Hernias: Mark A. Malangoni, Michael J. Rosen

44 CHAPTER
Hernias
Mark A. Malangoni, Michael J. Rosen
OUTLINE
Inguinal Hernias
Femoral Hernias
Special Problems
Ventral Hernias
Unusual Hernias
More than 600,000 hernias are repaired annually in the United occurs when the hernia sac is contained within a musculoaponeu-
States, making hernia repair one of the most common operations rotic layer of the abdominal wall. In broad terms, most abdominal
performed by general surgeons. Despite the frequency of this wall hernias can be separated into inguinal and ventral hernias.
procedure, no surgeon has ideal results, and complications such This chapter focuses on the specific aspects of each of these condi-
as postoperative pain, nerve injury, surgical site infection, and tions individually.
recurrence remain.
Hernia is derived from the Latin word for rupture. A hernia is INGUINAL HERNIAS
defined as an abnormal protrusion of an organ or tissue through
a defect in its surrounding walls. Although a hernia can occur at Inguinal hernias are classified as direct or indirect. The sac of an
various sites of the body, these defects most commonly involve indirect inguinal hernia passes from the internal inguinal ring
the abdominal wall, particularly the inguinal region. Abdominal obliquely toward the external inguinal ring and ultimately into
wall hernias occur only at sites at which the aponeurosis and fascia the scrotum. In contrast, the sac of a direct inguinal hernia pro-
are not covered by striated muscle (Box 44-1). These sites most trudes outward and forward and is medial to the internal inguinal
commonly include the inguinal, femoral, and umbilical areas; ring and inferior epigastric vessels. As indirect hernias enlarge, it
linea alba; lower portion of the semilunar line; and sites of prior sometimes can be difficult to distinguish between indirect and
incisions (Fig. 44-1). The so-called neck or orifice of a hernia is direct inguinal hernias. This distinction is of little importance
located at the innermost musculoaponeurotic layer, whereas the because the operative repair of these types of hernias is similar. A
hernia sac is lined by peritoneum and protrudes from the neck. pantaloon-type hernia occurs when there is both an indirect and
There is no consistent relationship between the area of a hernia direct hernia component.
defect and the size of a hernia sac.
A hernia is reducible when its contents can be replaced within Incidence
the surrounding musculature, and it is irreducible or incarcerated Hernias are a common problem; however, their true incidence is
when it cannot be reduced. A strangulated hernia has compro- unknown. It is estimated that 5% of the population will develop
mised blood supply to its contents, which is a serious and poten- an abdominal wall hernia, but the prevalence may be even higher.
tially fatal complication. Strangulation occurs more often in large About 75% of all hernias occur in the inguinal region. Two thirds
hernias that have small orifices. In this situation, the small neck of these are indirect and the remainder are direct inguinal hernias.
of the hernia obstructs arterial blood flow, venous drainage, or Femoral hernias represent only 3% of all groin hernias.
both to the contents of the hernia sac. Adhesions between the Men are 25 times more likely to have a groin hernia than
contents of the hernia and peritoneal lining of the sac can provide women. An indirect inguinal hernia is the most common hernia,
a tethering point that entraps the hernia contents and predisposes regardless of gender. In men, indirect hernias predominate over
to intestinal obstruction and strangulation. A more unusual type direct hernias at a ratio of 2 : 1. Indirect hernias are by far the most
of strangulation is a Richter hernia. In Richter hernia, a small common type of hernia in women. The female-to-male ratio for
portion of the antimesenteric wall of the intestine is trapped femoral and umbilical hernias, however, is about 10 : 1 and 2 : 1,
within the hernia, and strangulation can occur without the pres- respectively. Although femoral hernias occur more frequently in
ence of intestinal obstruction. women than in men, inguinal hernias remain the most common
An external hernia protrudes through all layers of the abdomi- hernia in women. Femoral hernias are rare in men. Ten percent
nal wall, whereas an internal hernia is a protrusion of intestine of women and 50% of men who have a femoral hernia have or
through a defect in the peritoneal cavity. An interparietal hernia will develop an inguinal hernia.
1092
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CHAPTER 44 Hernias 1093
Indirect inguinal and femoral hernias occur more commonly Strangulation, the most common serious complication of a hernia,
on the right side. This is attributed to a delay in atrophy of the occurs in only 1% to 3% of groin hernias and is more common
processus vaginalis after the normal slower descent of the right at the extremes of life. Most strangulated hernias are indirect
testis to the scrotum during fetal development. The predominance inguinal hernias; however, femoral hernias have the highest rate
of right-sided femoral hernias is thought to be caused by the of strangulation (15% to 20%) of all hernias, and it is therefore
tamponading effect of the sigmoid colon on the left femoral canal. recommended that all femoral hernias be repaired at the time of
The prevalence of hernias increases with age, particularly for discovery.
inguinal, umbilical, and femoral hernias. The likelihood of stran-
gulation and need for hospitalization also increase with aging. Anatomy of the Groin
The surgeon must have a comprehensive understanding of the
anatomy of the groin to select and to use various options for
hernia repair properly. In addition, the relationships of muscles,
BOX 44-1 Primary Abdominal Wall Hernias aponeuroses, fascia, nerves, blood vessels, and spermatic cord
structures in the inguinal region must be completely understood
Groin Pelvic
to obtain the lowest incidence of recurrence and to avoid compli-
Inguinal Obturator
cations. These anatomic considerations must be understood from
Indirect Sciatic
the anterior and posterior approaches because both are useful in
Direct Perineal
different situations (Figs. 44-2 and 44-3).
Combined
Posterior From anterior to posterior, the groin anatomy includes the skin
Femoral
Lumbar and subcutaneous tissues, below which are the superficial circum-
Anterior Superior triangle flex iliac, superficial epigastric, and external pudendal arteries and
Umbilical Inferior triangle accompanying veins. These vessels arise from and drain to the
Epigastric proximal femoral artery and vein, respectively, and are directed
Spigelian superiorly. If encountered during operation, these vessels can be
retracted or even divided when necessary.
Diaphragmatic,
most frequently through
esophageal hiatus
Ventral, Phrenopulmonary hiatus

lateral
12th ribs
Ventral, Lumbar
epigastric Superior lumbar trigone
(Grynfeltt’s)
Inferior lumbar trigone
(Petit's)
Umbilical
Sciatic, most frequently
through greater sacrosciatic
Inguinal ligament
foramen
Ventral, Piriformis muscle

hypogastric Coccygeus muscle
Lesser sacrosciatic foramen
(probably below coccygeus
Deep inferior epigastric vessels muscle following internal
Indirect Inguinal obturator muscle)
at internal inguinal ring
Iliococcygeus muscle (cut)
Direct Inguinal
Perineal, most frequently
Femoral posterior to superficial
at femoral ring transverse perineal muscle
Obturator Rectum
at obturator foramen Superficial transverse
perineal muscle
Internal obturator muscle
FIGURE 44-1 Types of abdominal wall hernias. (From Dorland’s illustrated medical dictionary, ed 31, Phila-
delphia, 2007, WB Saunders, Plate 21.)
1094 SECTION X Abdomen
External Transversus abdominis muscle

oblique muscle
Transversalis fascia (anterior lamina)
Inferior epigastric artery and vein

Transversalis fascia (posterior lamina)
Internal
oblique muscle Internal inguinal ring
Inner inguinal canal
Inguinal Internal inguinal ring

