Hernia Ingunalis

LUGANSK STATE MEDICAL UNIVERSITY DEPARTMENT OF CLINICAL ANATOMY AND OPR. SURGERY  PROJECT ON :  INGUINAL HERNIAS BY  Yao Doe Supervised by: Prof. Konstantin Tkachenko Presented On:

HERNIAS Hernia is a protrusion of a viscus or part of viscus through an abnormal opening in the walls of its containing cavity. it can be through abdominal wall, muscle fascia or diaphragm. Most common forms include, inguinal, femoral and umbilical accounting for about 75%.hernias may be acquired or conginental.

Aetiological factors Two main aetiological factors for acquired hernia are: • Increased intra-abdominal pressure such as powerful muscular effort or • Abdominal weakness such as advancing age or malnutrition

Composition of hernia A hernia consists of three parts: The sac-is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus. The neck is usually well defined, but in some direct inguinal hernias and in many incisional hernias there is no actual neck. Diameter of neck is significant because strangulation of bowel is a likely complication where the neck is narrow as in femoral and paraumbilical hernias

Covering of the sac-derived from layers of abdominal wall through which the sac passes Content-these can be: Omentum (omentocele) • Intestine (enterocele) • Portion of circumference of • intestine(Richter’s hernia) Portion of bladder(or a diverticulum) • Ovary with or without corresponding • fallopian tube Michel’s diverticulum(litters hernia) • Fluid as part of ascites or as a residuum • thereof.

Classification Irrespective of site hernias can be put into 5 classes: • Reducible-content can be returned to abdomen • Irreducible-contents can’t be returned but there are no other complications • Obstructed-bowel in the hernia has good blood supply but bowel is obstructed • Strangulated-blood supply of bowel is obstructed • Inflamed-content of the sac become inflamed.

INGUINAL HERNIA Surgical Anatomy • The inguinal canal is the weakest spot of the anterior abdominal wall. It’s about 4 cm in length. It consists of 4 walls and two openings. The walls are: • Anterior wall-formed by aponeurosis of external oblique • Posterior wall which is formed by transverse fascia which merges with inguinal ligament inferiorly. On medial border transverse fascia is reinforced by tendinious fibers of transversus abdominis called inguinal falx (henle’s ligament) • Superior wall is formed by lower margin of transversus abdominis and internal oblique. This passes over spermatic cord or round ligament of the uterus. • Inferior wall by curved margin of inguinal ligament.

Content of inguinal canal • • • • •

Spermatic cord/round ligament Ilioinguinal nerve Genital branch of genital femoral nerve Obliterated processus vaginalis. NB: iliohypogastric nerve, which is not a content of spermatic cord lies 0.5 inch above the canal and should be borne in mind during procedure.

The two rings are: • Superficial inguinal-is a triangular aperture formed as a result of separation of external oblique into:  Medial crus –which bounds the ring above and inserts into pubic sympysis  Lateral crus- bounds the ring below and attached to pubic tubercle. Medially and postrriorly the ring is reinforced by tendinious fibers of external oblique, reflected ligament (Colles ligament) Superiorly and laterally, the ring is strengthened by intercrural fibers .superficial inguinal ring projects into medial inguinal fossa.

• Deep inguinal ring- resides on the inner surface of anterior abdominal wall, it’s a depression in transverse fascia, which invaginates along the path of spermatic cord and fuses with it. Medially, the ring is reinforced by tendinious fibers called the interfoveolar ligaments. Posteriorly its reinforced by peritoneum. On the peritoneum there is the lateral inguinal fossa which corresponds to deep inguinal ring.

Direct Inguinal hernia- it comes out through Hesselbach’s triangle lying behind the medial part of inguinal canal. the triangle is bounded by inferior epigastric artery laterally, medially by lateral edge of rectus abdominis muscle and inferiorly by inguinal ligament. The hernia pushes the medial part of posterior wall of inguinal canal and comes out through superficial ring. Occurs in patients, who are flabby type, obese or of asthenic origin with poor muscular development. its never conginental. shows less tendency towards strangulation

Oblique inguinal hernias – the hernia comes out through the deep inguinal ring, so the sac containing the intraabdominal viscera comes out through the deep inguinal ring and follow the course of the spermatic cord and comes out through superficial inguinal ring to reach the scorutum. its covering from inward to outward are: Skin, two layers of superficial fascia , extra peritoneal tissue and peritoneum. the sac lies in front of the spermatic cord and covers it from above and below.

Choice of operation Oblique inguinal hernia should as a rule be treated by operation to avoid strangulation. Surgical intervention should be advised even if the hernia is small. The use of truss should be condemned as it causes pressure atrophy of muscle in inguinal region, reducing chances of successful operation later , should it be required. the use of truss is thus limited to patients who refuse operation and others who because of some reason can not under go operation. Choice of operation must take into consideration age groups:

Truss- condemned

Children- when the deep ring is not stretched, and the hernia is due to preformed sac, simply herniotomy, removal of the sac is required. Young adults-when inguinal defense mechanism has been impaired, herniorhappy, i.e. repair of posterior wall of inguinal canal should be performed. Older patient-whose muscle around inguinal region are weak leading to direct inguinal herniae, hernioplasty, i.e. reconstructive repair of inguinal region is the operation of choice

Techniques of hernia repair • Herniotomy involves removal of the sac and closure of the neck • Herniorrhaphy involves a form of reconstruction to o Restore the disturbed anatomy o Increase the strength of the abdominal wall o Construct a barrier to recurrence

• Herniorrhaphy can be achieved with following techniques – Bassini +/- Tanner Slide – Darn – Shouldice – Lichtenstein – Other Mesh - Stoppa – Laparoscopic – Shouldice or Liechtenstein now regarded as ’gold standard’ as judged by low risk of recurrence – Laparoscopic hernia repair should be reserved for bilateral or recurrent hernia

Herniorrhaphy (Hernioplasty) is a surgical procedure for correcting hernia. This technique can be divided into 4 groups: • Groups 1 and 2: open "tension" repair • A workable technique of repairing hernia was first described by Bassini . the Bassini technique was a "tension" repair, in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed.

• Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today; these include the Shouldice and the Cooper's ligament/McVayrepair

Group 3 • The meshes used are typically made from polypropylene or polyester. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery. Patients are encouraged to walk and move around immediately post-operatively, and they can usually resume all their normal activities within a week or two of the operation. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair. Rates of complications are generally low but they can be quite serious, and can include chronic pain, ischemic orchitis, and testicular atrophy

Laparascopy

laparoscopic repair ."Lap" repairs are also tension-free, although the mesh is placed within the pre-peritoneal space behind the defect as opposed to in or over it. It has no proven superiority to the open method other than a faster recovery time and a slightly lower post-operative pain score. Unlike the open method, laparoscopic surgery requires general anesthesia. It is usually more expensive and consumes more Operating Room time than open repair, carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-free repairs.

Complications of hernia repairs • • • • •

Urinary retention · Scrotal haematoma · Damage to the ileoinguinal nerve Ischaemic orchitis Recurrent hernia

Conclusion: The whole problematic dealing with indications, technical details of advantages and disadvantages of different methods is in fluent development. Except of some convincing and generally accepted indications, it is not possible today to offer an univocally valuable direction for hernial treatment, which could be presented as a surgical dogma. There is only one law valid, as in the rest of the surgery: the only criterion is the profit of the patient – if there is possible to obtain very good results using a certain method, then there is no reason for its change…