Inguinal HerniasRobert J. Fitzgibbons, Jr., and Hardeep S. AhluwaliaThe latter part of the eighteenth century heralded dramatic changes as theanatomy of the groin became better understood. In 1881, a French surgeon,Lucas-Championni`ere, performed high ligation of an indirect inguinal herniasac at the internal ring with primary closure of the wound. Edoardo Bassini(18441924) is considered the father of modern inguinal hernia surgery. Byincorporating the developing disciplines of antisepsis and anesthesia with anew operation that included reconstruction of the inguinal floor along withhigh ligation of the hernia sac, he was able to substantially reduce morbidity.It is universally agreed that this concept was responsible for the advent ofthe modern surgical era of inguinal herniorrhaphy and is still valid today. Theoperation resulted in a recurrence rate one-fifth of that which generally wasaccepted and was considered the standard criterion for inguinal hernia repairfor most of the twentieth century.Although Bassinis principle of posterior wall reinforcement remains validin a surgical practice today, his operation has lost its popularity and is usedonly in selected cases in which prosthetic material is contradicted. This isbecause of the widespread acceptance of the concept of avoiding tension duringherniorrhaphy, championed by Lichtenstein. Lichtenstein theorized that byusing a mesh prosthesis to bridge the hernia defect rather than closing it withsutures, as with the Bassini repair and its modifications, tension is avoidedostensibly resulting in a less painful operation. He also felt that the lack oftension reduced the incidence of suture pullout, which would result in a lowerrecurrence rate. A Lichtenstein type operation has now become the method ofchoice in the United States.The preperitoneal space also can be used for repair of an inguinal herniaand has strong proponents because of the mechanical advantage gained fromprosthesis placement behind the abdominal wall. Access to the preperitonealspace can be gained through a lower abdominal incision, transabdominally atthe time of laparotomy or with the aid of laparoscopic guidance. Irrespectiveof the mode of entry to the preperitoneal space, a large prosthesis is usedthat extends far beyond the margins of the myopectineal orifice. This briefoverview of the history of inguinal herniorrhaphy provides a background fora comprehensive look at the problem of inguinal herniation.EPIDEMIOLOGYSeventy-five percent of all abdominal wall hernias occur in the groin. Indirecthernias outnumber direct hernias by about 2:1, with femoral hernias makingup a much smaller proportion. Right-sided groin hernias are more commonthan those on the left. The male:female ratio for inguinal hernias is 7:1. Thereare approximately 750,000 inguinal herniorrhaphies performed per year in theUnited States, compared to 25,000 for femoral hernias, 166,000 for umbilicalhernias, 97,000 for incisional hernias, and 76,000 for miscellaneous abdominalwall hernias.Femoral hernias account for less than 10% of all groin hernias, but 40%of these present as emergencies with incarceration or strangulation. The920Copyright 2006 by The McGraw-Hill Companies, Inc. Click here for terms of use.CHAPTER 36 INGUINAL HERNIAS 921mortality rate for emergency repair is higher than for elective repair. Femoralhernias are more common in older patients and in men who have previouslyundergone an inguinal hernia repair. Although the absolute number of femoralhernias in males and females is about the same, the incidence in females isfour times that of males because of the lower overall frequency of groin herniain women.Estimates of the risk for developing an inguinal hernia vary greatly in theliterature, probably because of the lack of a entirely reproducible way to makethe diagnose. Self-reporting by patients, audits of routine physical examinations,and insurance company databases are among the diverse sources fromwhich such figures are derived, all of which are known to be notoriously inaccurate.Physician physical examination, even by trained surgeons, also is notdependable because of the difficulty differentiating between lipomas of thecord, a normal expansile bulge and a true groin hernia.NATURAL HISTORYRisk factors that are useful in predicting complications in an adult patient witha groin hernia include old age, short duration, femoral hernia and coexistingmedical illness. In children, the risk factors are very young age, male sex, shortduration and right-sided hernia. A better understanding of the natural historytherefore becomes particularly important to identify subgroups that might beat greater risk for a complication.HERNIA ACCIDENT (INCARCERATION, BOWEL OBSTRUCTION,STRANGULATION)An incarcerated hernia is by definition an irreducible hernia. However, thisshould not imply a surgical emergency, as chronic states of incarceration arecommon because of the size of the neck of the hernia in relationship to itscontents or because of adhesions to the hernia sac. The recommended treatmentof an incarcerated hernia is surgical repair, but there is no urgency because thereis no life threatening complication present.A patient with an incarcerated inguinal hernia exhibiting signs of a bowelobstruction or one who develops an acute incarceration that remains exquisitelytender represents a completely different clinical scenario. Unlike adhesivesmall bowel obstructions, partial small bowel obstructions are rare. Therefore,most patients will have had vomiting and absolute constipation (obstipation).In the western world, groin hernia ranks third after adhesive obstruction andcancer as the most common cause of bowel obstruction. In other areas, itremains the most common. It is common for it to be overlooked on clinicalexamination and therefore must be kept in mind in patients being evaluatedfor bowel obstruction.Imaging studies are important in cases in which there is the slightest questionabout the cause of the patients obstructive pattern. This is because a distalintestinal obstruction secondary to another cause (e.g., adhesions) may result indistention of a coincidental nonobstructing groin hernia. Should the examinerfocus attention exclusively on the hernia, the stage is set for disaster whenthe hernia is repaired and the real cause of the obstruction is missed. Plainroentgenograms of the abdomen will reveal the usual signs of an intestinalobstruction: dilated loops of bowel with air-fluid levels, absence of bowel gasdistal to the obstruction and bowel shadows in the region of the hernia. Alateral view often is useful to demonstrate this more clearly. Computerized922 PART II SPECIFIC CONSIDERATIONStomographic (CT) scans reliably demonstrate the hernia with characteristicfeatures of obstruction and should be considered if the clinical diagnosis is notcertain.The initial treatment, in the absence of signs of strangulation, is taxis.Taxis is performed with the patient sedated and placed in the Trendelenburgposition. The hernia sac neck is grasped with one hand with the otherapplying pressure on the most distal part of the hernia. The goal is toelongate the neck of the hernia so that the contents of the hernia may beguided back into the abdominal cavity with a rocking movement. Taxisshould not be performed with excessive pressure. If the hernia is strangulated,gangrenous bowel might be reduced into the abdomen or perforatedin the process. One or two gentle attempts should be made at taxis. If thisis unsuccessful, the procedure should be abandoned. Rarely, the hernia togetherwith its peritoneal sac and constricting neck may be reduced intothe abdomen (reduction en masse). Reduction en masse of a hernia is definedas the displacement of a hernia mass without relief of incarcerationor strangulation. This diagnosis has to be considered in all cases of intestinalobstruction after apparent reduction of an incarcerated hernia. Laparoscopycan be both diagnostic and therapeutic and therefore is a particularlygood option. Surgeon expertise may make laparotomy a better choice forsome.The most significant complication of either acute incarceration or intestinalobstruction is strangulation. It is a serious, life-threatening condition becausethe hernia contents have become ischemic and nonviable. The clinicalfeatures of a strangulated obstruction are dramatic. In addition to thepatient having developed an irreducible hernia and an intestinal obstruction,clinical signs indicate that strangulation has taken place. The herniais tense, very tender and the overlying skin may be discolored with a reddishor bluish tinge. There are no bowel sounds present within the herniaitself. The patient commonly has a leukocytosis with a left shift, is toxic,dehydrated and febrile. Arterial blood gases may reveal a metabolic acidosis.Rapid resuscitation with intravenous fluids is essential with electrolyte replacement,antibiotics and nasogastric suction. Urgent surgery is indicatedonce resuscitation has taken place. The initial surgical approach is to make aconventional inguinal hernia incision. If the bowel is viable, it is reduced intothe abdominal cavity prior to repairing the