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Home , Femoral hernia, Obturator hernia

MINISTRY OF HEALTHCARE OF UKRAINE DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY

DEPARTMENT OF SURGERY #1

ABDOMINAL CLASSIFICATION. ETIOLOGY AND PATHOGENESIS. CLINICAL PRESENTATION. PRINCIPELS OF SURGICAL TREATMENT. COMPLICATIONS

Guidelines for Medical Students

LVIV – 2019

Approved at the meeting of the surgical methodological commission of Danylo Halytsky Lviv National Medical University (Meeting report № 56 on May 16, 2019)

Guidelines prepared: GERYCH Igor Dyonizovych – PhD, professor, head of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University VARYVODA Eugene Stepanovych – PhD, associate professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University STOYANOVSKY Igor Volodymyrovych – PhD, assistant professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University CHEMERYS Orest Myroslavovych – PhD, assistant professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University

Referees: ANDRYUSHCHENKO Viktor Petrovych – PhD, professor of Department of at Danylo Halytsky Lviv National Medical University OREL Yuriy Glibovych - PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University

Responsible for the issue first vice-rector on educational and pedagogical affairs at Danylo Halytsky Lviv National Medical University, corresponding member of National Academy of Medical Sciences of Ukraine, PhD, professor M.R. Gzegotsky

I. Background A hernia is an abnormal protrusion of a viscus or part of a viscus through a defect either in the containing wall of that viscus or within the cavity in which the viscus normally is situated. In abdominal , the ‘wall’ refers to the anterior and posterior muscle layers of the abdomen, the diaphragm, and the walls of the pelvis. Hernias are composed of a sac, the parts of which are described as the neck, body and fundus, and the hernial contents. The sac consists of which protrudes through the defect or ‘hernial orifice’, and envelopes the hernial contents. The neck of the sac is situated at the defect. Hernias with a narrow or rigid neck are more likely to obstruct and strangulate. The body is the widest part of the hernial sac, and the fundus is the apex or furthest extremity. Viscera most likely to enter a hernial sac are those normally situated in the region of the defect and those which are mobile, namely the omentum, and colon. Some hernial contents have been ascribed generic names.

II. Learning Objectives 1. To study the etiological factors of disease, classification of hernias, clinical signs, diagnostic methods, treatment and complications (α = I). 2. To know the main causes of the disease, typical clinical course and complications, diagnostic value of laboratory and instrumental methods of examination and the principles of the modern conservative and surgical treatment (α = II). 3. To be able to collect and analyze the complaints and disease history, thoroughly perform , determine the order of the most informative examination methods and perform their interpretation, establish clinical diagnosis, justify the indications for surgery, choose adequate method of surgical intervention (α = III). 4. To develop creativity in solving complicated clinical tasks in patients with atypical clinical course or complications of hernias (α = ІV).

III. Purpose of personality development Development of professional skills of the future specialist, study of ethical and deontological aspects of physicians job, regarding communication with patients and colleagues, development of a sense of responsibility for independent decision making. To know modern methods of treatment of patients with hernias and its complications.

IV. Interdisciplinary integration

Subject To know To be able Previous subjects

1. Anatomy and Anatomical structure, Determine the structure of Physiology innervation and of the inguinal and femoral chanels imguinal area

2. Pathomorphology Etiological factors of Describe different types of and Pathophysiology disease hernias

3. Propedeutics of Sequence of patient’s Determine the patients internal diseases survey and physical complaints, medical history examination of the of the disease, perform abdominal cavity superficial and deep palpation of the abdomen 4. Pharmacology Groups and Prescribe conservative representatives of treatment of patient with antibiotics, spasmolytics, hernias analgesics, antiinflammatory drugs, colloid and crystalloid solutions 5. Radiology Efficiency of radiological Indications and descrition of investigation in patients x-ray, ultrasound, computed with hernias tomography examination Future subjects Anesthesiology and Clinical signs urgent Determine the symptoms of Critical Care conditions that occur in urgent conditions, differential Medicine patients with diagnosis and treatment complications of hernias, methods of diagnosis and pharmacotherapy Intradisciplinary integration 1. Acute Clinical picture of acute Check Mondor’s, Grey- pancreatitis Turner’s, Cullen’s, Mayo- Robson’s signs 2. Acute Clinical picture of acute Check Ortner’s, Kehr’s, cholecystitis Merphy’s, Mussy’s signs 3. Peptic ulcer of Clinical picture of peptic Check Blumberg’s sign, stomach and ulcer of stomach and describe plain abdominal film duodenum in patient with peptic ulcer perforation 4. Acute bowel Clinical picture of acute Describe x-ray signs of acute obstruction bowel obstruction

5. Renal colic Clinical signs of renal Check Pasternasky’s sign colic

V. Content of the topic and its structuring

Classification of hernias due to International Classification of Diseases 1. (code K 40). 2. (code K 41). 3. (code K 42). 4. Abdominal wall hernia (code K 43). 5. (code K 44). 6. Other hernia of abdominal cavity (code K 45). 7. Unspecified hernia of the abdominal cavity (code K 46).

Richter’s hernia Only part of the circumference of the bowel (usually the anti-mesenteric border) is trapped within the hernial sac. The herniated part may become ischaemic. Because the lumen of the bowel is not occluded, intestinal obstruction does not occur, and there are few symptoms until the ischaemic part perforates. Littre’s hernia A Meckel’s diverticulum lies within the hernial sac. Littr´e’s hernia occurs most commonly in a femoral or inguinal hernia. Maydl’s hernia The hernial sac contains two loops of intestine. The loop of intestine within the abdominal cavity may become obstructed or strangulated, and this may not be recognised unless the hernial contents are inspected and returned to the abdominal cavity (‘reduced’) completely. Predisposing factors A hernia occurs because of (a) weakness or defect in the abdominal wall, and (b) positive intra-abdominal pressure (IAP) (which is often raised) forces the viscus into the defect. Sites of weakness in the abdominal wall Weaknesses in the abdominal wall may be: - Congenital (i.e. present at birth) – e.g. patent processus vaginalis or canal of Nuck, posterolateral or anterior parasternal diaphragmatic defect, patent umbilical ring in children. - Where a normal anatomical structure passes through the abdominal wall – e.g. oesophageal hiatus, umbilical ligament in adults, obturator foramen, sciatic foramen. - Acquired – e.g. surgical scar, site of an intestinal stoma, muscle wasting with increasing age, fatty infiltration of tissues because of obesity. Increased intra-abdominal pressure Raised intra-abdominal pressure (IAP) stretches the abdominal vertically and horizontally, thereby increasing the circumference of any defect. Also, high IAP forces abdominal contents through a defect. Sudden or sustained increases in IAP are due to several causes: - Coughing - Vomiting - Straining during urination or defecation - Pregnancy and childbirth - Occupational heavy lifting or straining, and strenuous muscular exercise - Obesity - Ascites - Continuous ambulatory (CAPD) - Gross organomegaly