canal
External iliac artery and vein
Iliopubic tract
FIGURE 44-2 Nyhus’s classic parasagittal diagram of the right midinguinal region illustrating the muscular
aponeurotic layers separated into anterior and posterior walls. The posterior laminae of the transversalis
fascia have been added, with the inferior epigastric vessels coursing through the abdominal wall medially to
the inner inguinal canal. (From Read RC: The transversalis and preperitoneal fasciae: A re-evaluation. In Nyhus
LM, Condon RE, editors: Hernia, ed 4, Philadelphia, 1995, JB Lippincott, pp 57-63.)
External Oblique Muscle and Aponeurosis This structure actually is present in only 5% to 10% of patients
The external oblique muscle is the most superficial of the lateral and is most evident at the insertion of these muscles on the pubic
abdominal wall muscles; its fibers are directed inferiorly and medi- tubercle. The cremaster muscle fibers arise from the internal
ally and lie deep to the subcutaneous tissues. The aponeurosis of oblique, encompass the spermatic cord, and attach to the tunica
the external oblique muscle is formed by a superficial and deep vaginalis of the testis. These muscle fibers are essential to maintain
layer. This aponeurosis, along with the bilaminar aponeuroses of the cremasteric reflex but have little relevance to the results of
the internal oblique and transversus abdominis, forms the anterior inguinal hernia repairs.
rectus sheath and, finally, the linea alba by linear decussation. The
external oblique aponeurosis serves as the superficial boundary of Transversus Abdominis Muscle and Aponeurosis and
the inguinal canal. The inguinal ligament (Poupart ligament) is Transversalis Fascia
the inferior edge of the external oblique aponeurosis and extends The transversus abdominis muscle layer is oriented horizontally
from the anterior superior iliac spine to the pubic tubercle, turning throughout most of its area; in the inguinal region, these fibers
posteriorly to form a shelving edge. The lacunar ligament is the course in a slightly oblique downward direction. The strength and
fan-shaped medial expansion of the inguinal ligament, which continuity of this muscle and aponeurosis are important for the
inserts into the pubis and forms the medial border of the femoral prevention and treatment of inguinal hernia.
space. The external (superficial) inguinal ring is an ovoid opening The aponeurosis of the transversus abdominis covers anterior
of the external oblique aponeurosis that is positioned superiorly and posterior surfaces. The lower margin of the transversus
and slightly laterally to the pubic tubercle. The spermatic cord abdominis arches along with the internal oblique muscle over the
exits the inguinal canal through the external inguinal ring. internal inguinal ring to form the transversus abdominis aponeu-
rotic arch. The transversalis fascia is the connective tissue layer
Internal Oblique Muscle and Aponeurosis that underlies the abdominal wall musculature. The transversalis
The internal oblique muscle forms the middle layer of the lateral fascia, sometimes referred to as the endoabdominal fascia, is a
abdominal musculoaponeurotic complex. The fibers of the inter- component of the inguinal floor. It tends to be denser in this area
nal oblique are directed superiorly and laterally in the upper but still remains relatively thin.
abdomen; however, they run in a slightly inferior direction in the The iliopubic tract is an aponeurotic band that is formed by
inguinal region. The internal oblique muscle serves as the cepha- the transversalis fascia and transversus abdominis aponeurosis and
lad (or superior) border of the inguinal canal. The medial aspect fascia. The iliopubic tract is located posterior to the inguinal liga-
of the internal oblique aponeurosis fuses with fibers from the ment and crosses over the femoral vessels and inserts on the
transversus abdominis aponeurosis to form a conjoined tendon. anterior superior iliac spine and inner lip of the wing of the ilium.
Area of
direct hernia
Area of
indirect hernia
Internal
inguinal
ring
Pubic
tubercle Edge of
Inferior inguinal
epigastric vessels ligament
Iliopubic tract
Cooper
ligament
Gonadal
Femoral canal vessels
External iliac
Vas deferens vessels
FIGURE 44-3 Anatomy of the important preperitoneal structures in the right inguinal space. (From Talamini
MA, Are C: Laparoscopic hernia repair. In Zuidema GD, Yeo CJ, editors: Shackelford’s surgery of the alimen-
tary tract, ed 5, vol 5, Philadelphia, 2002, WB Saunders, p 140.)
The inferior crus of the deep inguinal ring is composed of the border of the femoral canal. In approximately 75% of patients,
iliopubic tract; the superior crus of the deep ring is formed by the there will be a vessel that crosses the lateral border of Cooper liga-
transversus abdominis aponeurotic arch. The lateral border of ment that is a branch of the obturator artery. If this vessel is
the internal ring is connected to the transversus abdominis muscle, injured, troublesome bleeding can result. Cooper ligament is an
which forms a shutter mechanism to limit the development of an important landmark for open and laparoscopic repairs and is a
indirect hernia. useful anchoring structure, particularly in laparoscopic repairs.
The iliopubic tract is an extremely important structure in the
repair of hernias from the anterior and posterior approaches. It Inguinal Canal
composes the inferior margin of most anterior repairs. The portion The inguinal canal is about 4 cm in length and is located just
of the iliopubic tract lateral to the internal inguinal ring serves as cephalad to the inguinal ligament. The canal extends between the
the inferior border below which staples or tacks are not placed internal (deep) inguinal and external (superficial) inguinal rings.
during a laparoscopic repair because the femoral, lateral femoral The inguinal canal contains the spermatic cord in men and the
cutaneous, and genitofemoral nerves are located inferior to the round ligament of the uterus in women.
iliopubic tract. Although it cannot always be visualized during The spermatic cord is composed of the cremaster muscle fibers,
posterior repairs, if the tacking device cannot be palpated on the testicular artery and accompanying veins, genital branch of the
anterior abdominal wall, one must assume it is below the iliopubic genitofemoral nerve, vas deferens, cremasteric vessels, lymphatics,
tract. and processus vaginalis. These structures enter the cord at the
internal inguinal ring, and vessels and vas deferens exit the exter-
Pectineal (Cooper) Ligament nal inguinal ring. The cremaster muscle arises from the lowermost
The pectineal (Cooper) ligament is formed by the periosteum and fibers of the internal oblique muscle and encompasses the sper-
aponeurotic tissues along the superior ramus of the pubis. This matic cord in the inguinal canal. The cremasteric vessels are
structure is posterior to the iliopubic tract and forms the posterior branches of the inferior epigastric vessels and pass through the
posterior wall of the inguinal canal through their own foramen. nerves provide sensation to the skin of the groin, base of the penis,
These vessels supply the cremaster muscle and can be divided to and ipsilateral upper medial thigh. The iliohypogastric and ilioin-
expose the floor of the inguinal canal during hernia repair without guinal nerves lie beneath the internal oblique muscle to a point
damaging the testis. just medial and superior to the anterior superior iliac spine, where
The inguinal canal is bounded superficially by the external they penetrate the internal oblique muscle and course beneath the
oblique aponeurosis. The internal oblique and transversus abdom- external oblique aponeurosis. The main trunk of the iliohypogas-
inis musculoaponeuroses form the cephalad wall of the inguinal tric nerve runs on the anterior surface of the internal oblique
canal. The inferior wall of the inguinal canal is formed by the muscle and aponeurosis medial and superior to the internal ring.
inguinal ligament and lacunar ligament. The posterior wall, or The iliohypogastric nerve may provide an inguinal branch that
floor of the inguinal canal, is formed by the aponeurosis of the joins the ilioinguinal nerve. The ilioinguinal nerve runs anterior
transversus abdominis muscle and transversalis fascia. to the spermatic cord in the inguinal canal and branches at
Hesselbach triangle refers to the margins of the floor of the the superficial inguinal ring. The genital branch of the genito-
inguinal canal. The inferior epigastric vessels serve as its supero- femoral nerve innervates the cremaster muscle and skin on the
lateral border, the rectus sheath as the medial border, and the lateral side of the scrotum and labia. This nerve lies on the ilio-
inguinal ligament and pectineal ligament as the inferior border. pubic tract and accompanies the cremaster vessels to form a neu-
Direct hernias occur within Hesselbach triangle, whereas indirect rovascular bundle.
inguinal hernias arise lateral to the triangle. It is not uncommon,
however, for medium and large indirect inguinal hernias to involve Preperitoneal Space
the floor of the inguinal canal as they enlarge. The preperitoneal space contains adipose tissue, lymphatics, blood
The iliohypogastric and ilioinguinal nerves and genital branch vessels, and nerves. The nerves of the preperitoneal space of spe-
of the genitofemoral nerve are the important sensory nerves in cific concern to the surgeon include the lateral femoral cutaneous
the groin area (Fig. 44-4). The iliohypogastric and ilioinguinal nerve and genitofemoral nerve. The lateral femoral cutaneous
Femoral branch
genitofemoral nerve
Danger zone
Femoral nerve
Genital branch
genitofemoral nerve
Lateral femoral
cutaneous nerve
Iliacus muscle
Psoas muscle
FIGURE 44-4 Important nerves and their relationship to inguinal structures (the right side is illustrated).
(From Talamini MA, Are C: Laparoscopic hernia repair. In Zuidema GD, Yeo CJ, editors: Shackelford’s surgery
of the alimentary tract, ed 5, vol 5, Philadelphia, 2002, WB Saunders, p 140.)
nerve originates as a root of L2 and L3 and is occasionally a direct BOX 44-2 Differential Diagnosis of Groin
branch of the femoral nerve. This nerve courses along the anterior
and Scrotal Masses
surface of the iliac muscle beneath the iliac fascia and passes under
or through the lateral attachment of the inguinal ligament at the Inguinal hernia
anterior superior iliac spine. This nerve runs beneath or occasion- Hydrocele
ally through the iliopubic tract, lateral to the internal inguinal Varicocele
ring. Ectopic testis
The genitofemoral nerve usually arises from the L2 or L1-L2 Epididymitis
nerve roots. It divides into genital and femoral branches on the Testicular torsion
anterior surface of the psoas muscle. The genital branch enters the Lipoma
inguinal canal through the deep ring, whereas the femoral branch Hematoma
enters the femoral sheath lateral to the artery. Sebaceous cyst
The inferior epigastric artery and vein are branches of the Hidradenitis of inguinal apocrine glands
external iliac vessels and are important landmarks for laparoscopic Inguinal lymphadenopathy
hernia repair. These vessels course medial to the internal inguinal Lymphoma
ring and eventually lie beneath the rectus abdominis muscle, Metastatic neoplasm
immediately superficial to the transversalis fascia. The inferior Femoral hernia
epigastric vessels serve to define the types of inguinal hernia. Femoral lymphadenopathy
Indirect inguinal hernias occur lateral to the inferior epigastric Femoral artery aneurysm or pseudoaneurysm
vessels, whereas direct hernias occur medial to these vessels.
The deep circumflex iliac artery and vein are located below the
lateral portion of the iliopubic tract in the preperitoneal space. of hernia. A bulge identified below the inguinal ligament is con-
These vessels are branches of the inferior epigastric or external iliac sistent with a femoral hernia.
artery and vein. It is important to dissect only above the iliopubic A bulge of the groin described by the patient that is not dem-
tract during a laparoscopic hernia repair to avoid injury to these onstrated on examination presents a dilemma. Having the patient
vessels. stand or ambulate for a time may allow an undiagnosed hernia to
The vas deferens courses through the preperitoneal space from become visible or palpable. If a hernia is strongly suspected but
caudad to cephalad and medial to lateral to join the spermatic undetectable, repeated examination at another time may be
cord at the deep inguinal ring. helpful.
Ultrasonography also can aid in the diagnosis. There is a high
Femoral Canal degree of sensitivity and specificity for ultrasound in the detection
The boundaries of the femoral canal are the iliopubic tract ante- of occult direct, indirect, and femoral hernias.1 Other imaging
riorly, Cooper ligament posteriorly, and femoral vein laterally. The modalities are less useful. Computed tomography (CT) of the
pubic tubercle forms the apex of the femoral canal triangle. This abdomen and pelvis may be useful for the diagnosis of obscure
canal usually contains connective tissue and lymphatic tissue. and unusual hernias as well as atypical groin masses.2 On occasion,
A femoral hernia occurs through this space and is medial to the laparoscopy can be diagnostic and therapeutic for particularly
femoral vessels. challenging cases.
Diagnosis Classification
A bulge in the inguinal region is the main diagnostic finding in There are numerous classification systems for groin hernias.
most groin hernias. Most patients will have associated pain or One simple and widely used system is the Nyhus classification
vague discomfort in the region, but one third of patients will have (Box 44-3). Although their purpose is to promote a common
no symptoms. Groin hernias are usually not extremely painful language and understanding for communication of physicians and
unless incarceration or strangulation has occurred. In the absence to allow appropriate comparisons of therapeutic options, these
of physical findings, alternative causes for pain need to be consid- classifications are incomplete and contentious. Most surgeons
ered. On occasion, patients may experience paresthesias related to continue to describe hernias by their type, location, and volume
compression or irritation of the inguinal nerves by the hernia. of the hernia sac.
Masses other than hernias can occur in the groin region. Physical
examination alone often differentiates between a groin hernia and Treatment
these masses (Box 44-2). Nonoperative Management
The inguinal region is examined with the patient in the supine Most surgeons recommend operation on discovery of a symptom-
and standing positions. The examiner visually inspects and pal- atic inguinal hernia because the natural history of a groin hernia
pates the inguinal region, looking for asymmetry, bulges, or a is that of progressive enlargement and weakening, with a small
mass. Having the patient cough or perform a Valsalva maneuver potential for incarceration and strangulation. However, in patients
can facilitate identification of a hernia. The examiner places a with minimal symptoms, the clinician is often faced with balanc-
fingertip over the inguinal canal and repeats the examination. ing the risk for hernia-related complications, such as incarceration
Finally, a fingertip is placed into the external inguinal ring by and bowel strangulation, with the potential for complications in
invaginating the scrotum to detect a small hernia. A bulge moving the short and long term. Fitzgibbons and colleagues3 reported a
lateral to medial in the inguinal canal suggests an indirect hernia. prospective randomized trial of a watchful waiting strategy for
If a bulge progresses from deep to superficial through the inguinal men with asymptomatic or minimally symptomatic inguinal
floor, a direct hernia is suspected. This distinction is not critical hernias. These investigators randomized more than 700 men to a
because repair is approached the same way, regardless of the type watchful waiting or open tension-free hernia repair. At 2 years of
Operative Repair
BOX 44-3 Nyhus Classification
Anterior repairs. Anterior repairs are the most common opera-
of Groin Hernia
tive approach for inguinal hernias. Tension-free repairs are now
Type I standard, and there are a variety of different types. Older tissue
Indirect inguinal hernia: internal inguinal ring normal (e.g., pediatric hernia) types of repair are rarely indicated, except for patients with simul-
taneous contamination or concomitant bowel resection, when
Type II placement of a mesh prosthesis may be contraindicated.
Indirect inguinal hernia: internal inguinal ring dilated but posterior inguinal There are some technical aspects of the operation common to
wall intact; inferior deep epigastric vessels not displaced all anterior repairs. Open hernia repair is begun by making a
transversely oriented linear or slightly curvilinear incision above
Type III
the inguinal ligament and a fingerbreadth below the internal
Posterior wall defect
inguinal ring. The internal inguinal ring is located topographically
A. Direct inguinal hernia
at the midpoint between the anterior superior iliac spine and
B. Indirect inguinal hernia: internal inguinal ring dilated, medially
ipsilateral pubic tubercle. Dissection is continued through the
encroaching on or destroying the transversalis fascia of Hesselbach
subcutaneous tissues and Scarpa fascia. The external oblique fascia
triangle (e.g., scrotal, sliding, or pantaloon hernia)
and external inguinal ring are identified. The external oblique
C. Femoral hernia
fascia is incised through the superficial inguinal ring to expose the
Type IV
inguinal canal. The genital branch of the genitofemoral nerve and
Recurrent hernia
the ilioinguinal and iliohypogastric nerves are identified and
A. Direct
avoided or mobilized to prevent transection and entrapment. The
B. Indirect
spermatic cord is mobilized at the pubic tubercle by a combina-
C. Femoral
tion of blunt and sharp dissection. Improper mobilization of the
D. Combined
spermatic cord too lateral to the pubic tubercle can cause confu-
sion in the identification of tissue planes and essential structures
and may result in injury to the spermatic cord structures or dis-
ruption of the floor of the inguinal canal.
The cremaster muscle of the mobilized spermatic cord is sepa-
follow-up, there were no deaths attributed to the study, and the rated parallel to its fibers from the underlying cord structures. The
risk for hernia incarceration in the watchful waiting group was cremaster artery and vein, which join the cremaster muscle near
extremely low, 0.3% of study participants or 1.8 events/1000 the inguinal ring, can usually be avoided but may need to be
patient-years. Almost 25% of patients assigned to watchful waiting cauterized or ligated and divided. When an indirect hernia is
crossed over to the surgical group, usually for pain related to the present, the hernia sac is located deep to the cremaster muscle and
hernia that limited activity. In a later report, the crossover rate anterior and superior to the spermatic cord structures. Incising
had increased to 68% at 10 years, with nearly 80% of men older the cremaster muscle in a longitudinal direction and dividing it
than 65 years having an operation.4 Patients who later had surgery circumferentially near the internal inguinal ring help expose the
did not have increased surgical site infections or higher recurrence indirect hernia sac. The hernia sac is carefully separated from
rates than those who were initially assigned to early repair. A adjacent cord structures and dissected to the level of the internal