hernia. The neck of the hernia iswidened if any difficulty is encountered reducing the hernia. Although rare,the surgeon must be cognizant of the possibility that a nonviable abdominalorgan may have been reduced into the abdominal cavity during the course ofusual surgical maneuvers before it could be visualized. If such a suspicion ispresent, the entire GI tract must be evaluated. If the bowel is found to be obviouslygangrenous, more bowel must be pulled into the hernia so that viablebowel can be transected and the gangrenous portion removed. In the ideal situation,an end to end anastomosis is performed and the bowel is reduced intothe abdominal cavity, followed by hernia repair. The slightest suspicion thatthe entire process cannot be addressed from the groin mandates exploratorylaparoscopy or laparotomy to unequivocally prove that all nonviable tissue hasbeen resected. In the case of a femoral hernia, it is frequently necessary to incisethe inguinal ligament anteriorly or the lacunar ligament medially to facilitatereduction.CHAPTER 36 INGUINAL HERNIAS 923ETIOLOGYThe cause of an inguinal hernia in a human is far from completely understoodbut is undoubtedly multifactorial (Table 36-1). Familial predisposition playsa role. However, there is increasing evidence that connective tissue disorderspredispose to hernia formation by altering collagen formation. A higher prevalenceof inguinal hernias is well known among patients suffering from certaincongenital connective tissue disorders. In children with congenital hip dislocation,inguinal hernia occurs five times more often in girls and three times moreoften in boys compared to children without this disease. The role of physicalexertion in the development of inguinal hernia is probably less important thanis commonly believed. The cause and effect relationship between a specificlifting episode and the development of an inguinal hernia is present in less than10 percent except in circumstances in which workers compensation issues areinvolved. Additionally, athletes, even weightlifters, do not seem to have an excessiveincidence of inguinal hernias. This begs the question whether patientswith un-repaired inguinal hernias should be restricted from heavy lifting.Indirect Inguinal HerniaThe so-called saccular theory of indirect inguinal hernia formation proposedby Russell remains popular. Russells hypothesis that the presence of a developmentaldiverticulum associated with a patent processus vaginalis, wasessential in every case is still valid in the minds of many surgeons even today.Russell felt that increased intraabdominal pressure might serve to furtherstretch and weaken the internal ring allowing additional intraabdominal organsto herniate through the orifice but could not actually cause an indirect inguinalhernia. This does not explain all cases of indirect groin hernias, however. First,TABLE 36-1 Presumed Causes of Groin HerniationCoughingChronic obstructive pulmonary diseaseObesityStrainingConstipationProstatismPregnancyBirthweight less than 1500 gFamily history of a herniaValsalva maneuversAscitesUpright positionCongenital connective tissue disordersDefective collagen synthesisPrevious right lower quadrant incisionArterial aneurysmsCigarette smokingHeavy liftingPhysical exertion ?924 PART II SPECIFIC CONSIDERATIONSa patent processus vaginalis can be found at autopsy without clinical evidenceof a hernia. Second, there are patients with an obliterated processus vaginaliswho have an abdominal wall defect lateral to the epigastric vessels. Third,congenital structural malformations of the transversalis fascia and transversusabdominis aponeurosis can alter the strength and size of the internal inguinalring. Denervation of the internal oblique muscle by adjacent incisions (e.g.,appendectomy) also can be associated with the eventual development of aninguinal hernia.Excessive fatty tissue involving the cord or round ligament encountered bya surgeon during elective herniorrhaphy traditionally has been referred to asa lipoma of the cord. This term is unfortunate because it implies a neoplasticprocess but a lipoma of the cord consists of normal fatty tissue. The reason forthe term lipoma is that the fatty tissue can easily be separated from the cordstructures and reduced into the preperitoneal space en masse as if it were atumor. A lipoma of the cord is important from a clinical standpoint for threereasons: (1) it can cause hernia type symptoms although with less frequencythan indirect hernias with a peritoneal sac; (2) it is often difficult to distinguishat physical examination from an indirect hernia with a peritoneal sac; and (3)it can be responsible for an unsatisfactory result because of an unchangedphysical examination after elective inguinal herniorrhaphy, especially whena preperitoneal repair is used. For the purposes of the large clinical trialsreferred to in other parts of this chapter, a lipoma of the cord was classified asan indirect hernia. There is no peritoneal sac by definition because the contentsof the indirect hernia (i.e., preperitoneal fat) come from the preperitoneal spacerather than the abdominal cavity.

Direct Inguinal HerniasTwo major factors are felt to be important in the development of direct inguinalhernias. The first is increased intraabdominal pressure associated with a varietyof conditions listed in Table 36-1. The second factor is relative weakness ofthe posterior inguinal wall. An abnormally high lying arch of the main body ofthe transversus abdominis above the superior ramus of the pubis resulting ina large area at risk has been incriminated (see Anatomy). Similarly, a limitedinsertion of the transversus abdominis muscle onto the pubis, weakness of theiliopubic tract, limited insertion of the iliopubic tract aponeurosis into a Cooperligament or a combination of these have been reported to contribute.Femoral HerniasThe size and shape of the femoral ring and increased intraabdominal pressureare factors that contribute to the development of a femoral hernia. The iliopubictract anteriorly and medially accounts for the variability that allows thedevelopment of the hernia. The iliopubic tract normally inserts for a distanceof 12 cm along the pectinate line between the pubic tubercle and the midportionof the superior pubic ramus. A femoral hernia can result if the insertion isless than 12 cm or if it is shifted medially. The net effect of either anatomicsubtlety is to widen the femoral ring, predisposing to the hernia. Femoral herniasare particularly dangerous because of the rigid structures that make upthe femoral ring. The slightest amount of edema at the ring can produce gangrenouschanges of the sac contents continuing distally into the femoral canaland thigh.CHAPTER 36 INGUINAL HERNIAS 925Sliding Inguinal HerniaA sliding inguinal hernia is defined as any hernia in which part of the sac is thewall of a viscus. Approximately 8 percent of all groin hernias present with thisfinding but the incidence is age related. It rarely is found in patients less than 30years of age but increases to 20 percent after the age of 70. If the hernia is on theright, the cecum, ascending colon or appendix most commonly are involved;and on the left, the sigmoid colon. The uterus, fallopian tubes, ovaries, uretersand bladder can be involved on either side. The sliding component usually isfound on the posterior lateral side of the internal ring. The importance of thiscondition has lessened considerably in the last several years with the realizationthat it is not necessary to resect hernia sacs and that simple reduction into thepreperitoneal space is sufficient. This eliminates the primary danger associatedwith sliding hernias, which is injury to the viscus during high ligation and sacexcision.ANATOMYThe anatomy of the groin is best understood when observing from the approachfor the herniorrhaphy to be performed. For a conventional operation, this meansfrom the skin to the deeper layers. For the laparoscopic operations or thepreperitoneal operations, one should consider the anatomy from the abdominalcavity to the skin. The first layers encountered beneath the skin are the Camperand Scarpa fascia in the subcutaneous tissue. The aponeurosis of the externaloblique muscle is the next structure encountered as dissection proceeds throughthe abdominal wall. The muscle arises from the posterior aspects of the lowereight ribs. The posterior portion of the muscle is orientated vertically and insertson the crest of the ileum. The anterior portion of the muscle courses inferiorlyin an oblique direction toward the midline and pubis. The obliquely orientedanterior-inferior fibers of the aponeurosis of the external oblique muscle foldback on themselves to form the inguinal ligament which attaches laterally tothe anterior superior iliac spine. The medial insertion of the inguinal ligamentin most individuals is dual. One portion inserts on the pubic tubercle and thepubic bone. The other folds back as the lacunar ligament. It blends laterallywith a Cooper (pectineal) ligament. The more medial fibers of the aponeurosisof the external oblique divide into a medial and a lateral crus to form theexternal or superficial