COMPLICATIONS Most hernias are uncomplicated at presentation. The three important complications of hernias are, in order of progression, irreducibility, obstruction and strangulation. Irreducibility A hernia is ‘irreducible’ when the sac cannot be emptied completely of contents. Irreducibility is caused by (i) adhesions between the sac and its contents, (ii) fibrosis leading to narrowing at the neck of the sac, or (iii) a sudden increase in IAP that causes transient stretching of the neck and forceful movement into the sac of contents, which cannot subsequently return to their original location. Generally, irreducible hernias should be operated on soon after presentation. Although irreducibility is not an indication for urgent operation, it is the step before obstruction supervenes. In addition, irreducible hernias are usually painful. Obstruction A hernia becomes obstructed when the neck is sufficiently narrow to occlude the lumen of the intestine contained within the sac. Obstructed hernias are nearly always irreducible and, if not treated, may become strangulated. Often, there is a history of a sudden increase in IAP that has pushed intestine or other contents into the sac. The patient presents with symptoms and signs of intestinal obstruction (abdominal colic, vomiting, , abdominal distension), together with a tender irreducible hernia. Failure to examine the hernia orifices in a patient with intestinal obstruction may lead to the wrong operative approach being undertaken. It may be difficult to distinguish obstruction from strangulation on clinical grounds, and therefore obstructed hernias should be treated as a matter of urgency.

Strangulation Strangulation means that the blood supply of the contents has ceased due to compression at the hernial orifice. Initially, lymphatic and venous channels are obstructed, leading to oedema and venous congestion but with continued arterial inflow. When the tissue pressure equals arterial pressure, arterial flow ceases and tissue necrosis ensues. Strangulation is a serious complication and, if the intestine is involved, leads to which can be fatal. A strangulated hernia is both irreducible and obstructed, and is very tense and usually exquisitely tender. Erythema of the overlying is a late sign. Strangulated hernias must be operated on urgently. A strangulated Richter’s hernia is not preceded by intestinal obstruction and there maybe few local signs.

Inguinal hernia Inguinal hernia is the commonest hernia, and is approximately10 times more common in males than females. Two types of inguinal hernia (IH) are recognised, indirect (IIH) and direct DIH), but they can occur together. Anatomy of Inguinal Canal Several structures course within the inguinal canal and require familiarity to avoid iatrogenic injury during herniorraphy. The canal contains the spermatic cord in males and the round ligament of the uterus in females. The canal lies obliquely between the internal or deep inguinal ring, derived from transversalis fascia, and the external or superficial inguinal ring, derived from external oblique aponeurosis. The spermatic cord courses from the internal ring through the inguinal canal and exits through the external ring to join the testicle within the scrotum. The spermatic cord contains multiple structures including the superficial spermatic fascia, derived from Camper’s and Scarpa’s fascia; the external spermatic fascia, derived from external oblique muscle; a circumferential layer of cremaster muscle, derived from internal oblique muscle; the cremasteric or external spermatic artery; the internal spermatic fascia, derived from transversalis fascia; the vas deferens and arteries to the vas deferens; the testicular or internal spermatic artery, which arises from the aorta just inferior to the renal arteries; the pampiniform venous plexus, which coalesces into the testicular veins and drains into the inferior vena cava on the right and the renal vein on the left; the ilioinguinal nerve; the genital branch of the genitofemoral nerve; and sympathetic fibers from the hypogastric plexus. The inguinal canal can be defined by its borders. The inguinal canal is bound anteriorly by the external oblique aponeurosis, superiorly by internal oblique and transversus abdominis muscles and aponeuroses, and inferiorly by the inguinal and lacunar ligaments. The posterior wall or floor is formed by transversalis fascia. A defect in this layer may allow peritoneum and the contents of the abdominal cavity to herniate. Hesselbach’s triangle is formed by the laterally, the rectus sheath medially, and the inferior epigastric vessels superiorly. Indirect inguinal hernia The hernial sac of an IIH is a patent processus vaginalis, and the neck of the sac is situated at the deep inguinal ring, lateral to the inferior epigastric artery. The sac accompanies the spermatic cord along the inguinal canal towards the scrotum for a varying distance. The sac lies in front of the cord and is enclosed by the coverings of the cord. Except in children and infants, the essential cause of an IIH is (a) failure of the processus vaginalis to become completely obliterated to form the ligamentum vaginale, which normally occurs within a few days after birth, and (b) loss of integrity of the inguinal canal (see above). Even though the sac of an IIH is congenital, herniation may not occur until later in life, when there is failure of the normal mechanisms that maintain the inguinal canal. The incidence of IIH is approximately 800–1000 per million male population. Indirect IHs are approximately four times more common than DIH, occur at any time during life, and have a male to female ratio of about 10:1. Classification of indirect inguinal hernias Indirect IHs are classified according to the length of the hernial sac: - Bubonocele – the sac is confined to the inguinal canal. - Funicular – the sac extends along the length of the inguinal canal and through the superficial inguinal ring, but does not extend to the scrotum or labium majora. - Complete, scrotal or inguinoscrotal – the sac passes through the inguinal canal and superficial inguinal ring and extends into the scrotum or labium. Direct inguinal hernia A DIH protrudes directly through the posterior wall of the inguinal canal, medial to the inferior epigastric artery and deep inguinal ring. The essential fault with a DIH is weakness of the inguinal canal, and is invariably associated with poor abdominal musculature. Herniation occurs at a site where the transversalis fascia is not supported by the conjoint tendon or the transversus aponeurosis, an area known as Hesselbach’s triangle. The neck of a DIH is usually larger than the body and so strangulation is rare. The hernia passes forwards as it enlarges, stretching muscle and fascial layers. It rarely reaches a large size or approaches the scrotum. Occasionally, the inferior epigastric vessels straddle the hernia which is then known as a ‘pantaloon hernia’. Direct IH is rare in females and does not occur in children. It is more common on the right side after appendicectomy, suggesting that damage to the iliohypogastric and ilio-inguinal nerves with subsequent weakness of the internal oblique and transversus abdominis muscles is an aetiological factor. Clinical features of inguinal hernias Inguinal hernias present with inguinal discomfort, with or without a lump. Discomfort is due to stretching of the tissues of the inguinal canal and occurs typically when IAP is increased. Pain may also be referred to the testis because of pressure on the spermatic cord and ilio-inguinal nerve. Severe inguinal or abdominal suggests obstruction or strangulation. A lump is usually obvious to the patient, is often precipitated by increasing IAP, and may reduce completely with rest and lying down. The patient initially is examined standing to demonstrate the lump and possible cough impulse, and then lying down to allow the hernia to be reduced. An IIH protrudes along the line of the inguinal canal for a variable distance towards the scrotum or labia; a DIH appears as a diffuse bulge at the medial end of the inguinal canal. The significance of a ‘cough impulse’, or sudden bulging of the inguinal region with coughing, must be interpreted carefully. A generalised weakness in the inguinal region will result in a diffuse bulge appearing with coughing, but this condition (known as a Malgaigne’s bulge) is not the same as a hernia in which the cough impulse is discrete and confined to the area of herniation. Abdominal examination is performed to detect organomegaly, a mass or ascites. Indirect or direct inguinal hernia? An IIH is prevented from appearing by applying pressure over the deep inguinal ring (which lies just above the midpoint of the inguinal ligament) because an IIH protrudes through the deep inguinal ring. A DIH protrudes through the posterior wall of the inguinal canal medial to the deep ring. IIH and DIH may be distinguished by firstly reducing the hernia by gently it upwards and laterally. Then, the index and middle fingers are placed firmly over the surface marking of the deep ring and the patient is asked to cough. If the hernia is controlled by pressure over the deep ring, then it is presumed to be indirect. If the hernia appears medial to the examiner’s two fingers, then it is direct. Accurate distinction of an IIH from a DIH may not possible because of slight variation in the position of the deep inguinal ring. However, an attempt should made to distinguish between the two because IIHs are more likely to complications and should be repaired sooner rather than later. Sliding inguinal hernia A sliding inguinal hernia is a variant in which part of a viscus (usually the colon) is adherent to the outside of the peritoneum forming the hernial sac beyond the hernial orifice. Thus, the viscus and the hernia sac, which may contain another abdominal viscus, lie within the inguinal canal. Sliding hernias are more common on the left side (where they contain part of the sigmoid colon) than on the right (where they contain part of the caecum). Sliding hernias occasionally contain part of the bladder or an ovary and ovarian tube. A sliding hernia may be indirect or direct. They are nearly always found in males. A sliding hernia should be suspected if the neck of the hernia is bulky, or if the hernial sac does not separate easily from the cord at operation.

