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Abd Wall Hernias AbdominalAbdominal WallWall HerniasHernias DefinitionDefinition ProtrusionProtrusion ofof aa viscusviscus throughthrough anan openingopening inin thethe wallwall ofof thethe cavitycavity inin whichwhich itit isis containedcontained TheThe sizesize ofof aa herniahernia isis determineddetermined byby thethe dimensiondimension ofof thethe neckneck andand thethe volumevolume ofof thethe distendeddistended sacsac ReducibleReducible (incarcerated)(incarcerated) whenwhen thethe protrudedprotruded viscusviscus cancan bebe returnedreturned toto thethe abdomenabdomen StrangulatedStrangulated whenwhen thethe vasculaturevasculature isis compromised,compromised, usu.usu. AtAt thethe neck.neck. SitesSites ofof herniationherniation WhereWhere aponeurosisaponeurosis andand fasciafascia areare devoiddevoid ofof supportsupport ofof striatedstriated musclemuscle MostMost commoncommon sites:sites: –– GroinGroin –– UmbilicusUmbilicus –– LineaLinea AlbaAlba –– SemilunarSemilunar lineline ofof SpiegelSpiegel –– DiaphragmDiaphragm –– SurgicalSurgical IncisionIncision SitesSites ofof herniationherniation OtherOther rarerare sites:sites: –– PerineumPerineum –– SuperiorSuperior triangletriangle ofof GrunfeltGrunfelt –– InferiorInferior lumbarlumbar lineline ofof PetitPetit –– ObturatorObturator –– SciaticSciatic foramenforamen ofof thethe pelvispelvis IndicationIndication forfor surgerysurgery AllAll herniahernia shouldshould bebe repairedrepaired unlessunless locallocal oror systemicsystemic conditionsconditions precludepreclude aa safesafe outcomeoutcome Exception:Exception: aa herniahernia withwith aa widewide neckneck andand aa shallowshallow sacsac thatthat isis anticipatedanticipated toto enlargeenlarge slowlyslowly TrussesTrusses andand surgicalsurgical BeltsBelts areare helpfulhelpful inin smallsmall herniashernias whenwhen operationoperation isis contraindicated.contraindicated. (NOT(NOT inin FemoralFemoral H.)H.) HerniasHernias ofof thethe GroinGroin InguinalInguinal MostMost commoncommon Men=Men= 25women25women IndInd=2=2 DirectDirect inin menmen IncidenceIncidence isis 3%3% inin menmen FHFH && IHIH areare twicetwice moremore onon thethe rightright FemoralFemoral herniahernia isis aa herniahernia ofof thethe GroinGroin –– UncommonUncommon inin menmen –– 10%10% ofof menmen affectedaffected willwill havehave IHIH laterlater –– 50%50% ofof WomenWomen willwill havehave IHIH laterlater –– AlmostAlmost alwaysalways presentpresent asas anan irreducibleirreducible walnutwalnut sizesize massmass atat thethe medialmedial basebase ofof thethe ScarpaScarpa’’ss femoralfemoral triangle.triangle. AnatomyAnatomy ofof thethe GroinGroin AnatomyAnatomy ofof thethe GroinGroin HerniaHernia’’ss LocationsLocations FrunchaudFrunchaud’’ss MyopectinalMyopectinal OrificeOrifice The fundame ntal cause of all groin hernias is the failure of the transver salis fascia to retain the perito- neum OtherOther FactorFactor Insuffic- iencies of the internal oblique expose the deep ring to the intra abdom- inal pressure Hernioplasty:Hernioplasty: Basics:Basics: TwoTwo fundamentalfundamental Concepts:Concepts: – Aponeurotic closure of the myopectinal orifice – Replacement of the defective transversalis fascia with a prosthesis – Or the two at the same time TensionTension isis thethe principalprincipal causecause ofof failurefailure TwoTwo types:types: – Anterior or classical repair – Posterior or pro-peritoneal AnteriorAnterior ClassicalClassical GroinGroin HernioplastyHernioplasty OnlyOnly threethree approachesapproaches areare stillstill used:used: –– MarcyMarcy simplesimple repairrepair –– BassiniBassini RepairRepair (modified(modified toto Shouldice)Shouldice) –– McVayMcVay--LotheissenLotheissen CooperCooper ligamentligament repairrepair ThreeThree parts:parts: –– DissectionDissection ofof thethe InguinalInguinal canalcanal –– RepairRepair ofof thethe myopectinalmyopectinal orificeorifice –– ClosureClosure ofof thethe inguinalinguinal canalcanal AA-- DissectionDissection ofof thethe ICIC consistconsist ofof Opening of the IC Preservation of the ilioinguinal nerve Division of the cremaseter muscle (often omitted by surgeons!) Exposure of the deep ring Mobilization of the spermatic cord Division + excision of the weak area in post wall of the inguinal canal (often omitted by surgeons!) Elimination of the peritoneal sac Removal of the cord lipoma DISSECTION IS AS IMP AS REPAIR BB-- RepairRepair ofof thethe myopectinalmyopectinal orificeorifice ContraryContrary toto thethe beliefbelief ofof somesome surgeons,surgeons, thethe anatomyanatomy ofof thethe deepdeep ringring isis suchsuch thatthat strangulationstrangulation ofof thethe spermaticspermatic cordcord byby reconstructionreconstruction ofof thethe posteriorposterior wallwall