Manipal Manual Of Surgery 4th Edition PDF

34 Hernia Anatomy Sportsmen hernia lnterparietal hernia Indirect hernia Sliding hernia Spigelian hernia...

34 Hernia Anatomy Sportsmen hernia lnterparietal hernia Indirect hernia Sliding hernia Spigelian hernia Direct hernia Femoral hernia Lumbar hernia Clinical examination Rare types of femoral hernia Obturator hernia Complications Umbilical hernia Perinea! hernia Recurrent hernia lncisional hernia Special hernias What is new?/Recent Epigastric hernia Giant hernia advances Introduction The midpoint between these two structures is called Hernia is a common condition affecting patients, especially midpoint of the inguinal ligament. inguinal hernia in males and incisional hernia in females. Even. though several types of surgery have been described Lacunar ligament (Gimbernat's ligament) for hernias, mesh hernioplasty remains the gold standard Some fibres of inguinal ligament pass posteriorly to attach treatment. Majority of the hernias require surgical treatment to superior pubic ramus lateral to the tubercle and forms leaving apart small asymptomatic direct hernias in elderly. lacunar ligament. Today, laparoscopic hernia is becoming gold standard. The midpoint between the anterior superior iliac spine and Obstructed hernia is an emergency and late cases carry pubic symphysis is called midinguinal point. significant mortality. As far as students are concerned, hernia is the most common case in the examination. Hence, detailed Inguinal canal (2) clinical examination of hernia, complications, and various It is 4 cm in length extending from the deep inguinal ring types of hernias and their treatment have been described in to the superficial inguinal ring. this chapter. Hernia means to bud or protrude or rupture (Latin). Anterior superior Definition iliac spine Conjoined muscle (5) Abnormal protrusion of a viscus or a part of it through a weak point in the body (opening) is known as a hernia. Inguinal hernia occurs either through the deep inguinal ring (indirect hernia) or through the posterior wall of the inguinal canal (direct hernia). ---,11r.-- Inguinal canal (2) ANATOMY OF THE INGUINAL REGION (Fig. 34.1) Spermatic cord-----' Inguinal ligament (Poupart's ligament) (1) It is the ligamentous portion of the external oblique External ring--+-+ aponeurosis which folds inwards and extends from anterior (4) superior iliac spine to the pubic tubercle. Fig. 34.1: Anatomy of the inguinal region 842  Hernia 843 Deep ring (internal ring) (3) It is a 'U' shaped defect in the fascia transversalis which forms MIINIIIIIIIIIWIIIII the posterior wall of the inguinal canal. It lies 1.25 cm above CONTENTS OF THE SPERMATIC CORD the midpoint of the inguinal ligament. Vas deferens Testicular artery External ring (superficial ring) (4) Artery to the vas Superficial ring is a triangular defect in external oblique Cremasteric artery aponeurosis. It is bounded by the lateral and medial crura Pampiniform plexus of veins formed by the external oblique aponeurosis and the base of Lymphatics the triangle is formed by the pubic crest. Sympathetic nerves Genital branch of genitofemoral nerve Boundaries of inguinal canal Processus vaginalis Anterior: External oblique aponeurosis and a few fibres of the conjoined muscle (especially of internal oblique) laterally. Superior: Arched fibres of the conjoined muscle (5). IMIM........., ILIOINGUINAL NERVE Inferior: Inguinal ligament and the lacunar ligament on T he ilioinguinal nerve is a branch of the first lumbar nerve the medial side (Gimbernat's ligament). (L 1 ). It separates from the first lumbar nerve along with the Posterior: Fascia transversalis and the conjoined tendon larger iliohypogastric nerve. llioinguinal nerve does not pass through the deep inguinal medially. Thus, the inguinal canal is strong in the lateral ring. It only travels through part of the inguinal canal. part anteriorly and the medial part posteriorly. After going through inguinal canal, it pierces the internal oblique muscle, distributes nerve fibres to it, and then Contents of inguinal canal accompanies the spermatic cord through the superficial 1. Spermatic cord (Key Box 34.1) inguinal ring. 2. Ilioinguinal nerve (Key Box 34.2) Divides into anterior scrotal nerve and anterior labial nerve. 3. Genital branch of genitofemoral nerve Supplies the skin of the upper and medial part of the thigh, 4. Round ligament in females scrotum and vulva. 