REPAIRS Anterior approaches The goal of all repairs is to close the myofascial defect through which the hernia protrudes. This closure can be done from a number of approaches with or without placement of a prosthetic mesh. The classic tissue repairs use permanent suture to reinforce the internal inguinal ring and the floor of the inguinal canal and do not employ the use of a prosthesis. These techniques include the Marcy, Bassini, Shouldice, and McVayrepairs. The Lichtenstein repair uses prosthetic mesh, as does the plug technique. Common to all these methods is the anterior dissection of the inguinal canal and hernia sac, followed by a myofascial repair, and closure of the canal. The basic technique of inguinal canal and sac dissection is the same for all anterior approaches, whereas the repair of the myofascial defect differs. After incising and dividing the layers of the anterior abdominal wall to expose the inguinal canal, the spermatic cord is isolated at the level of the pubic tubercle, and mobilized to the level of the internal ring. The cord is then dissected by dividing cremasteric muscle fibers to identify an indirect sac, if present. The sac is usually found on the anteromedial side of the cord. The sac is opened and its contents reduced back into the abdominal cavity. The sac is ligated at its base with a pursestring suture and amputated. If an indirect sac extends inferiorly beyond the pubic tubercle, the distal sac should simply be divided and left open. If a direct hernia sac is identified, it generally should not be operated but should be reduced bluntly back into the abdominal cavity and imbricated with one or more sutures placed superficially in the transversalis fascia. This maneuver effectively avoids injury to any organs such as the colon or bladder, which may form a sliding component in a direct hernia. Marcy repair The Marcy repair refers to a high ligation of the sac and closure of the internal inguinal ring along its medial aspect, displacing the cord laterally. This technique can be used only to repair indirect inguinal hernias, and its main utility is in pediatric patients or in adults (especially women) with a small indirect hernia and minimal damage to the internal ring. Patients with a direct inguinal hernia require the addition of another type of repair. Bassini repair After a complete and deliberate dissection of the inguinal canal, the floor is reconstructed by approximating the internal oblique muscle, the transversus abdominis muscle, and the transversalis fascia (the Bassini triple layer) with the iliopubic tract and shelving edge of the inguinal ligament using interrupted sutures. This repair may be used for both indirect and direct inguinal hernias. Shouldice repair This technique is remarkably similar to the Bassini operation in that the layers approximated to reconstruct the inguinal canal floor are the same for both. However, the Shouldice technique uses a series of running sutures to imbricate the reconstruction into several layers. As in the Bassini operation, the cord is mobilized, the cremaster muscle is divided, a high ligation of the sac is performed, and the transversalis fascia forming the floor of the inguinal canal is incised. The floor is reconstructed by placing a series of running sutures to approximate the lateral edge of the rectus abdominis muscle near the pubic tubercle, the internal oblique muscle, the transverses abdominis muscle, and the transversalis fascia to the iliopubic tract and the shelving edge of the inguinal ligament. McVay (Cooper’s Ligament) repair The McVay repair approximates the transversus abdominis arch to Cooper’s ligament, the iliopubic tract, and the inguinal ligament. The McVay repair may be used for inguinal and femoral hernias. Lichtenstein repair The Lichtenstein approach is a tension-free method that uses prosthetic mesh to reinforce the transversalis fascia forming the canal floor without attempting to use any attenuated native tissues in the repair .Polypropylene mesh is trimmed to extend 4 cm lateral to the internal ring and 2 cm medial to the public tubercle, and is then secured to the inguinal ligament laterally and the lateral edge of the rectus sheath and internal oblique muscle and aponeurosis medially using permanent monofilament suture. Local anesthesia maybe used, and several studies have shown that this repair enables a quicker return to work, is associated with less postoperative pain, and has fewer recurrences than tissue repairs. The Lichtenstein repair may be used for direct and indirect inguinal hernias but does not address femoral hernias. Given the results of several studies which have compared the tension-free to classical tissue repair techniques, the Lichtenstein repair has reshaped the way surgeons perform hernia recurrence rates dramatically. It has also reversed the notion that bilateral hernias should not be repaired simultaneously. The short- and long-term recurrence rates seem better than the results previously achieved with tissue repairs. The procedure is readily reproducible by those who do not specialize in , with comparable excellent results. Mesh Plug repair A variety of techniques have been developed that use a polypropylene mesh plug to fill the hernia defect and effect a repair. These techniques are championed as tension free and are becoming quite popular in combination with a mesh patch repair. There may be particular utility in using this approach for recurrent hernias, as remobilization of the cord may be avoided, which may decrease the risk of ischemic orchitis. Open preperitoneal approach Nyhus introduced the open preperitoneal repair in 1960. He has championed this method for the repair of all recurrent and complicated groin hernias, namely those involving incarcerated or strangulated intestine, as well as for femoral hernias. For the recurrent hernia, densely scarred tissue in the inguinal canal is avoided, possibly reducing the risk of nerve injury and cord damage. In strangulated hernias, proximal unaffected intestine can be controlled and necrotic intestine may be isolated before its reduction. The peritoneal cavity can be opened to perform an intestinal resection and anastomosis. Sliding hernias can also be readily reduced. For femoral hernias, ample access is afforded to reduce and repair the hernia without disturbing the floor of the inguinal canal, which is necessitated by anterior approaches. Preperitoneal repairs can be performed both with and without mesh. Although the use of mesh provides lower recurrence rates, contamination may preclude its use if is necessary. Giant prosthetic reinforcement of the visceral sac (GPRVS OR STOPPA) repair Placing a giant prosthetic reinforcement of the visceral sac in the preperitoneal space using a large sheet of unsutured polyester mesh, is commonly referred to as the Stoppa repair. In contrast to other approaches, no attempt is made at repairing the musculofascial defect creating the hernia. Instead, the transversalis fascia is functionally replaced by the insertion of a large chevron-shaped piece of mesh into the preperitoneal space after all hernias have been reduced. The transverse dimension of the mesh is equal to the distance between both anterior superior iliac spines minus 2cm. The height is the distance between the umbilicus and the pubis with an average mesh size of 24 - 16 cm. By adhering to the visceral sac, the mesh renders the peritoneum indistensible so that it cannot protrude through any abdominal wall defects. The Stoppa repair can be very useful in complex hernias including recurrent and bilateral hernias, and hernias at high risk for recurrence such as in patients with connective tissue disorders, ascites, obesity, or advanced age. The Stoppa repair is contraindicated if contamination is present because the risk of prosthetic infection is high. Laparoscopic approaches Since its introduction, three techniques of laparoscopic repair have proved more effective and emerged as the most popular. These techniques are the transabdominal preperitoneal (TAPP), the intraperitoneal onlay mesh (IPOM), and the totally extraperitoneal (TEP). These repairs approach the myopectineal orifice posteriorly, similar in anatomical perspective to the open preperitoneal approaches. A clear understanding of the anatomy from this perspective is crucial to avoid a number of complications, mainly vascular and nerve injuries. provides a clear view of the entire myopectineal orifice, and repairs of both inguinal and femoral hernias can be performed. In the TAPP procedure, three trocars are placed through the abdominal wall into the peritoneal cavity after a has been created. The peritoneum cephalad to the groin is then transversely incised from the median umbilical fold to several centimeters lateral to the internal ring, taking care not to injure the underlying inferior epigastric vessels. The hernia is reduced using blunt dissection and gentle traction. The vas deferens and testicular vessels are parietalized by carefully freeing them from their proximal and lateral peritoneal attachments. The inferior epigastric vessels are defined but not completely skeletonized, which can lead to bleeding. A large piece of polypropylene mesh (at least 10 -15 cm) is then placed over the entire myopectineal orifice with generous overlap of its borders, and secured in place with helical fasteners or staples. The fasteners are applied medially into the rectus muscle, superiorly to the transversus abdominis arch, inferiorly to Cooper’s ligament up to the medial aspect of the external iliac vein, and laterally to the iliopubic tract. The peritoneum is reapproximated using staples or sutures. Care must be taken to completely close the peritoneum without leaving gaps that can allow small-bowel entrapment or adherence to the mesh. The IPOM repair uses an intraabdominal approach and places a large piece of mesh against the peritoneum after hernia contents have been reduced. The mesh is secured with staples placed into the same anatomical structures as in the TAPP repair but is placed in an intraperitoneal position instead of a preperitoneal position. The TEP technique gains access to the groin via a completely extraperitoneal approach. A small infraumbilical incision is made and carried down through the anterior rectus sheath. The rectus muscle is retracted away from the midline and the anterior surface of the posterior rectus sheath is clearly visualized. A balloon dissector is placed along this surface, advanced inferiorly to the pubic bone, and inflated with air or saline, creating a working space between the peritoneum and the abdominal wall. After the preperitoneal working space has been developed, a cannula is inserted and the preperitoneal space is insufflated. Two additional trocars are placed in the midline under direct visualization without violation of the peritoneum. The hernia is reduced using blunt dissection and gentle traction. The remainder of the operation, including the dissection of the myopectineal orifice, parietalization of the cord and testicular vessels, and mesh placement, is identical to the TAPP procedure. Many of the data support laparoscopic repairs as being effective and safe. Although many of the earlier trials had short follow-up, several of the more recent trials provide encouraging results, showing recurrence rates of 0% to 6% at follow-up as long as 28 months (mean).The incidence of complications associated with laparoscopic repairs is comparable to or better than that of open repairs, especially after the learning curve has been overcome. Almost all the trials show that laparoscopic repairs are associated with less postoperative pain and a decreased time for return to work, but take longer to perform and cost more than conventional open repairs. A large, prospective, randomized VA trial is currently under way to further compare TEP, TAPP, and Lichtenstein repairs.

