Inguinal hernia
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INGUINAL HERNIA
Max Angelo G. Terrenal – Post Graduate Medical Intern – Veterans Memorial Medical Center
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WHAT IS AN INGUINAL HERNIA?
Protrusion of a peritoneal sac through a musculoaponeurotic barrier
Direct or Indirect
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DIRECT INGUINAL HERNIA
Within the floor of Hesselbach’s triangle
Acquired defect from mechanical breakdown over the years
~1% Lifetime risk
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INDIRECT INGUINAL HERNIA
Through the internal ring of inguinal canal
CongenitalPatent processus vaginalis
~5% Lifetime riskHigher risk of strangulation than direct
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INDIRECT INGUINAL HERNIA
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INCARCERATED STRANGULATED
Hernia which cannot be reduced
Incarcerated hernia with resulting ischemia
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EPIDEMIOLOGYOne of the most common surgical procedures Incidence: ~5-10% lifetime75% of abdominal wall hernias
Male > Female Indirect > DirectRight > Left1/3 may develop a contralateral inguinal hernia
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ETIOLOGYMultifactorialWeakness in abdominal wall musculature
PRESUMED CAUSES OF GROIN HERNIATIONCoughing Valsalva's maneuversChronic obstructive pulmonary disease
Ascites
Obesity Upright positionStraining Congenital connective tissue
disordersConstipation Defective collagen synthesisProstatism Previous right lower quadrant
incisionPregnancy Arterial aneurysmsBirthweight <1500 g Cigarette smokingFamily history of a hernia Heavy liftingPhysical exertion (?)
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ANATOMYInguinal Hernia
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ABDOMINAL WALL Skin
Subcutaneous fat
Scarpa’s fascia
External oblique muscle
Internal oblique muscle
Transversus abdominis
Transveralis fascia
Preperitoneal fat
Peritoneum
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INGUINAL CANAL4-6 cm longAnteroinferior of pelvic basin
Cone-shapedBase superolateral margin
Apex Inferomedially
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BOUNDARIES Anterior
external oblique aponeurosis
Lateral Internal oblique muscle
Posterior fusion of the transversalis
fascia and transversus abdominus muscle,
Superior arch formed by the fibers of
the internal oblique muscle.
Inferior inguinal ligament
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SPERMATIC CORDCremasteric muscle fibersVas deferensTesticular arteryTesticular pampiniform
venous plexusGenital branch of the
genitofemoral nerve+/- hernia sac
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HESSELBACH’S TRIANGLE
Medial aspect of Rectus abdominis muscle
Inferior epigastric vessels
Inguinal ligament
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POSTERIOR
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MYOPECTINEAL ORIFICE OF FRUCHAUD Superior
Arch of IOM and TA
Lateral Iliopsoas muscle
Medial Lateral edge of RA and
Pubic pectin
Iliopubic tract Spermatic cord Iliac vessels
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TRIANGLE OF DOOM External iliac vessels
Deep circumflex iliac vein
Femoral nerve
Genital branch of GF nerve
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TRIANGLE OF PAINNerves Lateral femoral cutaneousFemoral branch of GF nerveFemoral nerve
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CLASSIFICATION
Inguinal Hernia
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NYHUS CLASSIFICATION SYSTEM
Type I INDIRECT HERNIA; internal abdominal ring normal; typically in infants, children, small adults
Type II INDIRECT HERNIA; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum
Type IIIA
DIRECT HERNIA; size is not taken into account
Type IIIB
INDIRECT HERNIA that has enlarged enough to encroach upon the posterior inguinal wall; INDIRECT SLIDING OR SCROTAL HERNIAS are usually placed in
this category because they are commonly associated with EXTENSION TO THE DIRECT SPACE; also includes PANTALOON HERNIAS
Type IIIC
FEMORAL HERNIA
Type IV RECURRENT HERNIA; modifiers A–D are sometimes added, which correspond TO INDIRECT, DIRECT, FEMORAL, AND MIXED, RESPECTIVELY
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DIAGNOSIS
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HISTORY Groin pain
Extrainguinal symptoms Change in bowel habits Urinary symptoms
Pressure on nerves Generalized pressure Local sharp pains Referred pain
Scrotum, testicle or inner thigh
Duration
Progressiveness
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PHYSICAL EXAMINATION Inspection
Standing
Palpation Inguinal Occlusion test
Direct Indirect
Cough Impulse
Manifested Controlled
Dorsum of finger
Fingertip
