Inguinal Hernia Repair

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CHAPTER 4 Inguinal Hernia Repair

Demetri J. Merianos, Steven E. Raper

Case Study

A 29-year-old male presents to his primary care physician’s office complaining of a bulge in his right groin, which he first noticed 2 weeks earlier. He denies associated pain, nausea, or vomiting. He denies a history of constipation, difficulty with urination, or chronic cough. He recently began a rigorous exercise program involving heavy lifting. Physical examination shows a nontender, reducible right groin mass that protrudes into the right scrotum when the patient coughs.

BACKGROUND

A hernia is defined as the protrusion of any structure beyond its normal anatomic boundaries. In the case of an inguinal hernia, a peritoneum-lined sac containing abdominal organs (e.g., small intestine or omentum) protrudes through a defect in the inguinal region of the abdominal wall. When a hernia can be replaced within the abdominal wall musculature, it is described as reducible; when it cannot, it is described as incarcerated. Strangulation, which is caused by compromise of the blood supply to the contents of an incarcerated hernia, is the most serious complication of an untreated hernia.

Inguinal hernias are further characterized as either indirect or direct. Indirect inguinal hernias enter the inguinal canal through the deep inguinal ring lateral to the inferior epigastric vessels and may communicate with the scrotum. Direct inguinal hernias protrude directly through the floor of the inguinal canal medial to the inferior epigastric vessels through a space known as Hesselbach’s triangle. The term pantaloon hernia describes concomitant direct and indirect hernias. Indirect inguinal hernias are the most common type in both male and female patients and are believed to result from persistent patency of the processus vaginalis. Factors that result in elevation of intra-abdominal pressure (e.g., lifting, straining with urination or defecation, ascites, chronic cough) may contribute to the development of both indirect and direct inguinal hernias.

The processus vaginalis is an outpouching of the peritoneum through which the testicle descends into the scrotum during development.

Hesselbach’s triangle is the space bounded by the lateral border of the rectus abdominis medially, the inguinal ligament inferiorly, and the inferior epigastric vessels laterally. Direct inguinal hernias protrude through this space.

Approximately 700,000 inguinal hernia repairs are performed annually, making this one of the most common surgical procedures. Historically, surgeons repaired inguinal hernias by directly approximating tissues to reinforce the area of abdominal wall weakness. Over the course of the last two decades, the “tension-free” repair, using prosthetic mesh to repair the hernia defect, has emerged as the preferred technique. More recently, a variety of laparoscopic approaches have gained popularity. The open (anterior) mesh repair is the primary focus of this chapter, but several other approaches are briefly described.

INDICATIONS FOR INGUINAL HERNIA REPAIR

I. Reducible Hernias: Traditionally, the presence of an inguinal hernia constituted an indication for its repair. Two major arguments were made in favor of this approach: (1) over time, hernias tend to enlarge and become symptomatic; and (2) the seriousness of complications associated with untreated hernias, namely, incarceration and strangulation, justifies the risks associated with surgical repair. Although many surgeons continue to subscribe to this approach, a role for expectant management of asymptomatic inguinal hernias has emerged, particularly in high-risk patients. Low- to moderate-risk patients are generally offered the option of hernia repair.
II. Incarcerated Hernias: Edema of the contents of a hernia, or formation of adhesions to the peritoneum-lined hernia sac, may result in incarceration. Incarceration of a bowel-containing hernia may result in intestinal obstruction and, if left untreated, strangulation and bowel necrosis. Incarceration of a hernia that contains only one sidewall of the bowel may progress to strangulation without signs of obstruction; such hernias are known as Richter’s hernias. Acutely incarcerated hernias require immediate operative repair. Strangulated, nonviable bowel requires resection at the time of surgery. In contrast, in the absence of pain or obstructive symptoms (e.g., nausea and vomiting), chronically incarcerated hernias may be repaired electively (Fig. 4-1).

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Figure 4-1 Algorithm for the management of reducible versus incarcerated inguinal hernias.

ACUTE INCARCERATION OF A HERNIA GENERALLY MANDATES URGENT OPERATIVE REPAIR TO PREVENT STRANGULATION.