Femoral hernia A femoral hernia occurs when the transversalis fascia which normally covers the is disrupted, so that a peritoneal sac and hernial contents pass through femoral ring into the . The femoral canal is the most medial compartment of the femoral sheath, medial to the femoral vein. Femoral hernias are2–3 times more common in females than males, and occur in the older age group, often after a period of weight loss. Femoral hernias are never congenital, and are twice as common in parous as in non-parous females. Inguinal hernias are more common than femoral hernias in females. Approximately 60% of femoral hernias are on the right, 30% on the left, and 10% bilateral. A femoral hernia is the commonest site for a Richter’s hernia. Factors in femoral hernia formation are: - localised weakness at the femoral ring. - factors which increase intra-abdominal pressure. Femoral canal A femoral hernia is a visceral protrusion through the femoral ring, which is bounded laterally by the femoral vein, anteriorly by the inguinal ligament, medially by the , and posteriorly by Cooper’s ligament. The femoral canal represents an extension of the femoral ring for approximately 2 cm inferiorly into the thigh. The femoral sheath is derived from transversalis fascia and contains the femoral artery, vein, and canal. The femoral triangle is bounded by the inguinal ligament, the sartorius muscle, and the adductor longus muscle and contains, from lateral to medial, the femoral nerve, artery, vein, “empty” space (femoral canal), and lymphatics (hence the pneumonic NAVEL). Clinical presentation A femoral hernia presents as either discomfort in the groin together with a lump, or as intestinal obstruction with or without strangulation. A small hernia may be difficult to palpate, especially in the obese patient. The hernia is frequently irreducible and may not have a cough impulse. On examination, the bulge of a femoral hernia appears in the region of the . The neck of the sac is always located below the line of the inguinal ligament, even though the fundus may appear be above the ligament. This is because once within the femoral canal, the hernial sac is prevented from continuing inferiorly down the thigh with the femoral vessels because the femoral sheath (which encloses the femoral vessels and the femoral canal) becomes narrow and tapers to a point around the vessels. The hernia is therefore directed forwards through the fossa ovalis, and is quite superficial at this point. It cannot continue down the thigh in a subcutaneous plane because the superficial fascia of the thigh is attached to the lower border of the fossa ovalis and is firmer than the superficial fascia above the level of the foramen ovalis. As the hernia enlarges, it turns upwards into the looser areolar tissue beneath the skin of the groin crease and may be confused with an inguinal he rnia. Thus, the direction taken by a femoral hernia is initially downwards through the femoral canal, then forwards through the fossa ovalis, and then upwards in the loose areolar tissue of the upper thigh. Therefore, in attempting to reduce the hernia, pressure is applied in the reverse order, that is, initially downwards, backwards and then upwards. Femoral repairs Femoral hernias are much less common than inguinal hernias, but are more often associated with complicated presentations, with a 20% incidence of incarceration. Some authors have suggested that the ideal way to repair femoral hernias is via a preperitoneal approach, either open or laparoscopic. This method facilitates control of hernia contents, avoids the disruption of the inguinal floor mandated by an anterior approach, and avoids the difficulty associated with approaching a femoral hernia through a thigh incision. The McVay repair has been used, however, with successful results.54 Strangulated femoral hernias require proximal control, resection, and anastomosis of intestine and may best be approached through a preperitoneal incision or a midline .

