Abdominal Hernias. Ada Yee

Warm up
Indirect inguinal hernias are caused by weakness of the transversalis fascia
Direct inguinal hernias are often more bilateral than indirect
Definition
Protruding viscus beyond covering of the cavity in which it is normally contained
FALSE
TRUE

Anatomy
Inguinal Canal
Post – transversalis fascia
Anterior – internal & external obliques
Roof – Conjoint Tendon, transverse abdominis & internal oblique
Floor – inguinal ligament

Types
>♂ (descent of testes)
Indirect
due to patent processus vaginalis, 70% all inguinal hernias
Lateral to inferior epigastric vessel
Direct
weakness posterior wall, can be often B/L
Medial to inferior epigastric vessel

Types
Pantaloon
Indirect & direct at same time
Tend to be in the elderly
Sliding
Sometimes retroperitoneal structure slides down posterior abdo wall & herniates into inguinal canal taking along overlying peritoneum with it

Types
Incarcerated
A chronically irreducible hernia which is not strangulated
Strangled
Tends to occur with indirect hernias.
Hernia contents become constricted by the narrow deep ring or they twist.
Venous return obstructed, swelling appears, arterial obstruction & infarction soon follows.
Associated with Sx & Sx of bowel obstruction & peritonitis

Inguinal Hernias
Examination
Supine & standing
Palpate landmarks
Ask pt to cough
Characteristics of lump
Reducible / compressible
Pulsatile, expansile
Hot, tender
Smooth, irregular
Soft, hard
Cough impulse
Surface landmarks
ASIS & pubic tubercle – inguinal ligament lies b/w
Deep ring 2cm above midpoint of inguinal ligament
Mid inguinal point is ½ way b/w ASIS & pubic symphysis – femoral artery
Superficial ring is 2cm above & medial to pubic tubercle

ΔΔ
Femoral hernia
Lie lateral & below the pubic tubercle
Lymphadenopathy
Mobile, pain, fever, recent infections, weight loss (examine other nodes)
Saphina varix
Dilatation long saphenous vein. Look for emptying on pressure & refilling on release. Disappears supine.
Femoral artery aneurysm
Below inguinal ligament. Expansile pulsation.
Groin abscess
Undescended tests
Varacocoele / hydrocoele
Littre’s hernia

Investigations
Underlying diseases such as chronic respiratory problems, constipation, urinary issues
Herniography
Not commonly used – dye into peritoneum
CT – rare hernias

Management & Indications for Surgery

Open Inguinal Repair
Anaesthesia – general, spinal, local
Position - supine
Incision – 2cm above & parallel to medial ½ of inguinal ligament
Procedure
Wound is deepened to external oblique aponeurosis & the inguinal ligament is exposed.
Inguinal canal is entered 1 cm above the ligament by dividing the aponeurosis along its length. Identify & protect the ilioinguinal nerve
Spermatic cord is mobilized off the inguinal ligament & posterior wall. If it is a direct hernia, it is reduced & held in position with an absorbable suture.
If indirect hernia, the spermatic fascia & cremaster is divided longitudinally to enter the cord

Open Inguinal Repair
Procedure cont’
Indirect sac will be identified by separating the cord structures. The sac then dissected from the cord to the level of the internal ring.
The indirect sac is opened & any contents reduced back into the abdomen.
The neck of the sac is transfixed & the sac excised.
A piece of synthetic (e.g. polypropylene) mesh is trimmed to size & sutured without tension from the pubic tubercle along the inguinal ligament below, to the internal oblique aponeurosis above, using non-absorbable sutures. The lateral limit of the mesh encircles the cord at the internal ring
Closure – in layers
Post op complications – recurrence, haematoma, infection, ilioinguinal neuropathy

Laparoscopic
Anaesthesia – general
Position – supine
Incision & Approach
A 2 cm transverse incision is made lateral to the lower part of the umbilicus on hernia side. The anterior rectus sheath is opened transversely & rectus muscle retracted laterally. Pass a finger to sweep open the space behind rectus
This space & the retropubic space may be further opened by inflating a balloon
A 10 mm blunt port, with an air-tight seal, is inserted into the wound & the space is inflated with CO2 at 15 mmHg. Laparoscope with camera is inserted through this port.
Under direct vision two further ports, a 10 mm and a 5mm, are inserted in the midline into the new preperitoneal space for instumentation.

Laparoscopic
Procedure
The peritoneum is separated from the abdominal wall behind the inguinal area, laterally to the ASIS & medially across the midline.
The inferior epigastric vessels identified & left attached to back of abdominal wall. A direct sac lies medial to these vessels & is withdrawn into abdomen.
To find indirect sac, the cord is 1st identified lateral to these vessels. When the outer layer of the cord is separated, the sac will be seen & withdrawn into the abdomen separating it from the vas & testicular vessels
A 15 cm x 10 cm mesh is placed over the inguinal area running from lateral to & covering deep inguinal ring, & extending across the midline. Metal tacks can be placed medially to hold it in place
When the position of the mesh is satisfactory gas is vented & the peritoneum obliterates the preperitoneal space & secures mesh position.
Closure - The ports are withdrawn & skin closed.
Post op Complications - recurrence

Complications of Op
Infection
Bleeding
Recurrence
Urinary retention
Testicular atrophy
Neuropraxia / nerve entrapment