PREOPERATIVE EVALUATION

A thorough history and physical examination are nearly always sufficient to make the diagnosis of an inguinal hernia.

I. History: Important components of the history include the chronicity of a hernia and the presence of associated symptoms. Additionally, an attempt should be made to elicit a history of straining from constipation, urinary obstruction, or chronic cough; these symptoms sometimes reflect underlying comorbidities necessitating additional evaluation (e.g., colonoscopy or urologic evaluation).
II. Physical Examination: Physical examination is performed with the patient supine and standing. The examiner generally places one hand over the inguinal ligament and, if the patient is male, palpates the superficial inguinal ring through the scrotal skin with the other hand. The patient is asked to cough or perform a Valsalva maneuver. Appreciation of a bulge moving from lateral to medial against the examiner’s finger suggests an indirect inguinal hernia; a mass that protrudes directly through the abdominal wall suggests a direct hernia. Bilateral examination should be performed to rule out a contralateral hernia. In appropriate patients, a digital rectal examination should be performed to exclude enlargement of the prostate or a rectal mass.

What predisposing factors may have contributed to hernia formation in your patient?

III. Imaging. In rare cases, the diagnosis of a hernia may be aided by ultrasound or cross-sectional imaging (e.g., computed tomography scan or magnetic resonance imaging).

The spermatic cord contains cremasteric muscle fibers (derived from the internal oblique muscle), the testicular artery, veins of the pampiniform plexus, the genital branch of the genitofemoral nerve, the vas deferens, lymphatics, and the processus vaginalis.

Although often referred to as the conjoint tendon, the transversus abdominis and internal oblique aponeuroses, which make up the superior border of the inguinal canal, only fuse to form a true conjoint tendon in a minority of patients.

COMPONENTS OF THE PROCEDURE AND APPLIED ANATOMY

See Figure 4-2.

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Figure 4-2 The right inguinal canal. The external oblique aponeurosis forms the roof of the inguinal canal. The floor of the canal is formed by the transversalis fascia and the aponeurosis of the transversus abdominis muscle. Superiorly, the canal is bounded by the conjoint tendon. Inferiorly, the external oblique aponeurosis folds under itself to form the inguinal ligament. The inferior epigastric vessels course between the transversus abdominis muscle and transversalis fascia. The internal abdominal ring (deep inguinal ring) is an opening in the transversalis fascia and transversus abdominis muscle through which the spermatic cord (or round ligament in females) enters the inguinal canal. The external abdominal ring (superficial inguinal ring) is an opening in the external oblique aponeurosis adjacent to the pubic tubercle through which the cord exits the canal.

(From Read RC: The transversalis and preperitoneal fasciae: A re-evaluation. In Nyhus LM, Condon RE [eds]: Hernia, 4th ed. Philadelphia, Lippincott, 1995, pp 57–63.)

A variation of the procedure described by Lichtenstein, using a mesh patch to reinforce the floor of the inguinal canal and a mesh plug to partially occlude the internal inguinal ring, has become the most common approach to inguinal hernia repair and is described below.

Preoperative Considerations

I. Prophylactic antibiotics are often given before hernia repair, particularly in the era of prosthetic mesh repairs.
II. Adequate anesthesia can be achieved with regional, spinal, epidural, or general anesthesia.

Patient Positioning and Preparation

I. The patient is placed in the supine position.
II. The sterile preparation should include both inguinal regions and the genitalia, and should extend to the umbilicus superiorly, the midaxillary lines laterally, and the mid-thighs inferiorly.

Incision and Exposure

I. A 3- to 4-inch incision is made one fingerbreadth above, and parallel to, the inguinal ligament.

The inguinal ligament forms a line between the anterior superior iliac spine laterally and the pubic tubercle medially.

II. The incision is carried down through the subcutaneous fat and Scarpa’s fascia to the external oblique aponeurosis. The aponeurosis is incised parallel to the direction of its fibers. When encountered, care is taken not to injure the ilioinguinal nerve, which lies directly beneath this layer.
III. The external oblique fascia is bluntly dissected off of the spermatic cord. The cord is then encircled at the level of the pubic tubercle (Fig. 4-3).

image

Figure 4-3 Exposure of the spermatic cord. The spermatic cord is identified and is bluntly dissected free from surrounding structures.