ofof thethe inguinalinguinal canalcanal isis virtuallyvirtually impossible.impossible. Indeed,Indeed, insufficientinsufficient repairrepair ofof thethe deepdeep ringring isis thethe principalprincipal causecause ofof indirectindirect recurrencerecurrence MarcyMarcy RepairRepair CalledCalled simplesimple ringring closureclosure ItIt consistsconsists ofof tighteningtightening anan enlargedenlarged deepdeep ringring onlyonly IsIs indicatedindicated inin menmen andand womenwomen whowho havehave indirectindirect herniahernia withwith onlyonly minimalminimal damagedamage toto thethe deepdeep ringring IsIs thethe hernioplastyhernioplasty ofof choicechoice forfor womenwomen withwith indirectindirect inguinalinguinal herniahernia AfterAfter dividingdividing thethe roundround ligamentligament andand eliminatingeliminating thethe sac,sac, thethe deepdeep ringring isis abolishedabolished withwith aa fewfew permanentpermanent suturessutures BassiniBassini--ShouldiceShouldice HernioplastyHernioplasty IsIs indicatedindicated inin allall indirectindirect herniahernia repairrepair ItIt consistconsist ofof highhigh ligationligation ofof thethe sacsac andand approximationapproximation ofof thethe conjoinedconjoined tendontendon andand thethe internalinternal obliqueoblique musclemuscle toto thethe shelvingshelving ofof thethe inguinalinguinal ligamentligament withwith interruptedinterrupted suturessutures oror byby preciseprecise imbricationimbrication withwith continuouscontinuous suturessutures ((shouldiceshouldice)) DoesDoes notnot repairrepair thethe femoralfemoral canalcanal RepairRepair isis nonenone anatomicanatomic becausebecause thethe transversalistransversalis aponeurosisaponeurosis isis suturedsutured toto thethe inguinalinguinal ligamentligament ShouldiceShouldice McVayMcVay RepairRepair CalledCalled CooperCooper ligamentligament hernioplastyhernioplasty RepairRepair thethe deepdeep ringring HesselbashHesselbash’’ss triangletriangle andand thethe femoralfemoral canalcanal IndicatedIndicated forfor thethe threethree commoncommon typestypes ofof herniahernia RequireRequire thethe excisionexcision ofof thethe medialmedial portionportion ofof thethe iliopubiciliopubic tracttract McVayMcVay ExcessExcess tensiontension isis alwaysalways presentpresent AA relaxingrelaxing incisionincision isis mandatorymandatory FemoralFemoral repairrepair InIn womenwomen repairedrepaired fromfrom belowbelow thethe inguinalinguinal ligamentligament InIn menmen oror whenwhen largelarge herniahernia existexist thethe useuse McVayMcVay coopercooper ligamentligament repairrepair oror withwith aa prosthesisprosthesis CC-- ClosureClosure ofof thethe inguinalinguinal canalcanal TheThe aponeurosisaponeurosis ofof thethe externalexternal obliqueoblique isis reapproximatedreapproximated TheThe distaldistal stumpstump ofof aa divideddivided cremastercremaster musclemuscle shouldshould bebe attachedattached toto thethe superficialsuperficial ringring toto hitchhitch upup thethe testicletesticle ProstheticProsthetic materialmaterial forfor herniolastyherniolasty HernioplastyHernioplasty NoneNone isis perfectperfect MarlexMarlex,, TerlexTerlex,, ProleneProlene meshmesh areare porousporous knittedknitted monofilamentmonofilament MersileneMersilene isis anan openopen--knittedknitted meshmesh composedcomposed ofof uncoateduncoated braidedbraided fibersfibers ofof polyesterpolyester DacronDacron GoreGore--TexTex (( PTFEPTFE oror Teflon)Teflon) isis nonporous,nonporous, smoothsmooth andand supplesupple throughthrough whichwhich nono fluidfluid cancan flowflow GoreGore--TexTex doesdoes notnot inciteincite fibroplasiafibroplasia oror inflammationinflammation PolyesterPolyester andand polypropylenepolypropylene shouldshould nevernever contactcontact thethe visceraviscera InfectionInfection ofof thethe prosthesisprosthesis MonofilamentMonofilament filamentfilament toleratetolerate infectioninfection TheyThey getget integratedintegrated ratherrather thanthan infectedinfected GoreGore--TexTex isis intolerantintolerant ofof earlyearly infectioninfection becausebecause ofof thethe slowslow integrationintegration CompleteComplete integrationintegration ofof thethe monofilamentmonofilament cancan bebe expectedexpected inin 33 toto 44 weeksweeks WhenWhen delayeddelayed infectioninfection existexist exciseexcise onlyonly thethe exposedexposed partpart TensionTension freefree HernioplastyHernioplasty (Lichtenstein)(Lichtenstein) KnownKnown asas GiantGiant prostheticprosthetic reinforcementreinforcement ofof thethe visceralvisceral sacsac GPRSVGPRSV TheThe meshmesh isis suturedsutured circumferentiallycircumferentially toto thethe internalinternal oblique,oblique, thethe rectusrectus sheathsheath andand thethe shelvingshelving edgeedge ofof thethe
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