Chapter 8 Hernias of abdominal wall

Hernia of the abdominal wall or external hernia is such surgical disease, which is characterized by protrusion of the visceral organs from the place of their physiological placement through the natural canals or defects of the abdominal and pelvic wall. Uncomplicated abdominal wall hernias do well. However, hernias with associated strangulation have an associated mortality rate of 10%.

Aetiology of hernias

Hernias are divided into two main groups:

congenital;

acquired.

Predisposing factors: weakness of the abdominal wall (anatomical; congenital; connected with sex, age, weight loss, injury, postoperative scar, pregnancy).

Causative factors: increased abdominal pressure (hard physical activity, chronic cough, chronic constipation, obstructive uropathy and ascites).

Pathomorphology

Each abdominal hernia consists of hernia’s orifice, hernia’s sac and hernia’s contents. Hernia’s sac is formed by the parietal peritoneum and can contain any organ from abdominal cavity, but mostly – small intestine and omentum. Sometimes it contains other organs: large intestine, urinary bladder, ovary and appendix.

The main parts of the hernia pouch are neck, body and fundus. Peritoneum is protruding through the hernia’s orifice. The sliding hernia occurs when the hernia’s sac is partially formed by the wall of an organ without peritoneal covering (e.g., posterior cecum, ovary, blad­der, sigmoid).

Classification

1. According to the anatomical localization:

inguinal (indirect and direct) hernia;

midline hernia;

femoral hernia;

umbilical hernia;

lumbar hernia;

obturator hernia;

ischiorectal hernia.

2. According to the clinical presentations:

complete and incomplete;

reducible (when the contents of the hernia sac can be returned to their normal anatomic domain) and nonreducible;

traumatic;

postoperative;

complicated and noncomplicated.

Hernia’s complications

incarceration;

strangulation;

contain’s inflammation;

contain’s trauma;

contain’s malignization.

Abdominal Wall Anatomy

The skin of the lower anterior abdominal wall is innervated by anterior and lateral cutaneous branches of the ventral rami of the seventh through 12th intercostal nerves and by the ventral rami of the first and second lumbar nerves. These nerves course between the lateral flat muscles of the abdominal wall and enter the skin through the subcutaneous tissue.

The first layers encountered beneath the skin are Camperis and Scarpais fasciae in the subcutaneous tissue. The only significance of these layers is that when sufficiently developed, they can be reapproximated to provide another layer between a repaired inguinal floor and the outside. The major blood vessels of this superficial fatty layer are the superficial inferior and superior epigastric vessels, the intercostals vessels, and the superficial circumflex iliac vessels (which are branches of the femoral vessels).

The external oblique muscle is the most superficial of the great flat muscles of the abdominal wall. This muscle arises from the posterior aspects of the lower eight ribs and interdigitates with both the serratus anterior and the latissimus dorsi at its origin. The posterior portion of the external oblique muscle is oriented vertically and inserts on the crest of the ileum. The anterior portion of the muscle courses inferiorly and obliquely toward the midline and the pubis. The muscle fibers themselves are of no interest to the inguinal hernia surgeon until they give way to form its aponeurosis, which occurs well above the inguinal region. The obliquely arranged anterior inferior fibers of the aponeurosis of the external oblique muscle fold back on themselves to form the inguinal ligament, which attaches laterally to the anterior superior iliac spine. In most persons, the medial insertion of the inguinal ligament is dual: one portion of the ligament inserts on the pubic tubercle and the pubic bone, whereas the other portion is fan-shaped and spans the distance between the inguinal ligament proper and the pectineal line of the pubis. This fan-shaped portion of the inguinal ligament is called the lacunar ligament. It blends laterally with Cooperis ligament. The more medial fibers of the aponeurosis of the external oblique muscle divide into a medial crus and a lateral crus to form the external or superficial inguinal ring, through which the spermatic cord (or the round ligament) and branches of the ilioinguinal and genitofemoral nerves pass.

The rest of the medial fibers insert into the linea alba after contributing to the anterior portion of the rectus sheath.

Beneath the external oblique muscle is the internal abdominal oblique muscle. The fibers of the internal abdominal oblique muscle fan out following the shape of the iliac crest, so that the superior fibers course obliquely upward toward the distal ends of the lower three or four ribs while the lower fibers orient themselves inferomedially toward the pubis to run parallel to the external oblique aponeurotic fibers. These fibers arch over the round ligament or the spermatic cord, forming the superficial part of the internal (deep) inguinal ring.

