ABDOMINAL WALL HERNIA

Rene Mendoza,MD, MHSA

Associate Professor
Department of Surgery
Our Lady of Fatima University

A.B., 32/M
10 yrs PTA: enlargement of scrotum; sought consult; ABDOMINAL WALL HERNIA
unrecalled dx & meds taken

few weeks PTA hospital: consult at a private

Dx: indirect inguinal hernia, L advised Sx

few hours PTA sought consult at our institution

admitted
Epigastric
PMH: Paraumbilical (above umbilicus)
(+) chicken pox, (-) measles, (-)allergy to food or drugs; Umbilical
no previous hospitalizations Lumbar (flanks)
Spigelian(lateral to rectus muscle below umbilicus)
PSH: Femoral
Businessman; nonsmoker; occasional alcoholic Inguinal (most common)
beverage drinker
GROIN HERNIAS
FH:
Only important layer to surgeon is the innermost
Denies history of heredofamilial disease in both
apneuroticofascial layer
paternal or maternal side
Contents
o Intraperitoneal structures
PHYSICAL EXAMINATION
o Retroperitoneal structures Sliding
BP = 110/80; CR = 75; RR=18 o Anti-mesenteric Richters
HEENT: pink palpebral conjunctivae, anicteric sclera, o Meckels diverticulum Littres
(-) NAD, (-)TPC
Neck: supple, (-) CLAD Hernia
Chest/Lungs: SCE, no retractions, CBS, GAE Protrusion of abdominal viscera through the
Heart: AP, NRRR, no murmur abdominal wall
Abdomen: slightly globular, soft, nontender, no 2 components:
organamegaly, NABS o Sac hernial sac outpouch of peritoneum
Genitalia: enlarge Left testis o Defect hernial orifice defect in innermost
Extremeties: no gross deformities, full & equal aponeurotic layer of the abdomen
pulses
Skin: no active dermatoses Reducible
Contents can be returned to the abdominal wall
ASSESSMENT: Strangulated
Indirect inguinal hernia, left scrotal hernia Incarcerated hernia with vascular comprise
Doopler study
PLAN Incarcerated
DAT Swollen or fixed within the hernia sac
For CBC May cause intestinal obstruction
For UA Strangulated
CXR (PA) Complete
Schedule for herniorrhaphy o Sac & contents protrude all the way throughout
the defect
Incomplete
o Defect present without sac or contents
protruding completely through it