5. Vestigeal remnant of processus vaginalis sac. Entrapment or injury to the ilioinguinal nerve is one of the causes of postherniorrhaphy pain. Myopectineal orifice of Fruchaud (Fig. 34.2) Hence, a few recommend division of ilioinguinal nerve during hernia surgery. This weak area is the site of all groin hernias according to Fruchaud. It is the area between inguinal ligament anteriorly and Boundaries of myopectineal orifice of Fruchaud: iliopubic tract posteriorly. lliopubic tract: It is the thickened inferior margin of the Superiorly: Arched fibres of internal oblique transversalis fascia which appears as a fibrous band running Laterally: Iliopsoas muscle parallel and posterior (deep) to inguinal ligament. It inserts Medially: Lateral border of rectus abdominus muscle into superior pubic ramus to form lacunar ligament. Inferiorly: Pubic pecten-Cooper's ligament Femoral Surgical importance of iJiopubic tract: Recognition of nerve this is a part of laparoscopic repair (initial step)-visualising from within. This structure reinforces posterior wall and Myopectineal floor of inguinal canal as it bridges structures traversing ---- line subinguinal space...... Hesselbach's triangle (Fig. 34.3) It is bounded medially by lateral border of rectus abdominus muscle, laterally by inferior epigastric artery and inferiorly by inguinal ligament. Femoral Femoral Pectineus Direct hernias occur commonly through Hesselbach's artery vein triangle (medial), indirect hernia lateral to inferior epigastric Fig. 34.2: Myopectineal line and anatomy artery.  844 Manipal Manual of Surgery Inferior epigastric artery D CLASSIFICATION OF HERNIA I. The European hernia society classification: Primary (P), Recurrent (R) Lateral (L), Medial (M), Femoral (F) Defect size assumed to be 1.5 cm Thus primary direct hernia with 3 cm defect size is written as PM2. Lateral border IL Anatomical classification of rectus 1. Indirect hernia abdominus 2. Direct hernia Hesselbach's lll. Nyhus classification triangle This classification is based primarily on the defect, which helps in planning an appropriate repair. Type I: Indirect hernia with normal deep ring Fig. 34.3: Hesselbach's triangle Type 11: Indirect hernia with dilated deep ring Type III: Based on posterior wall defect INGUINAL DEFENCE MECHANISMS a. Direct b. Pantaloon 1. Obliquity of inguinal canal (in children it is straight). c. Femoral 2. During straining or coughing, the conjoined tendon Type IV: Recurrent hernia. contracts, and since it forms the anterior, superior and posterior boundaries, it closes the inguinal canal-shutter IV. Gilbert's classification (Table 34.1) or sphincter-like effect. It is based on the defect in the posterior wall (direct hernia) 3. Increased intra-abdominal pressure produces plugging effect or defect in the internal ring (indirect). at the external ring. The deep ring is pulled upwards and Depending upon the defect, the suggested repair is given laterally because it is adherent to the posterior surface of below. However, basic principles are the same. transversalis muscle. This occludes the ring and prevents The last two types-Type VI and Type VII are modifications herniation-Ball valve effect. by Robbin. Gilbert's classification and suggested repair Types Classification Repair I. Snug internal ring Herniorrhaphy or hernioplasty Preperitoneal indirect sac Does not admit one finger II. Moderately enlarged internal ring Hemiorrhaphy or hernioplasty Bubonocoele Admits one finger III. Large defect-2 or 3 finger-breadths internal ring. May be Preperitoneal mesh by slitting transversalis fascia sliding hernia IV. Large direct hernia with full blow out defect Mesh repair Internal ring is normal V. Direct hernia with punched out hole/defect in the transversalis fascia Plug the defect or purse-string closure of the The internal ring is intact defect followed by mesh repair VI. Pantaloon hernia Mesh repair VII. Femoral hernia Femoral hernia repair  Hernia 845 AETIOLOGY OF HERNIA: Processus vaginalis sac WHAT CAUSES HERNIA? The testis originates in the lumbar region-in the retroperitoneum. Testis is guided or pulled down by a ligament Indirect hernia occurs largely due to persistent processus called as gubernaculum. As the testis is pulled down it also vaginalis sac. Manifestations of this can be seen in elderly pulls down the peritoneum along with it. T his is processus patients in whom an indirect hernia can be triggered by vaginalis sac (tube). This process is obliterated in the normal situation. However, failure to close or obliterate is responsible some factors which increase intra-abdominal pressure. Direct hernia occurs mainly due to weakness oftransversalis for development of hernia. New theory or recent advances: Hormonal cause has been fascia in Hesselbach's area. Increase in abdominal pressure responsible for development of a hernia. Hepatocyte growth can occur due to chronic cough, constipation or difficulty factor and calcium gene related peptide influence closure of in passing urine, development of ascites (portal the tube. hypertension, nephrotic syndrome), etc. D Collagen disorder: In prune-belly syndrome, collagen fibre Parts of the hernia (Fig. 34.4) disorder causes development of not only hernias but also Hernial sac is part ofthe peritoneum which is dragged into the intestinal hernias, bilateral hernias, etc. (Key Box 34.3). inguinal canal. The mouth ofthe sac is in the peritoneal cavity. Hernia occur due to inherited imbalance in the types of The neck is the narrowest portion (deep ring). The actual collagen. hernial sac has a body and a fundus. Depending upon the contents it can be named as follows: Omentum---omentocoele, Mt!M!IIIIIIIIWIIIIII Intestine- enterocoele, Littre's hernia-hernia containing Meckel's diverticulum. It may also contain ovary or appendix. When part of the wall of the gut is involved, it is known as A 1. Congenital CAUSES OF HERNIA Richter's hernia. Persistent processus vaginalis sac: chief cause of indirect Neck hernia. 