Surgical anatomy of Inguinal hernia

Zeeshan

Hernia

• A condition in which part of an organ is displaced and protrudes through the wall of the cavity containing it.

• Incidence: 25% in males and 2% in females

• 75% of hernias- groin hernias

• 2/3rd indirect and 1/3rd direct.

History of inguinal hernia

• Greek (hernios): bud

• or offshoot.

• Taxis for reduction of

incarcerated hernias

Inflating, inverting and shaking the patient

• Pt with strangulated inguinal hernia

• Purgatives / enemas of no avail

• Following use of “bellows” patient screams

“ YOU ARE BLOWING UP MY PURSE”

• Scrotum was distended with air

• Treatment of groin hernias are divided into 5 epochs.

• Oldest epoch- ancient era from ancient egypt till 15th century

• 19 – 20th century: Era of hernia repair under tension

- Antiseptic/aseptic precautions

- High ligation of hernial sac

- Narrowing of superificial inguinal ring

• Bassini : Repair of posterior wall of inguinal canal

• Shouldice : Imbrication of transverse fascia and strengthening of posterior wall of inguinal canal – 4 layer technique

• Currently – Era of tension free hernia repair.

Anterior abdominal wall

• External oblique aponeurosis:

- Origin:

• 8 fleshy strips from the outer surface and lower border of lower 8 ribs

- Insertion:

• Anterior half of outer lip of iliac crest

• Pubic tubercle

• Pubic crest and pecten pubis

• Linea alba

External oblique

Inguinal ligament

• Known as ?? Poupart’s ligament

- Thickened lower free border of external oblique aponeurosis

- Extent: Anterior superior iliac spine to pubic tubercle

Modifications of inguinal ligament

• Lacunar ligament (Gimbernat’s ligament)

• Pectineal ligament of Cooper

• Superficial inguinal ring

• Reflected part

Importance

• Lacunar ligament:

- Release of ligament required to reduce femoral hernias

• Pectineal ligament:

- Facilitates reconstruction of floor of inguinal canal

Superficial inguinal ring

• Opening in aponeurosis of external oblique above the pubic crest

• Triangular opening with superior and inferior crura

• Intercrural fibres cross over at the apex of the ring

Internal oblique abdominis

• Origin:

- Lateral 2/3rd of inguinal ligament

- Intermediate lip of ventral segment of iliac crest

- Thoracolumbar fascia at lateral border of quadratus lumborum

Internal oblique aponeurosis

• Insertion:

- Conjoint tendon to pubic crest and pectenpubis

- Linea alba

- Lower border of lower 4 ribs and costal cartilages

Cremastric muscle and fascia

• Derived from internal oblique aponeurosis

• Forms coverings of spermatic cord and testis

• Nerve supply: Genital branch of genitofemoralnerve (L1,2)

Transversus abdominis

• Origin:

- Lateral 1/3rd of inguinal ligament

- Anterior 1/3rd of inner lip of ventral part of iliac crest

- Thoracolumbar fascia

- Inner surface of lower six ribs and costal cartilage

• Insertion:

- Conjoint tendon to pubic crest and pectenpubis

- Linea alba

Conjoint tendon

• Formed by fusion of lower most fibres of internal oblique and transversus abdominus

• Inserts into pubic crest and medial part of pecten pubis

Fascia transversalis

• Lies between peritoneum and inner surface pftransversus abdominis

• Attaches to upturned part of inguinal ligament.

• Extends as internal spermatic fascia with the spermatic cord

Deep inguinal ring

• Opening in transversalis fascia

• Lies ½ an inch above midinguinal point

• Inguinal canal begins

• Medial relation : Inferior epigastric artery

Inguinal canal

• Musculo-aponeurotic tunnel

• From deep ring to superficial ring

• 4 cm long and 1 cm wide

Relations of inguinal canal

• Anterior wall:

- Aponeurosis of external oblique aponeurosis

- Internal oblique in lateral 1/3

- Superficial fascia

- Skin

• Posterior wall:

- Conjoint tendon (medial half)

- Transversalis fascia

- Extraperitoneal fat

- Peritoneum

• Roof:

- Arched fibres of

Internal oblique and transverse abdominusaponeurosis

• Floor:

- Inguinal ligament (upturned part)

Contents

• Spermatic cord (males)

• Round ligament (females)

• Ilioinguinal nerve ( Enters after piercing internal oblique and leaves through superficial inguinal ring)

Direct inguinal hernia

• Herniation through the posterior wall

• The inferior epigastric artery is found lateral to the neck of the hernial sac

• Can happen either medial or lateral to the medial umblical fold

Indirect inguinal hernia

• Congenital

• Inferior epigastric artery medial to sac.

Steps of hernia repair

Thank-you