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External abdominal hernias

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The latter part of the eighteenth century heralded dramatic changes as the anatomy of the groin became better understood. In 1881, a French surgeon, Lucas-Championniere performed high ligation of an indirect inguinal hernia sac at the internal ring with primary closure of the wound. Edoardo Bassini (1844–1924) is considered the father of modern inguinal hernia surgery. By

incorporating the developing disciplines of antisepsis and anesthesia with a new operation that included reconstruction of the inguinal floor along with high ligation of the hernia sac, he was able to substantially reduce morbidity. It is universally agreed that this concept was responsible for the advent of the modern surgical era of inguinal herniorrhaphy and is still valid today. The operation resulted in a recurrence rate one-fifth of that which generally was accepted and was considered the standard criterion for inguinal hernia repair for most of the twentieth century.

Although Bassini’s principle of posterior wall reinforcement remains valid in a surgical practice today, his operation has lost its popularity and is used only in selected cases in which prosthetic material is contradicted. This is because of the widespread acceptance of the concept of avoiding tension during herniorrhaphy, championed by Lichtenstein. Lichtenstein theorized that by using a mesh prosthesis to bridge the hernia defect rather than closing it with sutures, as with the Bassini repair and its modifications, tension is avoided ostensibly resulting in a less painful operation. He also felt that the lack of tension reduced the incidence of suture pullout, which would result in a lower recurrence rate. A Lichtenstein type operation has now become the method of choice in the United States. The preperitoneal space also can be used for repair of an inguinal hernia and has strong proponents because of the mechanical advantage gained from prosthesis placement behind the abdominal wall. Access to the preperitoneal space can be gained through a lower abdominal incision, transabdominally at the time of laparotomy or with the aid of laparoscopic guidance. Irrespective of the mode of entry to the preperitoneal space, a large prosthesis is used that extends far beyond the margins of the myopectineal orifice. This brief overview of the history of inguinal herniorrhaphy provides a background for a comprehensive look at the problem of inguinal herniation.


Seventy-five percent of all abdominal wall hernias occur in the groin. Indirect hernias outnumber direct hernias by about 2:1, with femoral hernias making up a much smaller proportion. Right-sided groin hernias are more common than those on the left. The male:female ratio for inguinal hernias is 7:1. There are approximately 750,000 inguinal herniorrhaphies performed per year in the United States, compared to 25,000 for femoral hernias, 166,000 for umbilical hernias, 97,000 for incisional hernias, and 76,000 for miscellaneous abdominal wall hernias. Femoral hernias account for less than 10% of all groin hernias, but 40% of these present as emergencies with incarceration or strangulation. The 920 mortality rate for emergency repair is higher than for elective repair. Femoral hernias are more common in older patients and in men who have previously undergone an inguinal hernia repair. Although the absolute number of femoral hernias in males and females is about the same, the incidence in females is four times that of males because of the lower overall frequency of groin hernia in women.

Estimates of the risk for developing an inguinal hernia vary greatly in the literature, probably because of the lack of a entirely reproducible way to make the diagnose. Self-reporting by patients, audits of routine physical examinations, and insurance company databases are among the diverse sources from which such figures are derived, all of which are known to be notoriously inaccurate. Physician physical examination, even by trained surgeons, also is not dependable because of the difficulty differentiating between lipomas of the cord, a normal expansile bulge and a true groin hernia.



An incarcerated hernia is by definition an irreducible hernia. However, this should not imply a surgical emergency, as chronic states of incarceration are common because of the size of the neck of the hernia in relationship to its contents or because of adhesions to the hernia sac. The recommended treatment of an incarcerated hernia is surgical repair, but there is no urgency because there is no life threatening complication present. A patient with an incarcerated inguinal hernia exhibiting signs of a bowel obstruction or one who develops an acute incarceration that remains exquisitely tender represents a completely different clinical scenario.

The initial treatment, in the absence of signs of strangulation, is taxis. Taxis is performed with the patient sedated and placed in the Trendelenburg position. The hernia sac neck is grasped with one hand with the other applying pressure on the most distal part of the hernia. The goal is to elongate the neck of the hernia so that the contents of the hernia may be guided back into the abdominal cavity with a rocking movement. Taxis should not be performed with excessive pressure. If the hernia is strangulated, gangrenous bowel might be reduced into the abdomen or perforated in the process. One or two gentle attempts should be made at taxis. If this is unsuccessful, the procedure should be abandoned. Surgeon expertise may make laparotomy a better choice for some.