2. Collagen fibre disorder Prune-belly disorder-congenital Smoking: Acquired collagen deficiency 3. Obesity Fundus 4. Chronic causes of increased intra-abdominal pressure Chronic cough Fig. 34.4: Parts of the hernial sac Chronic constipation Straining at micturition Ascites Types of indirect hernia 5. Weakness of conjoined tendon/rupture of a few fibres 1. Complete hernia (scrotal): When the sac is patent up to Lifting heavy weight the bottom of the scrotum, it is a complete scrotal hernia Postappendicectomy-injury to ilioinguinal nerve. (Fig. 34.5). Chronic illness/debilitating disease causing weakness of 2. Funicular: The processus vaginalis sac is patent up to the transversalis fascia in the Hesselbach's area. root ofscrotum, it is a incomplete indirect hernia (Figs 34.6 and 34.8). INDIRECT HERNIA 3. Bubonocoele: Processus vaginalis sac is confined to the inguinal region or the inguinal canal only. Such hernias are It is a herniation of abdominal contents through the deep ring seen in young patients (Fig. 34.7). into the inguinal canal. Indirect hernia occurs due to persistent processus vaginalis sac. It is the most common Coverings of the indirect inguinal hernia from outside type of hernia in the body. The preformed sac passes through to inside the deep ring, traverses the inguinal canal and may extend l. Skin into the scrotum through the external ring. As it comes into 2. Two layers of superficial fascia: Fatty and membranous the inguinal canal, it is invested by the following coverings: (Camper's and Scarpa's fascia respectively). 1. External spermatic fascia derived from external oblique 3. External spermatic fascia, a continuation of the external aponeuros1s. oblique aponeurosis. 2. Cremasteric fascia derived from internal oblique. 4. Cremaster muscle and fascia, a continuation of the internal 3. Internal spermatic fascia from fascia transversalis. oblique.  846 Manipal Manual of Surgery Figs 34.5 to 34.7: Three types of indirect hernia Fig. 34.9: Direct hernia: Pops out when patient stands 4. Conjoined tendon 5. Fascia transversalis 6. Peritoneum Precipitating factors 1. Weakness of fibres of transversus abdominis or congenital absence of a few fibres is a major factor responsible for direct hernia. 2. In elderly patients, it is precipitated by: Chronic cough, chronic bronchitis Pops on coughing (Fig. 34.9) Difficulty in passing urine due to benign prostatic hypertrophy (BPH). Chronic constipation due to habitual constipation, or malignancy of left colon. 3. Smoking: Decreased strength of abdominal muscles due to Fig. 34.8: Incomplete hernia bulge is seen decreased elastin. 5. Internal spermatic fascia: Derived from the fascia transversalis. PEARLS OF WISDOM 6. Extraperitoneal fat As the direct hernia pushes through the posterior wall, 7. Peritoneum it is very unusual for it to descend into the scrotum. DIRECT HERNIA Ogilvie hernia It is always acquired (Fig. 34.9). I t occurs through This is a type of direct hernia wherein the hernial sac appears Hesselbach 's triangle, a weakness in the posterior wall of the through a circular defect (congenital) in the conjoined tendon. inguinal canal (transversalis fascia). Its boundaries are: Medially: Lateral border of the rectus abdominis Laterally: Inferior epigastric artery CLINICAL EXAMINATION OF A CASE OF HERNIA Below: Inguinal ligament History Coverings of the direct inguinal hernia from outside Swelling in the inguinal region which is gradually increasing to inside in size. 1. Skin To start with, the swelling disappears on lying down and 2. Two layers of superficial fascia increases on straining, walking, etc. Later it cannot be 3. External oblique aponeurosis reduced (due to adhesions).  Hernia 847 History of dragging pain indicates omentocoele. Since the omentum is attached to the stomach above and supplied by T l 0, the pain is referred to the umbilical region. Sudden, severe pain in the hernia, vomiting and in·educibility indicates 'obstructed hernia'. H/o chronic cough, constipation, difficulty in passing urine should be asked. If present, it may suggest the cause of hernia. History of appendicectomy Division of ilioinguinal nerve during appendicectomy may cause denervation of fibres of the right transversus abdominis, which forms 'U' shaped ring, resulting in weakness of the abdominal wall. Fig. 34.10: Incomplete indirect Fig. 34.11: Complete indirect hernia hernia-scrotal hernia Inspection (a model case of incomplete hernia) (Fig. 34.1O and 34.11) At the root of scrotum, the spermatic cord is palpated between the finger and the thumb. In cases of