Abdominal Wall Defects Ventral Hernias Approximately 90,000 ventral hernias are repaired in the United States each year. Important to remember is the anatomical structure of the anterior abdominal wall, which above the semilunar line of Douglas consists of skin, subcutaneous fat, anterior rectus sheath, rectus muscle, posterior rectus sheath, and peritoneum. Below the semilunar line, the layers are the same except that there is no posterior rectus sheath. Laterally, the layers are skin, subcutaneous fat, external oblique aponeurosis and muscle, internal oblique aponeurosis and muscle, transversus abdominis aponeurosis and muscle, transversalis fascia, and peritoneum. A ventral hernia is a defect in the abdominal wall. Ventral hernias present as a protrusion or bulge and may contain preperitoneal fat or intestinal contents. The size may range from very small to massive. Patients may or may not be symptomatic. The fascial edge along the circumference of the defect is usually palpable on exam. In obese patients, a CT scan or ultrasound examination may help confirm the diagnosis. As with groin hernias, ventral hernias may present with incarceration, strangulation, or bowel obstruction; elective repair is preferred to emergent repair. Umbilical hernias are caused by an error in the embryological development of the abdominal wall. Umbilical hernias occur in 10% to 30% of live births, but frequently close during the first few years of life. If larger than 2 cm, the likelihood of the defect spontaneously closing is much less, and repair is not delayed. Otherwise, repair is usually postponed until the child reaches 4 years of age to allow time for spontaneous closure. Most infants are asymptomatic, and incarceration or strangulation is extremely rare. Repair consists of simple fascial closure. Defects may persist, become evident in adulthood, and should be repaired. Epigastric hernias arise in the upper abdomen along the linea alba, and usually appears in adulthood, often in association with obesity or pregnancy. Epigastric hernias frequently present as small defects with incarcerated preperitoneal fator omentum, causing pain and warranting repair. Diastasis recti is a condition in which the medial borders of the rectus muscles slowly spread apart with thinning and stretching of the rectus sheath, resulting in a diffuse bulge in the upper midline abdomen. In contrast to epigastric hernias, diastasis recti is not a fascial defect or hernia per se, and consequently presents no threat of complication; diastasis recti is merely a cosmetic deformity. Excision of the thinned fascia and placement of a mesh prosthesis alleviate the deformity. Incisional hernias occur in at least 2% to 11% of abdominal wound closures. Many risk factors for developing an have been cited, including obesity, wound infection, advanced age, postoperative pulmonary complications, jaundice, abdominal distension, emergency operation, reuse of a previous incision, pregnancy, postoperative chemotherapy, steroids, malnutrition, ascites, and peritoneal dialysis. Most of these risk factors are associated with excessive strain on the incision or poor wound healing. Wound infection is the most important risk factor, with hernias four times more likely to occur after a wound infection. Obesity has also been clearly established as a risk factor. Reuse of an incision has been shown to double the incidence of subsequent incisional hernias. Suture technique has been extensively studied, with no difference in hernia incidence shown between continuous and interrupted suture techniques, or layered versus mass wound closure. Repair Techniques A variety of repair methods exists and a prosthetic mesh mayor may not be used. In open repairs, the hernia is approached through a skin incision placed directly over the fascial defect, usually incorporating the scar from the previous incision. The sac is dissected free from subcutaneous tissues and the fascial edges. The sac may be opened to facilitate lysis of adhesions and inspection and reduction of sac contents. If possible, the sac is not completely excised, so that there is a sufficient amount of sac to close over the intestinal contents. This method provides protection against adhesive complications if mesh is to be used in the repair. The superficial and deep surfaces of the fascia are exposed several centimeters back from the hernia defect. Attenuated fascia is excised. A thorough search for concomitant hernias is performed. Depending on the type of repair, fascia may then be closed with or without placing a mesh buttress. Fascia should only be closed when it can be done so without tension. Closed suction drains may be placed in the dead space superficial to the fascia to minimize seroma formation. Primary repair Ventral hernias may be repaired by primary closure so long as the repair can be performed in a tension-free fashion. The direction of closure is not important. Primary closure is the preferred technique for umbilical hernias in children and some small epigastric or umbilical hernias in adults. Permanent suture is used and the fascial edges are approximated. Unfortunately, the results of primary repair in all but the smallest of incisional hernias are poor, with failure rates as high as 49% to 58%; this is likely because patients with incisional hernias have fascia that is weakened and that does not have sufficient tensile strength to hold sutures when placed under mechanical stress.