prospective randomized trial at a single institution in Great Britain inguinal ring. The sac is opened and examined for visceral con-
had similar long-term results.5 These studies provide conclusive tents if it is large; however, this step is unnecessary in small
evidence that a strategy of watchful waiting is safe for older hernias. The sac can be mobilized and placed within the preperi-
patients with asymptomatic or minimally symptomatic inguinal toneal space, or the neck of the sac can be ligated at the level of
hernias and that even though most patients eventually undergo the internal ring and any excess sac excised. If a large hernia sac
repair, when they do, the operative risks and complication rates is present, it can be divided with use of electrocautery to facilitate
are no different from those of patients undergoing immediate ligation. It is not necessary to excise the distal portion of the sac.
repair. Watchful waiting can be a cost-effective management strat- If the sac is broad based, it may be easier to displace it into the
egy for selected patients with no or minimal symptoms or who peritoneal cavity rather than to ligate it. Direct hernia sacs pro-
have suboptimal risk for operation. These results should not be trude through the floor of the inguinal canal and can be reduced
applied to women, as women have not been included in these below the transversalis fascia before repair. A “lipoma” of the
studies, or to patients with femoral hernias, which have a greater cord actually represents retroperitoneal fat that has herniated
risk of strangulation than inguinal hernias. through the deep inguinal ring; this should be suture ligated and
Patients electing nonoperative management can occasionally removed.
have symptomatic improvement with the use of a truss. This A sliding hernia presents a special challenge in handling the
approach is more commonly used in Europe. Spring trusses are hernia sac. With a sliding hernia, a portion of the sac is composed
more versatile than elastic ones, although most information on of visceral peritoneum covering part of a retroperitoneal organ,
their use has been anecdotal. Correct measurement and fitting are usually the colon or bladder. In this situation, the grossly redun-
important. Symptom control has been reported in about 30% of dant portion of the sac (if present) is excised and the peritoneum
patients. Complications associated with the use of a truss include reclosed. The organ and sac then can be reduced below the trans-
testicular atrophy, ilioinguinal or femoral neuritis, and hernia versalis fascia, similar to the procedure for a direct hernia.
incarceration. Tissue repairs. Although tissue repairs have largely been aban-
It is generally agreed that nonoperative management is not doned because of unacceptably high recurrence rates, they remain
used for femoral hernias because of the high incidence of associ- useful in certain situations. In strangulated hernias, for which
ated complications, particularly strangulation. bowel resection is necessary, mesh prostheses are contraindicated
and a tissue repair is necessary. Available options for tissue repair are sutured to the inguinal ligament. The Shouldice repair is
include iliopubic tract, Shouldice, Bassini, and McVay repairs. associated with a very low recurrence rate and a high degree of
The iliopubic tract repair approximates the transversus abdom- patient satisfaction in highly selected patients.
inis aponeurotic arch to the iliopubic tract with the use of inter- The Bassini repair is performed by suturing the transversus
rupted sutures (Fig. 44-5). The repair begins at the pubic tubercle abdominis and internal oblique musculoaponeurotic arches or
and extends laterally past the internal inguinal ring. This repair conjoined tendon (when present) to the inguinal ligament. This
was initially described using a relaxing incision (see later); however, once popular technique is the basic approach to nonanatomic
many surgeons who use this repair do not perform a relaxing hernia repairs and was the most popular type of repair done before
incision. the advent of tension-free repairs.
The Shouldice repair emphasizes a multilayer imbricated repair Cooper ligament repair, also known as the McVay repair, has
of the posterior wall of the inguinal canal with a continuous traditionally been popular for the correction of direct inguinal
running suture technique. After completion of the dissection, the hernias, large indirect hernias, recurrent hernias, and femoral
posterior wall of the inguinal canal is reconstructed by superim- hernias. Interrupted nonabsorbable sutures are used to approxi-
posing running suture lines progressing from deep to more super- mate the edge of the transversus abdominis aponeurosis to Cooper
ficial layers. The initial suture line secures the transversus ligament. When the medial aspect of the femoral canal is reached,
abdominis aponeurotic arch to the iliopubic tract. Next, the inter- a transition suture is placed to incorporate Cooper ligament and
nal oblique and transversus abdominis muscles and aponeuroses the iliopubic tract. Lateral to this transition stitch, the transversus
Transversus
abdominis
arch
Iliopubic
tract
Transversus abdominis
arch
Iliopubic
tract
FIGURE 44-5 Iliopubic Tract Repair. Top, Sutures lateral to the cord complete reconstruction of the deep
inguinal ring. These sutures encompass the transversus abdominis arch above and the cremaster origin and
iliopubic tract below. Bottom, The complete repair is ready for wound closure. The reconstruction of the
deep ring should be snug but also loose enough to admit the tip of a hemostat. (From Condon RE: Anterior
iliopubic tract repair. In Nyhus LM, Condon RE, editors: Hernia, ed 2, Philadelphia, 1974, JB Lippincott,
p 204.)
abdominis aponeurosis is secured to the iliopubic tract. An impor- Tension-free anterior inguinal hernia repair. The tension-free
tant principle of this repair is the need for a relaxing incision. This repair has become the dominant method of inguinal hernia repair
incision is made by reflecting the external oblique aponeurosis (Fig. 44-6). Recognizing that tension in a repair is the principal
cephalad and medial to expose the anterior rectus sheath. An cause of recurrence, current practices in hernia management
incision is then made in a curvilinear direction, beginning 1 cm use a synthetic mesh prosthesis to bridge the defect, a concept
above the pubic tubercle throughout the extent of the anterior popularized by Lichtenstein. There are several options for place-
sheath to near its lateral border. This relieves tension on the suture ment of mesh during anterior inguinal herniorrhaphy, including
line and results in decreased postoperative pain and hernia recur- the Lichtenstein approach, plug and patch technique, and sand-
rence. The fascial defect is covered by the body of the rectus wich technique, with both an anterior and preperitoneal piece of
muscle, which prevents herniation at the relaxing incision site. mesh.
The McVay repair is particularly suited for strangulated femoral In the Lichtenstein repair,6 a piece of prosthetic nonabsorbable
hernias because it provides obliteration of the femoral space mesh is fashioned to fit the canal. A slit is cut into the distal lateral
without the use of mesh. edge of the mesh to accommodate the spermatic cord. There are
Iliohypogastric nerve
External oblique
aponeurosis
Internal oblique
muscle and
aponeurosis
Ilioinguinal
nerve
Genital
branch of
genitofemoral
nerve
A External spermatic vessels B
Internal
oblique External
muscle oblique
aponeurosis
Rectus
sheath
Polypropylene
mesh
Genital
nerve
Ilioinguinal
nerve
Cremaster covering
C D of cord
FIGURE 44-6 Lichtenstein Tension-Free Hernia Repair. A, This procedure is performed by careful
dissection of the inguinal canal. High ligation of an indirect hernia sac is performed, and the spermatic cord
structures are retracted inferiorly. The external oblique aponeurosis is separated from the underlying internal
oblique muscle high enough to accommodate a 6- to 8-cm-wide mesh patch. Overlap of the internal oblique
muscle edge by 2 to 3 cm is necessary. A sheet of polypropylene mesh is fashioned to fit the inguinal canal.
A slit is made in the lateral aspect of the mesh, and the spermatic cord is placed between the two tails of
the mesh. B, The spermatic cord is retracted in the cephalad direction. The medial aspect of the mesh
overlaps the pubic bone by approximately 2 cm. The mesh is secured to the aponeurotic tissue overlying
the pubic tubercle by a running suture of nonabsorbable monofilament material. The suture is continued
laterally by suturing the inferior edge of the mesh to the shelving edge of the inguinal ligament to a point
just lateral to the internal inguinal ring. C, A second monofilament suture is placed at the level of the pubic
tubercle and continued laterally by suturing the mesh to the internal oblique aponeurosis or muscle approxi-
mately 2 cm from the aponeurotic edge. D, The lower edges of the two tails are sutured to the shelving
edge of the inguinal ligament to create a new internal ring made of mesh. The spermatic cord structures
are placed within the inguinal canal overlying the mesh. The external oblique aponeurosis is closed over the
spermatic cord. (From Arregui ME, Nagan RD, editors: Inguinal hernia: Advances or controversies? Oxford,
England, 1994, Radcliffe Medical.)
various preformed, commercially available prostheses available for preperitoneal space is identified. If further exposure is needed, the
use. Monofilament nonabsorbable suture is used to secure the anterior rectus sheath can be incised and the rectus muscle
mesh, beginning at the pubic tubercle and running a length of retracted medially. The preperitoneal tissues are retracted cephalad
suture in both directions toward the superior aspect above the to visualize the posterior inguinal wall and the site of herniation.
internal inguinal ring to the level of the tails of the mesh. The The inferior epigastric artery and veins are generally beneath the
mesh is sutured to the aponeurotic tissue overlying the pubic midportion of the posterior rectus sheath and usually do not need
tubercle medially, continuing superiorly along the transversus to be divided. This approach avoids mobilization of the spermatic
abdominis or conjoined tendon. The inferolateral edge of the cord and injury to the sensory nerves of the inguinal canal, which
mesh is sutured to the iliopubic tract or shelving edge of the is particularly important for hernias previously repaired through
inguinal ligament to a point lateral to the internal inguinal ring. an anterior approach. If the peritoneum is incised, it is sutured
At this point, the tails created by the slit are sutured together closed to avoid the evisceration of intraperitoneal contents into
around the spermatic cord, snugly forming a new internal ingui- the operative field. The transversalis fascia and transversus abdom-
nal ring. It is important to protect the ilioinguinal nerve and inis aponeurosis are identified and sutured to the iliopubic
genital branch of the genitofemoral nerve from entrapment by tract with permanent sutures. Femoral hernias repaired by this
placing them with the cord structures as they are passed through approach require closure of the femoral canal by securing the
this newly fashioned internal inguinal ring or avoiding their repair to Cooper ligament. A mesh prosthesis is frequently used
enclosure in the repair. to obliterate the defect in the femoral canal, particularly with large
Adapting the principles of tension-free repair, Gilbert7 has hernias.
reported using a cone-shaped plug of polypropylene mesh that Laparoscopic repair. Laparoscopic inguinal hernia repair is
when inserted into the internal inguinal ring would deploy like another method of tension-free mesh repair based on a preperi-
an upside-down umbrella and occlude the hernia. This plug is toneal approach. The laparoscopic approach provides the mechan-
sewn to the surrounding tissues and held in place by an additional ical advantage of placing a large piece of mesh behind the defect,
overlying mesh patch. This patch may not need to be secured by covering the myopectineal orifice, and using the natural forces of
sutures; however, to do so requires dissection to create a sufficient the abdominal wall to disperse intra-abdominal pressure over a
space between the external and internal oblique muscles for the larger area to support the mesh in place. Proponents have touted
patch to lie flat over the inguinal canal. This so-called plug and quicker recovery, less pain, better visualization of anatomy, and
patch repair, an extension of Lichtenstein’s original mesh repair, usefulness for fixing all inguinal hernia defects. Critics have
has now become the most commonly performed primary anterior emphasized longer operative times, technical challenges, increased
inguinal hernia repair. Although this repair can be done without risk of recurrence, and increased cost. Laparoscopic repair is also
suture fixation by some experienced surgeons, most secure plug associated with an approximately 0.3% risk of visceral or vascular
and patch with several monofilament nonabsorbable sutures, injury.11 Although controversy exists about the usefulness of lapa-
especially for very weak inguinal floors or large defects. roscopic repair for primary unilateral inguinal hernias, most agree
The sandwich technique involves a bilayered device, with three that this approach has advantages for patients having bilateral or
polypropylene components. An underlay patch provides a poste- recurrent hernia repairs.12 Adopting practice guidelines for the
rior repair similar to that of the laparoscopic approach, a connec- performance of laparoscopic hernia repairs could help control
tor functions similar to a plug, and an onlay patch covers the costs.
posterior inguinal floor. The use of interrupted fixating sutures is When considering the laparoscopic approach for repair of
not mandatory, but most surgeons place three or four fixation inguinal hernias, the surgeon has several options. The most
sutures in this repair. popular techniques are totally extraperitoneal (TEP) and transab-
Another option for a tension-free mesh repair involves a pre- dominal preperitoneal (TAPP) approaches. The main difference
peritoneal approach using a self-expanding polypropylene patch.8 between these two techniques is the sequence of gaining access to
A pocket is created in the preperitoneal space by blunt dissection, the preperitoneal space. In the TEP approach, the dissection
and then a preformed mesh patch is inserted into the hernia begins in the preperitoneal space using a balloon dissector. With
defect, which expands to cover the direct, indirect, and femoral the TAPP repair, the preperitoneal space is accessed after initially
spaces. The patch lies parallel to the inguinal ligament. It entering the peritoneal cavity. Each approach has its merits. With
can remain without suture fixation, or a tacking suture can be the TEP approach, the preperitoneal dissection is quicker, and the
placed. potential risk for intraperitoneal visceral damage is minimized.
The Stoppa-Rives repair uses a subumbilical midline incision However, the use of dissection balloons is costly, the working
to place a large mesh prosthesis into the preperitoneal space.9 space is more limited, and it may not be possible to create a
Blunt dissection is used to create an extraperitoneal space that working space if the patient has had a prior preperitoneal opera-
extends into the prevesical space, beyond the obturator foramen, tion. Also, if a large tear in the peritoneum is created during a
and posterolateral to the pelvic brim. This technique has the TEP approach, the potential working space can become obliter-
advantage of distributing the natural intra-abdominal pressure ated, necessitating conversion to a TAPP approach. For these
across a broad area to retain the mesh in a proper location. The reasons, knowledge of the transabdominal technique is essential
Stoppa-Rives technique is particularly useful for large, recurrent, in performing laparoscopic inguinal hernia repairs. The transab-
or bilateral hernias. dominal approach allows identification of the groin anatomy
Preperitoneal repair. The open preperitoneal approach is before extensive dissection and disruption of natural tissue planes.
useful for the repair of recurrent inguinal hernias, sliding hernias, The larger working space of the peritoneal cavity can make early
femoral hernias, and some strangulated hernias.10 A transverse experience with the laparoscopic approach easier.
skin incision is made 2 cm above the internal inguinal ring and There are no absolute contraindications to laparoscopic ingui-
is directed to the medial border of the rectus sheath. The muscles nal hernia repair other than the patient’s inability to tolerate
of the anterior abdominal wall are incised transversely, and the general anesthesia. Patients who have had extensive prior lower
abdominal surgery can require significant adhesiolysis and may to the anterior superior iliac spine. Finally, the spermatic cord is
be best approached anteriorly. In particular, in patients who have skeletonized.
had a radical retropubic prostatectomy with the preperitoneal In the TAPP approach, an infraumbilical incision is used to
space previously dissected, accurate and safe dissection can be gain access to the peritoneal cavity directly. Two 5-mm ports are
challenging. placed lateral to the inferior epigastric vessels at the level of the
In the TEP approach, an infraumbilical incision is used. The umbilicus. A peritoneal flap is created high on the anterior
anterior rectus sheath is incised, the ipsilateral rectus abdominis abdominal wall, extending from the median umbilical fold to the
muscle is retracted laterally, and blunt dissection is used to create anterior superior iliac spine. The remainder of the operation pro-
a space beneath the rectus. A dissecting balloon is inserted deep ceeds similar to a TEP procedure.
to the posterior rectus sheath, advanced to the pubic symphysis, A direct hernia sac and associated preperitoneal fat are gently
and inflated under direct laparoscopic vision (Fig. 44-7). After it reduced by traction if not already reduced by balloon expansion
is opened, the space is insufflated, and additional trocars are of the peritoneal space. A small, indirect hernia sac is mobilized
placed. A 30-degree laparoscope provides the best visualization of from the cord structures and reduced into the peritoneal cavity.
the inguinal region (see Fig. 44-3). The inferior epigastric vessels A large sac may be difficult to reduce. In this case, the sac is
are identified along the lower portion of the rectus muscle and divided with cautery near the internal inguinal ring, leaving the
serve as a useful landmark. Cooper ligament must be cleared from distal sac in situ. The proximal peritoneal sac is closed with a loop
the pubic symphysis medially to the level of the external iliac vein. ligature to prevent pneumoperitoneum from occurring. After all
The iliopubic tract is also identified. Care must be taken to avoid hernias are reduced, a 12 × 14-cm piece of polypropylene mesh
injury to the femoral branch of the genitofemoral nerve and lateral is inserted through a trocar and unfolded. It covers the direct,
femoral cutaneous nerve, which are located lateral to and below indirect, and femoral spaces and rests over the cord structures. It
the iliopubic tract (see Fig. 44-4). Lateral dissection is carried out is imperative that the peritoneum be dissected at least 4 cm off
Endoscope with balloon in

