Inguinal Hernia

Inguinal HerniaManagementUncomplicated hernias require either:No treatmentSupport with a trussOperative treatmentComplicated hernias:Always require surgery, often urgently

Management

A number of effective operative therapies exist in the treatment of inguinal hernias. To attain and maintain consistent, successfuloutcomes, the general surgeon must have a proficient understanding of groin anatomy and be mindful of surgical principles. Theapplication of prosthetics to effect a tension-free repair created an operation that was simple, effective, and reproducible across a rangeof operative experience, and reduced recurrence rates to a much lower level. Further advances in hernia treatment were part of thelaparoscopic revolution, which has improved postoperative pain and shortened recovery time. Although laparoscopic repairs require moreextensive training and equipment than open repairs, significant benefits can be imparted to the patient. Despite the controversiesassociated with laparoscopic inguinal hernia repair for primary unilateral inguinal hernias, the general surgeon must not only becognizant, but also able to perform a variety of inguinal hernia repairs. By having more than one approach in one's armamentarium, thesurgeon has the ability to choose the appropriate procedure for the problem at hand3Conservative ManagementAimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contentsFor Hernias that or not strangulated or incarcerated can be mechanically reducedAssuming a recumbent positionTruss, an elastic belt or brief

The definitive treatment of all hernias is surgical repair.A hernia defect will not decrease in size, but likely increase and possibly progress to incarceration or strangulation of the sac's contents.

Surgery can be delayed or avoided in situations where the patient's medical status prohibits operative treatment.

Conservative management is aimed at alleviating symptoms related to the inguinal hernia, such as pain, pressure, and protrusion of abdominal contents.

Simple maneuvers include assuming a recumbent position, which aids in self-reduction of the hernia. 4

A truss, an elastic belt or brief that aims to keep the hernia reduced, may also be worn; however, its use does not prevent hernia progression or incarceration. A truss may provide relief in up to 65% of patients; however, many will use it only intermittently as it does not provide continuous control of the hernia and may actually lead to an increased rate of hernia incarceration4TRUSS

Emergent repairIncarcerated herniasStrangulated herniasSliding herniasINCARCERATED HERNIAReasons for incarceration large amount of intestinal contents within the hernia sacdense and chronic adhesions of hernia contents to the sacsmall neck of the hernia defect in relation to the sac contentsINCARCERATED HERNIAAn incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergencyHowever, once the patient demonstrates bowel obstruction secondary to incarceration or a sliding inguinal hernia, operative intervention becomes expedited. Patients will often present with vomiting, constipation, obstipation, a distended abdomen, or combination thereof8INCARCERATED HERNIAReduction should be attempted before definitive surgical intervention. INCARCERATED HERNIAHernias that are not strangulated and do not reduce with gentle pressure should undergo taxis. TAXISThe patient is sedated and placed in a Trendelenburg position. The hernia sac is grasped with both hands, elongated, and then milked back through the hernia defect.

Pressure applied to the most distal portion of the sac will cause the contents to mushroom and prevent reduction. Before attempting taxis, the patient should be made aware of potential surgery in the case of failure of the maneuver. 11STRANGULATED HERNIAFemoral > Indirect > DirectFever, leukocytosis, and hemodynamic instability. The hernia bulge usually is very tender, warm, and may exhibit red discoloration.

Taxis should not be applied to strangulated hernias as a potentially gangrenous portion of bowel may be reduced into the abdomen without being addressedIf the blood supply to incarcerated contents becomes compromised, an incarcerated hernia becomes a strangulated hernia. These pose a significant risk to life because the strangulated contents are ischemic and may quickly lose viability.Clinical signs that indicate strangulation include Fever, leukocytosis, and hemodynamic instability.

12OPERATIVE TECHNIQUESSurgery aims to Reduce the hernia contentsExcise the sac (herniotomy) in most casesRepair and close the defect either by herniorrhapy or hernioplastyAnterior repairnon prostheticOPEN APPROACH

An oblique or horizontal incision is performed over the groin.A point two fingerbreadths inferior and medial to the anterior superior iliac spine is chosen as the most lateral point of the incisionIt is then progressed medially for approximately 6 to 8 cm16OPEN Approach

The iliohypogastric and ilioinguinal nerves are identified and retracted from the operative field by placing a hemostat beneath their course and then grasping one of the edges of the aponeurosis

Some surgeons obtain preoperative consent to cut the ilioinguinal nerve to avoid possible entrapment and post operative pain however, the patient may experience numbness of inner thigh or lateral scrotum which usually goes away in 6 months

With the contents of the inguinal canal completely encircled, identification of cord contents and the hernia sac can be effected

Direct hernias will become evident as the floor of the inguinal canal is dissected.