Mesh onlay repair Significantly better results have been reliably achieved with mesh repairs, with rates of complications comparable to that of primary repairs. Recurrence rates average 6% for mesh repairs. In the mesh onlay technique, a mesh prosthesis is placed superficial to the anterior rectus sheath. The mesh is then held in place by full- thickness horizontal mattress sutures. Ideally, this method allows for a barrier between the abdominal contents and the mesh to prevent adhesions and fistula formation. Mesh inlay and patch repairs The inlay method of repair places a prosthetic mesh deep to the posterior rectus fascia. The mesh is placed in either an intraperitoneal or a preperitoneal position. Mattress sutures are placed from the deep aspect of the mesh through the abdominal wall. Once all sutures have been placed, they are tied on the anterior fascial surface. The patch method simply sutures the prosthesis to the fascial edge circumferentially. With either the inlay or patch technique, if the prosthesis is placed in an intraperitoneal position or, if no tissue can be interposed between bowel and the prosthesis, the potential for adhesions and fistulization is created. Stoppa repair Stoppa and Wantz have both described the use of a giant Mersilene mesh prosthesis in the repair of large (>10 cm) incisional hernias. This approach is similar to the inlay method but overlaps the defect by 8 to 10 cm and avoids raising extensive subcutaneous flaps by passing sutures through separate stab incisions. The hernia is reduced, and adhesiolysis is performed to widely expose the deep surface of the abdominal wall. Peritoneum is dissected free from the posterior rectus sheath, and the mesh is inserted in the preperitoneal space. Alternatively, the mesh may be inserted between the posterior rectus sheath and the rectus muscle. Before mesh insertion, the peritoneum, hernia sac, or posterior rectus sheath is closed to prevent contact between abdominal contents and mesh, to minimize potential adhesive complications. Laparoscopic repair Laparoscopy has recently gained momentum in the area of ventral hernias. Most reports describe a transabdominal approach, placing several trocars in an intraperitoneal position, reducing the hernia through sharp adhesiolysis and blunt manipulation, leaving the hernia sac in situ, and using a mesh prosthesis to close the defect. Mesh is sized externally to provide at least 2 cm of overlap on all sides of the defect. A suture is placed through each corner and tied, with tails left long. The skin is marked at the sites where the four corner sutures will exit, and small stab incisions are made. Mesh is then rolled and passed intraabdominally through a port, unfolded, and positioned over the defect. A fascial closure device is passed through the skin stab incision and used to individually retrieve the tails of each corner suture. The tails are tied superficial to fascia in a subcutaneous position. Hernia staples or helical fasteners are used to secure the mesh to peritoneum and fascia, preventing herniation of bowel or omentum between the mesh and the abdominal wall. Although randomized controlled trials are lacking, preliminary reports suggest that this approach is safe and effective, and may offer a shortened postoperative course and faster resumption of normal activities, compared to the conventional open approaches. Emergency Abdominal Wall Defects Abdominal wall closure can be difficult and morbid in the emergency setting. Emergency closures are often required in the face of vigorous resuscitation with massive tissue edema or in the case of tissue loss secondary to trauma, surgical debridement for necrotizing infections, or resection of tumors. Such wounds may be heavily contaminated, and postoperative wound sepsis is common. Primary fascial approximation may create a closure under tension and result in abdominal compartment syndrome, dehiscence, evisceration, or fistula formation. A prosthetic repair provides tension-free closure and is effective in alleviating evisceration and restoring abdominal wall continuity in the acute phase. Prosthetic repairs, however, can be fraught with long-term complications, such as mesh extrusion or enteric fistulas. The use of absorbable mesh provides a lower incidence of fistulization and wound complications but universally leads to ventral hernias, which must be cared for at a later date. The proponents of absorbable mesh note that it is effective in closing acute abdominal wall defects that are contaminated. Unlike permanent mesh, absorbable mesh does not chronically harbor infection; this allows complete clearance of infection before definitive ventral hernia repair, providing a better chance of a successful repair. It also provides no residual foreign body to complicate wound management should a fistula form. The ideal method of preventing acute evisceration and long-term ventral hernia formation in acute full-thickness abdominal wall defects in the face of contamination has yet to be determined. Much of the evidence supports the use of absorbable mesh with planned definitive ventral hernia repair at a later date. A protocol using permanent or absorbable mesh with early mesh removal, wound coverage, and planned ventral hernia repair yields good results as well but requires an additional operation for mesh removal.

Other Abdominal Hernias Spigelian hernias are rare. A Spigelian hernia occurs through the transversus abdominis aponeurosis of the anterior abdominal wall, usually below the level of the umbilicus. The vertical curved line at which the transverse abdominis muscle becomes an aponeurosis is the semilunar line, and it extends from the costal margin to the pubic tubercle. The transversus abdominis aponeurosis extends medially from the semilunar line to the lateral edge of the rectus sheath. A Spigelian hernia usually occurs at the widest and weakest point of the aponeurosis, which is about halfway between the umbilicus and the inguinal ligament. Clinically, the diagnosis of a Spigelian hernia may be difficult. The patient, who typically is a middle-aged female, presents with diffuse aching pain in the area of the hernia, which is small and may not be palpable. Pain is often present during the day but may recede at night if the hernia reduces, and may be made worse by raising the arm on the affected side. If a lump is not palpable, the diagnosis may be confirmed by ultrasound or computed tomography scanning. The hernia usually contains omentum but may contain small or large bowel. A Richter’s hernia may occur, and obstruction strangulation are well-recognised complications. Treatment Spigelian hernias should be treated surgically because of the severity of symptoms and the risk of complications. A skin crease incision is made over the hernia, the sac is excised and the defect in the transversus abdominis aponeurosis is closed with non-absorbable sutures. Lumbar hernias Lumbar hernias are rare. They occur typically in individuals with poor muscle tone, either spontaneously, or following trauma, surgery, or paralysis of paravertebral muscles secondary to poliomyelitis. Differential diagnosis includes a lipoma, lumbar abscess or haematoma. Lumbar hernias occur through two triangular sites of weakness in the lumbar region of the abdominal wall: - Inferior lumbar triangle hernia (triangle of Petit) –herniation occurs between the iliac crest inferiorly, the posterior edge of external oblique muscle anteriorly, and the anterior edge of latissimus dorsi posteriorly. The ‘floor’ of the triangle through which the hernia protrudes is formed by the internal oblique and transversus abdominis muscles. - Superior lumbar triangle (triangle of Grynfeltt–Lesshaft) – the hernia occurs between the lower most edge of serratus posterior inferior muscle and the twelfth rib superiorly, the anterior border of internal oblique muscle anteriorly, and the lateral edge of erector spinae muscle medially. Grynfeltt’s triangle lies superior to Petit’s triangle, and the ‘floor’ is formed by the quadratus lumborum muscle. The hernia is covered by the latissimus dorsi. Treatment Treatment of lumbar hernias is difficult because of their anatomical boundaries, their size, the type of patient in whom they occur, and because they are bounded in part by muscle rather than tough aponeurotic tissue. Prosthetic mesh repair is required.