Peritoneum preperitoneal space
Endoscope with balloon advanced
Pubis Bladder Intestine inferiorly in preperitoneal space
Peritoneum
Pubis
Bladder
A B
Expanded preperitoneal space

maintained with insufflation
Balloon inflated in
preperitoneal space
Pubis
Peritoneum
D
Bladder
C
FIGURE 44-7 TEP Laparoscopic Hernia Repair. A, Access to the posterior rectus sheath is gained in
the periumbilical region. A balloon dissector is placed on the anterior surface of the posterior rectus sheath.
B, The balloon dissector is advanced to the posterior surface of the pubis in the preperitoneal space. C, The
balloon is inflated, thereby creating an optical cavity. D, The optical cavity is insufflated by carbon dioxide,
and the posterior surface of the inguinal floor is dissected.
Epigastric vessels
Direct
space Indirect
space
Iliopubic tract
Cooper's ligament
Vas deferens
External iliac vein
External iliac artery

FIGURE 44-8 Prosthetic mesh placement for TEP hernia repair. (From Corbitt J: Laparoscopic transabdomi-
nal transperitoneal patch hernia repair. In Ballantyne GH, editor: Atlas of laparoscopic surgery, Philadelphia,
2000, WB Saunders, p 511.)
the cord structures to prevent the peritoneum from encroaching and not by physical examination. The national registries collect
beneath the mesh, which can lead to recurrence. The mesh is information only on operations, so the incidence of recurrence is
carefully secured with a tacking stapler to Cooper ligament from lower than if all patients had been interviewed and examined.
the pubic tubercle to the external iliac vein, anteriorly to the The mortality of all types of repair is low, and there are no
posterior rectus musculature and transversus abdominis aponeu- significant differences reported among the various techniques.
rotic arch at least 2 cm above the hernia defect, and laterally to There is a greater mortality associated with the repair of strangu-
the iliopubic tract. The mesh extends beyond the pubic symphysis lated hernias. Otherwise, the risk of death is related to individual
and below the spermatic cord and peritoneum (Fig. 44-8). The comorbid conditions and should be evaluated in each patient. The
mesh is not fixed in this area and tacks are not placed inferior to type of anesthetic does not affect the recurrence rate.14 Open
the iliopubic tract beyond the external iliac artery. Staples placed repairs can be performed under local anesthesia, which can be an
in this area may injure the femoral branch of the genitofemoral advantage in operating on high-risk patients.
nerve or lateral femoral cutaneous nerve. Staples are also avoided There are important differences in the results of primary hernia
in the so-called triangle of doom, bounded by the ductus deferens repair. Hernia recurrence is the primary outcome assessed by most
medially and spermatic vessels laterally, to avoid injury to the studies. Large series, including multiple types of repairs, have
external iliac vessels and femoral nerve. As long as one can palpate suggested that recurrence ranges from 1.7% to 10%.13-15
the tip of the tacking device, these structures are not likely to be The results of tissue repairs were often based on reports consist-
injured. ing of personal or single institutional series that were not prospec-
tive or randomized and had erratic follow-up periods. Not
Results of Hernia Repair surprisingly, recurrence was variable.
The true measure of success for the various types of hernia repair Tension-free repairs have a lower rate of recurrence than tissue
is based on the results. The best information on the results of repairs.14,16,17 Results from the Danish Hernia Database have dem-
hernia repair is available from large prospective randomized trials, onstrated that hernia recurrence resulting in reoperation after the
meta-analyses of clinical trials, and two large national registries, Lichtenstein repair is only 25% that of nonmesh repairs.13 A
the Danish Hernia Database and the Swedish Hernia Register. Cochrane review reported that prosthetic mesh repairs have a 50%
The Danish Hernia Database includes more than 98% of inguinal to 75% lower risk of hernia recurrence, a lower risk of chronic
hernia repairs; the capture rate of the Swedish Hernia Register is postherniorrhaphy groin pain, and an earlier return to work
approximately 80%.13,14 In spite of the randomized nature of some than open repairs.16 The Shouldice repair has a higher recurrence
trials, caution must be used in interpreting the results. Many of rate than mesh repairs unless mesh is used.17 A meta-analysis
these patients were highly selected, and most trials excluded recur- comparing the Lichtenstein, mesh plug, and bilayered repairs has
rent hernias, obese individuals, and large inguinal hernias. Also, reported no significant differences in the rate of recurrence,
some follow-up results were completed by telephone interviews chronic groin pain, other complications, or time to return to
work.18 Approximately 50% of recurrences are found within 3 the femoral canal, either by approximation of the iliopubic tract
years after primary repair. Recurrence continues to occur after this to Cooper ligament or by placement of prosthetic mesh to obliter-
time in nonmesh-based repairs but is uncommon with tension- ate the defect. The incidence of strangulation in femoral hernias
free repairs. The bilayered repair was found to have a 20% hernia is high; therefore, all femoral hernias should be repaired, and
recurrence when used for large direct or recurrent hernias in one incarcerated femoral hernias should have the hernia sac contents
study.19 These results demonstrate the limitations of a fixed mesh examined for viability. In patients with a compromised bowel, the
size in these circumstances. Cooper ligament approach is the preferred technique because
An extensive systematic review of randomized controlled trials mesh is contraindicated. When the incarcerated contents of a
was published in 2002 by the European Union Hernia Trialists femoral hernia cannot be reduced, dividing the lacunar ligament
Collaboration.20 The authors reported a meta-analysis of 4165 can be helpful.
patients in 25 studies. Based on the available data, the laparo- Femoral hernias were reported to occur in conjunction with
scopic repair resulted in a more rapid return to normal activity inguinal hernias in 0.3% of patients in a large national hernia
and decreased persistent postoperative pain. The recurrence rate database of almost 35,000 patients.24 The occurrence of a femoral
for the laparoscopic repair was lower compared with open hernia after repair of an inguinal hernia has been reported to be
nonmesh repairs; however, open and laparoscopic mesh repairs 15 times the normal expected rate. It is unclear whether this
had similar recurrence rates. represents a femoral hernia overlooked at the prior operation or
A prospective trial sponsored by the Veterans Administration a propensity to development of a new hernia after inguinal hernia
randomized 1983 patients to undergo an open Lichtenstein repair repair. Recurrence of femoral hernia after operation is only 2%.
or laparoscopic repair, of which 90% were TEP repairs.15 Most Recurrent femoral hernia repairs have a re-recurrence rate of about
surgeons in this study may have had a suboptimal experience with 10%.
the laparoscopic approach; only 25 prior repairs were necessary to
be eligible to enroll patients, which is consistent with the seem- SPECIAL PROBLEMS
ingly high conversion rate of 5%. Despite these factors, the inves-
tigators found a twofold higher incidence of recurrence after Sliding Hernia
laparoscopic repair (10%) than after open repair (5%). This dif- A sliding hernia occurs when an internal organ composes a portion
ference in recurrence remained for primary hernias (10% laparo- of the wall of the hernia sac. The most common viscus involved
scopic versus 4% open); however, recurrent hernias repaired by is the colon or urinary bladder. Most sliding hernias are a variant
the laparoscopic approach tended to have fewer re-recurrences of indirect inguinal hernias, although femoral and direct sliding
(10% versus 14%). In another study by this group, surgeon inex- hernias can occur. The primary danger associated with a sliding
perience with laparoscopy and surgeon age older than 45 years hernia is the failure to recognize the visceral component of the
were both predictors of recurrence after laparoscopic repair.18 A hernia sac before injury to the bowel or bladder. The sliding hernia
large cohort study and a recent meta-analysis have found a sig- contents are reduced into the peritoneal cavity, and any excess
nificantly higher risk of recurrence after laparoscopic repair that hernia sac is ligated and divided. After reduction of the hernia,
is nearly twice that of open repairs (4.1% versus 2.1%).21,22 What one of the techniques described earlier can be used for repair of
can be concluded from these results? These results demonstrate the inguinal hernia.
that the laparoscopic repair of inguinal hernias has a definite
learning curve to achieve an acceptably low recurrence rate. Recurrent Hernia
In a Cochrane review of more than 1000 patients in eight The repair of recurrent inguinal hernias is challenging, and results
nonrandomized trials, there was no difference in hernia recurrence are associated with a higher incidence of secondary recurrence.
between TAPP and TEP repairs.23 TAPP procedures were associ- Recurrent hernias almost always require placement of prosthetic
ated with more port site hernias and vascular injuries, whereas the mesh for successful repair. The exception is when infected mesh
TEP approach had a greater conversion rate. is associated with a recurrent hernia. Recurrences after anterior
hernia repair using mesh are best managed by a laparoscopic or
open posterior approach, with placement of a second prosthesis.
FEMORAL HERNIAS Strangulated Hernia
A femoral hernia occurs through the femoral canal, which is Repair of a suspected strangulated hernia is most easily done using
bounded superiorly by the iliopubic tract, inferiorly by Cooper a preperitoneal approach (see earlier). With this exposure, the
ligament, laterally by the femoral vein, and medially by the junc- hernia sac contents can be directly visualized and their viability
tion of the iliopubic tract and Cooper ligament (lacunar liga- assessed through a single incision. The constricting ring is identi-
ment). A femoral hernia produces a mass or bulge below the fied and can be incised to reduce the entrapped viscus with
inguinal ligament. On occasion, some femoral hernias will minimal danger to the surrounding organs, blood vessels, and
present over the inguinal canal. In this case, the femoral hernia nerves. If it is necessary to resect strangulated intestine, the peri-
sac still exits inferior to the inguinal ligament through the toneum can be opened and resection done without the need for
femoral canal but ascends in a cephalad direction. Approximately a second incision.
50% of men with a femoral hernia will have an associated direct
inguinal hernia, whereas this relationship occurs in only 2% of Bilateral Hernias
women. The approach to repair of bilateral inguinal hernias is based on
A femoral hernia can be repaired by the standard Cooper liga- the extent of the hernia defect. Simultaneous repair of bilateral
ment repair, a preperitoneal approach, or a laparoscopic approach. hernias has a similar recurrence rate to unilateral repair, regardless
The essential elements of femoral hernia repair include dissection of whether the open or laparoscopic technique is used.25 The use
and reduction of the hernia sac and obliteration of the defect in of a giant prosthetic reinforcement of the visceral sac (Stoppa
repair)9 or the laparoscopic repair is preferred for simultaneous with cefazolin, 1 to 2 g, given intravenously 30 to 60 minutes
repair of bilateral inguinal hernias. before the incision. Clindamycin, 600 mg intravenously, can be
used for patients allergic to penicillin. Only a single dose of anti-
Complications biotic is necessary. The placement of prosthetic mesh does not
There are myriad complications related to open and laparoscopic increase the risk for infection and does not affect the need for
inguinal hernia repair (Table 44-1). Some are general complica- prophylaxis. Superficial surgical site infections are treated by
tions that are related to underlying diseases and the effects of opening the incision, local wound care, and healing by secondary
anesthesia. These vary by patient population and risk. In addition, intention. Some mesh infections will be manifested as a chronic
there are technical complications that are directly related to the draining sinus that tracks to the mesh or occur with extruded
repair. Technical complications are affected by the experience of mesh. Deep surgical site infections usually involve the prosthetic
the surgeon and are more frequent during and after the repair of mesh, which should be explanted.
recurrent hernias. There is increased scarring and disturbed The risk for infection can be decreased by using proper opera-
anatomy with hernia recurrence that can result in an inability to tive technique, preoperative antiseptic skin preparation, and
identify important structures at operation. This is the principal appropriate hair removal. There is an increased risk for infection
reason that we recommend using a different approach for recur- for patients who have had prior hernia incision infections, chronic
rent hernias. skin infections, or infection at a distant site. These infections are
Although the overall complication rate from hernia repair treated before elective surgery.
has been estimated to be approximately 10%, many of these
complications are transient and can be easily addressed. Nerve Injuries and Chronic Pain Syndromes
More serious complications from a large experience are listed in Nerve injuries are an infrequent and underrecognized complica-
Table 44-1. tion of inguinal hernia repair. Injury can occur from traction,
electrocautery, transection, and entrapment. The use of prosthetic
Surgical Site Infection mesh can result in dysesthesias, which are usually temporary. The
The risk for surgical site infection is estimated to be 1% to 2% nerves most commonly affected during open hernia repair are the
after open inguinal hernia repair and slightly less with laparo- ilioinguinal, genital branch of the genitofemoral, and iliohypogas-
scopic repairs. These are clean operations, and the risk for infec- tric nerves. During laparoscopic repair, the lateral femoral cutane-
tion is primarily influenced by associated patient diseases. Most ous and genitofemoral nerves are most often affected.27 Rarely, the
would agree that there is no need to use routine antimicrobial main trunk of the femoral nerve can be injured during open or
prophylaxis for hernia repair.20 Prospective randomized clinical laparoscopic inguinal hernia repair.
trials have not supported the routine use of perioperative antimi- Transient neuralgias involving sensory nerves can occur and
crobial prophylaxis for inguinal hernia repair for patients at low are usually self-limited and resolve within a few weeks after
risk for infection.26 Patients who have significant underlying surgery. Persistent neuralgias usually result in pain and hyperes-
disease, as reflected by an American Society of Anesthesiology thesia in the area of distribution. Symptoms are often reproduced
score of 3 or more, receive perioperative antimicrobial prophylaxis by palpation over the point of entrapment or hyperextension of
the hip and may be relieved by flexion of the thigh. Transection
of a sensory nerve usually results in an area of numbness corre-
sponding to the distribution of the involved nerve.
With more attention to patient outcomes, chronic groin pain
has replaced recurrence as the primary complication after open
TABLE 44-1 Complications After Open inguinal hernia repair. Approximately 10% of patients will have
and Laparoscopic Inguinal Hernia Repair (%) chronic postherniorrhaphy pain, defined as pain persisting more
OPEN REPAIR LAPAROSCOPIC than 3 months after operation,28 and pain has been reported to
COMPLICATION (N = 994) REPAIR (N = 989) interfere with activities of daily living in 2% to 4%.29 Strategies
of routine nerve division in open surgery have not been associated
Intraoperative complications 1.9 4.8
