anatomic constriction at the neck of the hernia. The herniated, ischemic tissue is, therefore, in various stages of gangrenous changes. Strangulated hernias are surgical emergencies. 26. Do all hernias require urgent repair? No. Acute incarceration or strangulation of abdominal contents in a hernia is a surgical emergency. Patients with chronic discomfort benefit from elective repair. However, recent data on men with asymptomatic or minimally symptomatic hernias indicates it may be safe to wait to operate until symptoms worsen. As with any surgical procedure, an individual’s risk factors and baseline function need to be considered along with the risk of an operative or nonoperative approach. In the case of hernias, only a small percentage of asymptomatic patients for whom elective repair is deferred will develop acute hernia incarceration at some time in the future. Of note, in athletes, operative repair has been shown to improve quality of life and return to athletics in comparison with conservative treatment. 27. What operation is done for an uncomplicated indirect infant hernia? High ligation of the hernia sac. 28. What operation is done for an uncomplicated indirect hernia in young adults? The appropriate operation consists of high ligation and possibly one or two stitches in the transversalis fascia to tighten the internal ring. This is the basic Marcy technique, developed by Henry Orlando Marcy (1837–1924); it is smaller and more anatomically focused than the Bassini repair. 29. What operation is done for an uncomplicated but sizable direct hernia in elderly adults? Traditionally, the Bassini or McVay repair was chosen. More recently, because of the low recurrence rate, the Shouldice or Lichtenstein repair is favored. 30. What organ systems should be reviewed with particular care in the workup of patients with hernia (especially elderly patients with recent onset of hernia)? The gastrointestinal, urinary, and pulmonary systems should be reviewed with particular care. One is looking for causes of chronic strain or sudden forces that may have induced the hernia. Straining during defecation or urination, unusual coughing, or difficulty with breathing, if corrected, may be of great value to the patient and reduce the chance of recurrent hernia. 31. What is a sliding hernia? A sliding hernia is formed when a retroperitoneal organ protrudes (herniates) outside the abdominal cavity in such a manner that the organ itself and the overlying peritoneal surface constitute a side of the hernia sac.
Inguinal Hernia 255 32. What organs can be found in sliding hernias? • Colon • Cecum • Appendix • Bladder • Fallopian tubes • Uterus (rare) • Ovary 33. What are common operative and postoperative complications of hernia repairs? Intraoperative complications: • Injury to the spermatic cord, especially in children. • Injury to the spermatic vessels, resulting in atrophy or acute necrosis of testes. • Injury to the ilioinguinal nerve, genitofemoral nerve, and lateral femoral cutaneous nerve (the lateral femoral cutaneous nerve is uniquely vulnerable in laparoscopic and properitoneal procedures). • Injury to the femoral vessels. Postoperative complications: • Infection: High risk in children with diaper rash and patients with bowel injury or necrosis. • Hematoma: Should resolve in time. • Nerve injury: The nerve is not always divided and, with time, may improve. If pain persists, try lidocaine block for both diagnosis and treatment. If a nerve block is not successful, one may consider reexploration to free the nerve from scar or to excise a postsurgical neuroma. • Recurrence of the hernia. • Direct hernias often recur at the pubic tubercle. Indirect hernias recur at the internal ring. The cause is usually related to poorly placed or insufficient stitches. Other possible causes include infection, poor tissue, poor collagen formation, or too much tension at the surgical suture line. A single line of repair under moderate tension fails in a significant number of patients, regardless of adequacy of repair or healing process. Tension is almost always bad in surgery.
CONTROVERSIES 34. What are some of the anatomic issues related to inguinal hernias? At issue is the iliopubic tract, which is central to the Anson/McVay anatomic description of the inguinal area and featured in the McVay Cooper’s ligament repair. Although the McVay repair is used in England, the iliopubic tract is not referred to or described in English anatomic texts. The term conjoined tendon, although commonly used, is considered by many to be anatomically inaccurate and misleading. The internal oblique and transversus abdominis muscles that make up the conjoined tendon are obvious and can be used surgically either alone or together. The tendinous edge of the transversus abdominis muscle and the tendinous edge of the internal oblique muscle start at their insertion on the pubic tubercle and course laterally and superiorly to the medial edge of the internal ring. At this point, the tendinous elements diminish, leaving only muscle tissues, and continue laterally and superiorly to their origins. Whether the lacunar ligament or the iliopubic tract defines the medial border of the femoral canal is controversial. The compromise position is that the iliopubic tract is the border, whereas in the normal unstretched state, the lacunar ligament (Gimbernat’s ligament) is the border in the presence of hernia (stretched state). At surgery, it is enough to say that a palpable, visible curved ligament is present and used in some femoral repairs. 35. How long should the patient avoid heavy lifting after a hernia repair? The standard advice for decades has been 4–6 weeks. However, recent data shows no increase in recurrence rate related to early resumption of normal activities. There is no evidence to support such a long convalescent period. Recent guidelines recommend that patients should self-limit their activity as required by their postoperative pain, and that they should be reassured that physical activity does not appear to cause hernia recurrence. 36. What are the typical indications for laparoscopic repair? Hernias that are bilateral or recurrent.
256 ABDOMINAL SURGERY 37. Is laparoscopic repair appropriate for initial, unilateral inguinal hernia? Recent studies show no significant difference between laparoscopic and open repair in terms of major complications, including hernia recurrence. In addition, laparoscopic repair has the benefit of shorter recovery time, and less postoperative pain. It is important, however, to recognize that laparoscopic repair has a very gradual learning curve. The literature supports use of laparoscopic, primary, unilateral hernia repair depending on the volume of the center and surgeon’s experience.
K EY POIN T S: T Y P E S O F I N G UI N A L H E R N I A R EPA I R 1. The Bassini repair sutures together the conjoined tendon and the shelving edge of the inguinal ligament up to the internal ring. 2. The McVay repair is most useful for femoral and direct hernias. 3. The Shouldice repair imbricates the transversalis fascia and conjoined tendon with four continuous lines, using two fine-wire sutures (not appropriate for femoral hernias). 4. The Lichtenstein repair consists of a sutured patch of polyprolene mesh that covers Hesselbach’s triangle and the indirect hernia sac.
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