Obturator hernia An is rare. It protrudes through the obturator canal or foramen, which is a normal anatomical structure between the obturator groove on the inferior aspect of the superior pubic ramus and superior border of the obturator membrane. The obturator canal carries the obturator nerve and vessels. When large, the hernial sac passes between the pectineus and adductor longus muscles and protrudes forwards to produce a diffuse bulge in the femoral triangle, where it can be mistaken for a femoral hernia. It is more common on the right side. The hernia occurs most often in elderly females, particularly in those who have become debilitated and lost weight rapidly. Usually, the patient presents with intestinal obstruction of unknown cause, and the hernia is diagnosed at laparotomy. Patients may complain of diffuse pain in the groin together with pain in the medial side of the thigh and knee because of pressure on the obturator nerve. The hernia may be felt in the femoral triangle and also on vaginal examination. A Richter’s hernia may occur with strangulation of the entrapped part of the intestinal wall.

Treatment Laparotomy is performed and the entrapped segment of bowel is released. The hernial defect is often found to be small. Care is taken not to damage the obturator nerve when either closing the defect or covering it with prosthetic mesh.

Sciatic hernias Sciatic hernias are very rare and occur when a peritoneal sac enters the greater (gluteal hernia) or lesser sciatic foramina. Pain caused by pressure on the sciatic nerve or a palpable swelling and tenderness in the buttock suggests the diagnosis. Most commonly, sciatic hernias are discovered at laparotomy for intestinal obstruction. The sac is excised, but attempts to close the defect run the risk of sciatic nerve damage.

Pelvic floor hernias hernias include (in decreasing frequency) obturator, perineal, and sciatic hernias. Obturator hernias occur when abdominal contents herniate through the obturator canal along the course of the obturator neurovascular bundle. The obturator membrane, which covers the obturator foramen and forms the canal, is indistensible, and herniated bowel often becomes incarcerated and strangulated. These hernias are most often seen in emaciated females in their eighth decade, almost always occurring on the right side. A preoperative diagnosis is difficult and infrequently made. Patients usually present with partial or complete acute small bowel obstruction without a palpable hernia. Rarely a mass may be palpable on the anteromedial aspect of the thigh or on pelvic and rectal examinations. Computed tomography or abdominopelvic ultrasound scanning can confirm the diagnosis. Exploration may be carried out via a number of incisions, but a lower midline provides the best exposure for resecting compromised bowel and adequate repair of the hernia defect. The defect may be closed primarily, with mesh, or by advancing adductor longus muscle flap. Recently success has also been reported using laparoscopic approaches. Even with appropriate operative treatment, mortality rates may be as high as 75% because of the advanced age and debilitated states of most patients and delays in diagnosis. Therefore, prompt treatment should be rendered. Perineal hernias may occur spontaneously or as incisional hernias after procedures such as abdominoperineal resections or pelvic exenterations. These hernias occur anteriorly in women, involving the urogenital diaphragm and passing into the labia majora. Posterior perineal hernias are defects in the levator ani muscles that occur in the ischiorectal fossa between the bladder and the . Patients present with soft reducible masses. A primary repair or a repair with mesh may be performed through either a perineal or an abdominal approach. Sciatic hernias, the rarest of all hernias, occur in the greater or lesser sciatic foramen through a defect in the piriformis muscle. Patients may be symptomatic with sciatic nerve palsy and a palpable mass, or may simply present with intestinal obstruction. Repair can be performed via a gluteal approach or a transabdominal approach.

Parastomal Parastomal hernias occur through defects adjacent to ostomy sites. The incidence of paracolostomy hernias is 12% to 32%, and for paraileostomy hernias is less than 10%. Construction of the ostomy through an appropriately small fascial defect in the rectus sheath and not maturing the ostomy through the laparotomy incision decrease the risk of subsequent hernia formation. The majority of patients are asymptomatic. Patients may, however, present with obstruction, incarceration, a poorly fitting appliance, or local pain, warranting repair. Options include primary fascial repair, prosthetic fascial repair, or stomal relocation. Local procedures pose an infectious risk if a prosthetic is used, but avoid a laparotomy and potentially extensive adhesiolysis. On the other hand, formal laparotomy alleviates ostomy contamination of prosthetic material and provides access for repair or relocation. No prospective randomized trials have been performed to date. Because parastomal hernias are generally well tolerated and all types of repair are associated with significant morbidity and high recurrence rates, repair should be avoided if possible.

INTERNAL HERNIAS Internal hernias occur when intraperitoneal contents prolapsed through a normal or abnormal orifice. Normally existing orifices include the foramen of Winslow (known as the hernia of Blandin). Abnormally existing orifices are congenital peritoneal fossae and include left and right paraduodenal, pericecal, intersigmoid, paravascular, supravesicular, and hernias inside the broad ligament of the uterus. These hernias account for up to 2% of all abdominal hernias. Patients present with a closed-loop intestinal obstruction, and diagnosis is usually made at the time of operation. The operation involves reduction of incarcerated bowel, resection of nonviable segments, and primary closure of the hernia orifice. Internal hernias may also be iatrogenic, occurring after a previous operation in which a defect in mesentery or omentum was not adequately closed. If such a hernia occurs, reduction and closure are necessary at laparotomy. Congenital abdominal wall defects Gastroschisis refers to herniation of the abdominal viscera without a sac and in the presence of an intact umbilical cord. It is now thought to be a separate entity from omphalocele. It is twice as common as omphalocele but associated with half as many anomalies. The most common associated anomaly is intestinal atresia, which is present in 10% of cases. The eviscerated intestine is edematous, matted with fibrinous adhesions, and shortened, resulting in intestinal absorptive and motility dysfunction. Repair can be performed by primary fascial closure or a staged procedure with closure of skin followed by subsequent fascial closure. Gentle stretching of the abdominal wall can enlarge the abdominal cavity and help facilitate repair. If visceroabdominal disproportion is severe, the eviscerated intestine is enclosed within a prosthetic silo attached at its base to the abdominal wall. As the edema diminishes, sequential compression of the top of the silo returns the herniated contents into the abdomen and allows fascial closure. Mortality is less than 10%. Omphalocele refers to herniation of the abdominal viscera into the umbilical cord, resulting in a sac lined internally by peritoneum and externally by amnion. Structural and chromosomal anomalies are present in up to 50% of cases. Repair of the abdominal defect can be performed similar to the methods used for gastroschisis. The severity of associated anomalies largely determines long-term survival. Congenital diaphragmatic hernias Congenital diaphragmatic hernias occur in 1 of every 2100pregnancies (including spontaneously aborted pregnancies)and 1 of every 4800 live births.91 They can be characterized by their location. Bochdalek’s hernias are located posterolaterally and Morgagni hernias are located anteriorly. Bochdalek’s hernias occur between the costal and spinal diaphragmatic attachments and account for the majority of congenital diaphragmatic hernias. Nonrotation of the intestine is usually associated with the defect. Hernia contents are enclosed within a sac in only 10% to 20% of cases. Because abdominal contents occupy the thoracic cavity during fetal development, pulmonary hypoplasia can be severe. Mortality rates are as high as 80% in the first month of life. Repair is via an abdominal approach and consists of reduction of hernia contents, sac excision, primary or prosthetic (usually PTFE) diaphragm repair, and a Ladd procedure. Occasionally, Bochdalek’s hernias may be diagnosed in older children exhibiting only mild symptoms. Elective repair is indicated to avoid potential complications. Morgagni hernias occur between the sternal and costal diaphragmatic attachments in a retrosternal or parasternal position. Associated cardiac anomalies are frequent. Contents are usually enclosed within a sac, and 90% of hernias are right- sided. In infants, respiratory distress is usually present. When discovered in adults, symptoms are often mild or absent. Repair is indicated in all cases to prevent incarceration. The repair can be performed via an abdominal or thoracic approach, similar to the repair of Bochdalek’s hernias. Recently, success in adult patients has been reported using laparoscopic approaches.

