Hernias

Basic Principles Underlying principle of good hernia repair = Tension free Most common cause for recurrent hernia = wound infection Rank as cause of SBO = 2nd to adhesion (worldwide = 1st) Figure 1 - Abdominal Wall Anatomy Abdominal Wall Anatomy

• Layers of abdominal wall just off midline:
• Skin
• Subcutaneous Fat/Camper’s Fascia
• Scarpa’s Fascia
• Anterior Rectus Sheath
• Rectus Muscle
• Posterior Rectus Sheath
• Preperitoneal Fat
• Peritoneum
• Layers of abdominal wall lateral to rectus:
• Skin

• Subcutaneous Fat/Camper’s Fascia

• Scarpa’s Fascia
• External Oblique
• Internal Oblique
• Transversus Abdominis
• Transversalis Fascia
• Preperitoneal Fat
• Peritoneum
• Where does rectus sheath end?
• Arcuate line (third of distance between umbilicus and pubis symphysis)
• Bloody supply to the rectus?
• Inferior and Superior Epigastrics
• Hesselbach’s Triangle Anatomy
• Medial Border - Rectus
• Inferior Border - Inguinal Ligament
• Lateral Border - Epigastrics
• Hernia in Hesselbach’s triangle = Direct Hernia
• What is the inguinal ligament?
• Extension of the external oblique fascia
• What are the embryological structures that are at or go through umbilicus?
• Omphalomesenteric duct (Vitelline duct) → Becomes Meckel’s Diverticulum
• Median umbilical ligament → urachus
• Medial umbilical ligaments → obliterated umbilical arteries
• Round ligament of the liver (ligamentum teres) → obliterated umbilical vein
• When does the midgut herniate? And what does it return?
• Herniates at 6 weeks

• Returns at 10 weeks

• Abdominal wall defect in Omphalocele? Gastroschisis?
• Omphalocele → Through the umbilical stalk
• Gastroschisis → Inferior/Right of the umbilicus Umbilical Hernias
• Usually congenital
• Usual contents → preperitoneal fat
• Repair options?
• Open vs . Laparoscopic
• Primary repair → <1cm and pediatric patients
• 2 yo with umbilical hernia
• Wait until 5yo to see if it will close and then repair
• Fix before going to school Inguinal Hernias
• What defines indirect/direct hernia?
• Indirect is lateral to inferior epigastrics
• Direct is medial to inferior epigastrics
• Etiology of indirect?
• Congenital - Patent processus vaginalis
• Etiology of direct?
• Acquired - Weakness in floor of inguinal canal
• Risk factors for direct?
• Obesity, smoking, poor nutrition, ascites, anything with increased abdominal pressure
• Contents of spermatic cord?
• Cremasteric muscles, testicular artery, vas deferens, pampiniform plexus, ilioinguinal nerve, genital branch of genitofemoral nerve
• What forms the cremaster muscles?

• Extension of the internal oblique muscle fibers

• What are the key nerves in open inguinal hernia repair?
• Ilioinguinal
• Genital branch of genitofemoral
• Iliohypogastric
• MC injured → Ilioinguinal (when opening external oblique)
• MC injured nerve in laparoscopic hernia repair
• Lateral femoral cutaneous
• Occurs from improperly placed tack laterally
• Bassini
• Conjoint tendon (transversalis + internal oblique) to inguinal ligament
• Shouldice
• Same as bassini in multiple (4) layers
• Lichtenstein repair
• Repair with mesh, sew inguinal ligament to conjoined/ transversalis
• Plug and patch
• Plug goes into internal repair and then Lichtenstein on top
• Pediatric repair basics?
• High ligation of sac
• Laparoscopic hernia repair
• Total Extra-Peritoneal Repair (TEP) and Trans-Abdominal Pre-Peritoneal Repair (TAPP)
• Repair covers internal, direct, and femoral spaces
• Main structure of fixation in laparoscopic repair?
• Cooper’s ligament
• What and where is the triangle of doom?

• Contains Iliac vessels, medial with apex at iliopubic tract and bounded by vas deferens medially and spermatic vessels laterally

• What and where is the triangle of pain?
• Contains Nerve structures, lateral to spermatic vessels below iliopubic tract Femoral Hernias
• Who is at highest risk for femoral hernias?
• Females and elderly
• Where is the defect?
• Below the inguinal ligament, medial to the femoral vein
• How do you repair it open?
• McVay (Cooper’s) Repair
• Open inguinal floor, close femoral space by suturing Conjoint tendon to Cooper’s Ligament Incarceration vs. Strangulation
• What are the signs of symptoms?
• Obstructive, non-reducible hernia, skin changes, severe tenderness and pain
• Open approach and needed bowel resection . How do you repair?
• Biologic mesh or tissue repair Ventral/Incisional Hernias
• Risks Factors for incisional hernia?
• Wound infection, obesity, COPD, smoking
• GET THEM TO STOP SMOKING prior to elective repair
• Where can you place the mesh?
• Underlay, inlay, onlay
• Highest recurrence in inlay mesh
• Choose macroporous mesh
• Biologic mesh if contamination
• How to manage large ventral hernia if you cannot obtain

primary closure?

• Component separation – There are several types/ variations. A common board question regards which layer is incised (See Image) .
• Anterior Component Separation (incise external oblique)
• Transversus Abdominis Repair (incise transversus abdominis)
• Posterior Component Separation (incise posterior rectus sheath)
• Optimal suture closer method?
• 5-7mm bites with absorbable suture Quick Hits
• Junction of semilunaris and arcuate line?
• Spigelian hernia → intramuscular hernia
• Appendix in inguinal hernia sac?
• Amyand hernia, primary repair in appendicitis
• Meckel’s diverticulum in inguinal hernia?
• Littre’s hernia
• Both indirect and direct hernia?
• Pantaloon hernia
• Sliding hernia?
• Retroperitoneal structure makes up a portion of the sac
• Do not open sac with a sliding hernia
• Richter’s hernia
• Part of the wall of the bowel is present in the hernia sac
• Strangulation without obstruction
• Doing inguinal hernia repair and skeletonized cord and can’t find hernia?

• Need to open floor and look for femoral hernia

• Child’s C cirrhotic with massive ascites and umbilical hernia with intermittent obstructive symptoms?
• TIPS first to control ascites before considering repair
• Laparoscopic inguinal hernia repair and tack mesh to cooper’s ligament and get large arterial bleeding?
• Corona mortis (branch between obturator and external iliac artery)
• Placing suture during open inguinal hernia repair and get sudden bleeding?
• Femoral vein injury, pull suture out and hold pressure
• Groin pain/significant medial thigh pain with internal rotation of the hip?
• Obturator hernia
• Obturator sign/Howship Romberg sign
• One-month s/p open inguinal hernia repair with prolene mesh and now have wound infection with purulent fluid around mesh?
• Mesh explantation
• Inguinal hernia repair and can’t reduce sac
• Ligate proximal portion that will reduce into abdominal cavity
• Keep distal portion open to reduce chances of hydrocele

Figures