with a reduction in chronic pain in mesh-based anterior repairs.30
Postoperative complications 19.4 24.6
In contrast, routine ilioinguinal nerve division is associated with
Urinary retention 2.2 2.8
significantly more sensory disturbances. In laparoscopic repairs,
Urinary tract infection 0.4 1.0
by operating in a remote area to the commonly injured nerves
Orchitis 1.1 1.4
and with judicious use of appropriately placed tacks, chronic groin
Surgical site infection 1.4 1.0
pain intuitively is less common. Some reports comparing laparo-
Neuralgia, pain 3.6 4.2
scopic and open repairs have reported lower rates of chronic
Life-threatening 0.1 1.1
postoperative inguinal pain, but this observation remains
complications
controversial.
Long-term complications 17.4 18.0
Various approaches to management of residual neuralgia have
Seroma 3.0 9.0
been described. Early symptoms are treated with anti-inflammatory
Orchitis 2.2 1.9
agents, analgesics, and local anesthetic nerve blocks. Patients with
Infection 0.6 0.4
nerve entrapment syndromes are best treated by repeated explora-
Chronic pain 14.3 9.8
tion with neurectomy and mesh removal through an anterior
Recurrence 4.9 10.1 approach. Laparoscopic nerve injuries are minimized by not
From Neumayer L, Giobbie-Hurder A, Jonassen O, et al: Open mesh placing any tacks or staples below the lateral portion of the ilio-
versus laparoscopic mesh repair of inguinal hernias. N Engl J Med pubic tract. If nerve entrapment occurs, patients undergo reopera-
350:1819–1827, 2004. tion to remove the offending tack or staple.
Ischemic Orchitis and Testicular Atrophy difference between open and laparoscopic mesh repairs in
Ischemic orchitis usually occurs from thrombosis of the small re-recurrence or chronic groin pain.32
veins of the pampiniform plexus within the spermatic cord. This Recurrence is more common after repair of recurrent hernias
results in venous congestion of the testis, which becomes swollen and is directly related to the number of previous attempts at
and tender 2 to 5 days after surgery. The process may continue repair. Large population-based studies have reported a re-recurrence
for an additional 6 to 12 weeks and usually results in testicular rate of 4% to 5% in the first 24 months, which increases to 7.5%
atrophy. Ischemic orchitis also can be caused by ligation of the at 5 years.31,33 Tension-free and mesh-based repairs have the lowest
testicular artery. It is treated with anti-inflammatory agents and rates of reoperation after recurrence and result in a reduction in
analgesics. Orchiectomy is rarely necessary. recurrence of approximately 60% compared with more traditional
The incidence of ischemic orchitis can be minimized by avoid- repairs.30
ing unnecessary dissection within the spermatic cord. The inci- There is a successive decrease in the time to hernia recurrence
dence increases with dissection of the distal portion of a large with each subsequent repair.33 Re-recurrences are associated with
hernia sac and in patients who have anterior operations for hernia increased operative times and a greater rate of complications.
recurrence or for spermatic cord disease. In these situations, the
use of a posterior approach is preferred. Quality of Life
Testicular atrophy is a consequence of ischemic orchitis. It is The major quality indicators that have been assessed for hernia
more common after repair of recurrent hernias, particularly when repair are postoperative pain and return to work. Tension-free and
an anterior approach is used. The incidence of ischemic orchitis laparoscopic mesh-based approaches have been demonstrated to
increases by a factor of three or four with each subsequent hernia be less painful than nonmesh repairs. Laparoscopic repairs have
recurrence. the least amount of postoperative pain and have been shown to
provide a marginal advantage in reducing time off work.12
Injury to the Vas Deferens and Viscera
Injury to the vas deferens and intra-abdominal viscera is unusual. VENTRAL HERNIAS
Most of these injuries occur in patients with sliding inguinal
hernias when there is failure to recognize the presence of intra- A ventral hernia is defined by a protrusion through the anterior
abdominal viscera in the hernia sac. With large hernias, the vas abdominal wall fascia. These defects can be categorized as spon-
deferens can be displaced in an enlarged inguinal ring before its taneous or acquired or by their location on the abdominal wall.
entry into the spermatic cord. In this situation, the vas deferens Epigastric hernias occur from the xiphoid process to the umbili-
is identified and protected. cus, umbilical hernias occur at the umbilicus, and hypogastric
hernias are rare spontaneous hernias that occur below the umbi-
Hernia Recurrence licus in the midline. Acquired hernias typically occur after surgical
Hernia recurrences are usually caused by technical factors, such incisions and are therefore termed incisional hernias. Although
as excessive tension on the repair, missed hernias, failure to include not a true hernia, diastasis recti can present as a midline bulge. In
an adequate musculoaponeurotic margin in the repair, and this condition, the linea alba is stretched, resulting in bulging at
improper mesh size and placement. Recurrence also can result the medial margins of the rectus muscles. Abdominal wall diastasis
from failure to close a patulous internal inguinal ring, the size of can occur at other sites in addition to the midline. There is no
which is always assessed at the conclusion of the primary surgery. fascial ring or hernia sac, and unless it is significantly symptom-
Other factors that can cause hernia recurrence are chronically atic, surgical correction is avoided.
elevated intra-abdominal pressure, a chronic cough, deep inci-
sional infections, and poor collagen formation in the wound. Incidence
Recurrences are more common in patients with direct hernias and Based on national operative statistics, incisional hernias account
usually involve the floor of the inguinal canal near the pubic for 15% to 20% of all abdominal wall hernias; umbilical and
tubercle, where suture line tension is greatest. The use of a relaxing epigastric hernias constitute 10% of hernias. Incisional hernias are
incision when there is excessive tension at the time of primary twice as common in women as in men. As a result of the almost
hernia repair is helpful to reduce recurrence. A femoral hernia is 4 million laparotomies performed annually in the United States
found in approximately 5% to 10% of patients with an inguinal and the 2% to 30% incidence of incisional hernia, almost 150,000
hernia recurrence and should always be investigated at surgery.13 ventral hernia repairs are performed each year. Several technical
Most recurrent hernias require the use of prosthetic mesh for and patient-related factors have been linked to the occurrence of
successful repair.30,31 Choosing a different approach (usually pos- incisional hernias. There is no conclusive evidence demonstrating
terior) avoids dissection through scar tissue, improves visualiza- that the type of suture at the primary operation affects hernia
tion of the defect and reduction of the hernia, and decreases the formation.34 Patient-related factors linked to ventral hernia forma-
incidence of complications, particularly ischemic orchitis and tion include obesity, older age, male gender, sleep apnea, emphy-
injury to the ilioinguinal nerve. Recurrences after initial prosthetic sema, and prostatism. It has been proposed that the same factors
mesh repairs can be caused by displaced prostheses or the use of associated with destruction of the collagen in the lung result in
a prosthetic of inadequate size. Recurrences are best managed by poor wound healing, with increased hernia formation. Wound
placing a second prosthesis through a different approach. infection has been linked to hernia formation. Recent data suggest
A meta-analysis of 58 reports comparing synthetic mesh tech- that the surgical technique used to close a midline laparotomy is
niques with nonmesh repairs has demonstrated an almost 60% highly associated with incisional hernia formation. The use of a
reduction in recurrence with the use of mesh.20 This report con- suture to wound length ratio of 4 : 1 has been shown to signifi-
cluded that there was no difference in the rate of hernia recurrence cantly reduce incisional hernia formation compared with the
between laparoscopic and open approaches that used mesh. A 1-cm bites and 1-cm advancement suturing technique typically
recent meta-analysis of recurrent hernia repairs reported no employed by most surgeons.35
Whether the type of initial abdominal incision influences the sheath below the arcuate line is composed of the transversalis
incisional hernia rate remains controversial. As noted, the inci- fascia and peritoneum only.
dence of ventral herniation after midline laparotomy ranges from The abdominal wall receives most of its innervation from inter-
3% to 20% and doubles if the operation is associated with a costal nerves 7 through 12 and the first and second lumbar nerves.
surgical site infection. A meta-analysis of 11 studies examining These rami provide innervation to the lateral abdominal muscles
the incidence of ventral hernia formation after various types of and the rectus muscle and overlying skin. The nerves traverse
abdominal incisions has concluded that the risk is 10.5% for through the lateral abdominal wall between the transversus
midline, 7.5% for transverse, and 2.5% for paramedian inci- abdominis and internal oblique muscles and penetrate the poste-
sions.36 A recently published prospective randomized trial has rior rectus sheath just medial to the linea semilunaris.
reported no difference in hernia formation in comparing midline The lateral abdominal muscles receive their blood supply from
versus transverse incisions after 1 year but noted a higher wound the lower three or four intercostal arteries, deep circumflex iliac
infection rate in the transverse incisions.37 Given the likely artery, and lumbar arteries. The rectus abdominis has a more
similar rates of incisional hernia formation after transverse and complex blood supply derived from the superior epigastric artery
midline incisions, the surgeon should plan the incision on the (a terminal branch of the internal mammary artery), inferior
basis of the operative exposure desired to complete the procedure epigastric artery (a branch of the external iliac artery), and lower
safely. intercostal arteries. The superior and inferior epigastric arteries
Few data are available about the natural history of untreated anastomose near the umbilicus. The periumbilical area provides
ventral hernias. As noted, asymptomatic or minimally symptom- critical perforator vessels that, if preserved, can decrease skin flap
atic inguinal hernias purposely observed during 2 years have a low necrosis during extensive skin undermining (Fig. 44-10).
incidence of complications.3 Whether this paradigm applies for
asymptomatic ventral or incisional hernias is unclear. Because Diagnosis
there is no prospective cohort available to determine the natural The evaluation of abdominal wall hernias requires diligent physi-
history of untreated ventral hernias, most surgeons recommend cal examination. As with the inguinal region, the anterior abdomi-
that these hernias be repaired when discovered. nal wall is evaluated with the patient in standing and supine
positions, and a Valsalva maneuver is also useful to demonstrate
Anatomy the site and size of a hernia. Imaging modalities may play a greater
The anatomy of the anterior abdominal wall is straightforward role in the diagnosis of more unusual hernias of the abdominal
and considerably easier to grasp than the anatomy of the inguinal wall.
area. However, a clear understanding of the blood supply and
innervation of the abdomen is important in performing advanced Classification
abdominal wall reconstruction. The lateral musculature is com- Umbilical Hernia
posed of three layers, with the fascicles of each directed obliquely The umbilicus is formed by the umbilical ring of the linea alba.
at different angles to create a strong envelope for the abdominal Intra-abdominally, the round ligament (ligamentum teres) and
contents. Each of these muscles forms an aponeurosis that inserts paraumbilical veins join into the umbilicus superiorly and the
into the linea alba, a midline structure joining both sides of the median umbilical ligament (obliterated urachus) enters inferiorly.
abdominal wall. The external oblique is the most superficial Umbilical hernias in infants are congenital and are common. They
muscle of the lateral abdominal wall. Deep to the external oblique close spontaneously in most cases by the age of 2 years. Those that
lies the internal oblique muscle. The fibers of the external oblique persist after the age of 5 years are frequently repaired surgically,
course in an inferomedial direction (like hands in pockets), although complications related to these hernias in children are
whereas those of the internal oblique muscle run deep to and unusual. There is a strong predisposition toward the development
opposite the external oblique. The deepest muscle layer of the of these hernias in individuals of African descent. In the United
abdominal wall is the transversus abdominis muscle. Its fibers States, the incidence of umbilical hernia is eight times higher in
course in a horizontal direction. These three lateral muscles give African American than in white infants.
rise to aponeurotic layers lateral to the rectus, which contribute Umbilical hernias in adults are largely acquired. These hernias
to the anterior and posterior layers of the rectus sheath. are more common in women and in patients with conditions
The medial extension of the external oblique aponeurosis forms that result in increased intra-abdominal pressure, such as preg-
the anterior layer of the rectus sheath. At the midline, the two nancy, obesity, ascites, or chronic abdominal distention. Umbili-
anterior rectus sheaths form the tendinous linea alba. On either cal hernia is more common in those who have only a single
side of the linea alba are the rectus abdominis muscles, whose midline aponeurotic decussation compared with the normal
fibers are directed longitudinally and run the length of the anterior decussation of fibers from all three lateral abdominal muscles.
abdominal wall. Below each rectus muscle lies the posterior layer Strangulation is unusual in most patients; however, strangulation
of the rectus sheath, which also contributes to the linea alba. or rupture can occur in chronic ascitic conditions. Small asymp-
Another important anatomic structure of the anterior abdomi- tomatic umbilical hernias barely detectable on examination need
nal wall is the arcuate line, which is located 3 to 6 cm below the not be repaired. Adults who have symptoms, a large hernia,
umbilicus. The arcuate line delineates the point below which the incarceration, thinning of the overlying skin, or uncontrollable
posterior rectus sheath is absent. Above the arcuate line, the apo- ascites should have a hernia repair. Spontaneous rupture of
neurosis of the internal oblique muscle contributes to the anterior umbilical hernias in patients with ascites can result in peritonitis
and posterior rectus sheaths, and the aponeurosis of the transver- and death.
sus abdominis muscle passes posterior to the rectus muscle to form Classically, repair was done using the vest over pants repair
the posterior rectus sheath. Below the arcuate line, the internal proposed by Mayo, which uses imbrication of the superior and
oblique and transversus abdominis aponeuroses pass completely inferior fascial edges. Because of increased tension on the repair
anterior to the rectus muscle (Fig. 44-9). The posterior rectus and recurrence rates of almost 30% with long-term follow-up,
Aponeurosis of
external oblique Anterior layer of Subcutaneous fat
Aponeurosis of muscle rectus sheath (superficial fascia)
internal oblique Rectus
muscle Linea Skin External oblique
abdominis
alba muscle
muscle
Aponeurosis
of transversus Internal oblique
muscle muscle
Falciform
Extraperitoneal Posterior ligament Transversalis
(subserous) layer of rectus fascia
tissue sheath
Transversus
Peritoneum muscle
Section above arcuate line
Aponeurosis of Anterior layer of