complete It should be done in the standing position. Both sides should indirect hernia, spermatic cord cannot be felt as a naked be checked. There is a swelling in the inguinal region extending to the structure because it is covered anterolaterally by the sac. This is called as getting above the swelling not possible root of the scrotum measuring about 6 x 3 cm. Its surface (negative). is smooth, borders are round and skin over the swelling is normal and it is pyriform in shape. PEARLS OF WISDOM Ask the patient to cough-expansile impulse on cough is present. If peristalsis is present, it indicates an enterocoele. Getting above the swelling is a test to differentiate scrotal Expansile impulse on cough is diagnostic of hernia swellings from inguinoscrotal swellings. (Key Box 34.4). 3. Reducibility-ask the patient to lie down. Presence of scar indicates a recurrent hernia. Ragged scar If the swelling becomes smaller or disappears, it is a hernia indicates infection. (hydrocoele is not reducible). Direct hernia pops out as soon as the patient stands and Omentocoele: Initially, reduction is easy but later, becomes often it is bilateral. difficult (due to adhesions). Palpation If it is difficult to reduce, ask the patient to reduce it. lnspectory findings should be confirmed. Otherwise, flex and medially rotate the hip and try to reduce Swelling is soft, and gurgles if it is an enterocoele. it, a method called as taxis. If in spite of this, the swelling It may be firm or granular if it is an omentocoele. is not reduced, it is called as an 1. Ask the patient to cough-expansile impulse is felt at the irreducible hernia. root of scrotum. 4. External ring invagination test 2. Getting above the swelling should be done in the standing (Fig. 34.12): At the root of the position. scrotum, skin is gathered and IIIMIIIIIIIIIWIIIIIW lifted up with the little finger. It is then invaginated into the external ring. As the external EXPANSILE IMPULSE ON COUGH ring is stretched in indirect Hernia hernia, the finger goes obliquely Meningocoele and laterally. In a direct hernia, Dermoid cyst with intracranial communication the finger goes backwards, and Laryngocoele the superior ramus of the pubic Lymphatic cyst in children Empyema necessitatis bone can be felt as a bare bone. Fig. 34.12: External ring On asking the patient to cough, invagination test 1This test has no meaning or usefulness in bubonocoele. It is a test to differentiate scrotal swelling from inguinoscrotal swelling and assumes significance in complete hernias.  848 Manipal Manual of Surgery the impulse touches the pulp of the finger in direct hernia and the tip in indirect hernia. PEARLS OF WISDOM This test causes discomfort to the patient. It cannot be done in female patients because the labial skin is thick and not lax. Hence, it is not a relevant test. However, in very early doubtful cases of indirect hernia an impulse on cough may be appreciated at the deep ring in this test. 5. Internal ring occlusion test (deep ring occlusion test): Reduce the swelling first (Fig. 34.13). Locate the deep ring above the midpoint between anterior Fig. 34.14: Leg raising test superior iliac spine and symphysis pubis. Occlude the deep ring with the thumb and ask the patient to cough. a. If impulse and the swelling are seen, it is a direct hernia Malgaigne's bulgings indicate weakness of the oblique because it occurs in the Hesselbach 's triangle (medial to muscles of the abdominal wall. deep ring). b. If the swelling is not seen, it is an indirect hernia. Deep 7. Zieman's method: Three finger method ring occlusion test can be done with the patient in standing Keep index finger at deep ring, middle finger on the and supine position. posterior wall above and lateral to the external ring and Problems of deep ring occlusion test ring finger at femoral ring. Now ask the patient to cough. a. If occlusion is not done properly, results may vary. Depending upon the type of hernia, impulse is felt. It is b. Pantaloon hernia (Romberg hernia, saddlebag hernia, dual not necessary to perform this test in incomplete or hernia). It is a direct hernia having indirect component. complete indirect hernias. 8. Per abdomen: To rule out any mass (colonic). 9. Look for phimosis/stricture urethra: Young patients having urinary complaints with hernia may be suffering from stricture urethra. Lift the scrotum and feel for any strictures in the bulbar urethra. Retract skin of prepuce and rule out phimosis. I 0. Per-rectal examination should be done in elderly patients to rule out prostatic enlargement. 11. Examination of respiratory system is done to rule out chronic bronchitis, tuberculosis, etc. PEARLS OF WISDOM Examine the opposite side also. Clinical examination of a hernia in a child Swelling may not be visible at first as it may be covered by thick pad of fat. Examine when a child strains (cry), or after Fig. 34.13: Deep ring occlusion test child's play Uumping, etc.). Examine the root of scrotum­ may find hernial sac (thickening). 