(Adapted from Condon RE, Telford GL: Hernia. In Nora PF [ed]: Operative Surgery: Principles and Techniques, 3rd ed. Philadelphia, Saunders, 1990.)

Does the patient have a direct or an indirect inguinal hernia?

High Ligation of the Hernia Sac

I. When present, an indirect hernia sac is usually encountered deep to the cremasteric muscle fibers (which surround the spermatic cord), and anterior and medial (superior) to the cord. To expose the sac, cremasteric fibers are first divided. The hernia sac is then dissected off of the spermatic cord.
II. Direct hernias protruding through the floor of the inguinal canal are likewise dissected free from surrounding structures.
III. The hernia sac is opened (explored) to confirm that all hernia contents have been reduced within the peritoneal cavity.
IV. The hernia sac is ligated just above the transversalis fascia (i.e., high ligation), and excess sac is excised.

An indirect hernia sac is usually located deep to cremasteric muscle fibers, anterior and medial (superior) to the spermatic cord.

Reconstruction

I. A mesh plug is placed in the internal ring alongside the spermatic cord or Hesselbach’s triangle, depending on the type of hernia. The plug is loosely secured to the surrounding tissues and serves to partially occlude the hernia defect.
II. A patch of mesh, sized to cover the floor of the inguinal canal, is sutured to the pubic tubercle medially. The inferior aspect of the mesh is then sutured to the edge of the inguinal ligament (known as the “shelving edge”). The superior aspect of the mesh is sutured to the conjoint tendon.
III. A slit is cut in the lateral edge of the mesh to accommodate the spermatic cord, which passes through this opening and lies over the mesh patch. The resultant tails of mesh are sutured together laterally around the spermatic cord, recreating the internal ring (Fig. 4-4).
image

Figure 4-4 Reconstruction with mesh. A mesh patch is sutured to the internal oblique and transversus abdominis aponeuroses superiorly and the shelving edge of the inguinal ligament inferiorly. A slit is cut in the patch laterally to accommodate the spermatic cord.

(Adapted from Knol JA, Eckhauser FE: Inguinal anatomy and abdominal wall hernias. In Greenfield LJ [ed]: Surgery: Scientific Principles and Practice, 2nd ed. Philadelphia, Lippincott, 1997, with permission.)

Closure

I. The external oblique aponeurosis is closed over the spermatic cord.
II. The subcutaneous tissues and skin are closed in separate layers.
III. Traction is applied to the ipsilateral testicle at the conclusion of the procedure because this testicle often migrates superiorly secondary to intraoperative traction on the spermatic cord.

Was traction applied to the testicle on the operative side at the conclusion of the hernia repair?

Other Approaches

I. Other open approaches to hernia repair are still occasionally performed. The incision, exposure, and hernia sac ligation as described earlier are common to all of these repairs. They differ from one another mainly in the technique of abdominal wall reconstruction. For example, the Bassini repair is performed by suturing the transversus abdominis and internal oblique aponeuroses directly to the shelving edge of the inguinal ligament without mesh (Fig. 4-5). The McVay repair, which allows for the repair of inguinal and femoral hernias, involves suturing the transversus abdominis aponeurosis to Cooper’s ligament medial to the femoral vein.

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Figure 4-5 The Bassini repair. The conjoint tendon is sutured to the shelving edge of the inguinal ligament with interrupted sutures.

(From Townsend CM, Beauchamp RD, Evers BM, Mattox KL [eds]: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 16th ed. Philadelphia, Saunders, 2004.)

Cooper’s ligament, the periosteum and fascia overlying the superior ramus of the pubic bone, forms the posterior border of the femoral canal (through which the femoral vessels pass). Cooper’s ligament is an important landmark for both the McVay repair and laparoscopic repairs.

II. Laparoscopic approaches to hernia repair have gained considerable popularity. Such approaches may be particularly useful for the repair of bilateral or recurrent hernias. There are two basic approaches to laparoscopic hernia repair, the transabdominal preperitoneal (TAPP) repair and the totally extraperitoneal (TEP) repair (Fig. 4-6). Both procedures involve the placement of mesh over the direct and indirect spaces.