Beneath the internal oblique muscle there is the transversus abdominis. This muscle arises from the inguinal ligament, the inner side of the iliac crest, the endoabdominal fascia, and the lower six costal cartilages and ribs, where it interdigitates with the lateral diaphragmatic fibers. The medial aponeurotic fibers of the transversus abdominis contribute to the rectus sheath and insert on the pecten ossis pubis and the crest of the pubis, forming the falx inguinalis. Infrequently, these fibers are joined by a portion of the internal oblique aponeurosis.

Aponeurotic fibers of the transversus abdominis also form the structure known as the aponeurotic arch. It is theorized that contraction of the transversus abdominis causes the arch to move downward toward the inguinal ligament, thereby constituting a form of shutter mechanism that reinforces the weakest region of the groin when intra-abdominal pressure is raised. The region beneath the arch varies. Many authorities believe that a high arch, resulting in a larger region from which the transversus abdominis is by definition absent, is a predisposign factor for a direct inguinal hernia. The transverse aponeurotic arch is also important because the term is used by many authors to describe the medial structure that is sewn to the inguinal ligament in many of the older inguinal hernia repairs.

The rectus abdominis forms the central anchoring muscle mass of the anterior abdomen. It arises from the fifth through seventh costal cartilages and inserts on the pubic symphysis and the pubic crest. It is innervated by the 7th through 12th intercostals nerves, which laterally pierce the aponeurotic sheath of the muscle. The semilunar line is the slight depression in the aponeurotic fibers coursign toward the muscle. In a minority of persons, the small pyramidalis muscle accompanies the rectus abdominis at its insertion. This muscle arises from the pubic symphysis. It lies within the rectus sheath and tapers to attach to the linea alba, which represents the conjunction of two rectus sheaths and is the major site of insertion for three aponeuroses from all three lateral muscle layers. The line of Douglas (i.e., the arcuate line of the rectus sheath) is formed at a variable distance between the umbilicus and the inguinal space because the fasciae of the large flat muscles of the abdominal wall contribute their aponeuroses to the anterior surface of the muscle, leaving only transversalis fascia to cover the posterior surface of the rectus abdominis.

The innervation of the anterior wall muscles is multifaceted.

The 7th through 12th intercostal nerves and the first and second lumbar nerves provide most of the innervation of the lateral muscles, as well as of the rectus abdominis and the overlying skin. The nerves pass anteriorly between the internal oblique muscle and the transversus abdominis, eventually piercing the lateral aspect of the rectus sheath to innervate the muscle therein.

The external oblique muscle receives branches of the intercostal nerves, which penetrate the internal oblique muscle to reach it.

The anterior ends of the nerves form part of the cutaneous innervation of the abdominal wall. The first lumbar nerve divides into the ilioinguinal nerve and the iliohypogastric nerve.

These important nerves lie in the space between the internal oblique muscle and the external oblique aponeurosis. They may divide within the psoas major or between the internal oblique muscle and the transversus abdominis. The ilioinguinal nerve may communicate with the iliohypogastric nerve before innervating the internal oblique muscle. The ilioinguinal nerve then passes through the external inguinal ring to run parallel to the spermatic cord, while the iliohypogastric nerve pierces the external oblique muscle to innervate the skin above the pubis. The cremaster muscle fibers, which are derived from the internal oblique muscle, are innervated by the genitofemoral nerve. There can beconsiderable variability and overlap.

The blood supply of the lateral muscles of the anterior wall comes primarily from the lower three or four intercostal arteries, the deep circumflex iliac artery, and the lumbar arteries. The rectus abdominis has a complicated blood supply that derives from the superior epigastric artery (a terminal branch of the internal thoracic [internal mammary] artery), the inferior epigastric artery (a branch of the external iliac artery), and the lower intercostal arteries. The lower intercostal arteries enter the sides of the muscle after traveling between the oblique muscles; the superior and the inferior epigastric arteries enter the rectus sheath and anastomose near the umbilicus.

The endoabdominal fascia is the deep fascia covering the internal surface of the transversus abdominis, the iliacus, the psoas major and minor, the obturator internus, and portions of the periosteum. It is a continuous sheet that extends throughout the extraperitoneal space and is sometimes referred to as the wallpaper of the abdominal cavity.

