Abdominal Hernias

Overview

Definition

A hernia is an abnormal protrusion of the abdominal contents through a weakness or defect along the wall of the abdomen. Hernias can be congenital Congenital Chorioretinitis or acquired.

Epidemiology

• 5 million Americans have hernias.
• A majority of hernias are groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination hernias (inguinal/ femoral).
• One-third of all repaired ventral hernias are incisional hernias and the remaining two-thirds are primary ventral hernias.

Etiology

• Some hernias can be congenital Congenital Chorioretinitis:
  • Inguinal (failure of the closure of the processus vaginalis)
  • Umbilical (present at birth in all infants, but most close within the 1st 2 years of life)
• Acquired hernias are due to loss of the mechanical integrity of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen:
  • Primary: A genetic component causes weakness of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen.
  • Incisional: damage to abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen muscles and fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis during surgery

Pathophysiology

• A hernia has a hernia sac: an outpouching of the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy, which covers the hernia contents
• Reducible hernia:
  • Contents of the hernia can freely return to the abdominal cavity.
  • During an examination, the hernia can be pushed back in.
• Incarceration Incarceration Inguinal Canal: Anatomy and Hernias:
  • Inability of the contents of the hernia to return to their original cavity
  • Presents with severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and nonreducible bulge
  • Symptoms of intestinal obstruction Intestinal obstruction Any impairment, arrest, or reversal of the normal flow of intestinal contents toward the anal canal. Ascaris/Ascariasis develop if intestines are incarcerated.
• Strangulation Strangulation Inguinal Canal: Anatomy and Hernias:
  • Contents of the hernia are incarcerated.
  • Blood supply to the incarcerated organs is compromised, causing ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage and resultant tissue death.

Anatomic classification

Various types of abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen hernias can be defined by anatomic location:

• Anterior hernia:
  • Epigastric
  • Umbilical
  • Spigelian
  • Incisional
  • Parastomal
• Groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination hernia:
  • Inguinal
  • Femoral
• Pelvic hernia:
  • Obturator
  • Sciatic
  • Perineal
• Posterior hernia:
  • Superior triangle (Grynfeltt hernia)
  • Inferior triangle (Petit hernia)

Ventral Hernias

Definition

Ventral hernias occur through a weakness in the anterior abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen and can be congenital Congenital Chorioretinitis or acquired.

Anatomy

Layers of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen include:

• Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
• Camper’s fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis (subcutaneous fatty tissue)
• Scarpa’s fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis (membranous layer of the anterior abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen)
• External abdominal oblique fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis and muscle (lateral), and rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy muscle (medial)
• Rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy has:
  • Anterior rectus fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis
  • Rectus muscle
  • Posterior rectus fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis:
    • Ends midway between the umbilicus and pubic tubercle
    • The lower edge is referred to as the arcuate line.
  • Linea alba: fibrous band Fibrous band Meckel’s Diverticulum that runs midline between the 2 rectus muscles
• Internal abdominal oblique muscle
• Transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy muscle
• Transversalis fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis (underlies the transversalis muscle and posterior rectus fascia Fascia Layers of connective tissue of variable thickness. The superficial fascia is found immediately below the skin; the deep fascia invests muscles, nerves, and other organs. Cellulitis)
• Preperitoneal fat
• Peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy

Types of ventral hernias

Epigastric hernias:

• Hernias that occur along the linea alba, from the xiphoid process Xiphoid process Chest Wall: Anatomy to the umbilicus
• Constitute 1.6%–3.6% of abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen hernias
• 2–3 times more common in men
• Small defects that produce pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways disproportionate to their size

Umbilical:

• Hernias that occur through the umbilical ring of the linea alba
• Pediatric population:
  • The umbilical ring is open at birth (to allow passage of umbilical vessels).
  • Spontaneous closure generally occurs during the 1st 2 years of life and is closed in most children by 5 years of age.
  • Surgical repair is indicated if umbilical hernias persist beyond the 5th year of life with no decrease in the size of the defect.
  • Up to 8 times more common in children of African American descent
• Adult population:
  • Most commonly acquired
  • More common in women and in conditions that cause increased intra-abdominal pressure:
    • Pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care
    • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
    • Ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites

Incisional hernias:

• Hernias that occur through the scar Scar Dermatologic Examination tissue of past surgical incisions due to poor wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing and excessive tension
• Risk factors for incisional hernia:
  • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
  • Malnutrition Malnutrition Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema). Malnutrition in children in resource-limited countries
  • Chronic obstructive pulmonary disease Pulmonary disease Diseases involving the respiratory system. Blastomyces/Blastomycosis
  • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus mellitus
  • Chronic corticosteroid use
  • Surgical site infection Surgical site infection Infection occurring at the site of a surgical incision. Surgical Complications

