Direct and Indirect inguinal Hernia

Dr. Ahmad Uzair QureshiFCPS ( SURGERY) / MCPS ( SURGERY)

MRCS ( ENGLAND) / Dip Med Edu (Cardiff) Colorectal Fellow Yonsei University, South Korea

Assistant Professor of Surgery, King Edward Medical University, Lahore

Objectives• The students will be able to

• Define hernia• Different sites and types of hernia• Enlist clinical features of groin hernia• Enumerate differences in direct and indirect hernia• Describe contents of hernia sac and their origin• Enlist complications which may arise from hernia• Describe the steps of open Hernia repair

ABDOMINAL REGIONS WHERE

HERNIAS OCCUR

What is a Hernia?It is an abnormal protrusion of a viscus or part of a viscus through

a potential weak space of its containing cavity.

CLINICAL FEATURES

Lump at an appropriate anatomical site

Increases in size on coughing or straining.

It reduces in size or disappears when relaxed or supine

position.

Examination may show it to have a cough impulse and to be

reducible

Rt. INDIRECT ING. HERNIA

FACTORS PREVENTING HERNIATION

1- Oblique coarse of the inguinal canal .2- Contraction of conjoint tendon during coughing or straining (shutter mechanism) .3- Contraction of cremasteric muscle : Plugging of inguinal canal

Groin hernia• Inguinal• Femoral• Obturator

•Two (2) types •Acquired •Congenital

Groin hernia•Inguinal

•Direct •Indirect

Depending on the site of origin of sac. And per operatively by relation to the deep

epigastric vessels

Layers of anterior abdominal wall

What is an Direct/ Indirect Hernia?

What is an Indirect Hernia?

• Congenital or acquired weaknesses in TF

• Location: lateral to deep epigastric vessels

• Protrude through deep inguinal ring; may descend into the scrotum

• Men

Deep ring

DIRECT INGUINAL HERNIA

• Acquired weaknesses in TF• Location: Hesselbach’s • Emerge between the deep

epig. artery and rectus abd. muscle and protrude into the ingu. canal but not into the SC.

• More difficult to repair?!• Men

HERNIAS…COMPLICATIONS

• Reducible • Irreducible • Obstructed or incarcerated • Strangulated

COMPLICATIONS

Obstruction • Irreducible• abdominal pain, • distension and vomiting may occur • The hernia will be tense tender and irreducible

Strangulation • become red and tender, • Irreducible• No impulse on cough.• If contains bowel signs of obstruction.

INGUINAL HERNIA REPAIR RATIONALE

TENTION FREE REPAIR

MESH REPAIR

HERNIA…PRINCIPLES OF REPAIR

Irrespective of approach used the following will be achieved

• Dissection of the sac • Reduction / inspection of the contents • Ligation of the sac • Approximation of the inguinal and pectineal ligaments

INGUINAL HERNIA.TYPES OF REPAIR

• Bassini repair : Suturing conjoined tendon to inguinal ligament behind

the cord .

• Lytle repair: Plication of the fascia transversals .

• Shouldice repair : incision of the fascia & double breasting of it .

• Halsted ‘s repair Bassini repair plus reinforced by suturing the 2 leaflets

of external oblique together behind the cord

INGUINAL HERNIA.TYPES OF REPAIR

• Shouldice or Liechtenstein

• Laparoscopic hernia repair:

Surgical Anatomy – land marks

Ant Sup Iliac Spine

Pubic tubercle

Incision

Ext Oblique Muscle

Ext Oblique Muscle - Incised

Ext Oblique reflected

Conjoined Muscle

Inguinal ligam

ent

Spermatic Cord + Indirect Hernia Sac

Pearly white Hernia Sac

Herniotomy (opening of sac)

Spermatic CordVas/ pampiniform plexus

Extraperitoneal fat( extend of dissection)

Transfixation of the hernia sac near the base after twisting the sac , using catgut

Division of sac

Lax porterior wall of inguinal canal

Plication of posterior inguinal canal wall

Darn / Mesh placement using prolene suture

Closure of External oblique

Closure of Skin

In case you have a question or a query ahmeduzairq@gmail.com +923144001410