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Figure 4-6 Totally extraperitoneal repair and preperitoneal anatomy. The spermatic cord structures are seen entering the inguinal canal through the internal ring, lateral to the epigastric vessels (indirect space). The triangular space between the spermatic vessels (right) and vas deferens (left), known as the “triangle of doom,” contains the external iliac vessels and nerve. The totally extraperitoneal repair involves placement of a mesh patch over both direct and indirect spaces after hernia reduction. Mesh is fixed to Cooper’s ligament inferiorly and to the rectus musculature and transversus abdominis aponeurosis above the hernia defect.

(From Corbitt J: Laparoscopic transabdominal transperitoneal patch hernia repair. In Ballantyne GH [ed]: Atlas of Laparoscopic Surgery. Philadelphia, Saunders, 2000, p 511.)

WHEN PERFORMING LAPAROSCOPIC REPAIR, THE SURGEON MUST BE COGNIZANT OF THE LOCATION OF THE VAS DEFERENS AND SPERMATIC VESSELS TO AVOID INJURY TO THE EXTERNAL ILIAC VESSELS AND FEMORAL NERVE IN THE “TRIANGLE OF DOOM.”

POSTOPERATIVE COURSE

Inguinal hernia repairs are generally performed on an outpatient basis. Patients resume a regular diet shortly after surgery and are discharged and prescribed oral pain medications after they urinate successfully. Most surgeons prohibit strenuous activity until approximately 6 weeks after hernia repair.

COMPLICATIONS

I. Postoperative urinary retention, believed to be secondary to both anesthesia and manipulation of pelvic nerves, is common after inguinal hernia repair. It is almost always self-limited, but may require temporary bladder catheterization.
II. Approximately 5% of patients experience chronic pain after inguinal hernia repair. Chronic pain may be related to nerve entrapment. The most commonly injured nerves are the ilioinguinal and the genitofemoral. Both nerves are routinely encountered during open inguinal hernia repairs. Division of these nerves may result in numbness. Some surgeons advocate transection of these structures when they are encountered to avoid entrapment, which may result in chronic pain. Analgesics and local anesthetic nerve blocks are sometimes helpful in treating chronic pain syndromes. Occasionally, if nerve entrapment is suspected and symptoms are severe, reoperation and neurectomy (excision of a segment of nerve) are indicated.
III. Rates of hernia recurrence are generally reported as less than 1%. Recurrent inguinal hernias are most commonly direct hernias at the medial aspect of the previous repair, near the pubic tubercle. Recurrences may be repaired using an open (anterior) approach. However, increasingly, laparoscopic approaches are used in this setting to avoid dissection through scar tissue.
IV. Infection rates of less than 1% are reported after inguinal hernia repair. When surgical site infections involve underlying mesh prostheses, mesh removal is frequently necessary.
V. Ischemic Orchitis: Compromise of the venous drainage of the testicle, typically from thrombosis of the small vessels of the pampiniform plexus, may result in testicular congestion, pain, swelling, and subsequent atrophy. Symptoms may persist for a period of several weeks and, rarely, orchiectomy is indicated.
VI. Injury to intra-abdominal organs and the vas deferens are rare but serious complications of inguinal hernia repair. Such injuries may be more common during the repair of large hernias, which can displace the vas deferens, making its identification challenging. The presence of a sliding hernia, in which part of a hernia sac is composed of intra-abdominal viscera (e.g., the bladder or colon), can also increase the likelihood of injuries.

SUGGESTED READINGS

Eubanks WS. Hernias. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia: Saunders; 2001:783-801.

Fitzgibbons RJJr, Giobbie-Hurder A, Gibbs JO, et al. Watchful waiting versus repair of inguinal hernia in minimally symptomatic men. JAMA. 2006;295:285-292.

Malangoni MA, Gagliardi RJ. Hernias. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, editors. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Philadelphia: Saunders; 2004:1199-1218.

Neumayer L, Giobbie-Hurder A, Jonasson O, et al. Open mesh versus laparoscopic mesh repair of inguinal hernia. N Engl J Med. 2004;350:1819-1827.

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