The transversalis fascia is particularly important for inguinal hernia repair because it forms anatomic landmarks known as analogues or derivatives. The most significant of these analogues for hernia surgeons are the iliopectineal arch, the iliopubic tract, the crura of the deep inguinal ring, and Cooperis ligament.

The iliopubic tract is the thickened band of the transversalis fascia that courses parallel to the more superficially located inguinal ligament. It is attached to the iliac crest laterally and inserts on the pubic tubercle medially. The insertion curves inferolaterally for 1 to 2 cm along the pectineal line of the pubis to blend with Cooperis ligament, ending at about the midportion of the superior pubic ramus. Cooperis ligament is actually a condensation of the periosteum and is not a true analogue of the transversalis fascia.

Hesselbachis inguinal triangle is the site of direct inguinal hernias. As viewed from the anterior aspect, the inguinal ligament forms the base of the triangle, the edge of the rectus abdominis forms the medial border, and the inferior epigastric vessels form the superolateral border.

Below the iliopubic tract are the critical anatomic elements from which a femoral hernia may develop. The iliopectineal arch separates the vascular compartment that contains the femoral vessels from the neuromuscular compartment that contains the iliopsoas muscle, the femoral nerve, and the lateral femoral cutaneous nerve. The vascular compartment is invested by the femoral sheath, which has three subcompartments: the lateral, containing the femoral artery and the femoral branch of the genitofemoral nerve; the middle, containing the femoral vein; and the medial, which is the cone-shaped cul-de-sac known as the femoral canal. The femoral canal is normally a 1 to 2 cm blind pouch that begins at the femoral ring and extends to the level of the fossa ovalis. The femoral ring is bordered by the superior pubic ramus inferiorly, the femoral vein laterally, and the iliopubic tract (with its curved insertion onto the pubic ramus) anteriorly and medially. The femoral canal normally contains preperitoneal fat, connective tissue, and lymph nodes (including Cloquetis node at the femoral ring),which collectively make up the femoral pad. This pad acts as a cushion for the femoral vein, allowing expansion such as might occur during a Valsalva maneuver, and serves as a plug to prevent abdominal contents from entering the thigh. A femoral hernia exists when the blind end of the femoral canal becomes an opening through which a peritoneal sac can protrude.

Between the transversalis fascia and the peritoneum is the preperitoneal space. In the midline behind the pubis, this space is known as the space of Retzius; laterally, it is referred to as the space of Bogros. The preperitoneal space is of particular importance for surgeons because many of the inguinal hernia repairs (see below) are performed in this region. The inferior epigastric vessels, the deep inferior epigastric vein, the iliopubic vein, the rectusial vein, the retropubic vein, the communicating rectusioepigastric vein, the internal spermatic vessels, and the vas deferens are all encountered in this space.

Clinical signs

History and physical examination remain the best means of hernias diagnosis. The review of systems should carefully seek out associated conditions, such as ascites, constipation, obstructive uropathy, chronic obstructive pulmonary disease and cough.

Inguinal hernia. The diagnosis of hernia is usually made because a patient, parent, or physician sees a bulge in the inguinal region or scrotum. This bulge may be intermittent as the herniating viscus may or may not enter the space depending on intra-abdominal pressure.

In infants, the only symptom of hernia may be increased irritability, especially with a large hernia. Hernias in older children and adults may be accompanied by a dull ache or burning pain, which often worsens with exercise or straining (e.g., coughing).

Examination of an adult is best performed from the seated position with the patient standing. One visualizes the inguinal canal regions for the bulge. Frequently, a provocative cough is necessary to expose the hernia. The cough is repeated as the examiner invaginates the scrotum and feels for an impulse. The diameter of the internal ring is assessed.

In a sliding inguinal hernia, a portion of viscus or its mesentery constitutes part of the hernia sac. The bladder can be seen medially in the hernia sac, while portions of the colon (cecum on the right side, sigmoid on the left side) may be part of any hernia sac. In females, the ovary or fallopian tubes may become part of the wall of the hernia sac and must be carefully preserved during repair.

If the visceral contents of a hernial sac do not easily reduce into the peritoneal cavity, the hernia is incarcerated. If the contents cannot be reduced at all, the hernia is irreducible. In chronic hernias, adhesions may impair reduction.