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INGUINAL CANAL GROIN HERNIAS
Space traversed by the cord between the internal Incidence
and external ring o Male: female = 7:1
Content o Lifetime risk of developing hernia
o Males: spermatic cord M = 5%; F = 1%
o Females: round ligament o 60% indirect, 36% direct, 4% femoral
o Most common groin hernia in either sex
Spermatic Cord Indirect inguinal hernia
Nerve in the spermatic cord: o Femoral hernia 3x more in women
o Iliohypogastric nerve o Right sided in 84%; 25% bilateral
o Ilioinguinal nerve (T12-L1)
o Genitofemoral nerve (L1,L2) Reducibility
o Reducible
Myopectineal Orifice single weak area o Incarcerated irreducible, no vascular
Transverse abd. Muscle & internal oblique compromise
(superior) o Strangulated vascular compromised
Rectus Muscle (medial) Clinical parameters for strangulation
Iliopsoas muscle (lateral) o Fever
Superior Pubic ramus (pectus pubis) (inferiorly) o Tachycardia
o Exquisite tenderness
Hesselbachs Triangle o Erythema of overlying skin
Lateral border: inferior epigastric vessels o Leukocytosis
Inferior border: inguinal ligament o Obstructive symptoms
Medial border: lateral edge of rectus abdominis
Abdominal wall in the Groin
FEMORAL TRIANGLE Skin
Boundaries: Campers fascia
Superior inguinal ligament Scarpas fascia
Lateral Sartorius External oblique muscle
Medial adductor longus muscle Internal oblique muscle
Contents: Transverses abdominis muscle
Femoral nerve, artery, vein, empty space Transversalis fascia
lymphatics (NAVEL) Pre-peritoneal fat
Peritoneum
NERVES OF THE FEMORAL TRIANGLE
Iliohypogastric (T12,L1) Abdominal Wall Spermatic Cord
Ilioinguinal (L1) Skin Scrotum
Genitofemoral (L1,L2) Campers & Scarpas f. Superficial spermatic f.
o Genital branch External oblique m. External spermatic f.
o Femoral branch Internal oblique m. Cremaster muscle
Lateral femoral cutaneous (L2,L3) Transverses abdominis
Femoral (L2,L4) Transversalis fascia Internal spermatic f.
Pre-peritoneal fat Fat layer
BLOOD VESSELS Peritoneum Processus vaginalis
External iliac artery & vein Canal of nuck
Testicular artery & vein
Deferential artery ETIOLOGY OF HERNIAS
Congenital
LIGAMENTS o Hydrocele vs. indirect hernia
Inguinal ligament o Patency rate of processus vaginalis
o Bisects myopectineal orifice 60% at 2 mo; 40% at 2yo; 20% in adults
Iliopubic tract Connective tissue abnormalities
o Between Coopers ligament &inguinal ligament Malnutrition, vitamin deficiency
Lacunar or Gimbernats ligament Increased intra-abdominal pressure
o Medial border of femoral canal o COPD, dialysis, ascites, BPH
Coopers or pectineal ligament o Chronic constipation
o Joins IPT & lacunar lifament in their insertion to o Strenuous labor
the pubis
Conjoined tendon DIAGNOSIS
o Lateral portion of rectus sheath History and PE GOLD STANDARD
o Standing vs. supine

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 o Indirect vs. direct inguinal hernia
o Inguinal vs femoral hernia
Herniography
Ultrasound
CT scan Anterior repairs
Laparoscopy gallbladder surgery Marcy Tightening of ring 10%
Halsted 1 TAA to IL 10%
DIFFERENTIAL DIAGNOSIS Bassini or Halsted 2 TAA to IL 10%
Femoral hernia Fergusson- TAA to IL +EO 10%
Lymphadenopathy Andrews imbrication
Testiscular masses Shouldice TF to TF, TAA to IL 0-1%
Hydrocele McVay-Anson Taa to coopers 10%
Orchitis ligament
Ectopic testicle Lichtenstein Mesh, tension-free 0-1%
Lipoma of the cord Mesh plug Rolled or conical 0-1%
mesh
Nyphus Classification of Groin H.
Type 1 patent processus vaginalis PREPERITONEAL SPACE
Type 2 widened internal ring Triangle of Doom
Type 3 posterior wall defects o Medial: vas deferens
o 3A direct inguinal hernia o Lateral: testicular artery & vein
o 3B massive scrotal, sliding, or pantaloon o Contents: external iliac artery & vein
o 3C femoral hernia Triangle of Pain
Type 4 recurrent hernia o Medial: testicular artery & vein
o 4A direct o Base: IPT (iliopubic tract)
o 4B indirect o Contents: genitofemoral nerve, femoral nerve,
o 4C femoral lateral femoral cutaneous nerve
o 4D combined Space of Retzius
o Space between the pubic bone & the urinary
MANAGEMENT OF GROIN HERNIAS bladders anterior & lateral walls
Natural couse Space of Bogros
Trusses o Extension of the space of Retzius laterally
Elective vs. emergent repair beyond the urinary bladder wall
en masse reduction
When we least expect it, life tests our courage.
ARTERY OF DEATH branch of femoral artery sutured Accept the challenge, stay strong and never give up!
by surgeon
Obturator branch of artery
Conjoined tendon transversalis
For tissue repair

SURGICAL TECHNIQUE
Anterior repairs
o Marcy
o Halsted 1
o Bassini or Halsted 3
o Fergusson-Andrews
o Shouldice
o McVay-Anson
o Lichtenstein
o Mesh plug
Posterior or Preperitoneal repairs
o Open approach
o GPRVS
o Laparoscopic approach
IPOM
TAPP
TEP

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