inguinal ring through which the spermatic cord or roundligament and branches of the ilioinguinal and genitofemoral nerves pass.The internal abdominal oblique muscle fibers fan out following the shapeof the iliac crest; the superior fibers course obliquely upward toward the distalends of the lower three or four ribs whereas the lower fibers orient themselvesinferomedially toward the pubis to run parallel to the external oblique aponeuroticfibers. These fibers arch over the round ligament or the spermatic cordforming the superficial part of the internal (deep) inguinal ring.The first lumbar nerve divides into the ilioinguinal and iliohypogastricnerves. These may divide within the psoas major muscle retroperitoneallyor between the internal oblique and transversus abdominis muscles. The ilioinguinalnerve may communicate with the iliohypogastric nerve before innervatingthe internal oblique. The ilioinguinal nerve then passes through theexternal inguinal ring to run with the spermatic cord, although the iliohypogastricnerve pierces the external oblique to innervate the skin above the pubis. Thecremaster muscle fibers, which are derived from the internal oblique muscle,are innervated by the genitofemoral nerve (L1, L2).926 PART II SPECIFIC CONSIDERATIONSThe transversus abdominis muscle arises from the inguinal ligament, theinner side of the iliac crest, the endoabdominal fascia and the lower six costalcartilages and ribs. The medial aponeurotic fibers of the transversus abdominiscontribute to the rectus sheath and insert on the pecten pubis and the crest ofthe pubis forming the falx inguinalis. These fibers are infrequently joined bya portion of the internal oblique aponeurosis; only then is a true conjoinedtendon formed.The myopectineal orifice of Fruchaud refers to an anatomic area in thegroin through which all hernias occur. Hesselbachs inguinal triangle is withinthis orifice and is the site of direct inguinal hernias. When described from theanterior aspect, the inguinal ligament forms the base of the triangle, the edge ofthe rectus abdominis is the medial border, and the inferior epigastric vessels arethe superolateral border. It should be noted, however, that Hesselbach actuallydescribed a Cooper ligament as the base.The transversalis fascia also is important because it forms anatomical landmarksknown as analogues or derivatives. The important transversalis fasciaanalogues for the hernia surgeon are the iliopectineal arch, the iliopubic tract,the crura of the deep inguinal ring and a Cooper (pectineal) ligament. Thesuperior and inferior crura form a transversalis fascia sling, a monks hoodshaped structure, around the deep inguinal ring. This sling has functional significanceas the crura of the ring are pulled upward and laterally by the contractionof transversus abdominis, resulting in a valvular action that helps topreclude indirect hernia formation. The iliopubic tract is the thickened band ofthe transversalis fascia that courses parallel to the more superficially locatedinguinal ligament. It is attached to the iliac crest laterally and inserts on thepubic tubercle medially. The insertion curves inferolaterally for 12 cm alongthe pectinate line to blend with a Cooper (pectineal) ligament, ending at aboutthe midportion of the superior pubic ramus. A Cooper ligament is actuallya condensation of periosteum and is not a true analogue of the transversalisfascia.The femoral ring is bordered by the superior pubic ramus inferiorly and thefemoral vein laterally. The iliopubic tract with its curved insertion onto thepubic ramus is the anterior and medial border. The canal normally containspreperitoneal fat, connective tissue and lymph nodes including a Cloquet nodeat its entrance, the femoral ring.The Posterior Perspective (Laparoscopic)An excellent view of the anterior abdominal wall can be obtained from alaparoscopic vantage point. Peritoneal folds are immediately obvious whichcorrespond to important anatomic landmarks in the preperitoneal space. Themedian umbilical fold extends from the umbilicus to the urinary bladder andcovers the urachus, the usually fibrous remnant of the fetal allantois. Thelateral umbilical fold covers the inferior epigastric artery as it courses towardthe posterior rectus sheath and enters it approximately at the level of the arcuateline.The fossa formed between the medial and the lateral ligaments is the site ofdirect inguinal hernias. The lateral fossa is less delineated than the other two.The deep inguinal ring is located in the lateral fossa just lateral to the inferiorepigastric vessels.When the peritoneum is divided and the preperitoneal space entered, thekey anatomic elements for a preperitoneal herniorrhaphy can be appreciated.CHAPTER 36 INGUINAL HERNIAS 927In the midline behind the pubis, the preperitoneal space is known as the spaceof Retzius, although laterally it is referred to as the space of Bogros. Thisspace is important because many of the repairs, which are described later,are performed in this area. Perhaps the single most important landmark is theinferior epigastric artery. This branch of the external iliac artery representsthe primary blood supply to the deep anterior wall. The veins in this areacan be troublesome especially the iliopubic, corona mortis obturator and theirtributaries.Other landmarks that require identification are the internal inguinal ring justlateral to the take off of the inferior epigastric vessels, the internal spermaticartery and vein, and the vas deferens that join to form the spermatic cord justbefore entering the internal ring. The iliopubic tract, attached to the iliac crestlaterally, crosses under the internal ring to make up its inferior border and at thesame time contributes to the anterior border of the femoral sheath continuingto its insertion on the pubic tubercle. A Cooper ligament extends from thepubic tubercle inferolateral along the pubic ramus crossing under the femoralvessel. The femoral ring is readily visible from this viewpoint being borderedby the femoral vein laterally, a Cooper ligament inferiorly, and the iliopubictract superiorly.The nerves traversing the preperitoneal space are prone to intraoperativeinjury. They can be damaged when fastening a prosthesis if deep penetrationof the fixation device occurs. The genitofemoral nerve may occur as a singletrunk lying deep to the peritoneum and fascia on the anterior surface of the psoasmuscle or it may divide into its component genital and femoral branches withinthe muscle. The genital branch travels with the spermatic cord, entering at thedeep inguinal ring; it ultimately innervates the cremaster muscle and the lateralscrotum. The femoral branch of the nerve innervates the skin of the proximalmid thigh. The lateral femoral cutaneous nerve crosses the preperitoneal spacelateral to the genitofemoral nerve and enters the thigh just beneath the iliopubictract and the inguinal ligament. This nerve supplies sensory branches for thelateral side of the thigh.SYMPTOMSPatients with groin hernias present with a wide range of clinical scenariosranging from no symptoms at all to the life-threatening condition caused bystrangulation of incarcerated hernia contents. Asymptomatic patients may havetheir hernias diagnosed at the time of a routine physical examination or seekmedical attention because of a painless bulge in the groin. Indirect herniasare more likely to produce symptoms than direct hernias. Many describe anannoying heavy feeling or dragging sensation, which tends to be worse as theday wears on. The pain is commonly intermittent and radiation into the testicleis not rare. Others complain of a sharper pain that is either localized or diffuse.Particularly severe patients may need to recline for a short period of time or useother posture altering techniques. Occasionally patients must manually reducetheir hernia to obtain relief.DIAGNOSISPhysical ExaminationPhysical examination is the best way to determine the presence or absenceof an inguinal hernia. The diagnosis may be obvious by simple inspection928 PART II SPECIFIC CONSIDERATIONSTABLE 36-2 Differential DiagnosisMalignancyLymphomaRetroperitoneal sarcomaMetastasisTesticular tumorPrimary TesticularVaricoceleEpididymitisTesticular torsionHydroceleEctopic testicleUndescended testicleFemoral artery aneurysm or pseudoaneurysmLymph nodeSebaceous cystHidradenitisCyst of the canal of Nuck (Female)Saphenous varixPsoas abscessHematomaAsciteswhen a visible bulge is present. The differential diagnosis must be consideredin questionable cases (Table 36-2). Nonvisible hernias require digitalexamination of the inguinal canal. Classic teaching is that an indirect herniawill push against the fingertip, whereas a direct hernia will push against thepulp of the finger. Additionally, applying pressure over the mid-inguinal pointwith the fingertip will control an indirect hernia and prevent it from protrudingwhen the patient strains. A direct hernia will not be effected with thismaneuver.A femoral hernia presents as a swelling below the inguinal ligament and justlateral to the pubic tubercle. Thin patients commonly have prominent bilateralbulges below the inguinal