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DIFFERENTIAL DIAGNOSIS Malignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumor Primary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle
Undescended testicle Femoral artery aneurysm or pseudoaneurysm
Lymph node Sebaceous cyst Hidradenitis Cyst of the canal of Nuck (female)
Saphenous varix Psoas abscess Hematoma Ascites
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IMAGINGInguinal Hernia
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UltrasoundCT ScanMRI
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MANAGEMENT
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CONSERVATIVE MANAGEMENT
Aimed at alleviating symptoms such as pain, pressure, and protrusion of abdominal contents
Assuming a recumbent positionTruss, an elastic belt or brief
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EMERGENT REPAIRIncarcerated herniasStrangulated herniasSliding hernias
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INCARCERATED HERNIA
Reasons for incarceration large amount of intestinal contents within the hernia sac
dense and chronic adhesions of hernia contents to the sac
small neck of the hernia defect in relation to the sac contents
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INCARCERATED HERNIA
An incarcerated inguinal hernia without the sequelae of a bowel obstruction is not necessarily a surgical emergency
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INCARCERATED HERNIA
Reduction should be attempted before definitive surgical intervention.
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INCARCERATED HERNIA
Hernias that are not strangulated and do not reduce with gentle pressure should undergo taxis.
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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.
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STRANGULATED HERNIA
Femoral > 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 addressed
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OPERATIVE TECHNIQUES
Inguinal hernia
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ANTERIOR REPAIRNON PROSTHETIC
Inguinal hernia
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OPEN APPROACH
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OPEN APPROACH
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BASSINI REPAIR Is frequently used for indirect
inguinal hernias and small direct hernias
The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
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MCVAY REPAIR inguinal and femoral canal defects
The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
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SHOULDICE REPAIR
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ANTERIOR REPAIRPROSTHETIC
Inguinal hernia
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LICHTENSTEIN TENSION-FREE REPAIR
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LAPAROSCOPIC HERNIA REPAIRTransabdominal Preperitoneal Procedure (TAPP)
Totally Extraperitoneal (TEP) Repair
Indications include bilateral inguinal hernia, recurring hernia, need for early recovery
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RECURRENCEAround 1% for Shouldice repairMost recurrences are of the same type as the original hernia
Recurrence FactorsPatientTechnicalTissue
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RECURRENCEPatient 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 repair
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COMPLICATIONSThe 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
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EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT
INGUINAL HERNIA
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EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA
PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES
1. What is the recommended treatment for inguinal hernia?
Mesh repair, Laparoscopic or the Open
2. If laparoscopic mesh repair is the preferred technique for inguinal hernias, what is the recommended laparoscopic technique?
Transabdominal Preperitoneal or Total Extra Preperitoneal
3. Is fixation of the mesh necessary in laparoscopic repair?
No
4. If open mesh repair, what is the recommended technique
Lichtenstein, plug and mesh or Prolene Hernia System
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EVIDENCE-BASED CPG ON THE MANAGEMENT OF ADULT INGUINAL HERNIA
PHILIPPINE JOURNAL OF SURGICAL SPECIALTIES
5. What is the recommended treatment for recurrent inguinal hernia?
Mesh repair, either laparoscopic or open method
6. What is the recommended treatment for bilateral inguinal hernia?
Mesh repair, either laparoscopic or open method
7. Is antimicrobial prophylaxis recommended for elective groin hernia surgery?
Not routinely recommended using mesh
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