6. Leg raising test or head raising test (Fig. 34.14) Gornall's test: By gentle compression on child's abdomen Weakness of oblique muscles is manifested by (hold the child on its back), hernia may become apparent. Malgaigne's bulgings above the medial half of inguinal Invagination test is almost impossible. Hence, it is better ligament. It is an absolute indication for hernioplasty. not to do it.  Hernia 849 Diagnosis (one example) swelling, high grade fever with chills and rigors an Right side, indirect, incomplete, uncomplicated, reducible characteristic. Spermatic cord is thickened and swelling i1 omentocoele. Table 34.2 for comparison and Table 34.3 for not reducible (Fig. 34.20). differences between hernia and hydrocoele. 7. Inguinal lymphadenitis: Pain and nodular swelling belo\\­ inguinal ligament is a feature. It is not reducible and some DIFFERENTIAL DIAGNOSIS OF A GROIN SWELLING source of infection in the lower limb is usually presen1 (Fig. 34.21). Groin refers to the junction of lower abdomen with the thigh. 8. Lipoma of the cord: It presents as a soft, lobulated but Hence, swellings in the inguinal region and upper thigh close irreducible swelling in the inguinal region (Figs 34.22 and to the inguinal ligament are included under groin swellings. 34.23). 1. Inguinal hernia (Fig. 34.15) 2. Femoral hernia: The main sac is below and lateral to pubic Investigations tubercle (Fig. 34.16). 1. Routine investigations such as complete blood picture 3. Vaginal hydrocoele: Fluctuation and transillumination tests (CBP) and urine examination are done. In elderly patients, are usually positive and getting above swelling is possible. chest X-ray, electrocardiography or even pulmonary (Please note that in infantile hydrocoele and hydrocoele en function tests may be necessary. Patients with urinary bisac, getting above swelling is not possible) (Fig. 34.17). complaints are evaluated for prostatic enlargement and stricture urethra. 4. Retractile testis: It can present as a firm swelling in the inguinal region. Scrotum is empty (Fig. 34.18). 2. Ultrasound: Hernia is a clinical diagnosis. In the vast majority of the cases, no investigations are required specific 5. Saphena varix: Patient can present with a swelling in the to the diagnosis of hernia. However, in appropriate cases thigh. Swelling is usually about 2.5 cm below the pubic imaging can be done. tubercle. A swelling that disappears on elevation of the In so-called occult cases wherein patient has groin pain but leg is characteristic of a swelling of venous origin clinically not evident. Ultrasound can detect a sac-however (Fig. 34.19). it is operator dependant, ultrasound is also useful in cases 6. Funiculitis: A funiculitis can occur with or without acute of postoperative swelling in the groin to rule out haematoma/ epididymoorchitis. Severe pain in the inguinal region, tender seroma/recurrence. Differences between direct and indirect hernia Direct hernia Indirect hernia I. Age Common in elderly Can occur in any age group 2. Aetiology Weakness of posterior wall of inguinal canal Preformed sac 3. Precipitating factors Chronic bronchitis, enlarged prostate 4. On standing Pops out Does not pop out 5. Side Usually bilateral Unilateral (30% bilateral) 6. Internal ring occlusion test Swelling is seen Swelling is not seen 7. Malgaigne's bulgings May be present Absent 8. Complications Not common because neck is wide Common, neck is narrow----obstruction and strangulation 9. Relationship of sac to the cord Sac is posterior to the cord Sac is anterolateral to the cord 10. Direction of the sac It comes out of Hesselbach's triangle Sac comes through the deep ring Clinical differences between hernia and hydrocoele Indirect complete hernia Vaginal hydrocoele I. Standing position Swelling of scrotum and inguinal region Swelling confined only to scrotum 2. Impulse on coughing Present Absent 3. Getting above swelling Not possible Possible 4. Reducibility Usually present unless complicated Not reducible 5. Consistency and transillumination Soft, gurgling, no transillumination Soft, fluctuant, transillumination is present  850 Manipal Manual of Surgery ) ) ) Fig. 34.15: Inguinal hernia Fig. 34.16: Femoral hernia Fig. 34.17: Infantile hydrocoele Fig. 34.18: Retractile testis ) ) ) Fig. 34.19: Saphena varix Fig. 34.20: Funiculitis Fig. 34.21: Inguinal lympha­ Fig. 34.22: Lipoma of the denitis cord Fig. 34.23: Left inguinal lipoma of the cord PEARLS OF WISDOM Elderly patients with bilateral hernia mostly suffer from benign prostatic hypertrophy. Prostatectomy should be Hernia is a clinical diagnosis. If you are asked to give considered first followed by repair of hernia, in such cases. one investigation to confirm hernia (may be in early Recent history of constipation and appearance of a hernia cases) it is ultrasound. should arouse the suspicion of carcinoma colon. Investigate by colonoscopy/fibreoptic sigmoidoscopy before the 3. Computed tomography(CT) scan is ideal in cases of giant