Spigelian hernia

Above the arcuate line: Both anterior and posterior rectus sheath (until the posterior sheath ends inferiorly) 

Below the arcuate ligament: anterior rectus sheath only.

Transverse. Above the arcuate line, the aponeurosis contributes to he posterior rectus sheath along with the internal oblique. Below the arcuate line, it joins the intern and external oblique to form the anterior rectus sheath.

Arching fibers of the internal oblique and transversus abdominis muscles, which forms the superior border of the inguinal canal.

What are the boundaries of Hasselbach's triangle?

What type of hernia protrudes through it?

Medial- Lateral border of the rectus

Lateral- Inferior epigastric artery

Inferior- Inguinal Ligament

Direct inguinal hernia

The spermatic cord passes through the deep inguinal ring  and consists of which structures?

As the cord passes through the deep inguinal ring, the transversalis fascia extends on to the cord, forming what?

1. Contents of spermatic cord:

Vas Deferens

Testicular Artery

Pampiniform Plexus

Obliterated (usually) procesus vaginalis

2. Internal Spermatic Fascia

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Thickening of the endoabdominal fascia where the transversalis fascia and the iliopsoas fascia meet is referred to as the ________ ________.

This also forms the inferior margin of the deep inguinal ring, and medially it forms the anterior and medial walls of the femoral canal.  

Iliopubic tract

Courses from the ASIS to the superior pubic ramus and pubic tubercle. It lies deep and superior to the inguinal ligament. 

Which abdominal wall layer corresponds with: 

1. External Spermatic Fascia

2. Cremasteric muscle

3. Internal spermatic fascia

4. Processus vaginalis

1. External Oblique

2. Internal Oblique

3. Transversalis fascia

4. Peritoneum

What are the boundaries of the femoral canal?

Laterally: Femoral Vein

Superior/anterior: Inguinal ligament

Posterior: Cooper's Ligament

Medially: Lacunar ligament

(Femoral hernia- peritoneal outpouching through the femoral canal)

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L1

Superior 

Superficial inguinal ring

Scrotum and Labia Majus canal

What nerve roots does the genital branch of the genitofemoral nerve arise from?

Where does the genital branch enter the inguinal canal?

What does does it innervate?

L1-L2

Inferior to the Deep ring

Motor: Cremaster Muscle

Sensory: Scrotum and Medial thigh

Indirect inguinal hernias occur because of persistent ______ _______, the peritoneal continuation between the abdominal cavity and the scrotum. 

What is the name of the female analogous embryologic remnant?

Processus vaginalis

Canal of Nuck

Remnant related to the migration of the gubernaculum of the round ligament to the labium majus

1. Integrity of the fascial tissue

Collagen strength- Marfan Syndrome

Overexpression of matrix metalloproteinases involved in extra-cellualr matrix synthesis and degredation

2. Increase in intraabdominal pressure

Obesity

Pregnancy

Urinary obstruction

Chronic pulmonary disease

Nausea

Vomiting

Distension

Constipation

Diarrhea

Abdominal Pain

28 yo male with one day h/o nausea, vomiting, abdominal pain in the right lower quadrant. Physical exam reveals a non-reducible, tender right groin bulge. You diagnose him with an incacerated right inguinal hernia. What additional physcial exam finding might make you think that the hernia is strangulated?

What are some systemic manifestations of strangulated hernias?

Erythema over the sac

Fever, tachycardia, hypotension, peritoneal signs. 

With hernias that are challenging to diagnose (femoral for example), imaging may be done to aide in the diagnosis. What studies would you order?

What would you expect to see?

Does negative imaging rule out hernia?

1. Ultrasound or CT scan

2. Loops of bowel in aberrant locations. 

3. NO. Negative studeis do NOT exclude the presence of a hernia. 

Imaging may also help help with other diagnoses in the differential, such as inguinal adenopathy, undescended testis, spermatocele, varicocele, hydrocele, llipoma, testicular cancer. 

General 

Epidural

Spinal anesthesia

Local field block of the ilihypogastric & ilioinguinal nerve 

Where do you make your incision for an open inguinal hernia repair?

Femoral hernia repair?