The most significant complication of either acute incarceration or intestinal obstruction is strangulation. It is a serious, life-threatening condition because the hernia contents have become ischemic and nonviable. The clinical features of a strangulated obstruction are dramatic. In addition to the patient having developed an irreducible hernia and an intestinal obstruction, clinical signs indicate that strangulation has taken place. The hernia is tense, very tender and the overlying skin may be discolored with a reddish or bluish tinge. There are no bowel sounds present within the hernia itself. The patient commonly has a leukocytosis with a left shift, is toxic, dehydrated and febrile. Arterial blood gases may reveal a metabolic acidosis. Rapid resuscitation with intravenous fluids is essential with electrolyte replacement, antibiotics and nasogastric suction. Urgent surgery is indicated once resuscitation has taken place. The initial surgical approach is to make a conventional inguinal hernia incision. If the bowel is viable, it is reduced into the abdominal cavity prior to repairing the hernia. The neck of the hernia is widened if any difficulty is encountered reducing the hernia. Although rare, the surgeon must be cognizant of the possibility that a nonviable abdominal organ may have been reduced into the abdominal cavity during the course of usual surgical maneuvers before it could be visualized. If such a suspicion is present, the entire GI tract must be evaluated. If the bowel is found to be obviously gangrenous, more bowel must be pulled into the hernia so that viable bowel can be transected and the gangrenous portion removed. In the ideal situation, an end to end anastomosis is performed and the bowel is reduced into the abdominal cavity, followed by hernia repair.


The cause of an inguinal hernia in a human is far from completely understood but is undoubtedly multifactorial. Familial predisposition plays a role. However, there is increasing evidence that connective tissue disorders predispose to hernia formation by altering collagen formation. A higher prevalence of inguinal hernias is well known among patients suffering from certain congenital connective tissue disorders. In children with congenital hip dislocation, inguinal hernia occurs five times more often in girls and three times more often in boys compared to children without this disease. The role of physical exertion in the development of inguinal hernia is probably less important than is commonly believed. The cause and effect relationship between a specific lifting episode and the development of an inguinal hernia is present in less than 10 % except in circumstances in which worker’s compensation issues are involved. Additionally, athletes, even weightlifters, do not seem to have an excessive incidence of inguinal hernias. This begs the question whether patients with un-repaired inguinal hernias should be restricted from heavy lifting.

^ Indirect Inguinal Hernia

The so-called “saccular theory” of indirect inguinal hernia formation proposed by Russell remains popular. Russell’s hypothesis that the “presence of a developmental diverticulum associated with a patent processus vaginalis, was essential in every case” is still valid in the minds of many surgeons even today. Russell felt that increased intraabdominal pressure might serve to further stretch and weaken the internal ring allowing additional intraabdominal organs to herniate through the orifice but could not actually cause an indirect inguinal hernia. This does not explain all cases of indirect groin hernias, however.

^ First Presumed Causes of Groin Herniation


Chronic obstructive pulmonary disease






Birthweight less than 1500 g

Family history of a hernia

Valsalva maneuvers


Upright position

Congenital connective tissue disorders

Defective collagen synthesis

Previous right lower quadrant incision

Arterial aneurysms

Cigarette smoking

Heavy lifting

Physical exertion

A patent processus vaginalis can be found at autopsy without clinical evidence of a hernia. Second, there are patients with an obliterated processus vaginalis who have an abdominal wall defect lateral to the epigastric vessels. Third, congenital structural malformations of the transversalis fascia and transverses abdominis aponeurosis can alter the strength and size of the internal inguinal ring. Denervation of the internal oblique muscle by adjacent incisions (e.g., appendectomy) also can be associated with the eventual development of an inguinal hernia. Excessive fatty tissue involving the cord or round ligament encountered by a surgeon during elective herniorrhaphy traditionally has been referred to as a lipoma of the cord. This term is unfortunate because it implies a neoplastic process but a lipoma of the cord consists of normal fatty tissue. The reason for the term lipoma is that the fatty tissue can easily be separated from the cord structures and reduced into the preperitoneal space “en masse” as if it were a tumor. A lipoma of the cord is important from a clinical standpoint for three reasons: (1) it can cause hernia type symptoms although with less frequency than indirect hernias with a peritoneal sac; (2) it is often difficult to distinguish at physical examination from an indirect hernia with a peritoneal sac; and (3) it can be responsible for an unsatisfactory result because of an unchanged physical examination after elective inguinal herniorrhaphy, especially when a preperitoneal repair is used. For the purposes of the large clinical trials referred to in other parts of this chapter, a lipoma of the cord was classified as an indirect hernia. There is no peritoneal sac by definition because the contents of the indirect hernia (i.e., preperitoneal fat) come from the preperitoneal space rather than the abdominal cavity.