treatment of hernia. hernias, or special types such as obturator hernia, perinea! Young adults with difficulty in passing urine may have a hernia, etc. stricture urethra. They should undergo proper treatment for 4. Magnetic resonance imaging (MRI): Ideal in sportsmen the stricture. Now it is rare to find a patient with hernia who complain of groin pain, to detect hernia or to rule out having a stricture urethra. muscle sprain or any other orthopaedic disorders. Treatment Preoperative preparation PEARLS OF WISDOM A patient with chronic bronchitis and bronchial asthma Herniotomy, herniorrhaphy and hernioplasty are the should be properly treated with bronchodilators, antibiotics, three "key" operations for inguinal hernia. mucolytic agents, etc. Cigarette smoking should be stopped.  Hernia 851 1. Herniotomy (Fig. 34.24) Criticism for Bassini's herniorrhaphy Excision of the sac alone is done in patients up to 14-16 It is a repair with tension years of age (children). Hernia occurs due to preformed Conjoined tendon and inguinal ligament approximation is sac. Hence, no repair is necessary. not physiological. 2. Herniorrhaphy PEARLS OF WISDOM It can be of two types: Bassini's and Shouldice. Hence irrespective of the type of hernia, mesh repair What is done today is the modified Bassini repair--{Read (Lichtenstein-next page) is recommended today asfirst also original Bassini operation). line of repair. A. Modified Bassini's herniorrhaphy (Fig. 34.25). Herniotomy with approximation of posterior wall of the What is original Bassini operation? inguinal canal by suturing the conjoined tendon (above) Eduardo Bassini incised the external oblique aponeurosis through the external ring. to the inguinal ligament below, by using interrupted, Resected the cremasteric muscle nonabsorbable suture material such as nylon, thick silk Divided the transversalis fascia from pubic tubercle to beyond or polypropylene. This is the most popular method. the internal ring. Repair of stretched deep ring by narrowing and laterally Reinforced the posterior wall of the inguinal canal with a single displacing the spermatic cord is done (Lytle's repair) in row of interrupted nonabsorbable sutures. selected cases at the end of the procedure. Sutured the internal oblique muscle, transversus abdominis If there is tension, an incision over the anterior rectus muscle and upper leaf of the transversal is fascia (triple layer) sheath will help in doing the repair (Tanner's slide). to the lower leaf of the transversalis fascia and inguinal liga­ ment (double layer) in a single row of interrupted non­ More details are given in Chapter 53 on operative surgery. absorbable sutures. Indications for Bassini's herniorrhaphy He then reapproximated the external oblique aponeurosis over Indirect hernia with good muscle tone. the cord structures. In modified Bassini repairs, the transversalis fascia is not Direct hernia with good muscle tone. opened. Cremasteric muscle is not excised. Only conjoined Young patients with good muscle tone. tendon is sutured to the inguinal ligament. B. Shouldice repair (Key Box 34.5) It is the most popular tensionless method wherein only local tissues are used. After opening the inguinal canal, hemiotomy is done. Transversalis fascia which forms the posterior wall, is incised from the internal ring till pubic tubercles. Thus, upper and lower flaps of transversalis fascia are sutured in a double-breasting manner by using non­ absorbable sutures such as 34 gauge stainless steel wire, polyamide or polypropylene. This is the first layer of Shouldice repair. The second layer is like Bassini 's, where in conjoined Fig. 34.24: Herniotomy tendon is sutured to the inguinal ligament by using nonabsorbable sutures. The third layer is completed by suturing upper flap of external oblique aponeurosis to the inguinal ligament. The results have been good in Shouldice's hands. The operation needs expertise. Inguinal Ml!Ml.........,.'V ligament SHOULDICE REPAIR First layer: Double breasting of the transversalis fascia. Second layer: Conjoined tendon is sutured to inguinal ligament. Third layer: Upper half of external oblique aponeurosis is sutured to inguinal ligament. Fig. 34.25: Bassini's herniorrhaphy............... 852 Manipal Manual of Surgery 3. Hernioplasty Indications I. Indirect or direct hernia with a good muscle tone. In such LICHTENSTEIN REPAIR cases, darning can be done. Polyprophylene mesh is used (Fig. 34.27) 8 x 16 cm mesh is tailored to patient's requirement. 