2 cm above and parallel to the inguinal ligament.

For a femoral hernia repair, an infrainguinal approach is an option too. 

Open inguinl hernia repair:

An incision is made supior and parallel to  the ingiunal ligament and the subcutaneous tissue is dissected down to the level of the ________, which is incised parallel to it's fibers and spead to expose the ________. 

Care must be take to visualize and avoid what 2 nerves?

External Oblique Fascia

Inguinal Canal

Ilioinguinal and iliohypogastric

The hernia sac is excposed by dividing what structure?

In relation to the spermatic cord, where does the sac usually lie?

After the hernia sac is dissected free of the cord, what do you do with the sac?

Cremasteric muscle longitudinally

Anteromedial to the spermatic cord. 

The sac is either displaced into the peritoneal cavity or, perferably, divided and ligated near the internal ring. 

While you are on call, a 28 yo male is admitted for repair of an incarcerated left inguinal hernia, which you diagnosed based on physical exam findings to include a non-reducible groin bulge. You are doing well this month and were able to describe an open inguinal hernia repair in detail to your Chief resident, so he lets you assist with the case. You notice intraoperativly that that the hernia sac extends into the scrotum. Your chief asks you what you would do with the hernia sac at this point. What do you tell him? Why?

The sac should be divided at the pubic tubercle with the distal end left open or marsupialized to prevent a hydrocele from forming and to minimize cord trauma.

If the hernia sac extends into the scrotum, no attempt should be made to retrieve the sac distal to the pubic tubercle.  

Name the repair:

The aponeurosis of the transversus abdominis muscle is approximated to the shelving edge of the inguinal ligament. 

If this repair is under tension, what can you do to decrease it?

Recurrence rates for this repair?

BASSINI REPAIR

A relaxing incision can be made in the rectus muscle aponeurosis.

Recurrence: 5-20%, depending on the size of the initial hernia.  

What are the steps of a Shouldice repair?

Recurrence rate?

Transversalis fascia is divided from the internal ring to the pubic tubercle.

The fascia is then imbricated to itself and the inguinal ligament with 2 suture lines. 

Relaxing incisions may be required. 

Recurrence rates (at least reported by the Shouldice clinic) are 0.6%

You are repairing a femoral hernia. What is the procedure of choice?

How do you do it?

MCVAY REPAIR

The floor of the inguinal canal is EXCISED and reconstructed by initally reapproximating the transversus abdominis aponeurosis and transversalis fascia to cooper's ligament medially from the pubic tubercle to the femoral vein. Lateral reapproximation to this point is then transitioned to the femoral sheath and the inguinal ligament. 

**The repair essentially closes of the femoral canal and is the procedure of choice for femoral hernias**

Inferiorly: Inguinal Ligament (and pubic tubercle)

Superiorly: Int. Oblique aponeurosis or Transversus abd aponeurosis

The mesh is split laterally to create an aperture for the cord to exit the deep ring. (The split ends are sutured together as well)

How does the plug and patch repair differ from the lichtenstein?

What is this procedure particularly ideal for?

With a plug and patch (aka "Rutkow") repair, a mesh plug is placed in the deep inguinal ring beside the spermatic cord to help attenuate the opening in the deep ring. 

A patch of mesh is then placed over the floor of the inguional canal with minimal or no suture fixation, reducing post-op disability. 

Ideal for simultaneous repair of bilateral inguinal hernias

Describe the posterior approach for hernia repair.

What is incised in order to gain access to the properitoneal space?

Posterior/Preperitoneal Approach:

Often used for femoral or recurrent hernias.

A 2-3cm incision is made above the pubis parallel to the inguinal ligament, while staying superior to the inguinal ring. While approaching the rectus sheath, the anterior sheath is incised and the rectus muscle is retracted medially. The exposed transversalis fascia is then incised to gain access to the properitoneal space. Peritoneum is pushed away from the abdominal wall inferiorly, exposing the internal surface of the inguinal region.

The hernia is then reduced by gentle traction, the sac amputated, and the hernia defect repaired.

In the properitoneal approach to hernia repair, what are the options for repair of the defect?