ligament medial to the femoral vessels. They areasymptomatic and disappear spontaneously when the patient assumes a supineposition. Operation is not indicated.Radiological InvestigationsHernias are visualized as abnormal ballooning of the anteroposterior diameterof the inguinal canal and/or simultaneous protrusion of fat or bowel within theinguinal canal. Magnetic resonance imaging (MRI) with the development ofthe fast imaging scanners that allow dynamic imaging (i.e., performed duringstraining), shows particular promise for further refinement with the tweakingof the best weights for images and the addition of intraperitoneal contrastagents. Both MRI and computerized tomography (CT) may reveal other causesof groin pain because of their ability to visualize related structures in the groin.In a comparative study, the sensitivity and specificitywas 74.5 percent and 96.3percent for physical examination, 92.7 percent and 81.5 percent for ultrasound,and 94.5 percent and 96.3 percent for MRI, respectively.CHAPTER 36 INGUINAL HERNIAS 929PREOPERATIVE CARENonoperative TreatmentThe term watchful waiting is used to describe this treatment recommendation.It is only applicable in asymptomatic or minimally symptomatic hernias.Patients are counseled about the signs and symptoms of complications fromtheir hernia so they might present promptly to their physician in cases in whichan adverse event takes place. Definitive data that this recommendation is safeis not available and it is for this reason that standard surgical texts continueto recommend surgical repair of all inguinal hernias at diagnosis. However,a randomized controlled trial is currently underway which should shed somelight on this subject in the next few years.ABDOMINAL WALL SUBSTITUTESThe modern era of herniorrhaphy has seen a progressive decrease in recurrencerate because of improvement in surgical technique and prosthetics. It is apparentthat the abdominal wall does not always heal satisfactorily after primaryclosure and that an irreducible percentage of recurrences is inevitable if onewere to insist on pure tissue repairs. The only reasonable solution is the use ofa structure that can bridge a defect in certain cases.Prosthetic MaterialsIt has now been proven that mesh herniorrhaphy can decrease the recurrencerate by approximately 50 percent when compared to nonmesh repairs. Chronicpost herniorrhaphy groin pain occasionally occurs after prosthetic repair and isrelieved by prosthesis removal. However, the overall incidence of chronic postherniorrhaphy groin pain is less with a prosthetic repair. The materials that haveemerged as suitable for routine use in hernia surgery include polypropylene, eithermonofilament (Marlex, Prolene) or polyfilament (Surgipro), Dacron (Mersilene)and expanded polytetrafluoroethylene (e-PTFE) (Gore-Tex).ANESTHESIA FOR GROIN HERNIORRHAPHYMost inguinal herniorrhaphies can be performed under local or regional anesthesia.Laparoscopic herniorrhaphy is the exception, as general endotrachealanesthesia is primarily mandated by the pneumoperitoneum. This is one of thestrongest arguments for conventional herniorrhaphy when compared to laparoscopicherniorrhaphy. Despite this, the best available evidence suggests thatthe majority of conventional herniorrhaphies are performed under a generalanesthetic with local and regional techniques, finding their greatest popularityin specialty clinics. Nevertheless, local anesthesia, when used in adequatedoses and far enough in advance of the initial incision, proves very effectivewhen combined with the newer, short-acting amnesic and anxiolytic agents.One hundred milliliters of 0.5 percent Xylocaine with epinephrine or0.25 percent bupivacaine with epinephrine or a combination of the two plusor minus sodium bicarbonate is most common. Seventy milliliters of this solutionis injected by the surgeon in an adult of normal size prior to preppingand draping the patient. Ten milliliters is placed medial to the anterior superioriliac spine to block the ilioinguinal nerve, and the other 60 mL is used as afield block along the orientation of the eventual incision in the subcutaneousand deeper tissues. Care is taken to inject the areas of the pubic tubercle and

930 PART II SPECIFIC CONSIDERATIONS

a Cooper ligament, both of which can easily be identified by tactile sensationexcept in the very obese. The remaining 30mLis reserved for discretionary useduring the procedure. With this technique, endotracheal intubation is avoidedand the patient can be aroused from sedation at intervals to perform Valsalvamaneuvers and test the repair.INGUINAL HERNIA REPAIRSBefore discussing specific conventional herniorrhaphies, several steps will bedescribed because they are common to all of the conventional operations.Initial Incision: Classically an oblique skin incision is made between theanterior superior iliac spine and the pubic tubercle. Many surgeons now usea more horizontally placed skin incision in the natural skin lines for cosmeticreasons. Regardless, it is deepened through the Camper and Scarpa fasciaand the subcutaneous tissue to expose the external oblique aponeurosis. Thisstructure is incised medially down to and through the external inguinal ring.Mobilization of the cord structures. The superior flap of the external obliqueaponeurosis is bluntly dissected off the internal oblique muscle laterally andsuperiorly. The iliohypogastric nerve is identified at this time. It can be leftin-situ or freed from the surrounding tissue and isolated from the operativefield by passing a hemostat under the nerve and grasping the upper flap ofthe external oblique aponeurosis. Routine division of this nerve along withthe ilioinguinal nerve is practiced by some surgeons but not advised by most.The cord structures are then separated from the inferior flap of the externaloblique aponeurosis by blunt dissection exposing the shelving edge of theinguinal ligament and the iliopubic tract. The cord structures are lifted enmassewith the fingers of one hand at the pubic tubercle so that the indexfinger can be passed underneath to meet the index finger of the other hand.Blunt dissection is used to complete mobilization of the cord structures anda Penrose drain is placed around them for retraction during the course of theprocedure.Division of the cremasteric muscle. Complete division of the cremastericmuscle, especially when dealing with an indirect hernia, has been commonpractice. The purpose is to facilitate sac identification and to lengthen thecord for better visualization of the inguinal floor. However, adequate exposureusually can be obtained by a longitudinal opening of the muscle, which lessensthe likelihood of damage to cord structures and avoids the complication oftesticular descent. It is probably best not to divide the cremasteric muscleunless the surgeon cannot obtain adequate visualization of the inguinal floorany other way.High ligation of the sac. The term high ligation of the sac will be usedfrequently as its historical significance has ingrained it in the description ofmost of the older operations. By convention, high ligation should be consideredequivalent to reduction of the sac into the preperitoneal space without excision.Both methods work equally well and are highly effective. Sac inversion, inlieu of excision, does protect intraabdominal viscera in cases of unrecognizedincarcerated sac contents or a sliding hernia.Management of inguinal scrotal hernia sacs. Complete excision of all indirectinguinal hernia sacs is felt to be important by some. The downside tothis practice is an excessive rate of ischemic orchitis caused by trauma to theCHAPTER 36 INGUINAL HERNIAS 931testicular blood supply, especially the delicate venous plexuses. Testicular atrophyis the logical further sequelae although the relationship has not beenconclusively proven. A better approach is to divide indirect inguinal herniasacs in the mid inguinal canal, once confident the hernia is not sliding andthere are no abdominal contents. The distal sac is not dissected but the anteriorwall is opened as far distally as is convenient. Contrary to popular opinion in theurological literature, this does not result in an excessive rate of postoperativehydrocele formation.Relaxing incision. A relaxing incision divides the anterior rectus sheath extendingfrom the pubic tubercle superiorly for a variable distance determinedby the tension. The relaxing incision works by allowing the various componentsof the abdominal wall to displace laterally and inferiorly.Wound closure. The external oblique fascia is closed, serving to reconstructthe superficial (external) ring. The external ring must be loose enough to preventstrangulation of the cord structures yet tight enough to avoid an inexperiencedexaminer from confusing a dilated ring with a recurrence. The later is sometimesreferred to as an industrial hernia because historically it has at timesbeen a problem during a preemployment physical. The Scarpa fascia and theskin are closed to complete the operation.Specific HerniorrhaphiesBassiniBassini called his new operation the radical cure for an inguinal hernia. Themajor components of this cure are as follows:(1) Division of the external oblique aponeurosis over the inguinal canalthrough the external ring.