^ Direct Inguinal Hernias

Two major factors are felt to be important in the development of direct inguinal hernias. The first is increased intraabdominal pressure associated with a variety of conditions. The second factor is relative weakness of the posterior inguinal wall. An abnormally high lying arch of the main body of the transversus abdominis above the superior ramus of the pubis resulting in a large area at risk has been incriminated. Similarly, a limited insertion of the transversus abdominis muscle onto the pubis, weakness of the iliopubic tract, limited insertion of the iliopubic tract aponeurosis into a Cooper ligament or a combination of these have been reported to contribute.

^ Femoral Hernias

The size and shape of the femoral ring and increased intraabdominal pressure are factors that contribute to the development of a femoral hernia. The iliopubic tract anteriorly and medially accounts for the variability that allows the development of the hernia. The iliopubic tract normally inserts for a distance of 1–2 cm along the pectinate line between the pubic tubercle and the midportion of the superior pubic ramus. A femoral hernia can result if the insertion is less than 1–2 cm or if it is shifted medially. The net effect of either anatomic subtlety is to widen the femoral ring, predisposing to the hernia. Femoral hernias are particularly dangerous because of the rigid structures that make up the femoral ring. The slightest amount of edema at the ring can produce gangrenous changes of the sac contents continuing distally into the femoral canal and thigh.

^ Sliding Inguinal Hernia

A sliding inguinal hernia is defined as any hernia in which part of the sac is the wall of a viscus. Approximately 8 percent of all groin hernias present with this finding but the incidence is age related. It rarely is found in patients less than 30 years of age but increases to 20 percent after the age of 70. If the hernia is on the right, the cecum, ascending colon or appendix most commonly are involved; and on the left, the sigmoid colon. The uterus, fallopian tubes, ovaries, ureters and bladder can be involved on either side. The sliding component usually is found on the posterior lateral side of the internal ring. The importance of this condition has lessened considerably in the last several years with the realization that it is not necessary to resect hernia sacs and that simple reduction into the preperitoneal space is sufficient. This eliminates the primary danger associated with sliding hernias, which is injury to the viscus during high ligation and sac excision.


