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 inguinalinguinal ligamentligament „ TheThe ilioinguinalilioinguinal nervenerve andand thethe genitofemoralgenitofemoral nervenerve isis allowedallowed toto passpass withwith thethe cordcord throughthrough thethe newlynewly fashionedfashioned deepdeep ringring inin thethe prosthesisprosthesis „ MayMay oror maymay notnot bebe suturedsutured (( GilbertGilbert’’ss suturlesssuturless tech)tech) „ ContraindicatedContraindicated whenwhen herniahernia resultingresulting fromfrom aa connectiveconnective tissuetissue diseasedisease „ NotNot neededneeded inin womenwomen withwith indirectindirect herniahernia LichtensteinLichtenstein PosteriorPosterior prostheticprosthetic hernioplastyhernioplasty

„ ProperitonealProperitoneal oror StoppaStoppa procedureprocedure „ FunctionallyFunctionally replacereplace thethe transversalistransversalis fasciafascia „ TheThe prosthesisprosthesis adhereadhere toto thethe peritoneumperitoneum andand renderrender itit inextensibleinextensible soso itit cannotcannot protrudeprotrude (Mersilene(Mersilene isis preferable)preferable) „ RepairRepair ofof thethe wallwall defectdefect isis unnecessaryunnecessary „ CanCan bebe performedperformed unilaterallyunilaterally oror bilaterallybilaterally „ UseUse TransverseTransverse oror antant groingroin incisionincision forfor unilateralunilateral approachapproach „ UseUse PfannensteilPfannensteil incisionincision forfor bilateralbilateral approachapproach LaparoscopicLaparoscopic RepairRepair

„ Include:Include: – Transabdominal preperitoneal (TAPP) repair (uses intraperitoneal trocars and the creation of a peritoneal flap over the posterior inguinal area) – Totally extraperitoneal approach (TEPA). (access to the preperitoneal space without entering the peritoneal cavity). „ RepairRepair isis similarsimilar inin bothboth thesethese techniques.techniques. „ MedialMedial toto thethe inferiorinferior epigastricepigastric vessels,vessels, thethe meshmesh isis securedsecured toto thethe CooperCooper ligament,ligament, thethe lacunarlacunar ligament,ligament, thethe posteriorposterior rectusrectus musculature,musculature, andand thethe transversustransversus abdominisabdominis aponeuroticaponeurotic arch.arch. „ Laterally,Laterally, thethe meshmesh isis attachedattached toto thethe laterallateral extensionextension ofof thethe transversustransversus aponeuroticaponeurotic archarch andand thethe superiorsuperior edgeedge ofof thethe iliopubiciliopubic tract.tract. LaparoscopicLaparoscopic RepairRepair

„ StaplesStaples shouldshould notnot bebe placedplaced belowbelow thethe laterallateral iliopubiciliopubic tracttract becausebecause ofof potentialpotential injuryinjury toto thethe genitofemoralgenitofemoral nervenerve andand thethe laterallateral femoralfemoral cutaneouscutaneous nervenerve inin thisthis region.region. „ StaplingStapling isis alsoalso avoidedavoided inin thethe triangulartriangular areaarea inferiorinferior toto thethe internalinternal inguinalinguinal ring,ring, calledcalled thethe triangletriangle ofof doom.doom. „ TheThe triangletriangle isis borderedbordered byby thethe ductusductus deferensdeferens mediallymedially andand thethe spermaticspermatic vesselsvessels laterallylaterally inin thethe malemale wherewhere thethe externalexternal iliaciliac arteryartery andand veinvein andand thethe femoralfemoral nervenerve areare located.located. „ TheThe obturatorobturator arteryartery isis locatedlocated medialmedial toto thethe triangletriangle ofof doomdoom butbut shouldshould alsoalso bebe avoidedavoided whenwhen securingsecuring thethe meshmesh toto thethe CooperCooper ligamentligament TAPPTAPP TEPATEPA LaparoscopicLaparoscopic RepairRepair

„ Pro:Pro: – Excellent visualization, minimal pain, rapid return to work and normal activities, small incisions that provide improved cosmesis and decreased wound infection complications, and potential cost savings secondary to decreased work loss. – simultaneous repair of bilateral inguinal hernias. „ Cons:Cons: – necessity for general anesthesia, the operative costs, the violation of the peritoneal cavity (with the TAPP repair), the necessity for advanced laparoscopic skills. UMBILICALUMBILICAL HERNIASHERNIAS

