has 4 borders: external oblique fascia (superficial), transversalis fascia (deep), abdominal
aponeurotic arch (superior), and inguinal ligament (inferior)
extends between the internal (deep inguinal) ring and the external (superficial inguinal) ring openings
contains either the spermatic cord or the round ligament of the uterus
External Oblique Fascia
reflects posteriorly in a curvilinear fashion to form the inguinal ligament
inguinal ligament extends from the anterior superior iliac spine to the pubic tubercle
lacunar ligament represents the most medial extent of the inguinal ligament and it attaches to
the pecten pubis (Cooper’s ligament)
Internal Oblique Muscle
lowermost fibers become the cremaster muscle
ilioinguinal nerve runs on top of the cremaster muscle
medial aspect of the internal oblique aponeurosis may fuse with the aponeurosis of the
transversus abdominis near the pubic tubercle to form the conjoint tendon (5-10%)
Transversus Abdominis Muscle
lower margin of this muscle forms a broad arch known as the transverse aponeurotic arch
in a primary hernia repair, this aponeurotic arch is secured to inferior structures such as the
shelving edge of the inguinal ligament, iliopubic tract, or Cooper’s ligament
Transversalis Fascia
envelopes the entire abdomen and forms the femoral sheath as well as the floor of the inguinal canal
direct hernias develop in defects of this layer
incising this layer gains access to the iliopubic tract, femoral canal, and Cooper’s ligament
Iliopubic Tract
located posterior to the inguinal ligament
connects the inguinal ligament to the transversalis fascia
formed by aponeurotic fibers of the transversus abdominis muscle
Cooper’s Ligament (Pectineal Ligament)
located on the posterior aspect of the superior ramus of the pubis
formed by periosteum and fascial condensations
Inguinal Nerves
Ilioinguinal Nerve
runs along the spermatic cord anteriorly
exits the inguinal canal through the external ring
supplies sensation to the skin of the upper and medial thigh
in males, it also innervates the base of the penis and upper scrotum
in females, it innervates the mons pubis and labia majora
Iliohypogastric Nerve
runs between the internal oblique and transverse abdominis muscles and supplies both
also supplies sensation to the lateral buttock and lower abdominal wall
Genital Branch of the Genitofemoral Nerve
enters the inguinal canal lateral to the inferior epigastric vessels
travels in the spermatic cord or round ligament
in males, it supplies the ipsilateral scrotum and cremaster muscle
in females, it supplies the ipsilateral mons pubis and labium majus
Femoral Branch of the Genitofemoral Nerve
travels along the femoral sheath
supplies the skin of the upper anterior thigh
Lateral Femoral Cutaneous Nerve
passes inferior to the inguinal ligament
supplies the lateral thigh
Laparoscopic Approach Anatomy
Initial view
Peritoneum Reflected
Quadrangle of Doom and Pain
consists of the triangle of doom and the triangle of pain
Triangle of Doom
anatomic space bounded by the vas deferens (round ligament) medially and the gonadal vessels laterally
inferior border is considered to be the peritoneal fold
apex of the triangle is the internal ring
contains the external iliac artery and vein, genital branch of the genitofemoral nerve
must avoid placing staples or tacks in this space
Triangle of Pain
bounded inferomedially by the gonadal vessels and superolaterally by the
inguinal ligament/iliopubic tract
contains the femoral nerve, femoral branch of the genitofemoral nerve, anterior femoral cutaneous nerve,
and the lateral femoral cutaneous nerve
Etiology and Classification of Groin Hernias
Direct Hernia
attributed to wear-and tear stresses
heavy lifting, straining to urinate or defecate, and chronic coughing have been implicated as causative factors
smoking, systemic illnesses, and connective tissue disorders are causative factors as well
results from a defect in the transversalis fascia
located medial to the inferior epigastric vessels
bladder or colon is a common sliding component of a direct sac
Direct Hernia - Laparoscopy
Indirect Hernia
results from a dilated persistent processus vaginalis
passes through the deep ring, lies within the spermatic cord (anterolateral side), and may descend