(2) Division of the cremaster muscle lengthwise followed by resection so thatan indirect hernia is not missed while exposing simultaneously the floorof the inguinal canal to more accurately assess for a direct inguinal hernia.(3) Division of the floor or posterior wall of the inguinal canal for its fulllength. This insures adequate examination of the femoral ring from aboveand exposes the tissue layers that will be used for reconstructing theinguinal floor(4) High ligation of an indirect sac.(5) Reconstruction of the posterior wall by suturing the transversalis fascia,the transversus abdominis muscle, the internal oblique muscle (Bassinisfamous triple layer) medially to the inguinal ligament laterally andpossibly the iliopubic tract.Following the initial dissection and reduction or ligation of the sac, attentionturns to reconstructing the inguinal floor. Bassini began this part of the operationby opening the transversalis fascia (some prefer to use the term posterioringuinal wall) from the internal inguinal ring to the pubic tubercle, exposingthe preperitoneal fat which was bluntly dissected away from the under surfaceof the superior flap of the transversalis fascia. This allowed him to properlyprepare the deepest structure in his famous triple layer (transversalis fascia,transversus abdominis muscle and internal oblique muscle). The first stitch inthe repair includes the triple layer superiorly and the periosteum of the medialside of the pubic tubercle along with the rectus sheath. Most surgeons nowtry to avoid the periosteum of the pubic tubercle to decrease the incidence932 PART II SPECIFIC CONSIDERATIONSof osteitis pubis. The repair is continued laterally with nonabsorbable suturesecuring the triple layer to the reflected inguinal ligament (Poupart ligament).These sutures are continued until the internal ring has been closed on its medialside. A relaxing incision was not part of the original description but iscommonly added now.ShouldiceLocal anesthesia with sedation is the rule, and epinephrine is empiricallyavoided in the event it might contribute to ischemic orchitis. The initial approachis similar to the Bassini repair with particular importance placed onfreeing the cord from its surrounding adhesions, resection of the cremastermuscle, high dissection of the hernia sac and division of the transversalis fascia.Continuous nonabsorbable suture is used to repair the floor. Traditionally,this has been monofilament steel wire. The Shouldice surgeons feel a continuoussuture distributes tension evenly and prevents defects that could potentiallyoccur between interrupted sutures resulting in a recurrence. The repair is startedat the pubic tubercle by approximating the iliopubic tract laterally to the undersurfaceof the lateral edge of the rectus muscle. The suture is continuedlaterally, approximating the iliopubic tract to the medial flap that is made up ofthe transversalis fascia, the internal oblique and transverse abdominis muscles.Eventually four suture lines are developed from the medial flap. The runningsuture is continued to the internal ring where the lateral stump of the cremastermuscle is picked up, forming a new internal ring. The direction of the sutureis reversed back toward the pubic tubercle, approximating the medial edgeof the internal oblique and transversus abdominis muscle to Poupart ligamentand the wire is tied to itself. Thus, there are two suture lines formed by thefirst suture. The second wire suture is started near the internal ring and approximatesthe internal oblique and transversus muscles to a band of externaloblique aponeurosis superficial and parallel to the inguinal ligament, in effectcreating a second artificial inguinal ligament. This forms the third suture linethat ends at the pubic crest. The suture is then reversed and a fourth sutureline is constructed in a similar manner, superficial to the third line. At theShouldice Clinic, the cribriforms fascia always is incised in the thigh, parallelto the inguinal ligament, to make the inner side of the lower flap of the externaloblique aponeurosis available for these multiple layers. This step commonlyis omitted in general practice.Conventional Anterior, ProstheticLichtenstein Tension-Free HernioplastyAt the Lichtenstein Clinic, the procedure is performed under local anesthesiawith sedation using 50mLor less of a 50/50 mixture of 1 percent lidocaine (Xylocaine)and 0.5 percent bupivacaine (Marcaine), with 1/200,000 epinephrine.General or regional anesthesia also can be used. The initial steps are similarto the Bassini repair. After the external oblique aponeurosis has been openedfrom just lateral to the internal ring through the external ring, the upper leaf isfreed from the underlying anterior rectus sheath and internal oblique muscleaponeurosis in an avascular plane from a point at least 2 cm medial to thepubic tubercle to the anterior superior iliac spine laterally. Blunt dissection iscontinued in this avascular plane from lateral to the internal ring, to the pubictubercle, along the inguinal ligament and iliopubic tract. Continuing this samemotion, the cord with its cremaster covering is swept off the pubic tubercle andCHAPTER 36 INGUINAL HERNIAS 933separated from the inguinal floor. The ilioinguinal nerve, external spermaticvessels, and the genital branch of the genitofemoral nerve all remain with thecord structures. The effect is to create a large space for the eventual placementof the prosthesis and at the same time providing excellent visualization of theimportant nerves.For indirect hernias, the cremasteric muscle is incised longitudinally andthe sac dissected free and reduced into the preperitoneal space. A theoreticalcriticism of this operation is that unless the inguinal floor is opened, an occultfemoral hernia may be overlooked. However, an excessive incidence ofmissed femoral hernias has not been reported. Additionally, it is possible toevaluate the femoral ring by entering the preperitoneal space through a smallopening in the canal floor. Direct hernias are separated from the cord and othersurrounding structures and reduced back into the preperitoneal space. Dividingthe superficial layers of the neck of the sac circumferentially, which ineffect opens the inguinal floor, usually facilitates reduction and aids in maintainingit while the prosthesis is placed. This opening in the inguinal flooralso can be used to palpate a femoral hernia. Suture can be used to invert thesac but this adds no strength as the purpose is simply to allow the repair toproceed unencumbered by the sac continually protruding into the operativefield.A mesh prosthesis with a minimum size of 15 8 cm for an adult ispositioned over the inguinal floor. The medial end is rounded to correspondto the patients anatomy and secured to the anterior rectus sheath a minimumof 2 cm medial to the pubic tubercle. Either nonabsorbable or long actingabsorbable suture should be used. The wide overlap of the pubic tubercle isimportant to avoid the all too common pubic tubercle recurrences seen withother operations. The suture is continued in a running locking fashion laterally,securing the prosthesis to either side of the pubic tubercle (not into it) andthe shelving edge of the inguinal ligament. The suture is tied at the internalring.A slit is made at the lateral end of the mesh creating two tails, a wide one(two thirds) above and a narrower (one-third) below. The tails are positionedaround the cord structures and placed beneath the external oblique aponeurosislaterally to about the anterior superior iliac spine with the upper tail beingplaced on top of the lower. A single interrupted suture is used to secure thelower edge of the superior tail to the lower edge of the inferior tail in effectcreating a shutter valve at the internal ring. This step is considered crucial forthe prevention of indirect recurrences that are occasionally seen when simplere-approximation of the tails is performed. The surgeons at the LichtensteinClinic also include the shelving edge of the inguinal ligament in this shuttervalve stitch that serves to buckle the mesh somewhat medially over the directspace, creating a dome like effect to assure there is no tension especially whenthe patient assumes an upright position. Recently the Lichtenstein group hasdeveloped a customized prosthesis with a built in dome-like configurationthat they feel makes suturing the approximated tails to the inguinal ligamentunnecessary. A few interrupted sutures are used to secure the superior andmedial aspects of the prostheses to the underlying internal oblique muscle andrectus fascia. If the iliohypogastric nerve crosses up to the external obliqueaponeurosis on the medial side, the prosthesis should be slit to accommodateit. The prosthesis can be trimmed in situ but care should be taken to maintainsufficient laxity to account for a difference between the supine and uprightpositions and the fact that mesh shrinkage is a reality.934 PART II SPECIFIC CONSIDERATIONSIf a femoral hernia is present, the posterior surface of the mesh