„ The vast majority of umbilical hernias are congenital in origin „ Eight times higher in black infants than in white infants „ Umbilical hernias presenting during adulthood are considered acquired hernias. „ Incarceration and strangulation are unusual; rupture can also rarely occur. „ Repaired with a variety of techniques: – Pants over vest manner as proposed by Mayo – Simple transverse closure of an adult umbilical hernia – Occasionally, mesh reinforcement is required for adequate repair of umbilical hernias. „ Recurrence of umbilical hernias is uncommon. VENTRALVENTRAL (INCISIONAL)(INCISIONAL) HERNIAHERNIA

„ Obesity is one of the leading causes of the development of incisional hernias „ Other factors that increase the risk of developing an incisional hernia include advanced age, malnutrition, ascites, postoperative hematoma, peritoneal dialysis, pregnancy. „ Steroids and chemotherapy have been implicated in the development of incisional hernias „ The most common causative factor in the development of incisional hernias is postoperative wound infection INCISIONALINCISIONAL HERNIAHERNIA RepairRepair

„ Occasionally Primary repair can be accomplished. „ More commonly requires prosthetic materials: – Some small incisional hernias are repaired with the placement of an onlay prosthetic mesh, which overlaps the approximated fascial edges by several centimeters. – More commonly, prosthetic mesh is used in place of approximating the wound edges. „ The laparoscopic repair of incisional hernias has been used with increasing frequency „ Pro: Smaller wounds have resulted in a marked reduction in infections and wound complications. „ Cons: Extensive adhesiolysis is required in some patients to perform the hernia repair laparoscopically. SLIDINGSLIDING HERNIAHERNIA

„ TheThe cecumcecum onon thethe RightRight „ TheThe sigmoidsigmoid onon thethe LeftLeft „ IndInd IHIH areare thethe mostmost commoncommon typestypes „ TheThe herniahernia sacsac shouldshould bebe openedopened onon thethe anteromedialanteromedial borderborder becausebecause thethe visceralvisceral componentcomponent mostmost commonlycommonly constitutesconstitutes thethe posterolateralposterolateral wallwall ofof thethe herniahernia sac.sac. „ TheThe keykey toto successfulsuccessful repairrepair ofof aa slidingsliding herniahernia isis thethe recognitionrecognition ofof thethe visceralvisceral componentcomponent andand thethe safesafe returnreturn ofof thethe visceraviscera toto thethe abdominalabdominal cavity,cavity, withwith aa carefulcareful reconstructionreconstruction ofof thethe inguinalinguinal canal.canal. UNUSUALUNUSUAL HERNIASHERNIAS

„ Epigastric Hernia: – More commonly above the umbilicus than below. – Usually small and can be difficult to diagnose in obese patients. – Painful, pulling sensation at the midline on reclining. – Repaired with simple suture closure. MAY BE MULTIPLE „ Richter's Hernia: – The antimesenteric border of the intestine must protrude into the hernia sac – The most common location is at the site of a femoral hernia. – Critical to the repair of Richter's hernia is an adequate evaluation of the intestine for viability. „ Littre's Hernia: – Meckel diverticulum as the sole component of the hernia sac – extremely difficult to diagnose due to the frequent lack of obstructive symptoms. „ Spigelian Hernia: – A hernia through the fascia along the lateral edge of the rectus muscle at the space between the semilunar line and the lateral edge of the rectus muscle – Usually successfully repaired by approximation with interrupted sutures SpigelianSpigelian HerniaHernia UNUSUALUNUSUAL HERNIASHERNIAS

„ ObturatorObturator HerniaHernia – Weakening of the obturator membrane can lead to intestinal incarceration – The obturator canal, which is 2 to 3 cm long, may contain a fat pad, which is considered by many surgeons to be pathologic. – May present with evidence of compression of the obturator nerve – Surgical repair through various approaches: „ abdominal approach, open or laparoscopic „ The retropubic (preperitoneal) approach is preferred by many surgeons when there are no signs of obstruction or intestinal involvement. „ The obturator, inguinal, and combination approaches have been described. „ The dilated obturator foramen is repaired with interrupted sutures UNUSUALUNUSUAL HERNIASHERNIAS

„ Lumbar (Dorsal) Hernia: – Grynfeltt's hernia @ superior lumbar triangle – Petit's hernia @ inferior lumbar triangle. – Diffuse lumbar hernias are most often iatrogenic (kidney operations) – Overlapping and imbricating suture / mesh reinforcement repairs „ Sciatic Hernia: – Extremely unusual hernias, difficult to diagnose, and the patient may be symptom free until intestinal obstruction occurs. – Or a mass in the gluteal or infragluteal area + discomfort on standing. – Sciatic nerve pain is rarely caused by pressure from a sciatic hernia. – Repaired transabdominally or through a transgluteal approach. „ Perineal Hernia: – Very uncommon, may occur after abdominoperineal resection. – A myocutaneous flap or mesh reinforcement is frequently required