1. Approximation of the transversus abdominus aponeurosis ro Cooper ligament medially and iliopubic tract laterally

OR

2. By suturing or tacking a piece of prosthetic mesh to the posterior aspect of the abdominal wall.

Testicular Atrophy

Residual Neuralgia

Ischemic Orchitis

Testicular (From Aorta)

Artery of the Ductus Deferens (From superior vesical)

Cremasteric Artery (From inferior epigastric)

3 days after your right inguinal hernia repair, the patient calls the clinic complaining of testicular/cord hardening, pain, and retraction, as well as significant testicular swelling.

1. What do you suspect?

2. What pathologic finding would you expect? 

3. What likely caused this?

1. Ischemic Testes (presents on day 2-5)

2. Significant venous congestion

3. Thrombosis, likely from traumatic handling of the spermatic cord.

What 2 modalities are used to diagnose thrombosis?

How long does it usually last?

Dopplar flow studies or Nuclear Medicine scan

The process can last 6-12 weeks, results in either complete resolution, or testicular atrophy.

It is usually not necessary, and care is supportive consisting of pain management mostly.

Orchiectomy is indicated for intractable pain or lack of flow to the testicle. Antibodies may develop in the atrophic testicle, which may be associated with infertility, and in this case orchiectomy is indicated.

Proliferation of nerve fibers outside the neurilemma of a partially or completely divided nerve.

Pain is variable and may depend on changes in position. it is often burning and permanent, and assocaited with intermittent paraxysmal exacerbations. Onset is usually delayed for one week after surgery, and tapping produces no exquisite pain.

TAPP: Transabdominal Pre-Peritoneal

TEP: Totally Extraperitoneal

IPOM: Intraperitoneal Onlay Mesh

All 3 procedures involve placement of mesh patch over the deep inguinal ring and the floor of the inguinal canal, similar to the open preperitoneal procedure. 

High risk from general anesthesia

Large scrotal hernia

Incarcerated hernia

Prior lower abdominal surgery

Previous Prostatectomy

Coagulopathy or requirement to operate on anticoagulants

History of pelvic irratiation

TAPP involves the standard laparoscopic entry into the peritoneal cavity at the level of the umbilicus, with the placement of 5mm ports lateral to the rectus sheath also at the level of the umbilicus. 

What structures does the mesh get attached to?

Cooper's ligament

Pubic Tubercle

Posterior Rectus

Transversus abdominus

Apex: interanl ring

Lateral border: Spermatic Vessels

Medial border: Vas Deferens

Doom- The iliac artery and vein lie within this

Lateral to the triangle of Doom is the triange of Pain. 

Nerve injury may result from tacks placed in this space, as it can damage which nerves?

Borders?

Leteral femoral cutaneous nerve

Genitofemoral nerve

Triangle of Pain:

Medially- Spermatic Vessels

Superior- Iliopubic tract

Protects the mesh from abdominal contents

Prevents Bowel Migration into the flap and subsequent bowel obstruction

Which side of the umbilicus is the rectus muscle reflected  laterally during a TEP procedure?

Once the dissecting baloon opens and defines the preperitoneal space, the TEP is just like the TAPP, with what exception?

Opposite of the hernia defect (or the larger of 2 hernias)

TEP: The peritoneal space does not need to be closed. 

In the simplified IPOM, no peritoneal flap is raised. Instead, the mesh is fixed directly to the peritoneum. 

Pros: Simpler, Less time than the TAPP because do not have to repair the peritoneum and raise it. 

Cons: SInce you secure the mesh to the peritoneum, rather than the fascia, there is risk that the mesh and peritoneum together could herniate through the defect.  Also, mesh is in direct contact with the bowel, so it needs to be coated to prevent adhesions. For these, IPOM is only experimental. 

Incisional hernias smaller than _____cm  may be closed primarily.

What is the recurrence rate for this?

30-50%. 

Repair with mesh 10% recurrence

What is the superior lumbar triangle?

Inferior?

Which occurs more commonly?

Grynfelt's Triangle

Petit's Triangle

Hernia's through the superior lumbar triangle are more common

(can occur spontaneously or through an old nephrectomy incision)