external oblique rectus sheath Subcutaneous fat
Aponeurosis of muscle (superficial fascia)
internal oblique Rectus External oblique
muscle abdominis Skin muscle
muscle Transversus
Aponeurosis muscle
of transversus Internal oblique
muscle muscle
Medial umbilical
Extraperitoneal Urachus ligament and fold
(subserous) (in median
tissue umbilical Umbilical
fold) prevesical Transversalis
Peritoneum fascia fascia
Section below arcuate line

FIGURE 44-9 Cross sections of the rectus abdominis muscle and aponeurosis above and below the arcuate
line. (From Netter FT: Atlas of human anatomy, Summit, NJ, 1989, Ciba-Geigy, Plate 235.)
Perforator Anterior cutaneous conclusively found clear advantages of one technique over another.
vessels branch of Options for mesh implantation include bridging the defect,
subcostal nerve External oblique placing a preperitoneal underlay of mesh reinforced with suture
muscle
repair, and placing it laparoscopically. The laparoscopic technique
Internal oblique requires general anesthesia and is reserved for large defects or
muscle recurrent umbilical hernias.39 There is no universal consensus on
the most appropriate method of umbilical hernia repair.
Epigastric Hernia
Rectus Branches of
abdominis inferior epigastric
Approximately 3% to 5% of the population has epigastric hernias.
vessels Epigastric hernias are two to three times more common in men.
These hernias are located between the xiphoid process and umbi-
Transversus licus and are usually within 5 to 6 cm of the umbilicus. Like
abdominis umbilical hernias, epigastric hernias are more common in indi-
viduals with a single aponeurotic decussation. The defects are
FIGURE 44-10 Cross section of the lateral abdominal wall detailing small and often produce pain out of proportion to their size
location of intercostal neurovascular bundle traveling between the
because of incarceration of preperitoneal fat. They are multiple in
transversus abdominis and internal oblique muscles.
up to 20% of patients, and approximately 80% are in the midline.
Repair usually consists of excision of the incarcerated preperito-
however, the Mayo repair is rarely performed today. Instead, small neal tissue and simple closure of the fascial defect, similar to that
defects are closed primarily after separation of the sac from the for umbilical hernias. Small defects can be repaired under local
overlying umbilicus and surrounding fascia. Defects larger than anesthesia. Uncommonly, these defects can be sizable, can contain
3 cm are closed using prosthetic mesh.38 There are a number of omentum or other intra-abdominal viscera, and may require mesh
techniques to place this mesh, and no prospective data have repairs. Epigastric hernias are better repaired anteriorly because
the defect is small and fat that has herniated from within the and patient comorbidities were not significant in this model for
peritoneal cavity is difficult to reduce. either outcome measure. Hernias could be grouped into stages (I
to III) using width and wound class alone (Table 44-2), with
Incisional Hernia ordinal increments in both outcome measures. Stage I hernias are
Of all hernias encountered, incisional hernias can be the most smaller than 10 cm/clean and associated with low SSO and recur-
frustrating and difficult to treat. Incisional hernias occur as a result rence risk. Stage II hernias are 10 to 20 cm/clean or smaller than
of excessive tension and inadequate healing of a previous incision, 10 cm/contaminated and carry an intermediate risk of SSO and
which may be associated with surgical site infection. These hernias recurrence. Stage III hernias are either 10 cm and larger/
enlarge over time, leading to pain, bowel obstruction, incarcera- contaminated or any hernia 20 cm or larger, and these are associ-
tion, and strangulation. Obesity, advanced age, malnutrition, ated with high SSO and recurrence risk. Table 44-3 demonstrates
ascites, pregnancy, and conditions that increase intra-abdominal the reported rates for SSO and recurrence using this system.
pressure are factors that predispose to the development of an The staging system is simple but comprehensive in its ability
incisional hernia. Obesity can cause an incisional hernia to occur to stratify patients by risk of wound morbidity and recurrence,
because of increased tension on the abdominal wall from the the two chief outcome parameters of repair. Importantly, this
excessive bulk of a thick pannus and large omental mass. Chronic system does not include intraoperative details, such as approach
pulmonary disease and diabetes mellitus have also been recognized (open versus laparoscopic), mesh choice (biologic versus syn-
as risk factors for the development of incisional hernia. Medica- thetic), or mesh position (onlay versus sublay). It is hoped that
tions such as corticosteroids and chemotherapeutic agents and this platform can be the basis of future inclusion and exclusion
surgical site infection can contribute to poor wound healing and criteria for studies regarding technique.
increase the risk for development of an incisional hernia.
Large hernias can result in loss of abdominal domain, which Treatment: Operative Repair
occurs when the abdominal contents no longer reside in the Primary repair of incisional hernias can be done when the defect
abdominal cavity. These large abdominal wall defects also can is small (≤2 to 3 cm in diameter) and there is viable surrounding
result from the inability to close the abdomen primarily because tissue or in cases in which the hernia was clearly a result of a
of bowel edema, abdominal packing, peritonitis, and repeated technical error at the initial operation, such as a suture fracturing.
laparotomy. With loss of domain, the natural rigidity of the Larger defects (>2 to 3 cm in diameter) have a high recurrence
abdominal wall becomes compromised and the abdominal mus- rate if closed primarily and are repaired with a prosthesis.39 Recur-
culature is often retracted. Respiratory dysfunction can occur rence rates vary between 10% and 50% and are typically reduced
because these large ventral defects cause paradoxical respiratory
abdominal motion. Loss of abdominal domain can also result in
bowel edema, stasis of the splanchnic venous system, urinary TABLE 44-2 Incisional Hernia Staging
retention, and constipation. Return of displaced viscera to the System
abdominal cavity during repair may lead to increased abdominal
Stage I <10 cm, clean
pressure, abdominal compartment syndrome, and acute respira-
Risk: low recurrence, low SSO
tory failure.
There is no simple mechanism for communicating the com- Stage II <10 cm, contaminated
plexity of a ventral incisional hernia. Defect size, location on the Risk: moderate recurrence, moderate SSO 10-20 cm, clean
abdominal wall, loss of domain, patient comorbidities, presence
of contamination, necessity for an ostomy, acuity of the presenta- Stage III ≥10 cm, contaminated
tion, and history of prior repairs with or without a prosthetic Risk: high recurrence, high SSO Any ≥20 cm
allow an infinite number of permutations. The absence of a uni-
SSO, surgical site occurrence.
versal classification system has hindered comparisons within the
literature and at meetings, indirectly delaying meaningful conver-
sations about repair techniques and prosthetic choice. The TNM
model for cancer staging is an enviable model to strive for in TABLE 44-3 Surgical Site Occurrence
hernia repair. As such, a recent group sought to stratify ventral (SSO) and Recurrence Rates
hernias into stages using a limited number of preoperative vari-
SSO RECURRENCE
ables to accurately predict the two most meaningful surgical out-
RATE RATE
comes: surgical site occurrence (SSO) and long-term hernia
recurrence rates. Stage I 7/77 7/77 (10%)
Two of the most popular ventral hernia classification tools to Risk: low recurrence, low SSO (10%)
date have been generated from expert opinion: the Ventral Hernia <10 cm, clean
Working Group grading scale and the European Hernia Society
Stage II 30/151 22/151 (15%)
system. The Ventral Hernia Working Group grading scale uses
Risk: moderate recurrence, moderate SSO (20%)
patient comorbidities and wound class to predict SSO risk. The
<10 cm, contaminated
European Hernia Society system assesses hernia width and loca-
10-20 cm, clean
tion; it was initially designed to gather data on recurrence risk.40
Using data from 333 ventral hernia repairs with no filter for Stage III 44/105 27/105 (26%)
technique, investigators presented a multivariate analysis that Risk: high recurrence, high SSO (42%)
identified hernia width (<10 cm, 10 to 20 cm, ≥20 cm) and the ≥10 cm, contaminated
presence of contamination as the two variables associated with Any ≥20 cm
wound morbidity (SSO) and hernia recurrence. Hernia location
by more than 50% with the use of prosthetic mesh.41 Prosthetic Unprotected polyester mesh should not be placed directly on the
material may be placed as an onlay patch to buttress a tissue repair, viscera because unacceptable rates of erosion and bowel obstruc-
interposed between the fascial defect, sandwiched between tissue tion have been reported.42 When it is placed in the preperitoneal
planes, or put in a sublay position. Depending on its location, position in complex ventral hernia repairs, complication rates are
several important properties of the mesh must be considered. low.9,50
When mesh is placed in an intraperitoneal position, several
Prosthetic Materials for Ventral Hernia Repair options are available. A single sheet of mesh with both sides con-
Synthetic materials. Various synthetic mesh products are structed to reduce adhesions and a composite-type mesh with one
available. Desirable characteristics of a synthetic mesh include its side made to promote tissue ingrowth and the other to resist adhe-
being chemically inert, resistant to mechanical stress while main- sion formation are available. Single-sheet mesh is composed of
taining compliance, sterilizable, and noncarcinogenic; it should expanded polytetrafluoroethylene (ePTFE). This prosthetic has a
incite minimal inflammatory reaction and be hypoallergenic. The visceral side that is microporous (3 µm) and an abdominal wall side
ideal mesh has yet to be defined. When selecting the appropriate that is macroporous (17 to 22 µm) and promotes tissue ingrowth.
mesh, the surgeon must consider the position of the mesh, This product differs from other synthetic meshes in that it is flexible
whether it will be in direct contact with the viscera, and the pres- and smooth. Some fibroblast proliferation occurs through the
ence or risk of infection. Mesh constructs can be classified on the pores, but PTFE is impermeable to fluid. Unlike polypropylene,
basis of weight of the material, pore size, water angle (hydropho- PTFE is not incorporated into the native tissue. Encapsulation
bic or hydrophilic), and whether there is an antiadhesive barrier occurs slowly, and infection can occur during the encapsulation
present. In placing a mesh in the extraperitoneal position without process. When it is infected, PTFE almost always must be removed.
the risk of bowel erosion, a macroporous unprotected mesh is To promote better tissue integration, composite mesh was
appropriate. Both polypropylene and polyester mesh have been developed. This product combines the attributes of polypropylene
successfully placed in the extraperitoneal position. Polypropylene and PTFE by layering the two substances on top of one another.
mesh is a hydrophobic macroporous mesh that allows the ingrowth The PTFE surface serves as a permanent protective interface
of native fibroblasts and incorporation into the surrounding against the bowel and the polypropylene side faces superficially to
fascia. It is semirigid, somewhat flexible, and porous. Placing be incorporated into the native fascial tissue. These materials have
polypropylene mesh in an intraperitoneal position directly variable rates of contraction and, when placed together, can result
apposed to the bowel is avoided because of unacceptable rates of in buckling of the mesh and visceral exposure to the polypropyl-
enterocutaneous fistula formation.42 Recently, lighter weight poly- ene component. Other composite meshes recently have been
propylene mesh has been introduced to address some of the long- developed that combine a macroporous mesh with a temporary,
term complications of heavyweight polypropylene mesh. The absorbable antiadhesive barrier. Basic constructs of these mesh
definition of lightweight mesh was arbitrarily chosen at less than materials include heavyweight or lightweight polypropylene or
50 g/m2, with heavyweight mesh weighing more than 80 g/m2. polyester. Absorbable barriers are typically composed of oxidized
These lightweight mesh products often have an absorbable com- regenerated cellulose, omega-3 fatty acids, or collagen hydrogels.
ponent of material that provides initial handling stability, typically A number of small animal studies have validated the antiadhesive
composed of Vicryl (polyglactin 910) or Monocryl (poliglecap- properties of these barriers, but currently no human trials exist
rone 25; Ethicon, Somerville, NJ). evaluating the ability of these composite materials to resist adhe-
Whether lightweight mesh results in improved patient out- sion formation.
comes is controversial. Two prospective randomized trials evaluat- Biologic materials. Biologic prostheses for ventral hernia
ing the incidence of postoperative pain after open inguinal hernia repair are nonsynthetic, natural tissue mesh. There are numerous
repair have shown mixed results.43 In a randomized controlled biologic grafts available for abdominal wall reconstruction (Table
trial evaluating lightweight versus heavyweight polypropylene 44-4). These products can be categorized on the basis of the source
mesh for ventral hernia repair, the recurrence rate in the light- material (e.g., human, porcine, bovine), postharvesting processing
weight group was more than twice that in the heavyweight group techniques (e.g., cross-linked, non–cross-linked), and sterilization
(17% for lightweight mesh versus 7% for heavyweight mesh), techniques (e.g., gamma radiation, ethylene oxide gas sterilization,
which approached statistical significance (P = .052).44 Several nonsterilized). These products are largely composed of acellular
investigators have reported concerning rates of central mesh fail- collagen and theoretically provide a matrix for neovascularization
ures with ultra-lightweight polypropylene mesh and lightweight and native collagen deposition. These properties may provide
polyester mesh.45,46 Another recent finding with regard to large- advantages in infected or contaminated cases in which synthetic
pore lightweight mesh is its ability to resist bacterial contamina- mesh is thought to be contraindicated. Ideal placement tech-
tion. Several animal studies have reported high rates of bacterial niques are yet to be defined for these relatively new products;
clearance with large-pore synthetic mesh when it is exposed to however, some general principles apply. These products function