is suturedto a Cooper ligament after the inferior edge has been attached to the inguinalligament. This closes the femoral canal and the wound is closed in layers.Mesh Plug and PatchThe mesh plug technique was developed by Gilbert, and then modified byRutkow, Robbins, Millikan and others. The groin is entered through a standardanterior approach. The hernia sac is dissected away from surrounding structuresand reduced back into the preperitoneal space. A flat sheet of polypropylenemesh is rolled up like a cigarette and held in place with suture. This plug isinserted in the defect and secured to either the internal ring for an indirect herniaor the neck of the defect for a direct hernia using interrupted sutures. Theuse of a prefabricated, commercially available prosthesis that has the configurationof a flower is recommended by Rutkow and Robbins. The prosthesisis individualized for each patient by removing some of the petals to avoidunnecessary bulk. This step is important, as rarely erosion into a surroundingstructure such as the bladder has been reported. Millikan further modifiedthe procedure by recommending that the inside petals be sewn to the ringof the defect. For indirect hernias the inside pedals are sewn to the internaloblique portion of the internal ring which forces the outside of the prosthesisunderneath the inner side of the defect making it act like a preperitonealunderlay. For direct hernias, the inside petals are sewn to a Cooper ligamentand the shelving edge of the inguinal ligament and the musculoaponeuroticring of the defect superiorly, again forcing the outside to act as an underlay.The patch portion of the procedure is optional and involves placing a flatpiece of polypropylene in the conventional inguinal space widely overlappingthe plug in a fashion similar to the Lichtenstein procedure. The differenceis that only one or two sutures, or perhaps no sutures are used to secure theflat prosthesis to the underlying inguinal floor. Some surgeons place so manysutures that they have in effect performed a Lichtenstein operation on top ofthe plug. The euphemism used to describe this is the plugtenstein. To thecredit of its proponents, the plug and patch in all of its varieties has beenskillfully presented and has rapidly become a popular repair. Not only is itfast but also easy to teach, making it popular in both private and academiccenters.Conventional Preperitoneal, ProstheticThe key to the preperitoneal prosthetic repairs is the placement of a largeprothesis in the preperitoneal space between the transversalis fascia and theperitoneum. The preperitoneal repair makes use of the abdominal pressure tohelp fix the prosthetic material against the abdominal wall, adding strength tothe repair. The preperitoneal space can be entered from its anterior or posterioraspect. The major difference between the anterior and posterior approachesis that in the latter, the inguinal canal is not entered. Proponents point outthat this avoids damage to the cremasteric muscle and lessens the chanceof cord injury. If an anterior approach is desirable, a groin incision is usedbecause the space is entered directly through the inguinal floor. Either a lowermidline, paramedian, or Pfannenstiel incision without opening the peritoneumcan be used for the purposes of entering the preperitoneal space posteriorly asoriginally popularized by Cheatle, and later by Henry.CHAPTER 36 INGUINAL HERNIAS 935The Anterior ApproachRead-Rives. This operation starts like a classical Bassini, including openingthe inguinal floor. The inferior epigastric vessels are identified and the preperitonealspace completely dissected. The spermatic cord is parietalized byseparating the ductus deferens from the spermatic vessels. A 12- 16-cmpiece of mesh is positioned in the preperitoneal space deep to the inferior epigastricvessels and secured with three sutures; one each to the pubic tubercle,a Cooper ligament and the psoas muscle laterally. The transversalis fascia isclosed over the prosthesis and the cord structures replaced. The rest of theclosure is as described above for the Bassini repair.The Posterior ApproachWantz/stoppa/rives (giant prosthetic reinforcement of the visceral sac orGPRVS). These three procedures are grouped together under the heading ofGPRVS because there are only minor variations between them. A lower midline,transverse or Pfannenstiel incision can be used according to surgeon preference.If a transverse incision is chosen, it should extend from the midline89 cm in each direction laterally and 23 cm below the level of the anteriorsuperior iliac spine but above the internal ring. The anterior rectus sheathand the oblique muscles are incised for the length of the skin incision. Thelower flaps of these structures are retracted inferiorly toward the pubis. Thetransversalis fascia is incised along the lateral edge of the rectus muscle andthe preperitoneal space entered. If a lower midline or Pfannenstiel incision isused, the fascia overlying the space of Retzius is opened without violating theperitoneum.Acombination of blunt and sharp dissection is continued laterally,posterior to the rectus muscle and the inferior epigastric vessels. The preperitonealspace is completely dissected to a point lateral to the anterior superioriliac spine. The symphysis pubis, a Cooper ligament and the iliopubic tract areidentified. Inferiorly the peritoneum is generously dissected away from the vasdeferens and the internal spermatic vessels to create a large pocket that willeventually accommodate a prosthesis without the possibility of roll-up. Theterm parietalization of the spermatic cord was popularized by Stoppa andrefers to the thorough dissection of the cord to provide enough length to moveit laterally.Direct hernia sacs are reduced during the course of the preperitoneal dissection.When reducing the peritoneum from a direct hernia defect, it is importantto stay in the plane between the peritoneum and the transversalis fascia allowingthe latter structure to retract back into the hernia defect toward theskin. The transversalis fascia can be thin and if it is inadvertently opened andincorporated with the peritoneal sac during reduction a needless and bloodydissection of the abdominal wall is the result. Indirect sacs are more difficult todeal with than direct as they can be adherent to the cord structures. Care mustbe taken to minimize trauma to the cord to prevent damage to the vas deferensor the blood supply to the testicle. If it is a small sac it should be mobilizedfrom the cord structures and reduced back into the peritoneal cavity. A largersac may be difficult to mobilize from the cord without undue trauma if an attemptis made to remove the sac in its entirety. In this situation, the sac shouldbe divided, leaving the distal sac in situ with dissection of the proximal sacaway from the cord structures. Division of the sac is easily accomplished byopening the side opposite of the cord structures. A finger can be placed in thesac to facilitate its separation from the cord. Downward traction is placed on936 PART II SPECIFIC CONSIDERATIONSthe cord structures to reduce excessive amounts of fatty tissue (lipoma of thecord) into the preperitoneal space to preclude the possibility of a pseudorecurrencewhen the fatty tissue is palpated during physical examinationpostoperatively.Management of the abdominal wall defect varies somewhat. Stoppa andWantz usually leave the defect alone but the transversalis fascia in the defectoccasionally is plicated by suturing it to a Cooper ligament to prevent the bulgecaused by a seroma in the undisturbed sac.The next step is the placement of the prosthesis. Dacron mesh is morepliable than polypropylene and is therefore considered particularly suitablefor this procedure as it conforms well to the preperitoneal space. For unilateralrepairs, the size of the prosthesis is approximately the distance between theumbilicus and the anterior superior iliac spine minus 1 cm for the width,with the height being approximately 14 cm. Wantz recommends cutting theprosthesis excentrically with the lateral side longer than the medial to achievethe best fit in the preperitoneal space. Because of his thorough parietalizationof the cord structures, Stoppa indicates that it is not necessary to split theprosthesis laterally to accommodate the cord structures. This avoids the keyholedefect created when the prosthesis is split, which has been incriminated inrecurrences. Rignault, on the other hand, prefers a keyhole defect in the meshto encircle the spermatic cord, feeling that this provides the prosthesis withenough security that fixation sutures or tacks can be avoided. Minimizingfixation in this area is important because of the numerous anatomical elementsin the preperitoneal space that may be inadvertently damaged during theirplacement. For Wantzs technique, three absorbable sutures are used to attachthe superior border of the prosthesis to the anterior abdominal wall well abovethe defect. The three sutures are placed near the linea alba, semilunar line,and the anterior superior iliac spine from medial to lateral. A Reverdin sutureneedle facilitates this. Three