Abdominal Wall Hernias

A

Henry Marcy (1837–1924)

• 1.

  Boston surgeon who described anterior approach to hernia repair with high ligation of the hernia sac in 1871

B

Edoardo Bassini (1844–1924)

• 1.

  In 1887 he wrote “Nuevo Metodo Operativo per la Cura Radicale dell’Ernia Inguinale.” In this landmark article, he described the “triple layer” consisting of the internal oblique muscle, transversus abdominis muscle, and transversalis fascia.

C

Sir Astley Cooper (1768–1841)

• 1.

  Published his description of inguinal anatomy and repair, which included a description of the superior pubic ligament, in 1804. He himself had a right indirect hernia as a teenager and wore a truss for 5 years.

D

Chester Mcvay (1911–1987)

• 1.

  Submitted his thesis on groin anatomy in 1939 for a doctorate at Northwestern University, asserting that normal groin anatomy involved Bassini’s “triple layer” inserting on Cooper’s ligament, not the inguinal ligament. In 1942, while a resident at the University of Michigan, he reported his technique of groin hernia repair, which included the critical “relaxing incision.”

E

Edward Earle Shouldice (1890–1965)

• 1.

  His interest in treatment of inguinal hernias developed in 1930s. The Shouldice Hospital opened in 1945 and has performed more than 300,000 hernia repairs since.

F

Irving Lichtenstein and Parviz Amid

• 1.

  Revolutionized hernia surgery with their “Lichtenstein open ‘tension-free’ mesh repair of inguinal hernias.” They reported four recurrences in more than 4000 patients.

A

Hernia

• 1.

  Protrusion of a part or structure through the tissues normally containing it; from the Latin for “rupture”

B

Reducibility

• 1.

  Contents of the hernia sac can be returned to their normal location.

C

Incarceration

• 1.

  Nonreducible hernia sac contents that, in the acute setting, may present with obstructive symptoms and pain, among other symptoms. This may also occur chronically and be essentially asymptomatic.

D

Strangulation

• 1.

  Incarcerated hernia with vascular compromise of contents of the sac leading to gangrene and perforation of hollow viscus if left untreated. This is a surgical emergency and is often accompanied by obstructive symptoms (exception is Richter hernia), pain (potentially focal peritonitis), leukocytosis, fever, and skin changes (e.g., warmth, erythema).

A

Incidence

• 1.

  Approximately 5% of all people will develop a hernia in their lifetime.

  • a.

    Lifetime risk reported variably in the literature: males 5%–24%; females 1%–2%

• 2.

  Likelihood of strangulation increases with age.

  • a.

    Only 1%–3% of all hernias will strangulate.

  • b.

    Femoral hernias have a significantly greater rate of strangulation at 15%–20%.

• 3.

  Inguinal hernias make up 75% of all abdominal wall hernias.

  • a.

    Indirect hernias are the most common type of hernia regardless of sex and outnumber direct hernias 2:1 in men.

  • b.

    Right-sided hernias are more common than left because of the slower descent of the right testicle and the delay in atrophy of the processus vaginalis.

• 4.

  Femoral hernias account for 10% of abdominal wall hernias, yet upward of 40% will present as surgical urgency or emergency in the form of an incarcerated or strangulated hernia.

  • a.

    Predominance of right-sided femoral hernias is thought to be due to the occluding effect of the sigmoid colon on the left femoral canal.

A

Layers of the Abdominal Wall

• 1.

  The layers of the abdominal wall in order of encounter while performing groin hernia surgery are skin, subcutaneous fat (Camper), Scarpa fascia, external oblique muscle laterally and aponeurosis medially, internal oblique muscle, transversus abdominis muscle, transversalis fascia, and peritoneum.

B

Inguinal Canal

• 1.

  It is a fibrous canal that contains the spermatic cord, the ilioinguinal nerve, the genital branch of the genitofemoral nerve, and hernia sac, if present.

• 2.

  The canal is bordered inferiorly by the inguinal ligament, superiorly by the conjoint tendon and the reflections of the transversus abdominis and the internal oblique muscle, anteriorly by the external oblique aponeurosis, and posteriorly by the transversalis fascia.

C

Spermatic Cord

• 1.

  Complex of structures exiting the abdomen, traversing the inguinal canal, and entering the scrotum

• 2.

  Composed of the testicular artery, pampiniform plexus of veins, vas deferens, cremasteric muscle fibers, genital branch of genitofemoral nerve, and hernia sac (if indirect hernia present, sac typically lies anteromedial to the cord structures)

D

Processus Vaginalis

• 1.

  Diverticulum of parietal peritoneum that descends from the abdomen along with the testicle and comes to lie adjacent to the spermatic cord. This structure subsequently obliterates in normal development to remain as the tunica vaginalis.

E

Deep (Internal) Inguinal Ring

• 1.

  Composed of fibers of the internal oblique muscle superiorly, and transversalis fascia and inferior epigastric vessels inferomedially

F

Superficial (External) Inguinal Ring

• 1.

  Composed of a medial and lateral crus of the external oblique aponeurotic fibers that is traversed by the spermatic cord (in male individuals) or round ligament (in female individuals), as well as branches of the ilioinguinal and genitofemoral nerves

G