into the scrotum
retroperitoneal organs such as the sigmoid colon or cecum may slide into an indirect sac
most common type of groin hernia
Indirect Hernia - Laparoscopy
Clinical Presentation
most patients present with a complaint of a bulge in the inguinal region
minor pain or vague discomfort may be associated with the bulge
having a patient Valsalva while standing will usually demonstrate the hernia
in difficult cases, ultrasound can be helpful
Strangulation
causes intense pain, followed by tenderness, obstruction, and sepsis
occurs at the extremes of life
femoral hernia has the highest rate of strangulation
Natural History
Men
lifetime risk of developing an inguinal hernia is > 25%
nonoperative management is low risk in asymptomatic or minimally symptomatic men
incarceration (not strangulation) occurs at a rate of 0.18% per year
over time, a majority of patients become symptomatic and require surgery
delay in repair is not associated with increased operative complications
Women
inguinal hernia repair in women has not been addressed in any randomized controlled trials
urgent repair of groin hernias is more common in women then men
women are thought to be at higher risk of incarceration and strangulation due to the inability of
examination or imaging to reliably differentiate femoral from inguinal hernias
repair without watchful waiting is recommended in nonpregnant women; a laparoscopic approach may help
avoid missing a femoral hernia
in pregnant women with an inguinal lump and pain, color-duplex ultrasound can identify round
ligament varicosity, which is more common than inguinal hernia
Surgical Management – Open
~55% of groin hernias are repaired via the open approach
does not require a general anesthetic
Tissue Repairs
main role is now in patients at high risk for mesh infections
recurrence rates are higher (15% - 20%) than in mesh repairs
may be associated with less chronic pain than mesh repairs
Bassini Repair
consists of high ligation of the sac and suturing of the internal oblique muscle and the
transverse aponeurotic arch to the shelving edge of the inguinal ligament
does not repair the femoral canal
Cooper’s Ligament (McVay) Repair
transverse aponeurotic arch is sutured to Cooper’s ligament medially up to the femoral canal
a transition stitch is then made to the inguinal ligament
closes off the femoral canal
relaxing incision is mandatory
Shouldice Repair
multilayer imbricated repair of the floor of the inguinal canal
continuous suture approximates the iliopubic tract to the undersurface of the
transverse aponeurotic arch
suture is then returned to its beginning by approximating the free edge of the aponeurotic arch
to the shelving edge of the inguinal ligament
Mesh Repairs
now the gold standard in the U.S.
recurrence rates are less than 5%
associated with higher incidences of chronic postprocedure pain than tissue repairs
Lichtenstein (Tension-Free) Repair
successful hernia repair requires a total absence of tension on the suture line
a mesh patch is sutured inferiorly to the shelving edge of the inguinal ligament and superiorly to
the internal oblique muscle and the transverse aponeurotic arch
medially, the mesh should overlap the pubic tubercle by 1.5 – 2.0 cm to minimize medial
recurrence
lateral edge of the mesh is split to allow passage of the spermatic cord between the split
limbs of mesh
Mesh Plugs
after the hernia sac is dissected out, a plug is placed into the defect and secured in place
second piece of mesh is placed as an overlay patch over the defect and inguinal floor
most useful in repairing recurrent hernias
Two-Layer Mesh Repairs
posterior leaflet is placed in the retromuscular, preperitoneal space as a sublay, and mimics the
laparoscopic repair
anterior leaflet is placed as an onlay patch similar to a Lichtenstein repair
the connector functions similarly to a plug
Surgical Management – Laparoscopic
~ 40% of inguinal hernia repairs
tension-free mesh repair based on a preperitoneal approach
proposed advantages include quicker recovery, less pain, better
visualization of anatomy, ability to fix all types of inguinal hernia defects
disadvantages include a high learning curve, longer OR times, increased cost, and a small chance of