An indirect hernia sac will generally be found on the anterolateral surface of the spermatic cord. In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identified to allow dissection of the sac from the cord

Once the reconstruction of the inguinal canal is complete, the cord contents are returned to their anatomic position

small enough to contain the contents of the inguinal canal and prevent a future false-positive diagnosis of recurrent herniaThe new external ring should be small enough to contain the contents of the inguinal canal and prevent a future false-positivenot be tight and should allow entrance of a finger

17Bassini RepairIs frequently used for indirect inguinal hernias and small direct herniasThe conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

Mcvay repairinguinal and femoral canal defectsThe conjoined tendon is sutured to Coopers ligament from the pubic cubicle laterally

The advantage of the McVay (Cooper's ligament) repair is the ability to address both inguinal and femoral canal defects19Shouldice Repair

The iliopubic tract is sutured to the medial flap, which is made up of the transversalis fascia and the internal oblique and transverse abdominis muscles.

This is the second of the four suture lines. After the stump of the cremaster muscle is picked up, the suture is reversed back toward the pubic tubercle approximating the internal oblique and transversus muscles to the inguinal ligament. Two more suture lines will eventually be created suturing the internal oblique and transversus muscles medially to an artificially created "pseudo" inguinal ligament developed from superficial fibers of the inferior flap of the external oblique aponeurosis parallel to the true ligament.20Anterior repairprostheticLichtenstein Tension-Free RepairThe most commonly performed inguinal hernia repair today is the Lichtenstein repair. A flat mesh is placed on top of the defect

It is a "tension-free" repair that does not put tension on muscles

It involves the placement of a mesh to strengthen the inguinal region.

Patients typically go home within a few hours of surgery, often requiring no medication beyond Paracetamol.

Patients are encouraged to walk as soon as possible postoperatively, and they can usually resume most normal activities within a week or two of the operation.

Lichtenstein Tension-Free Repair

23Initial exposure and mobilization of cord structures is identical to other open approachesA lateral view demonstrates that the prosthesis is situated between the cord and the hernia defect (HD). The hernia defect has been imbricated to allow for facile prosthesis placement only (this does not affect the strength of the repair). MESHPERMANENT MESHCommercial meshes are typically made of prolene (polypropylene) or polyester.

Mosquito-net mesh-Meshes made of mosquito net clothes, in co-polymer of polyethylene and polypropylene have been used for low-income.

ABSORBABLE MESHBiomeshes are increasingly popular since their first use in 1999. They are absorbable and they can be used for repair in infected environment, like for an incarcerated hernia. Moreover, they seem to improve comfort.

Transabdominal Preperitoneal Procedure (TAPP) Totally Extraperitoneal (TEP) Repair

Indications include bilateral inguinal hernia, recurring hernia, need for early recoveryLAPAROSCOPIC HERNIA REPAIR When performed by a surgeon experienced in hernia repair, laparoscopic repair causes less complications than Lichtenstein, and especially half less chronic pain.

25LAPAROSCOPIC HERNIA REPAIR

RECURRENCEAround 1% for Shouldice repairMost recurrences are of the same type as the original hernia

Recurrence FactorsPatientTechnicalTissueCommon causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair. 27RECURRENCEPatient factors malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors wound infection, tissue ischemia, and increased tension within the surgical repairCommon causes of hernia recurrence postrepair include patient, technical, and tissue factors. Patient factors that affect tissue healing include malnutrition, immunosuppression, diabetes, steroid use, and smoking. Technical factors include mesh size, prosthesis fixation, and technical proficiency of the surgeon. Tissue factors include wound infection, tissue ischemia, and increased tension within the surgical repair. 28complicationsThe overall risk of complications of inguinal hernia repair is low.

Common ComplicationsPain, injury to the spermatic cord and testes, wound infection, seroma, hematoma, bladder injury, osteitis pubis, and urinary retention