Groin Hernias

Posted by e-Medical PPT Tuesday, April 17, 2012
Definition
Abnormal protrusion of a peritoneal lined sac thru the musculoaponeurotic covering of the abdomen
In US 96% are inguinal, 4% femoral
20% bilateral
Most common in both sexes indirect.
Femoral hernias more common in elderly females
Male to female ratio in 9:1 for inguinal hernias, 1:3 for femoral hernias

Anatomy
4cm in length
2-4 cm cephalad to inguinal ligament
Extends between superficial and deep rings
Contains spermatic cord or round ligament
Bounded superficially by external oblique
Cephalad by internal oblique, TA, transversalis
Inferior border is inguinal ligament
Floor is transversalis fascia

Broadly classified as indirect and direct depending on relationship to epigastric vessels.
Hesselbach’s triangle is inferior epigastric artery laterally, lateral border of rectus medially, inguinal ligament inferiorly.
An indirect hernia passes lateral to Hesselbach’s triangle.
A direct hernia passes thru Hesselbach’s triangle.
Indirect hernia has a congenital component, from processus vaginalis.
The processus is supposed to obliterate after descent of testes
Direct hernias are usually not congenital.
Acquired by the development of tissue deficiencies of the transversalis fascia.
Development of femoral hernia less understood. Can result from increased intraabdominal pressure. The sac then migrates down the femoral vessels into thigh.

Nyhus Classification
I indirect, internal ring normal (kids)
II indirect, dilated internal ring
III posterior wall defects, direct inguinal hernia, dilated internal ring, massive scrotal, sliding, femoral hernia
IV recurrent hernia

Indications for Operative Repair
Early repair is justified when potential for strangulation is weighed against minimal risks for surgery.
Not warranted in terminally ill without incarceration
Patients with ascites should have it controlled before surgery
Incarceration, strangulation

Surgical Techniques
Open anterior repair (Bassini, McVay, Shouldice).
Open posterior repair (Nyhus, preperitoneal)
Tension-free repair with mesh(Liechtenstein, Rutkow)
Laparoscopic

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