Some hernias, such as obturator, femoral, or lumbar hernias, should be considered as causes of bowel obstruction. Intense pain is suggestive of strangulation with ischaemic bowel. Torsion of the bowel on entry into the sac may lead to precipitous symptoms, while a more gradual onset of pain arises from progressive lymphatic, venous, and then finally arterial compromise secondary to occlusion at the neck of the sac.

Spigelian hernias present with local pain and signs of obstruction from incarceration. This pain increases with contraction of the abdominal musculature.

Interparietal hernias between the layers of the abdominal wall present in a similar manner. A mass may be just superior and lateral to the external ring, and the scrotum may not contain a testis.

Internal supravesical hernias may have obstructive symptoms of the intestinal tract or those resembling a urinary tract infection.

An umbilical hernia presents as a central, midabdominal bulge. Altered sensorium and obesity enhance the danger of incarceration. Hypertrophic, hyperpigmented, papyraceous skin is testimony to high pressure on the skin. The size of the fascial defect and whether it is circular provide management clues.

Diastasis recti or a widened linea alba has no clinical significance and does not require operative repair. However, there may be small openings in the linea alba through which preperitoneal fat can protrude. These epigastric hernias occur in children as well as in adults, suggesting that the defects are congenital.

The name paraumbilical hernia applies when this defect is adjacent to the umbilicus, while the term epiplocele or ventral hernia is used to describe more craniad defects. These midline hernias present as lumps anywhere along the linea alba and tend to cause sudden severe pain with exercise.

Clinical signs of hernia’s strangulation:

acute pain;

incarceration;

meteorism;

vomiting.

Surgical treatment

Inguinal Herniorrhaphy.

Nonprosthetic Repair.

Local anaesthesia is entirely adequate, especially when combined with intravenous infusion of a rapid-acting, short-lasting, amnesic and anxiolytic agent such as propofol. This is the approach most commonly employed in specialty hernia clinics.

The various inguinal herniorrhaphies have a number of initial technical steps in common.

Step 1. Initial incision

Traditionally, the skin is opened by making an oblique incision between the anterior superior iliac spine and the pubic tubercle. For cosmetic reasons, however, many surgeons now prefer a more horizontal skin incision placed in the natural skin lines. In either case, the incision is deepened through Scarpais and Camperis fasciae and the subcutaneous tissue to expose the external oblique aponeurosis. The external oblique aponeurosis is then opened through the external inguinal ring.

Step 2. Mobilization of cord structures

The superior flap of the external oblique fascia is dissected away from the anterior rectus sheath medially and the internal oblique muscle laterally. The iliohypogastric nerve is identified at this time; it can be either left in situ or freed from the surrounding tissue and isolated from the operative field by passing a haemostat under the nerve and grasping the upper flap of the external oblique aponeurosis. Routine division of the iliohypogastric nerve along with the ilioinguinal nerve is practiced by some surgeons but is not advised by most. The cord structures are then bluntly dissected away from the inferior flap of the external oblique aponeurosis to expose the shelving edge of the inguinal ligament and the iliopubic tract. The cord structures are lifted en masse with the fingers of one hand at the pubic tubercle so that the index finger can be passed underneath to meet the thumb or the fingers of the other hand. Mobilization of the cord structures is completed by means of blunt dissection, and a drain is placed around them for retraction during the procedure.

Step 3. Division of cremaster muscle

Complete division of the cremaster muscle has been common practice, especially with indirect hernias. The purposes of this practice are to facilitate identification of the sac and to lengthen the cord for better visualization of the inguinal floor. Almost always, however, adequate exposure can be obtained by opening the muscle longitudinally, which reduces the chances of damage to the cord and prevents testicular descent.

Step 4. High ligation of sac

The term high ligation of the sac is used frequently in discussign hernia repair; its historical significance has ingrained it in the descriptions of most of the older operations. For our purposes in this chapter, high ligation of the sac should be considered equivalent to reduction of the sac into the preperitoneal space without excision. The two methods work equally well and are highly effective. Some surgeons believe that sac inversion results in less pain (because the richly innervated peritoneum is not incised) and may be less likely to cause adhesive complications. Sac eversion in lieu of excision does protect intra-abdominal viscera in cases of unrecognized incarcerated sac contents or sliding hernia.