The anatomy of the groin is best understood when observing from the approach for the herniorrhaphy to be performed. For a conventional operation, this means from the skin to the deeper layers. For the laparoscopic operations or the preperitoneal operations, one should consider the anatomy from the abdominal cavity to the skin. The first layers encountered beneath the skin are the Camper and Scarpa fascia in the subcutaneous tissue. The aponeurosis of the external oblique muscle is the next structure encountered as dissection proceeds through the abdominal wall. The muscle arises from the posterior aspects of the lower eight ribs. The posterior portion of the muscle is orientated vertically and inserts on the crest of the ileum. The anterior portion of the muscle courses inferiorly in an oblique direction toward the midline and pubis. The obliquely oriented anterior-inferior fibers of the aponeurosis of the external oblique muscle fold back on themselves to form the inguinal ligament which attaches laterally to the anterior superior iliac spine. The medial insertion of the inguinal ligament in most individuals is dual. One portion inserts on the pubic tubercle and the pubic bone. The other folds back as the lacunar ligament. It blends laterally with a Cooper (pectineal) ligament. The more medial fibers of the aponeurosis of the external oblique divide into a medial and a lateral crus to form the external or superficial inguinal ring through which the spermatic cord or round ligament and branches of the ilioinguinal and genitofemoral nerves pass. The internal abdominal oblique muscle fibers fan out following the shape of the iliac crest; the superior fibers course obliquely upward toward the distal ends of the lower three or four ribs whereas the lower fibers orient themselves inferomedially toward the pubis to run parallel to the external oblique aponeurotic fibers. These fibers arch over the round ligament or the spermatic cord forming the superficial part of the internal (deep) inguinal ring. The first lumbar nerve divides into the ilioinguinal and iliohypogastric nerves. These may divide within the psoas major muscle retroperitoneally or between the internal oblique and transversus abdominis muscles. The ilioinguinal nerve may communicate with the iliohypogastric nerve before innervating the internal oblique. The ilioinguinal nerve then passes through the external inguinal ring to run with the spermatic cord, although the iliohypogastric nerve pierces the external oblique to innervate the skin above the pubis. The cremaster muscle fibers, which are derived from the internal oblique muscle, are innervated by the genitofemoral nerve (L1, L2). The transversus abdominis muscle arises from the inguinal ligament, the inner side of the iliac crest, the endoabdominal fascia and the lower six costal cartilages and ribs. The medial aponeurotic fibers of the transversus abdominis contribute to the rectus sheath and insert on the pecten pubis and the crest of the pubis forming the falx inguinalis. These fibers are infrequently joined by a portion of the internal oblique aponeurosis; only then is a true conjoined tendon formed. The myopectineal orifice of Fruchaud refers to an anatomic area in the groin through which all hernias occur. Hesselbach’s inguinal triangle is within this orifice and is the site of direct inguinal hernias. When described from the anterior aspect, the inguinal ligament forms the base of the triangle, the edge of the rectus abdominis is the medial border, and the inferior epigastric vessels are

the superolateral border. It should be noted, however, that Hesselbach actually described a Cooper ligament as the base. The transversalis fascia also is important because it forms anatomical landmarks known as analogues or derivatives. The important transversalis fascia analogues for the hernia surgeon are the iliopectineal arch, the iliopubic tract, the crura of the deep inguinal ring and a Cooper (pectineal) ligament. The superior and inferior crura form a transversalis fascia sling, a “monk’s hood” shaped structure, around the deep inguinal ring. This sling has functional significance as the crura of the ring are pulled upward and laterally by the contraction of transversus abdominis, resulting in a valvular action that helps to preclude indirect hernia formation. The iliopubic tract is the thickened band of the transversalis fascia that courses parallel to the more superficially located inguinal ligament. It is attached to the iliac crest laterally and inserts on the pubic tubercle medially. The insertion curves inferolaterally for 1–2 cm along the pectinate line to blend with a Cooper (pectineal) ligament, ending at about the midportion of the superior pubic ramus. A Cooper ligament is actually a condensation of periosteum and is not a true analogue of the transversalis fascia.

The femoral ring is bordered by the superior pubic ramus inferiorly and the femoral vein laterally. The iliopubic tract with its curved insertion onto the pubic ramus is the anterior and medial border. The canal normally contains preperitoneal fat, connective tissue and lymph nodes including a Cloquet node at its entrance, the femoral ring.

^ The Posterior Perspective (Laparoscopic)

An excellent view of the anterior abdominal wall can be obtained from a laparoscopic vantage point. Peritoneal folds are immediately obvious which correspond to important anatomic landmarks in the preperitoneal space. The median umbilical fold extends from the umbilicus to the urinary bladder and covers the urachus, the usually fibrous remnant of the fetal allantois. The lateral umbilical fold covers the inferior epigastric artery as it courses toward the posterior rectus sheath and enters it approximately at the level of the arcuate line. The fossa formed between the medial and the lateral ligaments is the site of direct inguinal hernias. The lateral fossa is less delineated than the other two. The deep inguinal ring is located in the lateral fossa just lateral to the inferior epigastric vessels.

When the peritoneum is divided and the preperitoneal space entered, the key anatomic elements for a preperitoneal herniorrhaphy can be appreciated. In the midline behind the pubis, the preperitoneal space is known as the space of Retzius, although laterally it is referred to as the space of Bogros. This space is important because many of the repairs, which are described later, are performed in this area. Perhaps the single most important landmark is the inferior epigastric artery. This branch of the external iliac artery represents the primary blood supply to the deep anterior wall. The veins in this area can be troublesome especially the iliopubic, corona mortis obturator and their tributaries.