2. Indirect or direct hernia with weak muscle tone, meshplasty Preparation of mesh: Corners can be cut so as to give a is prefeITed. round shape. A slit is given on the lateral border of the mesh 3. Recu1Tent hernia at the junction of lower one-third and upper two-thirds, to Hernioplasty refers to strengthening the posterior wall of allow spermatic cord to pass through. The two tails (slit­ inguinal canal. There are two types of hemioplasties which ends) are overlapped. are commonly practised-A. Mesh repair, B. Darning. Suturing: Medially, the mesh overlaps the pubic tubercle and is sutured over the tissue of symphysis (avoid pubic A. Strengthening: The posterior wall (Lichtenstein repair) bone to prevent osteitis pubis). Laterally, the two tails are (Figs 34.26 and 34.27, Key Boxes 34.6 and 34.7) of inguinal placed beyond deep ring and sutured. Inferiorly, it is sutured canal by a prolene mesh or Marlex mesh. The fibroblasts to inguinal and lacunar ligaments and superiorly to conjoined and capillaries grow over the mesh, converting it into a thick tendon. fibrous sheath and strengthening the posterior wall. The mesh is fixed inferiorly to lacunar and inguinal ligaments, medially to overlap rectus sheath and fixed to fascia over the pubic bone. A few interrupted sutures are put to fix it to the transversalis fascia. Laterally, an artificial deep ring is created by crossing of both upper and lower leaves of the mesh. To attain this, a slit is given on one side of mesh. (Lacunar ligament is that portion of the inguinal ligament which extends backwards and upwards to the pectineal line and fonns the medial margin of the femoral ring). Characteristics of the ideal mesh Biocompatibility means it should not do any harm, should be chemically and physically inert. Risk of infection should not be there Handling should be good Socioeconomics economical Longevity B. Prolene nylon darning: Suturing the conjoined tendon to the inguinal ligament without tension in a criss-cross manner by using prolene suture material (handmade mesh). This is preferred in direct and indirect hernias (Fig. 34.28) Fig. 34.27: Lichtenstein repair is the most popular type of open described by Maloney. hernia repair Prolene mesh placed in the posterior wall High tensile strength Biocompatible, nonabsorbable Monofilament strong, elastic and transparent mesh Ideal porosity for high visibility and colonisation Strong mechanical reinforcement Encourages rapid ingrowth of connective tissue Cheaper Flexible for any anatomic placement ADVANTAGES OF LIGHT WEIGHT AND LARGE PORES MESH Less shrinkage of mesh, more flexible, better tissue integration, better comfort. Fig. 34.26: Prolene mesh repair: Lichtenstein repair  Hernia 853 2. Andrew's imbrication In this operation, overlapping of external oblique aponeurosi: is done. ---Prolene 3. McVay darning It refers to suturing of conjoined tendon to the Cooper'i ligament. Conjoined tendon 4. Nyhus repair Ideally indicated in bilateral direct hernia or recurrent hemi wherein a broad mesh is kept in the preperitoneal space. Note: Students should remember that the operation whid Fig. 34.28: Prolene darning you have seen in your hospital should be mentioned in the clinical examination. BIOLOGICAL MESH 5. Stoppa repair1 These are sterilised sheets of connective tissue derived from The Stoppa repair is a tension-free type of hernia repair. human or animal dermis or porcine intestinal submucosa: It is performed by wrapping the lower part of the parietal They are decellularised peritoneum with prosthetic mesh and placing it at a Like the mesh, they provide scaffold for connective tissue preperitoneal level over Fruchauds myopectineal orifice. This operation is also known as giant prosthetic to grow and collagen deposition. reinforcement of the visceral sac (GPRVS). Enzymatic reaction takes place in the host, later fibrous tissue fonnation occur. 6. Marcy repair Advantages: Chronic inflammation and foreign body Simple high ligation of the sac combined with tightening reaction, stiffness and fibrosis, and mesh infection are of the internal ring (done in children). uncommon-usually do not occur. They can be used in presence of infection. NEW DEVELOPMENTS They are very expensive 1. What is Dasarda technique? In this operation, a strip of external oblique aponeurosis is prepared isolated but still Other surgeries for inguinal hernia connected medially and laterally to the external oblique 1. Kuntz operation (Fig. 34.29) muscle, and sutured to conjoined tendon and inguinal In this operation the spermatic cord is divided at the deep ligament below. ring and it is removed along with the testis, so that the deep 2. What is hernia system? A two layered mesh is used-one ring can be permanently closed, and hernia never recurs. It to place deep to transversalis fascia (with finger in the deep is indicated in elderly patients with recurrent hernia and ring, blind and blunt dissection is done to develop a deep poor abdominal muscle tone. Hamilton Bailey's operation­ plane) and the other in front of the transversalis fascia. cord is divided but testis is retained. 3. What is mesh plug repairs? These are simple plugs of mesh inse1ied into the deep ring. It is a simple procedure but mesh migration and seroma within the mesh called as Meshoma are common. COMPLICATIONS OF HERNIA SURGERY These are common complications after surgery. Often they are mild and note so worrisome. However, some of the Spermatic complications can be serious which require immediate attention cord and treatment. I. Complications during surgery Injury to the iliac vessels: The most serious but rare complication is injuryto iliac vessels. It can happen in thin Fig. 34.29: Kuntz operation patients when suturing of the inguinal ligament is done from 1It was first described in 1975 by Rene Stoppa.  