Step 5. Management of inguinal scrotal hernial sacs

Some surgeons consider complete excision of all indirect inguinal hernial sacs important. The downside of this practice is that the incidence of ischaemic orchitis from excessive trauma to the cord rises substantially. The logical sequel of ischaemic orchitis is testicular atrophy, though this presumed relationship has not been conclusively proved.

In our view, it is better to divide an indirect inguinal hernial sac in the mild portion of the inguinal canal once it is clear that the hernia is not sliding and no abdominal contents are present. The distal sac is not removed, but its anterior wall is opened as far distally as is convenient. Contrary to the opinion commonly voiced in the urologic literature, this approach does not result in excessive postoperative hydrocele formation.

Step 6. Repair of inguinal floor

 Methods of repairing the inguinal floor differ significantly among the various repairs and are described separately.

Step 7. Relaxing incision

A relaxing incision is made through the anterior rectus sheath and down to the rectus abdominis, extending superiorly from the pubic tubercle for a variable distance, as determined by the degree of tension present.

Some surgeons prefer incision laterally at the superior end. This relaxing incision works because as the anterior rectus sheath separates, the various components of the abdominal wall are displaced laterally and inferiorly.

 

 

Step 8. Closure

Closure of the external oblique fascia serves to reconstruct the superficial (external) ring. The external ring must be loose enough to prevent strangulation of the cord structures yet tight enough to ensure that an inexperienced examiner will not confuse a dilated ring with a recurrence. A dilated external ring is sometimes referred to as an industrial hernia, because over the years it has occasionally been a problem during preemployment physical examinations. Scarpais fascia and the skin are closed to complete the operation.

Details of Some Specific Repairs

Bassini’s repair (fig. 23). Edoardo Bassini is considered the father of modern inguinal hernia surgery. The initial steps in the procedure have already described.

Bassini felt that the incision in the external oblique aponeurosis should be as superior as possible while still so that allowing the superficial external ring to be opened, reapproximation suture line created later in the operation would not be directly over the suture line of the inguinal floor reconstruction. Whether this technical point is significant is debatable.

Bassini also felt that lengthwise division of the cremaster muscle followed by resection was important for ensuring that an indirect hernial sac could not be missed and for achieving adequate exposure of the inguinal floor.

After performing the initial dissection and the reduction or ligation of the sac, Bassini began the reconstruction of the inguinal floor by opening the transversalis fascia from the internal inguinal ring to the pubic tubercle, thereby exposign the preperitoneal fat, which was bluntly dissected away from the undersurface of the superior flap of the transversalis fascia. This step allowed him to properly prepare the deepest structure in his famous “triple layer”.

The first stitch in Bassini’s repair includes the triple layer superiorly and the periosteum of the medial side of the pubic tubercle, along with the rectus sheath. In current practice, however, most surgeons try to avoid the periosteum of the pubic tubercle so as to decrease the incidence of osteitis pubis. The repair is then continued laterally, and the triple layer is secured to the reflected inguinal ligament (Poupartis ligament) with nonabsorbable sutures. The sutures are continued until the internal ring is closed on its medial side. A relaxing incision was not part of Bassini’s original description but now is commonly added.

Concerns about injuries to neurovascular structures in the preperitoneal space as well as to the bladder led many surgeons, especially in North America, to abandon the opening of the transversalis fascia. The unfortunate consequence of this decision is that the proper development of the triple layer is severely compromised. In lieu of opening the floor, a forceps (e.g., an Allis clamp) is used to grasp tissue blindly in the hope of including the transversalis fascia and the transversus abdominis. The layer is then sutured, along with the internal oblique muscle, to the reflected inguinal ligament as in the classic Bassini’s repair. The structure grasped in this modified procedure is sometimes referred to as the conjoined tendon, but this is not correct because of the variability in what is actually grasped in the clamp.

Shouldice’s repair (fig. 24). The repair is started at the pubic tubercle by approximating the iliopubic tract laterally to the undersurface of the lateral edge of the rectus abdominis. The suture is continued laterally, approximating the iliopubic tract to the medial flap, which is made up of the transversalis fascia, the internal oblique muscle, and the transversus abdominis. Eventually, four suture lines are developed from the medial flap. The continuous suture is extended to the internal ring, where the lateral stump of the cremaster muscle is picked up to form a new internal ring. Next, the direction of the suture is reversed back toward the pubic tubercle, approximating the medial edges of the internal oblique muscle and the transversus abdominis to Poupartis ligament, and the wire is tied to itself and then to the first knot. Thus, two suture lines are formed by the first suture. The second wire suture is started near the internal ring, approximating the internal oblique muscle and the transversus abdominis to a band of external oblique aponeurosis superficial and parallel to Poupartis ligament – in effect, creating the second, artificial Poupartis ligament. This third suture line ends at the pubic crest. The suture is then reversed, and the fourth suture line is constructed in a similar manner, superficial to the third line.