VI. Plan and structure of class

Learning Main stages of the objective in Methods of Time class, their # the levels teaching and Guidelines distributi function and of control on meaning mastering Preliminary stage 1. Arrangements 5 min. 2. Determining the 1. Relevance 5 min. relevance, 2. Educ. objectives educational objectives and motivation 3. Control of the 45 min. intput level of knowledge, skills and abilities: 1. Etiology and І Survey Questions pathogenesis 2. Clinical signs ІІ Survey, tests Questions, II level MCQs 3. Diagnosis ІІ Clinical Typical clinical cases, MCQs cases, II level MCQ 4. Treatment ІІ Clinical Typical clinical cases, MCQs cases, II level MCQ Main stage 4. Formation of ІІІ 95 min. students professional skills: 1. Master the skills Practical Patients with of the physical training hernia examination 2. Perform Practical Patients with physical training hernia, patients examination of cards the patient with hernia 3. Plan the patients laboratory and Practical Clinical cases, III instrumental training level MCQs examinations 4. Differential diagnosis Practical Diagnostic training algorithms, atypical clinical 5. Treatment cases schemes Practical Typical and training atypical clinical cases Final stage 5. Correction of the ІІІ Personal Clinical cases and 30 min. professional skills skills III level MCQs and abilities control, analysis and evaluation of the results of clinical work, clinical cases, level III MCQs

6. Summarizing class Results of patients examination, MCQs and clinical cases solutions 7. Homework Oriented card for (recommendation independent work of basic and with literature additional literature)

VII. Materials for classes

Questions (α =І, α =ІІ) 1. Etiology and pathogenesis of different types of hernias. 2. Classification of hernias. 3. Clinical signs of hernias. 4. Laboratory diagnosis of hernias. 5. Features of the clinical course of hernias in children and women. 6. Role of localization procedures in diagnosing of hernias. 7. Differential diagnosis of hernias. 8. Treatment of hernias. 9. Complications of hernias.

MCQs (α =ІІ) The commonest type of hernia is: A. Inguinal B. Femoral C. Epigastric D. Incisional E. Umbilical Correct answer: A.

2. The most serious and urgent complication of a hernia is: A. Pressure on the spermatic cord B. Irreducibility C. Obstruction D. Strangulation E. Neuralgia Correct answer: B.

3. Indirect inguinal hernias: A. Can hardly ever be distinguished from direct inguinal hernias by clinical examination B. Rarely occur in children C. Can be treated by herniotomy, herniorraphy and hernioplasty D. Should not be treated laparoscopically E. Arise beneath the inguinal ligament Correct answer: B.

4. Femoral hernias: A. May occasionally appear above the inguinal ligament in young children B. Should always be repaired surgically C. Can be treated with a surgical truss D. Are caused by a defect in the cribriform fascia E. May compress the femoral artery Correct answer: D.

5. Which of the following structures would be encountered during repair of an inguinal hernia in a male? A. Spermatic cord; B. Round ligament; C. Obturator nerve; D. Symphysis pubis E. Nerve to the adductor muscles of the thigh. Correct answer: A.

Typical clinical cases (α =ІІ)

1. A 58-year-old man presents with a right inguinal mass that has enlarged and has caused discomfort in recent months. The swelling, which does not extend to the scrotum, reduces when resting. What is the likely diagnosis? Answer: Strangulated indirect inguinal hernia

2. A 21-year-old professional football player has sudden pain and swelling in the right groin when attempting to intercept a pass. He is admitted to the local emergency department. On examination, there is a tender swelling in the right groin. The scrotum and penis show no abnormality. What is the next step in management? Answer: Preoperative preparation and exploration of the groin with hernia repair

Atypical clinical case (α =ІIІ)

1. At surgery for a right inguinal hernia, a 54-year-old man is found to have a hernia sac that is not independent of the bowel wall. The cecum forms part of the wall of the sac. Such a hernia is properly referred to as which of the following? Answer: Sliding hernia

Literature 1. Hurst RD, Butler BN, Soybel DI, et al. Management of groin hernias in patients with ascites. Ann Surg 1992;216:696–700. 2. Liem MSL, Van Der Graff Y, Van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541–1547. 3. Rutkow IM, Robbins AW. Demographic, classificatory, and socioeconomic aspects of hernia repair in the United States. SurgClin North Am 1993;73:413–426. 4. Nyhus LM. Individualization of hernia repair: a new era. Surgery(St. Louis) 1993;114:1–2. 5. Kark AE, Kurzer MN, Belsham PA. 3175 primary inguinal hernia repairs: advantages of ambulatory open mesh repair using local anesthesia. J Am Coll Surg 1998;186:447–456. 6. Beecherl EE, Jones DB, Carrico CJ. McVay to Lichtenstein: evolution of inguinal herniorrhaphy at a teaching institution. Presented at North Texas Chapter of American College of Surgeons, Dallas, TX, Feb. 27, 1998. 7. Nyhus LM, Condon RE, Harkins HN. Clinical experiences with the preperitoneal hernia repair for all types of hernia of the groin: with particular reference to the importance of transversalis fascia analogues. Am J Surg 1960;100:234–244. 8. Textbook of Surgery / J. J. Tjandra, G.J.A. Clunie, A. H. Kaye [etc.] – Massachusetts: Blackwell Publishing, 2006. – 708 p. 9. Essential Practice of Surgery/ J. A. Norton, R. R. Bollinger, A. E. Chang, S. F. [etc.] – New York: Springer-Verlag, 2003. – 761 p.