gastrointestinal flora and methicillin-resistant Staphylococcus best when used as a fascial reinforcement rather than as a bridge
aureus.47,48 A large multicenter retrospective experience with 100 or interposition repair.51 The long-term durability of biologic
cases of large-pore polypropylene mesh used in clean contami- mesh has recently been questioned in the largest series of biologic
nated and contaminated ventral hernia repairs was reported.49 mesh use in a contaminated setting.52 There are no prospective
These authors noted excellent medium-term results with a 7% randomized data comparing the effectiveness of these natural
recurrence rate. Longer term data to verify the safety and durabil- tissue alternatives with that of synthetic mesh repairs in various
ity of this approach are needed. settings of complex hernia repairs.
Polyester mesh is composed of polyethylene terephthalate and
is a hydrophilic, heavyweight, macroporous mesh. This mesh has Operative Technique
several different weaves that can yield a two-dimensional flat Ventral hernias. It is generally agreed that all but the smallest
screen-like mesh and a three-dimensional multifilament weave. incisional hernias can be repaired with mesh, and the surgeon has
TABLE 44-4 Biologic Mesh for Abdominal Wall Reconstruction and Postharvesting
Processing Techniques
PRODUCT SOURCE CROSS-LINKED STERILIZATION METHOD
AlloDerm (LifeCell, Branchburg, NJ) Human dermis No Ionic
AlloMax (Davol, Warwick, RI) Human dermis No E beam
FlexHD (Ethicon, Sommerville, NJ) Human dermis No Ethanol
Strattice (LifeCell, Branchburg, NJ) Porcine dermis No Gamma irradiation
Permacol (Covidien, Norwalk, CT) Porcine dermis Yes Ethanol
CollaMend (Davol, Warwick, RI) Porcine dermis Yes Ethanol
XenMatrix (Davol, Warwick, RI) Porcine dermis No Gamma irradiation
SurgiMend (TEI Biosciences, Boston, MA) Bovine fetal dermis No Ethanol
Veritas (Synovis, St. Paul, MN) Bovine No
Peri-Guard (Synovis, St. Paul, MN) Bovine Yes
Surgisis (Cook, Bloomfield, IN) Porcine intestine No Ethanol
various options for placing the mesh. The onlay technique involves Mesh placement options
primary closure of the fascia defect and placement of a mesh over
the anterior fascia. The major advantage of this approach is that
the mesh is placed outside the abdominal cavity, avoiding direct
interaction with the abdominal viscera. However, disadvantages
include the large subcutaneous dissection, the increased likelihood Inlay
of seroma formation, the superficial location of the mesh (which Mesh
places it in jeopardy of contamination if the incision becomes
infected), and the repair is usually under tension. Prospective
analysis of this technique is not available, but a retrospective
review has reported recurrence rates of 28%.53 Interposition pros-
Overlay
thetic repairs involve securing the mesh to the fascial edge without
overlap. This results in a predictably high recurrence rate; the
synthetic often pulls away from the fascial edge because of
increased intra-abdominal pressure. A sublay or underlay tech-
nique involves placing the prosthetic below the fascial compo-
nents. The mesh can be placed intraperitoneally, preperitoneally,
or in the retrorectus (retromuscular) space. It is highly desirable Underlay
to have the mesh placed beneath the fascia. With a wide overlap (intraperitoneal)
of mesh and fascia, the natural forces of the abdominal cavity act
to hold the mesh in place and prevent migration. This can be
accomplished by several techniques (Fig. 44-11).
Intraperitoneal mesh placement. After reopening of the
Retrorectus
prior incision and with the use of available dual-type mesh or
composite mesh, the mesh can be placed in an intraperitoneal Posterior sheath and peritoneum can be
approximated and closed with suture
position at least 4 cm beyond the fascial margin and secured with
interrupted mattress sutures. This technique requires raising sub-
cutaneous flaps, and the mesh may be in direct contact with the
abdominal contents.
The laparoscopic approach for ventral hernia repair relies on Preperitoneal
the same principles as the retrorectus repair; however, the mesh is
placed within the peritoneal cavity. This repair is useful, particu- Peritoneum Posterior rectus and
larly for large defects. Trocars are placed as far laterally as feasible peritoneal layer
based on the size and location of the hernia. The hernia contents
are reduced, and adhesions are lysed. The surface area of the defect
is measured, and a barrier-coated mesh is fashioned with at least
4 cm of overlap around the defect. The mesh is rolled, placed into
Intermuscular
the abdomen, and deployed. It is secured to the anterior abdomi-
nal wall with preplaced mattress sutures that are passed through FIGURE 44-11 Mesh placement options for abdominal wall
separate incisions; tacking staples are placed between these sutures reconstruction.
to secure the mesh 4 cm beyond the defect. There are fewer inci-
sional complications with the laparoscopic approach because large
incisions and subcutaneous undermining are avoided.
Myofascial releases. One of the underlying principles of possible. The procedure is performed by raising large subcutane-
abdominal wall reconstruction is to reestablish the linea alba. ous flaps above the external oblique fascia. These flaps are carried
Restoring the linea alba to the midline provides the advantage of laterally past the linea semilunaris. This lipocutaneous dissection
a functional abdominal wall, often protects the mesh from super- itself can provide some advancement of the abdominal wall. Large
ficial wound issues, and might result in a more durable repair. In perforating subcutaneous vessels can be preserved to prevent isch-
larger hernias, there are several options to provide the myofascial emic necrosis of the skin flaps. A relaxing incision is made 2 cm
advancement necessary to reconstruct the midline and to restore lateral to the linea semilunaris on the lateral external oblique
contour to the abdominal wall. The basic tenets of these proce- aponeurosis from several centimeters above the costal margin to
dures are that the abdominal wall and rectus muscle are bounded the pubis. The external oblique is then bluntly separated in the
by several different myofascial compartments, and by releasing avascular plane, away from the internal oblique, allowing its
one or more fascial bundles, advancement of the rectus muscle to advancement. Further relaxing incisions have been described to
the midline is possible. In essence, each of these procedures creates the aponeurotic layers of the internal oblique or transversus
a local advancement flap of the rectus muscle. Great care should abdominis, but this can result in problematic lateral bulges or
be taken to identify and to preserve the neurovascular structures herniation at this site. Additional release can be safely achieved by
to the rectus muscle to ensure a functional well-vascularized graft. incising the posterior rectus sheath. These techniques, when
Posterior rectus sheath incision with retromuscular mesh applied to both sides of the abdominal wall, can yield up to 20 cm
placement. This technique involves placing prosthetic mesh in of mobilization. Although this technique often allows tension-free
the extraperitoneal position in the preperitoneal space or retrorec- closure of these large defects, recurrence rates as low as 20% have
tus position. This technique was initially described by Stoppa.9 A been reported with the use of prosthetic reinforcement in large
large piece of mesh is placed in the retromuscular space on top of hernias.56 It is important that patients understand that a lateral
the posterior rectus sheath or peritoneum. The compartment is bulge can occur after release of the external oblique aponeurosis.
accessed through an incision in the posterior rectus sheath approx- Recognizing the high recurrence rates with component separation
imately 1 cm from the medial edge of the rectus muscle. This alone, several authors have reported small series of biologic mesh
space must be dissected laterally on both sides of the linea alba to reinforcement of these repairs.51 To date, no randomized con-
a distance of 8 to 10 cm beyond the defect. Both leaflets of the trolled trials have supported a lower recurrence rate with biologic
posterior sheath are then sutured together to create an extraperi- prosthetic reinforcement. If a bioprosthetic is placed, it can be
toneal pocket in which to place the prosthetic material. The secured with an underlay or onlay technique. No comparative
prosthetic mesh extends 5 to 6 cm beyond the superior and infe- data exist demonstrating the superiority of either repair
rior borders of the defect. The use of transfascial sutures to secure technique.57
the mesh remains controversial, and no definitive evidence exists Endoscopic component separation. One of the major limi-
supporting either approach. The authors selectively use transfas- tations of open component separation is that large skin flaps are
cial sutures. With smaller defects, the mesh does not need to be necessary to access the lateral abdominal wall musculature. Rec-
sutured because it is held in place by intra-abdominal pressure ognizing these limitations, innovative, minimally invasive
(Pascal’s principle), allowing eventual incorporation into the sur- approaches to component separation have been described.58 The
rounding tissues. Alternatively, in larger defects, the mesh can be basic principle of a minimally invasive component separation is
secured laterally with several sutures. This approach avoids contact to gain direct access to the lateral abdominal wall without creating
between the mesh and abdominal viscera and has been shown in a lipocutaneous flap. Typically, this is performed by a direct
long-term studies to have a respectable recurrence rate (14%) in cutdown through a 1-cm incision off the tip of the 11th rib over-
large incisional hernias. lying the external oblique muscle (Fig. 44-13). The external
Posterior component separation. The retrorectus space is oblique is split in the line of its fibers, and a standard bilateral
bordered laterally by the linea semilunaris. In very large hernias inguinal hernia balloon dissector is placed in between the external
or in those patients with atrophic narrowed rectus muscles, this and internal oblique muscles, toward the pubis. Three laparo-
might prevent adequate mesh overlap. Further advancement can scopic trocars are placed in the space created, and the dissection
be obtained by incising the posterior rectus sheath approximately is carried from the pubis to several centimeters above the costal
1 cm medial to the linea semilunaris. At this location, the poste- margin. The linea semilunaris is carefully identified, and the exter-
rior leaflet of the internal oblique and the transversus abdominis nal oblique is incised from beneath the muscle, at least 2 cm
muscle are incised to gain access to the preperitoneum. This plane lateral to the linea semilunaris. The muscle is released from the
can be extended to the retroperitoneum and eventually to the pubis to several centimeters above the costal margin. This proce-
psoas muscle if necessary.54 Very large sheets of prosthetic mesh dure is performed bilaterally. Synthetic or biologic mesh can be
can be placed in this location with wide defect coverage.55 A used to reinforce the repair of the midline closure. These relatively
retrospective review from the Mayo Clinic, with a median new techniques are feasible, but long-term data demonstrating
follow-up of 5 years, has documented a 5% overall hernia recur- equivalency to open techniques are lacking.
rence rate in 254 patients who underwent complex ventral hernia
repair during a 13-year period.43 In one comparative analysis of Results of Incisional Hernia Repairs
posterior and anterior component separation, similar amount of Several prospective randomized trials have compared laparoscopic
fascial advancement was reported with a significant reduction in and open ventral hernia repairs (Table 44-5).59-63 Although most
wound morbidity with use of the posterior approach.55 of these studies were small, with fewer than 100 patients, the
Anterior component separation. Another option for the results tend to favor a laparoscopic approach for small to medium-
repair of complex or large ventral defects is the anterior compo- sized defects. The incidences of postoperative complications and
nent separation technique (Fig. 44-12). This involves separating recurrence were less in hernias repaired laparoscopically. Several
the lateral muscle layers of the abdominal wall to allow their retrospective reports have demonstrated similar advantages for a
advancement. Primary fascial closure at the midline is often laparoscopic approach. Based on the comparative trials listed in
1 1
2 2
3 3
4 4
A B
3 2 1
1
2
3
4
C D
1
1 2
2
3 3
4 4
E F
FIGURE 44-12 Component Separation Technique. A, The skin and subcutaneous fat are dissected free
from the anterior sheath of the rectus abdominis muscle and the aponeurosis of the external abdominal
oblique muscle. B, The external abdominal oblique is incised 1 to 2 cm lateral to the rectus abdominis muscle.
C, The external abdominal oblique is separated from the internal abdominal oblique. D, The dissection is
carried to the posterior axillary line. E, Additional length can be achieved by incising the posterior rectus
sheath above the arcuate line. F, Care must be taken to avoid damaging the nerves and blood supply that
enter the rectus abdominis posteriorly. (From de Vries Reilingh TS, van Goor H, Rosman C, et al: Components
separation technique for the repair of large abdominal wall hernias. J Am Coll Surg 196:32–37, 2003.)
Table 44-5, laparoscopic incisional hernia repair results in fewer to seventh decades of life. Patients often present with localized
postoperative complications, lower infection rate, and decreased pain in the area without a bulge because the hernia lies beneath
hernia recurrence.54,56-60,64 Until an appropriately powered pro- the intact external oblique aponeurosis. Ultrasound or CT of the
spective randomized trial is performed, the ideal approach will abdomen can be useful to establish the diagnosis.
largely be based on surgeon expertise and preference. In addition, A spigelian hernia is repaired because of the risk for incarcera-
these trials will need to provide guidance on the most appropriate tion associated with its relatively narrow neck. The hernia site is
hernia size to be repaired by either an open or a laparoscopic marked before operation. A transverse incision is made over the
approach. defect and carried through the external oblique aponeurosis. The
hernia sac is opened, dissected free of the neck of the hernia, and
excised or inverted. The defect is closed transversely by simple
suture repair of the transversus abdominis and internal oblique
UNUSUAL HERNIAS muscles, followed by closure of the external oblique aponeurosis.
There are a number of hernias that occur infrequently, of various Larger defects are repaired with a mesh prosthesis. Recurrence is
types. uncommon.
Types Obturator Hernia