McVay’s repair. This operation is similar to the Bassini’s repair, except that it uses Cooperis’s ligament instead of the inguinal ligament for the medial portion of the repair.

Interrupted sutures are placed from the pubic tubercle laterally along Cooperis’s ligament, progressively narrowing the femoral ring; this constitutes the most common application of the repair – namely, treatment of a femoral hernia .The last stitch in Cooperis’s ligament is known as a transition stitch and includes the inguinal ligament. This stitch has two purposes:(1) to complete the narrowing of the femoral ring by approximating the inguinal ligament to Cooperis’s ligament, as well as to the medial tissue, and (2) to provide a smooth transition to the inguinal ligament over the femoral vessel so that the repair can be continued laterally (as in a Bassini repair). Given the considerable tension required to bridge such a large distance, a relaxing incision should always be used. In the view of many authorities, this tension results in more pain than is noted with other herniorrhaphies and predisposes to recurrence. For this reason, the McVay’s repair is rarely chosen today, except in patients with a femoral hernia or patients with a specific contraindication to mesh repair.

Girard’s repair. In these operations it is proposed to attach the edges of the internal oblique muscle and transverse muscle of abdomen to the inguinal ligament over the spermatic duct. The aponeurosis of the external oblique muscle sutured by second layer of the suture. Excess of the aponeurosis is fixed to the muscle in the form of duplication.

Spasokukotsky’s repair. Proposed to suture the edges of the internal oblique muscle and transverse muscle of abdomen with aponeurosis of the external oblique muscles by signle-layer interrupted suture.

Martynov’s repair. Proposed the fixation to the Poupartis ligament the internal edge of the external oblique muscle aponeurosis without muscles. External edge of the aponeurosis is sutured over internal in the form of duplication.

Kimbarovsky’s repair. Based on the principles of joining similar tissues, proposed special suture: Sutures placed on 1 cm from the edge of the external oblique abdominal muscle aponeurosis, grasped the part of the internal oblique and transverse muscle of abdomen. After that, aponeurosis is sutured one more time from behind to the front and attached to the Poupartis ligament.

Kukudganov’s repair. Proposed to restore back wall of inguinal interval. Sutures are placed between the Couperis ligament, direct abdominal muscle and aponeurosis of the transversal muscle.

Postempsky’s repair (fig. 25). Proposed the closure of inguinal interval with the lateralization moving of spermatic duct. The plastic narrowing of internal inguinal ring of to 0.8 cm is the important stage of this modification. On occasion, when internal and external inguinal rings are in one plaine, the spermatic duct is displaced in lateral direction by transversal incision of the oblique and transversus muscles.

 

Inguinal Herniorrhaphy. Alloplastic Repair

Lichtenstein’s repai. The first five steps of a Lichtenstein’s repair are very similar to the first five steps of a conventional anterior nonprosthetic repair, but there are certain technical points that are worthy of emphasis. The external oblique aponeurosis is generously freed from the underlying anterior rectus sheath and internal oblique muscle and aponeurosis in an avascular zone from a point at least 2 cm medial to the pubic tubercle to the anterior superior iliac spine laterally. Blunt dissection is continued in this avascular zone from the region lateral to the internal ring to the pubic tubercle along the shelving edge of the inguinal ligament and the iliopubic tract. As a continuation of this same motion, the cord with its cremaster covering is swept off the pubic tubercle and separated from the inguinal floor. Besides mobilizing the cord, these maneuvers create a large space beneath the external oblique aponeurosis that can eventually be used for prosthesis placement. The ilioinguinal nerve, the external spermatic vessels and the genital branch of the genitofemoral nerve all remain with the cord structures.

For indirect hernias, the cremaster muscle is incised longitudinally, and the sac is dissected free and reduced into the preperitoneal space. Theoretically, this operation could be criticized on the grounds that if the inguinal floor is not opened, an occult femoral hernia might be overlooked. To date, however, an excessive incidence of missed femoral hernias has not been reported. In addition, it is possible to evaluate the femoral ring via the space of Bogro’s through a small opening in the canal floor.