visceral or vascular injury
most clearly indicated for bilateral or recurrent hernias
2 main approaches: totally extraperitoneal (TEP), and transabdominal preperitoneal (TAPP)
in the TEP approach, a balloon dissector is used to gain access to the preperitoneal space
in the TAPP approach, the preperitoneal space is accessed after initially entering the peritoneal space
mesh is placed retromuscularly and retroperitoneally to widely cover the myopectineal orifice
mesh fixation is achieved with sutures, tacks, or self-gripping mesh
the mesh should be completely reperitonealized
Femoral Hernias
Femoral Canal Anatomy
boundaries: superiorly by the iliopubic tract, inferiorly by Cooper’s ligament, laterally by the femoral vein,
and medially by the junction of the iliopubic tract and Cooper’s ligament (lacunar ligament)
Clinical Presentation
present as a bulge below the inguinal ligament and medial to the femoral pulse
can be confused with a lipoma or lymph node
associated with a high incidence of strangulation, so all femoral hernias should be electively repaired
when diagnosed
Repair
must obliterate the defect in the femoral canal
this can be done with mesh, McVay repair, or laparoscopically
Complications
Wound Infection
risk is 1% to 2%
clinical trials do not support the routine use of preoperative antibiotics
infected mesh will need to be removed
Post-op Groin Pain
chronic groin pain occurs in up to 16% of patients following hernia repair
can result from neuropathic or nonneuropathic etiologies
nonneuropathic etiologies, such as hernia recurrence and meshoma, can cause chronic inguinal pain and should
be ruled out early in the evaluation
an MRI of the pelvis will help identify nonneuropathic causes of pain
Neuropathic Pain
usually secondary to mesh entrapment of a nerve, neuroma formation after nerve injury, or inappropriate
laparoscopic tack application
symptoms include a burning or shooting pain in the nerve distribution
in certain situations, a regional nerve block may be both diagnostic and, at least temporarily, therapeutic
many neuralgias are transient and will resolve within several weeks or months
persistent neuralgia may be treated with serial nerve blocks or a topical lidocaine patch
diagnostic laparoscopy may be necessary to evaluate positioning of the mesh and tacks once nonneuropathic
sources are ruled out and less invasive means of treatment have failed
nerves most affected in laparoscopic surgery include the lateral femoral cutaneous and genitofemoral nerves
similarly, in the case of an open hernia repair, resection of the nerves of the groin (i.e., resection
of the ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerves) and removal of
the mesh may be necessary
Ischemic Orchitis
results from thrombosis of the pampiniform plexus in the spermatic cord or ligation of the testicular artery
the testicle becomes swollen and tender several days after surgery, and may persist for 6 to 12 weeks
outcome is usually testicular atrophy
treatment is with anti-inflammatory drugs and analgesics
orchiectomy is rarely necessary
prevented by avoiding unnecessary dissection in the spermatic cord – the distal portion of a large,
indirect hernia sac should be left in place
incidence is much higher after each repair of a recurrent hernia
Recurrent Hernias
Risk Factors
Patient-Related
diabetes, wound infection, ascites, immunosuppression, connective tissue disorders, vascular disease
are all associated with poor wound healing and hernia recurrence
smoking is associated with poor wound healing, tissue ischemia
smoker’s cough applies constant tension to the abdominal wall and groin
Technical Factors
missing an indirect hernia when repairing a direct hernia
excessive tension on the repair
failure to anchor the mesh adequately at the pubic tubercle
improper mesh size and placement
Repair
often best managed by a different approach, especially in cases of multiple recurrences
for patients who have had an anterior repair, the preperitoneal approach (open or laparoscopic)
avoids the altered anatomy of the previous surgery
Stoppa Procedure
useful for large, multiply recurrent hernias
large piece of mesh is place into the preperitoneal space via a lower midline incision