Spigelian hernias:

• Hernias that occur through the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy muscle aponeurosis (Spigelian aponeurosis):
  • Bound by the lateral edge of the rectus muscle medially and linea semilunaris laterally
  • Most common in the “Spigelian belt”: the transverse 6-cm zone around the arcuate line (lower edge of the posterior rectus sheath)
• The majority of these hernias are small (1–2 cm) and most present during the 4th to 7th decades of life.
• Difficult to identify on physical exam, often require imaging

Parastomal hernias:

• Potential complication after creation of a stoma
• Occurs with up to 50% of colostomies, less common with ileostomy Ileostomy Surgical creation of an external opening into the ileum for fecal diversion or drainage. This replacement for the rectum is usually created in patients with severe inflammatory bowel diseases. Loop (continent) or tube (incontinent) procedures are most often employed. Large Bowel Obstruction
• Asymptomatic in most cases and routine repair is not recommended
• Obstruction or incarceration Incarceration Inguinal Canal: Anatomy and Hernias can occur in rare cases and require repair.

Surgical repair

Indications:

• Strangulated hernias or hernias with incarcerated intestines need to be repaired emergently due to the risk of bowel necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage.
• Nonincarcerated hernias can be approached electively:
  • Should be repaired if the hernia causes pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or discomfort
  • Spigelian hernias should always be repaired due to the high risk of incarceration Incarceration Inguinal Canal: Anatomy and Hernias.

Primary repair:

• Approximating the edges of the hernia defect with sutures
• Suturing, by definition, is not tension-free as it entails pulling together the edges of the defect.
• Thus, the rates of failure may be as high as 50%.
• Generally, only suitable for very small defects (< 1 cm)
• Other indications:
  • A contaminated surgical field, where the risk of mesh infection is unacceptably high
  • Hernias in children 

Mesh repair:

• Involves placement of a prosthetic material to cover the hernia defect
• Prosthetic materials can be synthetic (different types of polymers) or biologic (derived from human or animal tissues).
• Synthetic meshes provide more durable repair and are preferred in the majority of cases.
• Biologic meshes are preferred sometimes in a contaminated field to avoid synthetic mesh infection although evidence for their advantage in this situation is lacking.
• Options for mesh placement:
  • Between the bellies of the rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy muscle (inlay)
  • Over the anterior aponeurosis of the rectal sheath (overlay)
  • Intraperitoneally (underlay)
  • Behind the rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy muscles (retro rectus)
  • Between the rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy muscle and the peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy (preperitoneal)
  • Between the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy and transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy muscles that run behind the rectus abdominis Rectus Abdominis A long flat muscle that extends along the whole length of both sides of the abdomen. It flexes the vertebral column, particularly the lumbar portion; it also tenses the anterior abdominal wall and assists in compressing the abdominal contents. It is frequently the site of hematomas. In reconstructive surgery it is often used for the creation of myocutaneous flaps. Anterior Abdominal Wall: Anatomy muscle (intramuscular)
• Laparoscopic versus open approach:
  • Most small- and medium-sized hernias can be repaired with either approach.
  • The chosen method largely depends on the surgeon’s expertise.
  • Very large hernias, especially those involving the loss of abdominal domain, are repaired in an open fashion. The repair process can be quite complex and is sometimes done in stages.
  • Laparoscopy Laparoscopy Laparoscopy is surgical exploration and interventions performed through small incisions with a camera and long instruments. Laparotomy and Laparoscopy has the advantages of a shorter hospital stay and faster recovery.

Complications:

• Recurrence 
• Mesh infection
• Surgical site infection Surgical site infection Infection occurring at the site of a surgical incision. Surgical Complications
• Intestinal injury
• Mesh-enteric fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula
• Seroma: an accumulation of exudative secretions in potential spaces when the reabsorption capacity of the tissues is overwhelmed

Inguinal Hernias

Definition

Inguinal hernias Inguinal Hernias An abdominal hernia with an external bulge in the groin region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the abdominal wall (transversalis fascia) in Hesselbach’s triangle. The former type is commonly seen in children and young adults; the latter in adults. Inguinal Canal: Anatomy and Hernias occur through the floor or the internal ring of the inguinal canal Inguinal canal The tunnel in the lower anterior abdominal wall through which the spermatic cord, in the male; round ligament, in the female; nerves; and vessels pass. Its internal end is at the deep inguinal ring and its external end is at the superficial inguinal ring. Inguinal Canal: Anatomy and Hernias.