854 Manipal Manual of Surgery lateral to medial side. The sudden jet of fresh red blood lnguinodynia: The chief factor is injury to the following nerves: indicates that the bite has been taken through the artery. It is iliohypogastric, ilioinguinal and genital branch of genitofemoral better to call the vascular surgeon, extend the incision, have nerve. Injury can be in the form of entrapment of the nerves, a proximal control, suture directly or do a resection and end traction injury, cauterisation, transection, etc. These are more to end anastomosis. They have to be anticoagulated with low common after mesh repair because of entrapment of the molecular weight heparin followed by oral anticoagulants. nerves or perineural fibrosis and adhesions between mesh Injury to the urinary bladder: This can happen when and the nerves. Clinical features include dull aching or dragging pain in the anatomy is not clear as in few giant or scrotal hernias, groin, genitalia, suprapubic region. Some may complain of perinea! hernias or distortion due to previous surgery. diminished sensation or even hyperaesthesia. Treatment Sudden finding of clear fluid with urinary smell means include reassurance, simple analgesics, nerve blocks with bladder injury. Immediate repair with 2-0 vicryl followed anaesthetic agents and injection of steroids. Neurolysis by by urinary catheter placement for 3 weeks is the treatment. inguinal exploration or neurectomy may be required in appropriate cases. 2. Early postoperative period Testicular atropy: It is due to injury to the testicular artery Pain: Pain is common due to the incision in the skin and some which is not noticed during surgery. A few days later, the patient degree of retraction of structures such as inguinal ligament may complain of small testis. Examination reveals no downwards and conjoint tendon upwards. The pain can be sensation in the testis. Orchidectomy may be required in such decreased by local anaesthetic infiltration, examples cases. bupivacaine 0.25% up to a maximum of 2 mg/kg body weight. COMPLICATIONS OF HERNIA Bleeding: Perfect haemostasis is the aim of all surgeries. In spite of this, a few bleeders may open up, mostly venous 1. Irreducibility (Key Box 34.8) blood-may be pampiniform plexus veins or arterial blood Occurs due to adhesions formed between omentum, sac and from inferior epigastric artery. The bleeding may stop with the contents. Irreducibility produces dull aching pain. compression bandage. Otherwise, exploration and ligation of bleeders needs to be done in the operation theatre. Urinary retention is common, more so in males: Pain, MIMI..........,. spinal or epidural anaesthesia, sedatives, lack of privacy DIAGNOSIS OF IRREDUCIBLE HERNIA are contributing factors. Provide analgesia, privacy and hot Hernia is tense fomentation to suprapubic region. If all of these safe, Tender catheterise bladder as a last step. Irreducible Abdominal distension: This is not common. It can happen No impulse on cough when large intestinal contents of the hernia sac are reduced Recent increase in size of swelling or handled as in scrotal hernias or sliding hernias. It is also important to realise that omentum is attached to stomach 2. Obstructed hernia (Key Box 34.9 and Fig. 34.30) and colon above. One should see that bleeders from injured arteries of the omentum should be ligated properly. Some Irreducible hernia+ obstruction to the lumen of the gut gives intraperitoneal blood may add to paralytic ileus. rise to obstructed hernia. Clinically, it produces severe colicky abdominal pain, abdominal distension, vomiting and step 3. Intermediate-between 3 and 7 days ladder peristalsis. Seroma is due to inflammatory response to mesh or suture materials. It causes swelling and anxiety that it may be a recurrence. When in doubt, get an ultrasound examination first. Seroma needs to be aspirated. Seroma is more common M!MHIIIIIIWlllll lllr' after laparoscopic hernia repairs. FACTORS RESPONSIBLE FOR OBSTRUCTED HERNIA Wound infection: Hernia is a clean surgery. Infection should Narrow neck not occur. However, poor handling of the tissues, haematoma, Irreducibility seroma and diabetes may precipitate wound infection. Open Sudden straining the sutures, drain the pus and use appropriate antibiotics in Too many contents such cases. Persistent wound infection may prompt removal Long duration of hernia of the mesh. A few cases of tuberculosis have been reported. Sliding hernia This is due to improper sterilisation of the mesh used. 4. Late: Late complications are not all that common. One complication which bothers a few patients is chronic pain Fig. 34.30: Obstructed hernia called inguinodynia.