Direct hernias are separated from the cord and other surrounding structures and reduced back into the preperitoneal space. Dividing the superficial layers of the neck of the sac circumferentially – which, in effect, opens the inguinal floor – usually facilitates reduction and helps maintain it while the prosthesis is being placed? This opening in the inguinal floor also allows the surgeon to palpate for a femoral hernia. Sutures can be used to maintain reduction of the sac, but they have no real strength in this setting; their main purpose is to allow the repair to proceed without being hindered by continual extrusion of the sac into the field, especially when the patient strains.

Placement of prosthesis.  A mesh prosthesis is positioned over the inguinal floor. The medial end is rounded to correspond to the patients particular anatomy and secured to the anterior rectus sheath at least 2 cm medial to the pubic tubercle. A continuous suture of either nonabsorbable or long-lasting absorbable material should be used. Wide overlap of the pubic tubercle is important to prevent the pubic tubercle recurrences all too commonly seen with other operations. The suture is continued laterally in a locking manner, securing the prosthesis to either side of the pubic tubercle (not into it) and then to the shelving edge of the inguinal ligament. The suture is tied at the internal ring.

Creation of shutter valve. A slit is made at the lateral end of the mesh in such a way as to create two tails, a wider one (approximately two thirds of the total width) above and a narrower one below. The tails are positioned around the cord structures and placed beneath the external oblique aponeurosis laterally to about the anterior superior iliac spine, with the upper tail placed on top of the lower. A signle interrupted suture is placed to secure the lower edge of the superior tail to the lower edge of the inferior tail effect, creating a shutter valve. This step is considered crucial for preventing the indirect recurrences occasionally seen when the tails are simply reapproximated. The same suture incorporates the shelving edge of the inguinal ligament so as to create a domelike buckling effect over the direct space, thereby ensuring that there is no tension, especially when the patient assumes an upright position.

Securing of prosthesis. A few interrupted sutures are placed to attach the superior and medial aspects of the prosthesis to the underlying internal oblique muscle and rectus fascia. On occasion, the iliohypogastric nerve, which courses on top of the internal oblique muscle, penetrates the medial flap of the external oblique aponeurosis. In this situation, the prosthesis should be slit to accommodate the nerve. The prosthesis can be trimmed in situ, but care should be taken to maintain enough laxity to allow for the difference between the supine and the upright positions, as well as for possible shrinkage of the mesh.

Femoral Herniorrhaphy.

There are some methods of surgical treatment of the femoral hernia, where the plastic repair is performed intraperitoneally from the side of thigh through the inguinal canal.

The Bassini’s method is attributed to “femoral”. It is performed through an incision, that passes under inguinal fold. After removal of hernial sac the hernial opening is closed by suturing of inguinal ligament (1) to the pectineal ligament (2) without pressure of femoral vein (3) (fig. 26). The Rudgi-Parlavecho method (fig. 27). Ends of the transversus and internal oblique muscles and inguinal ligament sutured to the periosteum of pubic bone.

 

Umbilical and Paraumbilical hernia

An umbilical hernia is the result of improper healing of an umbilical scar, which leads to a fascial defect that is covered by skin. If the defect is to one side, it is called a paraumbilical hernia; this variant is more common in adults. The vast majority of umbilical hernias presenting in children are congenital, whereas 90% of those diagnosed in adults are acquired. These hernias are eight times more common in black children than in white ones.

The onset of umbilical or paraumbilical hernia in older patients is usually sudden, and the defect tends to be relatively small. In these patients, it is important to look for an underlying cause of increased intra-abdominal pressure (e.g., ascites or an intra-abdominal tumor).

The differential diagnosis of an umbilical hernia should include so-called caput medusae, a condition in which varicosities extend radially from the umbilicus as a consequence of portal hypertension.

Another condition to be considered is the so-called Sister Mary Joseph node, which is a metastatic deposit of intra-abdominal cancer at the umbilicus. The cancer cells reach this region via lymphatic vessels in the falciform ligament.

Other periumbilical masses that might be confused with an umbilical hernia are umbilical granulomas, omphalomesenteric duct remnant cysts, and urachal cysts.

Most of the defects are small and can therefore be closed by simple suturing. Alternatively, the Mayo technique may be used (fig. 28).