Epidemiology

• 75% of all hernias are inguinal.
• Men are 25 times more likely to have a groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination hernia.
• The indirect variant is more common than the direct variant (2:1).
• Most commonly occur on the right side
• Strangulation Strangulation Inguinal Canal: Anatomy and Hernias occurs in 1%–3% of all inguinal hernias Inguinal Hernias An abdominal hernia with an external bulge in the groin region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the abdominal wall (transversalis fascia) in Hesselbach’s triangle. The former type is commonly seen in children and young adults; the latter in adults. Inguinal Canal: Anatomy and Hernias.

Classification

• Indirect:
  • The hernia sac passes through the internal inguinal ring toward the external inguinal ring and into the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy.
  • Frequently congenital Congenital Chorioretinitis and associated with patent processus vaginalis
• Direct:
  • The hernia sac protrudes anteriorly and is medial to the internal inguinal ring and inferior epigastric vessels.
  • Hesselbach’s triangle Hesselbach’s triangle Inguinal Canal: Anatomy and Hernias (site of direct herniation Herniation Omphalocele): formed by the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy, inferior epigastric vessels, and rectus sheath
  • Mostly acquired secondary to muscular weakness and are more common in older men
• Combined (pantaloon): both indirect and direct hernia components

Anatomy of the inguinal canal Inguinal canal The tunnel in the lower anterior abdominal wall through which the spermatic cord, in the male; round ligament, in the female; nerves; and vessels pass. Its internal end is at the deep inguinal ring and its external end is at the superficial inguinal ring. Inguinal Canal: Anatomy and Hernias

• An oblique passage in the inferior aspect of the abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen of the inguinal regions
• Directed downward and medially
• 3.5–4 cm in length
• Allows passage of the spermatic cord Spermatic Cord Either of a pair of tubular structures formed by ductus deferens; arteries; veins; lymphatic vessels; and nerves. The spermatic cord extends from the deep inguinal ring through the inguinal canal to the testis in the scrotum. Testicles: Anatomy in men and the round ligament Round ligament A fibromuscular band that attaches to the uterus and then passes along the broad ligament, out through the inguinal ring, and into the labium majus. Uterus, Cervix, and Fallopian Tubes: Anatomy in women
• 2 openings:
  • Deep (internal) ring
  • Superficial (external) ring
• Processus vaginalis:
  • Peritoneal outpouching into the inguinal canal Inguinal canal The tunnel in the lower anterior abdominal wall through which the spermatic cord, in the male; round ligament, in the female; nerves; and vessels pass. Its internal end is at the deep inguinal ring and its external end is at the superficial inguinal ring. Inguinal Canal: Anatomy and Hernias associated with the descent of testes Testes Gonadal Hormones during embryonic development
  • Normally obliterated by birth
  • Creates anatomical predisposition for herniation Herniation Omphalocele if not obliterated

Surgical repair

Indications:

• Incarceration Incarceration Inguinal Canal: Anatomy and Hernias or strangulation Strangulation Inguinal Canal: Anatomy and Hernias (emergent)
• Symptomatic hernia (associated with pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways or discomfort)

Open approach: 

• A transverse incision is made above the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy, which is at the midpoint between the anterior superior iliac spine Anterior Superior Iliac Spine Chronic Apophyseal Injury and the pubic tubercle.
• The external oblique External oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy aponeurosis is incised, with care taken to identify the genital branch of the genitofemoral nerve Genitofemoral nerve Inguinal Canal: Anatomy and Hernias and the ilioinguinal nerve Ilioinguinal nerve Inguinal Canal: Anatomy and Hernias.
• The spermatic cord Spermatic Cord Either of a pair of tubular structures formed by ductus deferens; arteries; veins; lymphatic vessels; and nerves. The spermatic cord extends from the deep inguinal ring through the inguinal canal to the testis in the scrotum. Testicles: Anatomy is mobilized and the hernia sac is dissected free.
• The contents of the hernia sac are reduced.
• The hernia sac can be reduced (direct), or the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess of the hernia sac can be ligated and excised (indirect).
• Primary repair ( tissue repair tissue repair The process of generating a scar or less functional tissue with a different form and/or composition of the original tissue. Wound Healing) is rarely used nowadays as the failure rates are quite high.
• Options for tissue repair tissue repair The process of generating a scar or less functional tissue with a different form and/or composition of the original tissue. Wound Healing:
  • Bassini: approximation of the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy and the conjoint tendon ( internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy aponeurosis) to the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy
  • Shouldice:
    • Layered repair
    • Running suture to approximate the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy aponeurosis to the inguinal iliopubic tract
    • Running suture to approximate the internal oblique Internal oblique Muscles of the anterolateral abdominal wall consisting of the external oblique and the internal oblique muscles. The external abdominal oblique muscle fibers extend from lower thoracic ribs to the linea alba and the iliac crest. The internal abdominal oblique extend superomedially beneath the external oblique muscles. Anterior Abdominal Wall: Anatomy to the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy
  • McVay:
    • Interrupted, nonabsorbable suture to approximate the edge of the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy aponeurosis to Cooper’s ligament
    • Cooper’s ligament and the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy are secured to the iliopubic tract.
    • A relaxing incision is made in the anterior rectus sheath 1 cm above the pubic tubercle.
• Mesh repair:
  • Lichtensteinrepair:
    • A synthetic mesh with a slit in the middle is inserted into the canal to accommodate the spermatic cord Spermatic Cord Either of a pair of tubular structures formed by ductus deferens; arteries; veins; lymphatic vessels; and nerves. The spermatic cord extends from the deep inguinal ring through the inguinal canal to the testis in the scrotum. Testicles: Anatomy and wrap around it.
    • Using nonabsorbable suture, the mesh is secured to the pubic tubercle superiorly along the transversus abdominis Transversus abdominis Anterior Abdominal Wall: Anatomy and inferiorly along the shelving edge of the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy.
  • Plug and patch Patch Nonpalpable lesion > 1 cm in diameter Generalized and Localized Rashes:
    • A cone-shaped piece of polypropylene mesh is inserted into the internal ring.
    • A flat piece of mesh is used to reinforce the floor of the inguinal canal Inguinal canal The tunnel in the lower anterior abdominal wall through which the spermatic cord, in the male; round ligament, in the female; nerves; and vessels pass. Its internal end is at the deep inguinal ring and its external end is at the superficial inguinal ring. Inguinal Canal: Anatomy and Hernias similar to the process used in Lichtenstein repair.