long clamps are placed on each corner and themiddle of the inferior border of the prosthesis. The medial clamp is placed inthe space of Retzius and held by an assistant. The middle clamp is positionedso that the mesh covers the pubic ramus, obturator fossa and the iliac vessels,and is similarly held by an assistant. The lateral clamp is placed into theiliac fossa to cover the parietalized cord structures and the iliopsoas muscle.Care must be taken to prevent the prosthesis from rolling up as the clamps areremoved. Stoppas technique is most often associated with one large prosthesisfor bilateral hernias. The dimensions of this prosthesis are the distance betweenthe two anterior superior iliac spines minus 2 cm for the width and the heightis equal to the distance between the umbilicus and the pubis. The prosthesisis cut in a chevron shape and eight clamps are positioned strategically aroundthe prosthesis to facilitate placement into the preperitoneal space. The woundis closed in layers.Nyhus/Condon (iliopubic tract repair). The names Nyhus and Condon arefirmly associated with this preperitoneal repair, especially in North America.The two authorities carried out extensive cadaver dissections and pointed outthe importance of the iliopubic tract, which is the reason why their operation isreferred to as the Iliopubic Tract Repair.Atransverse lower abdominal incisionis made two fingerbreadths above the symphysis pubis. The anterior rectussheath is opened on its lateral side to allow the rectus muscle to be retractedmedially and the two oblique and the transversus abdominis muscles are incisedexposing the transversalis fascia. A combination of sharp and blunt dissectionCHAPTER 36 INGUINAL HERNIAS 937inferiorly opens the preperitoneal space and exposes the posterior inguinalfloor. Direct or indirect defects are similarly repaired after the peritoneal sachas been reduced or divided and closed proximally. The transverse aponeuroticarch is sutured to the iliopubic tract inferiorly, occasionally including a Cooperligament in the first few medial sutures. If the internal ring is particularly large,a suture is placed lateral to the internal ring. For femoral hernias, the iliopubictract is sutured to a Cooper ligament to close the canal. Once the defect hasbeen formally repaired, a tailored mesh prosthesis can be sutured to a Cooperligament and the transversalis fascia for reinforcement. Initially this was onlyrecommended for recurrent hernias but with further patient follow up, it hasnow become routine for all hernias.Kugel/Ugahary. These conventional preperitoneal prosthetic repairs were developedto compete with laparoscopy by using a small 23-cm skin incision,approximately 23 cm above the internal ring.Kugel locates this point by makingan oblique incision one third lateral and two thirds medial to a point halfway between the anterior superior iliac spine and the pubic tubercle. The incisionis carried deep through the external oblique fascia and the internal obliquemuscle is bluntly spread. The transversalis fascia is opened vertically approximately3 cm, but the internal ring is not violated. The preperitoneal space isentered and a blunt dissection performed. The inferior epigastric vessels areidentified to assure that the dissection is in the correct plane. These vesselsshould be left adherent to the overlying transversalis fascia and retracted mediallyand anteriorly. The iliac vessels, a Cooper ligament, pubic bone, andhernia defect are identified by palpation. Most hernia sacs are simply reduced.The exception is large indirect sacs that often are divided to leave the distal sacin situ with proximal sac closure. The author feels that the cord structures mustbe thoroughly parietalized to allowadequate posterior dissection if recurrencesare to be avoided. The basis of the procedure is a specifically designed 8-12-cm prosthesis made of two pieces of polypropylene with a specially extrudedsingle monofilament fiber located near its edge circumferentially. This allowsthe prosthesis to be formed to fit through the small incision. Once through theincision, it springs open to regain its normal shape to provide a wide overlap ofthe myopectineal orifice. The prosthesis also has a slit on its anterior surfacethrough which the surgeon places his finger to facilitate postioning.Ugaharys operation is similar but a special prosthesis is not required.Knownas the gridiron technique, the preperitoneal space is prepared through a 3 cmincision in a manner similar to Kugel. The space is held open using a narrowLangenbeck and two ribbon retractors. A 10- 15-cm piece of polypropylenemesh is rolled onto a long forceps after the edges have been rounded andsutures placed to correspond to various anatomical landmarks. The rolled-upmesh is introduced with forceps into the preperitoneal space and the meshunrolled using clamps and strategic movements of the ribbon retractors.Both of these operations have been very successful in some hands andhave important proponents, but because they are essentially blind, considerableexperience is required to assure that the patch has been placed properly.Laparoscopic Inguinal HerniorrhaphyThe best indications for a laparoscopic inguinal herniorrhaphy are: (1) a recurrenthernia after a conventional repair because the operation is performedin normal, nonscarred tissue; (2) bilateral hernias, as both sides can easily berepaired using the same small laparoscopic incisions; and (3) the presence of938 PART II SPECIFIC CONSIDERATIONSan inguinal hernia in a patient who requires a laparoscopy for another procedure,i.e., a laparoscopic cholecystectomy (assuming the Gram stain of thebile is negative). The more contentious issue is the use of laparoscopy for theuncomplicated unilateral hernia. Meta-analyses have confirmed a significantadvantage of the laparoscopic operation over the conventional nonprostheticrepairs in terms of pain, return to activity and recurrence rate. However, there isno difference in recurrence rate when comparing laparoscopy with prosthetictension free repairs and the laparoscopic operation takes longer. Laparoscopicherniorrhaphy patients return to work quicker and have less persisting painand numbness. The laparoscopic operation costs more but the difference maybe offset by the more rapid recovery. Operative complications are uncommonfor both methods but serious complications such as bowel perforation, bowelobstruction, vascular injury or adhesive problems at sites where the peritoneumhas been breached or prosthetic material has been placed are seen almost exclusivelywith laparoscopy.Absolute contraindications include any sign of intraabdominal infectionor coagulopathy. Relative contraindications include intraabdominal adhesionsfrom previous surgery, ascites or previous Space of Retzius surgery becauseof the increased risk of bladder injury. Severe underlying medical illness isalso a relative contraindication because of the added risk of general anesthesia.These patients are better suited for a conventional operation under localanesthesia. An incarcerated sliding scrotal hernia is a relative contraindicationespecially when involving the sigmoid colon because of the risk of perforationbecause of the traction needed to reduce it.The two commonly performed laparoscopic herniorrhaphies, the transabdominalpreperitoneal (TAPP) and the totally extraperitoneal (TEP) are modeledafter the conventional preperitoneal operations described above. The majordifference is that the preperitoneal space is entered through three trocar sitesrather than a large conventional incision. The ensuing radical dissection of thepreperitoneal space with the placement of a large prosthesis is similar to theconventional preperitoneal operation.Transabdominal PreperitonealThe operating room setup for the TAPP procedure. The surgeon stands on theopposite side of the table from the hernia. The first assistant stands oppositethe surgeon. Three laparoscopic cannulae are placed in a horizontal plane withthe umbilicus. After an initial diagnostic laparoscopy, pertinent anatomic landmarksincluding the median and medial umbilical ligaments, the bladder, theinferior epigastric vessels, the vas deferens, the spermatic vessels, the externaliliac vessels and the hernia defect are identified. An incision of the peritoneumis initiated at the medial umbilical ligament at least 2 cm above the herniadefect and extended laterally toward the anterior superior iliac spine. Thepreperitoneal space is exposed using a combination of blunt and sharp dissection,mobilizing the peritoneal flap inferiorly. The symphysis pubis, a Cooperligament, the iliopubic tract, and the cord structures are identified. Direct herniasacs are reduced during this dissection. Indirect sacs are more difficult todeal with as they can be tenaciously adherent to the cord structures. The cordstructures must be skeletonized but care must be taken to minimize trauma toprevent damage to the vas deferens or the blood supply to the testicle. Theperitoneal flap is dissected inferiorly well proximal to the divergence of thevas deferens and the internal spermatic vessels to assure that the prosthesisCHAPTER 36 