 

A subumbilical semilunar incision is made, the hernial sac is opened, the contents of the sac are reduced into the abdomen, and the sac is excised. An overlapping or waist-coating technique is then employed, in which the upper edge of the linea alba is placed so as to overlap the lower and fixed in place with a nonabsorbable mattress suture. This technique is controversial: some surgeons argue that the overlapping layers serve only to increase the tension on the repair, thus inviting recurrence.

The fascial defect is then bridged with prosthesis without fear of contact with the intra-abdominal viscera. The prosthesis is sutured circumferentially to the defect; alternatively, it can be sutured to the undersurface of the posterior rectus sheath and the linea alba above the peritoneal closure. If the peritoneum cannot be kept intact beneath the defect, omentum should be tacked to the peritoneum circumferentially to isolate the abdominal viscera from the prosthesis at least to some degree.

Postoperative Hernia

Simple nonprosthetic repair

Simple nonprosthetic repair of an incisional hernia is reserved for only the least complicated defects, because in large series of unselected patients, the recurrence rate ranges from 25 to 55%.

If there is a solitary defect 3 cm or less in diameter, primary closure with nonabsorbable suture material is appropriate.

Some surgeons use Mayo’s “vest-over-pants” repair. Various advancement and darn procedures have also been described.

A more substantial repair for these defects was popularized by Ramirez. In this operation, known as the component separation technique, the abdominal wall is lengthened by allowing the muscle to separate on either side of a defect. The hernia can then be repaired primarily with less tension on the repair. This procedure is especially useful at contaminated hernia sites.

A similar procedure is the keel operation of Maingot, which was popular in the middle of the 20th century. The anterior rectus sheath is incised longitudinally, and the medial edge is allowed to rotate behind the rectus abdominis. This, in effect, lengthens the posterior rectus sheath, allowing it to be closed under less tension. The lateral edges of the incised rectus sheath on each side are then approximated to each other.

Onlay prosthetic repair

In this technique, a prosthetic onlay is placed over any of a wide variety of simple repairs. Large series of selected patients have documented acceptable results with onlay prosthetic repair, but most surgeons feel that this technique offers little advantage over the simple repair that the prosthesis overlies.

Prosthetic bridging repair

Prosthetic bridging repair became popular in the 1990s, in keeping with the tension-free concept for inguinal herniorrhaphy.

When a hernia defect is bridged with a mesh prosthesis, every attempt should be made to isolate the material from the intraabdominal viscera to prevent erosion and subsequent fistula formation or adhesive bowel obstruction. This can be accomplished by means of a peritoneal flap constructed from the peritoneal sac or omentum. When contact with intra-abdominal organs cannot be avoided, expanded polytetrafluoroethylene (e-PTFE) should be strongly considered for the prosthesis. Most authorities feel that complications are less likely with e-PTFE, though this has not been unequivocally shown to be the case.

Combined fascial and mesh closure

The issue of contact between the intra-abdominal viscera and the prosthesis has been further addressed by techniques that combine features of the component separation technique with the tension-free concept. The posterior fascia is closed primarily, but the anterior fascia is allowed to remain open, so that there is no tension at all. The anterior fascia is then bridged with a prosthesis.

Sublay prosthetic repair

Sublay prosthetic repair, sometimes referred to as the retromuscular approach, is characterized by the placement of a large prosthesis in the space between the abdominal muscles and the peritoneum.

The posterior rectus sheath is opened on each edge of the hernia defect and dissected away from the undersurface of the recti or a distance of 10 to 15 cm. The posterior rectus sheaths are hen approximated to each other primarily. A large mesh prosthesis (composed of e-PTFE if the approximation of the posterior rectus sheath is inadequate) is then placed in this space outside he repaired posterior sheath but beneath the recti. The mesh is secured in this position with several sutures that are placed with a suture passer through small stab incisions at the periphery of he prosthesis and tied in the subcutaneous tissue above the fascia.

Postoperative complications

1. Recurrence of the hernia after repair is estimated to occur in 3–10% of patients.

2. Temporary urinary retention with difficulty urinating is common.

3. Wound infection occurs in 1–3% of patients postoperatively.

4. Injury:

to the ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerves rarely occurs and may result in paresthesias in their distribution of innervation;

to the structures of the spermatic cord rarely occurs.

5. Seroma and haematoma.