Laparoscopic approach:

• Always involves mesh placement
• Requires technical expertise
• Totally extraperitoneal (TEP) technique:
  • Abdominal cavity is not entered.
  • Dissection is performed in the preperitoneal space with a balloon and insufflation.
  • Limited working space
• Transabdominal preperitoneal (TAPP) technique:
  • Abdomen is entered using the open Hassan technique or Veress needle.
  • Peritoneum Peritoneum The peritoneum is a serous membrane lining the abdominopelvic cavity. This lining is formed by connective tissue and originates from the mesoderm. The membrane lines both the abdominal walls (as parietal peritoneum) and all of the visceral organs (as visceral peritoneum). Peritoneum: Anatomy is taken down and mesh is placed in the preperitoneal space.
  • Larger working space

Complications:

• Chronic groin Groin The external junctural region between the lower part of the abdomen and the thigh. Male Genitourinary Examination pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways 
• Testicular atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation (damage to the testicular artery)
• Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility (mesh fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans)
• Orchitis Orchitis Inflammation of a testis. It has many features of epididymitis, such as swollen scrotum; pain; pyuria; and fever. It is usually related to infections in the urinary tract, which likely spread to the epididymis and then the testis through either the vas deferens or the lymphatics of the spermatic cord. Epididymitis and Orchitis: acute inflammation Acute Inflammation Inflammation of the testis due to viral or bacterial infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Seroma
• Scrotal hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
• Urinary retention Urinary retention Inability to empty the urinary bladder with voiding (urination). Delirium

Femoral Hernias

Definition

Femoral hernias are hernias that occur through the femoral triangle Femoral triangle Femoral Region and Hernias: Anatomy (below the inguinal ligament Inguinal Ligament Femoral Region and Hernias: Anatomy).

Epidemiology

• Up to 10 times more common in women than men
• Occurs more commonly on the right side
• The highest rate of strangulation Strangulation Inguinal Canal: Anatomy and Hernias among all hernias (10%–20%)
• High likelihood of strangulation Strangulation Inguinal Canal: Anatomy and Hernias (40%); therefore, surgical intervention is always indicated

Anatomy

• The femoral ring Femoral ring Femoral Region and Hernias: Anatomy is roughly 1 cm in diameter and bound by:
  • Femoral vein laterally
  • Iliopubic tract anteriorly
  • Cooper’s ligament posteriorly
  • The pubic tubercle forms the apex of the femoral canal Femoral canal Femoral Region and Hernias: Anatomy triangle.
• The hernia will pass medial to the femoral vessels through the femoral canal Femoral canal Femoral Region and Hernias: Anatomy.

Surgical repair

• Open repair:
  • McVay repair approximates the iliopubic tract to Cooper’s ligaments.
  • Preferred approach if there is strangulated bowel, as there is no need for mesh placement
  • The lacunar ligament should be divided if the incarcerated contents cannot be reduced.
• Laparoscopic repair:
  • TEP laparoscopic approach
  • TAPP laparoscopic approach
• Complications are similar to those seen in inguinal hernias Inguinal Hernias An abdominal hernia with an external bulge in the groin region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the abdominal wall (transversalis fascia) in Hesselbach’s triangle. The former type is commonly seen in children and young adults; the latter in adults. Inguinal Canal: Anatomy and Hernias.