Spigelian Hernia The obturator canal is formed by the union of the pubic bone and
A spigelian hernia occurs through the spigelian fascia, which is ischium. This canal is covered by a membrane pierced at the
composed of the aponeurotic layer between the rectus muscle medial and superior border by the obturator nerve and vessels.
medially and semilunar line laterally. Almost all spigelian hernias Weakening of the obturator membrane may result in enlargement
occur at or below the arcuate line. The absence of posterior rectus of the canal and formation of a hernia sac, which can lead to
fascia may contribute to an inherent weakness in this area. These intestinal incarceration and strangulation. The patient can present
hernias are often interparietal, with the hernia sac dissecting pos- with evidence of compression of the obturator nerve, which causes
terior to the external oblique aponeurosis. Most spigelian hernias pain in the anteromedial aspect of the thigh (Howship-Romberg
are small (1 to 2 cm in diameter) and develop during the fourth sign) that is relieved by thigh flexion. Almost 50% of patients
Aponeurosis of
external oblique
External
oblique
Dissecting
balloon
Rectus
Internal
Transversus oblique
abdominis
Cranial
Aponeurosis
Caudal
Camera
port
External
oblique
Instrument
Rectus port
Transversus Internal
abdominis oblique
FIGURE 44-13 Endoscopic component separation: port placement and surgical technique.
TABLE 44-5 Comparative Randomized Studies Between Open and Laparoscopic Ventral
Hernia Repair
INTRAOP- POSTOP-
ERATIVE ERATIVE
NO. OF COMPLICA- COMPLICA- FOLLOW-UP RECUR-
PATIENTS MESH USED TIONS (%) LOS (DAYS) TIONS (%) (MONTHS) RENCE (%)
STUDY LAP OPEN LAP OPEN LAP OPEN LAP OPEN LAP OPEN LAP OPEN LAP OPEN
McGreevy et al,60 65 71 ePTFE or PP N/A N/A 1.1 1.5 7.70 21.10 N/A N/A N/A N/A
2003 polyester +
collagen
Lomanto et al,61 50 50 Polyester + ePTFE 2 2 2.74 4.7 26 40 19.6 21 2 10
2006 collagen
Bingener et al,62 127 233 ePTFE, PP, or PP N/A N/A N/A N/A 33.10 43.30 36 36 13 9
2007 ePTFE
Olmi et al,59 85 85 Polyester + PP N/A N/A 2.7 9.9 16.50 29.40 24 24 2 4
2007 collagen
Pring et al,73 31 27 PTFE PTFE N/A N/A 1 1 33 49 28 28 3.30 4.20
2008
Asencio et al,74 45 39 PTFE or PP PP 6.70 0 3.46 3.33 5.20 33.30 12 12 9.70 7.90
2009
ePTFE, expanded polytetrafluoroethylene; LAP, laparoscopic; LOS, length of stay; N/A, not available; PP, polypropylene.
with obturator hernia present with complete or partial bowel The gluteus maximus muscle is opened, and the sac is visualized.
obstruction. An abdominal CT scan can establish the diagnosis, The muscle edges of the defect are reapproximated with inter-
if necessary. rupted sutures, or the defect is obliterated with mesh.
A posterior approach, open or laparoscopic, is preferred. This
approach provides direct access to the hernia. After reduction of Perineal Hernia
the hernia sac and contents, any preperitoneal fat within the Perineal hernias are caused by congenital or acquired defects and
obturator canal is reduced. If necessary, the obturator foramen is are uncommon. These hernias may also occur after abdominoperi-
opened posterior to the nerve and vessels. The obturator nerve neal resection or perineal prostatectomy. The hernia sac protrudes
can be manipulated gently with a blunt nerve hook to facilitate through the pelvic diaphragm. Primary perineal hernias are rare,
reduction of the fat pad. The obturator foramen is repaired with occur most commonly in older multiparous women, and can be
prosthetic mesh, with care taken to avoid injury to the obturator quite large. Symptoms are usually related to protrusion of a mass
nerve and vessels. Patients with compromised bowel usually through the defect that is worsened by sitting or standing. A bulge
require laparotomy. is frequently detected on bimanual rectal-vaginal examination.
Perineal hernias are generally repaired through a transabdomi-
Lumbar Hernia nal approach or combined transabdominal and perineal
Lumbar hernias can be congenital or acquired after an operation approaches. After the sac contents are reduced, small defects may
on the flank and occur in the lumbar region of the posterior be closed with nonabsorbable suture, whereas large defects are
abdominal wall. Hernias through the superior lumbar triangle repaired with prosthetic mesh.
(Grynfeltt triangle) are more common. The superior lumbar tri-
angle is bounded by the 12th rib, paraspinal muscles, and internal Loss of Domain Hernias
oblique muscle. Less common are hernias through the inferior Loss of domain implies a massive hernia in which the herniated
lumbar triangle (Petit triangle), which is bounded by the iliac contents have resided for so long outside the abdominal cavity
crest, latissimus dorsi muscle, and external oblique muscle. Weak- that they cannot simply be replaced into the peritoneal cavity. We
ness of the lumbodorsal fascia through either of these areas results typically classify loss of domain hernias into patients with and
in progressive protrusion of extraperitoneal fat and a hernia sac. without preoperative contamination. Each group is then subcat-
Lumbar hernias are not prone to incarceration. Small lumbar egorized into two groups. Patients with a small hernia defect and
hernias are frequently asymptomatic. Larger hernias may be asso- a massive hernia sac (e.g., large inguinoscrotal hernias) require
ciated with back pain. CT is useful for diagnosis. restoration of peritoneal cavity domain, whereas patients with a
Both open and laparoscopic repairs are useful. Satisfactory large defect and a massive hernia sac (open abdomen with skin
suture repair is difficult because of the immobile bone margins of graft) require restoration of peritoneal domain and complex
these defects. Repair is best done by placement of prosthetic mesh, reconstruction of the abdominal wall.
which is sutured beyond the margins of the hernia. There is Before repair of these complex defects, the patient must
usually sufficient fascia over the bone to anchor the mesh. undergo careful preoperative evaluation. A clear understanding of
the morbidity and mortality associated with these reconstructive
Interparietal Hernia procedures is critical. Weight reduction, smoking cessation, opti-
Interparietal hernias are rare and occur when the hernia sac lies mization of nutrition, and glucose control are all important
between layers of the abdominal wall. These hernias most fre- aspects of complex abdominal wall reconstruction. Previously,
quently occur in previous incisions. Spigelian hernias are almost methods to stretch the abdominal wall gradually were used to
always interparietal. allow the restoration of abdominal domain and closure. This was
The correct preoperative diagnosis of interparietal hernia can accomplished by insufflation of air into the abdominal cavity to
be difficult. Many patients with complicated interparietal hernias create a progressive pneumoperitoneum. Repeated administra-
present with intestinal obstruction. Abdominal CT can assist in tions of increasing volumes of air during 1 to 3 weeks allowed the
the diagnosis. Large interparietal hernias usually require place- muscles of the abdominal wall to become lax enough for primary
ment of prosthetic mesh for closure. When this cannot be done, closure of the defect. This technique is particularly suited for small
the component separation technique may be useful to provide defects and massive hernia sacs.65 For large defects, some authors
natural tissues to obliterate the defect. have also described a staged approach using ePTFE dual mesh for
patients with loss of abdominal domain and lateral retraction of
Sciatic Hernia the abdominal wall musculature. The initial stage involves reduc-
The greater sciatic foramen can be a site of hernia formation. tion of the hernia and placement of a large sheet of ePTFE dual
These hernias are extremely unusual and difficult to diagnose and mesh secured to the fascial edges with a running suture. Subse-
frequently are asymptomatic until intestinal obstruction occurs. quent stages involve serial elliptical excision of the mesh until the
In the absence of intestinal obstruction, the most common fascia can be approximated in the midline without tension. Finally,
symptom is the presence of an uncomfortable or slowly enlarging the mesh is completely excised, and the fascia is reapproximated
mass in the gluteal or intragluteal area. Sciatic nerve pain can with component separation and a biologic underlay patch, if
occur, but sciatic hernia is a rare cause of sciatic neuralgia. necessary.66 This approach is technically feasible but does require
A transperitoneal approach is preferred if bowel obstruction or multiple operations and long hospital stays, and it is associated
strangulation is suspected. Hernia contents can usually be reduced with a fairly high morbidity rate.
with gentle traction. Prosthetic mesh repair is usually preferred.
A transgluteal approach can be used if the diagnosis is certain and Parastomal Hernia Repair
the hernia is reducible, but most surgeons are not familiar with Parastomal hernia is a common complication of stoma creation.
this approach. With the patient prone, an incision is made from In fact, the creation of a stoma by strict definition is an abdominal
the posterior edge of the greater trochanter across the hernia mass. wall hernia. The incidence of parastomal hernias is highest for
colostomies and occurs in up to 50% of stomas. Fortunately, most in the retromuscular space to cover the old stoma site and the
patients remain asymptomatic, and life-threatening complica- entire midline incision, and it is used to prophylactically reinforce
tions, such as bowel obstruction and strangulation, are rare. the new stoma site. The stoma is eventually brought out through
Unlike midline incisional hernia repair, routine repair of parasto- a keyhole incision in the mesh and matured.71 All these series are
mal hernias is not recommended. Surgical repair should be fairly small with fewer than 100 patients and have reported only
reserved for patients experiencing symptoms of bowel obstruc- short-term to medium-term follow-up, limiting our ability to
tion, problems with pouch fit, or cosmetic issues. make clear recommendations for this difficult problem.
Three general approaches are available for parastomal hernia
repair. These techniques include primary fascial repair, stoma relo- Complications
cation, and prosthetic repair. Primary fascial repair involves hernia Mesh Infection
reduction and primary fascial reapproximation through a peristo- Mesh infections are serious complications that can be difficult to
mal incision. This technique carries a predictably high recurrence treat. If ePTFE becomes infected, it requires removal with the
rate. The advantage of this approach is that the abdomen often is resultant morbidity of another defect, which often must be closed
not entered, making the operation less complex. Because of the under tension, leading to inevitable recurrence. In open ventral
high recurrence rate with this technique, it should be reserved for hernia repair, incisional and mesh infections are not infrequent.
patients who will not tolerate a laparotomy. Stoma relocation Use of the laparoscopic technique and placement of a large piece
improves results; however, it requires a laparotomy and predis- of mesh without undermining large subcutaneous tissue flaps
poses to another parastomal hernia in the future. To reduce the avoid wound complications. In a series of almost 1000 patients
rate of recurrent herniation, some surgeons reinforce the repair who had laparoscopic ventral hernia repair, mesh infections
with biologic or synthetic mesh in a keyhole fashion around the occurred in less than 1% of cases.72 Perhaps the greatest advantage
new stoma site. Early results are promising, but long-term out- of the laparoscopic approach for repairing ventral hernias is this
comes have not yet been reported.67 Prosthetic repairs of parasto- reduction in infectious complications. Two randomized controlled
mal hernias can provide excellent long-term results with a lower trials have compared laparoscopic and open ventral hernia
rate of hernia recurrence, but a higher rate of prosthetic complica- repair.73,74
tions must be accepted.
Regardless of the technique, a permanent foreign body placed Seromas
in apposition to the bowel can result in erosion, obstruction, and Seroma formation can occur after laparoscopic and open ventral
disastrous complications. Several approaches to prosthetic mesh hernia repair. In open ventral hernia repair, drains are often placed
placement have been described. The mesh can be placed as an in an attempt to obliterate the dead space caused by the hernia
onlay patch, intra-abdominally, or in the retrorectus position. and tissue dissection. These drains can cause mesh contamination,
When the mesh is placed intraperitoneally, a keyhole is fashioned and seromas can form after drain removal. With laparoscopic
around the stoma site or placed as a flat sheet, lateralizing the repair, the hernia sac is not resected, and a seroma cavity will
stoma as it exits the abdomen, as described by Sugarbaker.68 result. Most of these seromas will resolve over time as the mesh
Several authors have described laparoscopic approaches to para- becomes incorporated on the hernia sac. Preoperative discussions
stomal hernia repair, including keyhole and Sugarbaker-type with the patient describing the expectations of a temporary seroma
repairs69,70 (Fig. 44-14). A retromuscular repair that takes advan- are imperative before laparoscopic ventral hernia repair. We reserve
tage of many of the advanced reconstructive techniques described aspiration for symptomatic or persistent seromas after 6 to 8
in this chapter has recently been reported. In this approach, a weeks.
laparotomy is performed, and the stoma is taken down and even-
tually resited to the contralateral side of the abdomen. A posterior Enterotomy
component separation is then performed; a large mesh is deployed Intestinal injury during adhesiolysis can be catastrophic. Manage-
ment of an enterotomy during a hernia repair is controversial and
depends on the segment of intestine injured (small versus large
bowel) and amount of spillage. Options include aborting the
hernia repair, using a primary tissue or biologic tissue repair, and
performing a delayed repair with prosthetic mesh in 3 to 4 days.
When there is gross contamination, the use of synthetic mesh is
contraindicated.
A. Sugarbaker
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44 CHAPTER

Ventral, Phrenopulmonary hiatus

Ventral, Piriformis muscle

External Transversus abdominis muscle

Inferior epigastric artery and vein

Inner inguinal canal

Inguinal Internal inguinal ring

A External spermatic vessels B

Endoscope with balloon in

Expanded preperitoneal space

External iliac vein

External iliac artery

Aponeurosis of Anterior layer of

Section below arcuate line

Types Obturator Hernia

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