INGUINAL HERNIAS 939will lie flat in the preperitoneal space and will not roll up when the peritoneumis closed.A large piece of mesh, 15 11 cm or greater, is introduced into the abdominalcavity through the umbilical cannula and is positioned over the myopectinealorifice so that it completely covers the direct, indirect and femoralspaces. The landmarks for achieving this goal are the contralateral pubic tubercleand the symphysis pubis for the medial edge, a Cooper ligament orthe tissue just above it for the inferior border, and the posterior rectus sheathand transversalis fascia at least 2 cm above the hernia defect superiorly. Somesurgeons prefer to slit the mesh to accommodate the cord structures whereasothers prefer to simply place the prosthesis over them. Fixation of the meshis controversial. When closing the peritoneum, it is important to avoid gapsbecause small bowel has been known to find its way through them resulting ina clinical bowel obstruction.Totally ExtraperitonealThe preperitoneal space is entered by establishing a plane of dissection outsideof the peritoneal cavity between the posterior surface of the rectus muscle andthe posterior rectus sheath and peritoneum.Anincision is made at the umbilicusas if one were planning to perform open laparoscopy. The rectus sheath isopened on one side and the rectus muscle is retracted laterally. The space isenlarged by blunt or balloon dissection. Once the space is sufficiently enlarged,three additional cannulas are placed in the midline; one at the umbilicus for theoptics, another approximately 5 cm above the symphysis pubis and the finalcannula midway between the umbilicus and the symphysis pubis. Dissectionof the preperitoneal space is now possible under direct vision. The operationthen proceeds in an identical fashion to the TAPP procedure described above.TAPP versus TEP. The Achilles heel of the TAPP procedure is the peritonealclosure. The peritoneum is frequently thin and tears easily once dissected,making it difficult to obtain complete coverage of the prosthesis. This hasresulted in major complications. The TEP procedure is more demanding thanthe TAPP initially because of the limited working space but once masteredcompletely eliminates the peritoneal closure step, making it faster.COMPLICATIONS OF GROIN HERNIA REPAIRS (Table 36-3)Groin Hernias in FemalesGroin hernias are much less common in females than males. Less than 10percent of all elective inguinal hernia repairs are performed in women. Nevertheless,given the overall frequency of the condition, the absolute numberis still significant. Femoral hernias are ten times more common in womenthan men (10 percent in females vs. 1 percent in males), giving rise to thefalse notion that it is the most common groin hernia. In fact, indirect herniasare much more common. Direct hernias are rare almost to the point of beingreportable. Occult inguinal hernias are a significant problem in women becausethe skin of the labium majus does not allow easy examination of theinguinal canal. There is insufficient skin redundancy to invert and allow theexamining finger to coapt directly to the inguinal floor. The extensive differentialdiagnosis of groin pain makes the definitive diagnosis of an occult herniadifficult.940 PART II SPECIFIC CONSIDERATIONSTABLE 36-3 ComplicationsRecurrenceChronic Groin PainNociceptiveA) SomaticB) VisceralNeuropathicA) IliohypogastricB) IlioinguinalC) GenitofemoralD) Lateral CutaneousE) FemoralCord and testicularA) HematomaB) Ischemic orchitisC) Testicular atrophyD) DysejaculationE) Division of vas deferensF) HydroceleG) Testicular descentBladder InjuryWound InfectionSeromaHematomaA) WoundB) ScrotalC) RetroperitonealOsteitis pubisProsthetic ComplicationsA) ContractionB) ErosionC) InfectionD) RejectionE) FractureLaparoscopicVascular injuryA) Intra-abdominalB) RetroperitonealC) Abdominal wallD) Gas embolismVisceral injuryA) Bowel perforationB) Bladder perforationTrocar Site ComplicationsA) HematomaB) HerniaC) Wound infectionD) KeloidBowel ObstructionA) Trocar or peritoneal closure site herniaB) AdhesionsMiscellaneousA) Diaphragmatic dysfunctionB) HypercapniaGeneralUrinaryParalytic ileusNausea and vomitingAspiration pneumoniaCardiovascularRespiratory insufficiencyThe indications for surgery are similar in males and females. There is noplace for a strategy of watchful waiting for femoral hernias as the incidence ofincarceration and/or strangulation is far too high to justify such a recommendation.The choice of procedure is not unique to females and is largely left tothe surgeon based on experience and training. Resection of the round ligamentsimplifies many of the repairs because complete closure of the internal ring isthen possible. Groin hernias become evident during pregnancy (1:10003000pregnancies). They are best managed expectantly and repaired after gestationis complete.PEDIATRIC HERNIASMost inguinal hernias in children are indirect, related to a persistent patentprocesses vaginalis. Approximately 15 percent of children are born with ordevelop an inguinal hernia. However, the incidence rises in preterm infants andthose with low birth weights (13 percent of patients born before 32 weeks and30 percent of patients with a birth weight less than 1,000 g). Overall, rightsidedhernias are twice as common as left, and about 10 percent of herniasdiagnosed at birth are bilateral. However, this varies greatly on the basis ofnumerous risk factors, the most important of which is age. The right-sidedCHAPTER 36 INGUINAL HERNIAS 941TABLE 36-4 Conditions Associated with an Increased Incidenceof Pediatric HerniaFamily historyUndescended testisHypospadias/epispadiasVentriculoperitoneal shuntPeritoneal dialysisCryptorchismPrematurityOther abdominal wall defectCystic fibrosisAscitesIntersex conditionsConnective tissue disordersHunter-Hurler syndromeEhlers-Danlos syndromepredominance is felt by most authorities to be related to the later descent of theright testicle during gestation. There are several conditions which predisposea child to develop an inguinal hernia in Table 36-4.Infants or children may present with a mass in the groin or scrotum. Thediagnosis may be obvious but one must be careful to differentiate the massfrom other cord and testicular abnormalities such as a hydrocele, undescendedtesticle, varicocele or even a testicular tumor. Commonly no hernia is able tobe demonstrated when the patient presents to the surgeon. Some surgeons relyon the so called silk glove sign which reflects the way the hernia sac feelsas it is palpated over the cord structures. The finding is controversial and thereis some evidence that what is actually being felt is hypertrophied cremastericmuscle. In the end, the diagnosis commonly hinges on the observation of thereferring physician or a parent. Most surgeons feel the risk/benefit ratio favorsthis as an acceptable indication for operation when the source seems reliablerather than taking the chance of strangulation.Incarceration is a more serious problem in the pediatric patient than in theadult, with large series reporting rates up to 20 percent. The patient presentswith a hard, tender groin mass. In 7580 percent of these, they can be successfullyreduced initially using sedation, Trendelenburg position, ice packs andgentle taxis. A reasonable attempt at conservative management of an incarceratedpediatric hernia before proceeding to emergency surgery is in the patientsbest interest because the complication rate compared to elective herniorrhaphyis twenty fold, including irreversible abnormalities such as testicular infarctionor atrophy. If no progress in reduction is made within 6 h, or if the patientexhibits signs of peritonitis or systemic toxicity, immediate operation is appropriate.Most pediatric inguinal hernias are repaired using the principle of highligation of the sac. The external oblique aponeurosis is opened for a shortdistance beginning at the external ring and proceeding laterally. The sac is thengently dissected away from the cord structures proximally until the internalring is reached, twisted, suture ligated and amputated. If the sac extends into thescrotum, it can be divided leaving the distal sac in situ. Care must be taken toexclude abdominal contents such as the tube and ovary before suture ligation.Occasionally, a Marcy repair of the internal ring is added if the structure isunusually large.942 PART II SPECIFIC CONSIDERATIONSExploration of the opposite groin remains controversial. As an alternative,ultrasound examination has become popular at some centers, however, it islargely dependent on the expertise and/or interest of the ultrasonographer. Thesize of the internal ring and the presence of bowel or fluid in the spermaticcord are diagnostic criteria indicative of a positive exam. Another alternativeis laparoscopy using either a rigid or a flexible endoscope placed through thehernia sac to inspect the opposite side. The accuracy is high for properly trainedlaparoscopists, such that it is considered the gold standard in studies using bothultrasonography and laparoscopy. The disadvantage of laparoscopy is cost andpotential intraabdominal complications.Suggested Readings