Other landmarks that require identification are the internal inguinal ring just lateral to the take off of the inferior epigastric vessels, the internal spermatic artery and vein, and the vas deferens that join to form the spermatic cord just before entering the internal ring. The iliopubic tract, attached to the iliac crest laterally, crosses under the internal ring to make up its inferior border and at the same time contributes to the anterior border of the femoral sheath continuing to its insertion on the pubic tubercle. A Cooper ligament extends from the pubic tubercle inferolateral along the pubic ramus crossing under the femoral vessel. The femoral ring is readily visible from this viewpoint being bordered by the femoral vein laterally, a Cooper ligament inferiorly, and the iliopubic tract superiorly.

The nerves traversing the preperitoneal space are prone to intraoperative injury. They can be damaged when fastening prosthesis if deep penetration of the fixation device occurs. The genitofemoral nerve may occur as a single trunk lying deep to the peritoneum and fascia on the anterior surface of the psoas muscle or it may divide into its component genital and femoral branches within the muscle. The genital branch travels with the spermatic cord, entering at the deep inguinal ring; it ultimately innervates the cremaster muscle and the lateral scrotum. The femoral branch of the nerve innervates the skin of the proximal mid thigh. The lateral femoral cutaneous nerve crosses the preperitoneal space lateral to the genitofemoral nerve and enters the thigh just beneath the iliopubic tract and the inguinal ligament. This nerve supplies sensory branches for the lateral side of the thigh.


Patients with groin hernias present with a wide range of clinical scenarios ranging from no symptoms at all to the life-threatening condition caused by strangulation of incarcerated hernia contents. Asymptomatic patients may have their hernias diagnosed at the time of a routine physical examination or seek medical attention because of a painless bulge in the groin. Indirect hernias are more likely to produce symptoms than direct hernias. Many describe an annoying heavy feeling or dragging sensation, which tends to be worse as the day wears on. The pain is commonly intermittent and radiation into the testicle is not rare. Others complain of a sharper pain that is either localized or diffuse. Particularly severe patients may need to recline for a short period of time or use other posture altering techniques. Occasionally patients must manually reduce their hernia to obtain relief.


Physical Examination

Physical examination is the best way to determine the presence or absence of an inguinal hernia. The diagnosis may be obvious by simple inspection

^ Differential Diagnosis



Retroperitoneal sarcoma


Testicular tumor

Primary Testicular



Testicular torsion


Ectopic testicle

Undescended testicle

Femoral artery aneurysm or pseudoaneurysm

Lymph node

Sebaceous cyst


Cyst of the canal of Nuck (Female)

Saphenous varix

Psoas abscess



when a visible bulge is present. The differential diagnosis must be considered in questionable cases. Nonvisible hernias require digital examination of the inguinal canal. Classic teaching is that an indirect hernia will push against the fingertip, whereas a direct hernia will push against the pulp of the finger. Additionally, applying pressure over the mid-inguinal point with the fingertip will control an indirect hernia and prevent it from protruding when the patient strains. A direct hernia will not be effected with this maneuver. A femoral hernia presents as a swelling below the inguinal ligament and just lateral to the pubic tubercle. Thin patients commonly have prominent bilateral bulges below the inguinal ligament medial to the femoral vessels. They are asymptomatic and disappear spontaneously when the patient assumes a supine position. Operation is not indicated.

^ Radiological Investigations

Hernias are visualized as abnormal ballooning of the anteroposterior diameter of the inguinal canal and/or simultaneous protrusion of fat or bowel within the inguinal canal. Magnetic resonance imaging (MRI) with the development of the fast imaging scanners that allow dynamic imaging (i.e., performed during straining), shows particular promise for further refinement with the “tweaking” of the best weights for images and the addition of intraperitoneal contrast agents. Both MRI and computerized tomography (CT) may reveal other causes of groin pain because of their ability to visualize related structures in the groin. In a comparative study, the sensitivity and specificitywas 74.5 % and 96.3 % for physical examination, 92.7 percent and 81.5 percent for ultrasound, and 94.5 percent and 96.3 percent for MRI, respectively.


Nonoperative Treatment

The term “watchful waiting” is used to describe this treatment recommendation. It is only applicable in asymptomatic or minimally symptomatic hernias. Patients are counseled about the signs and symptoms of complications from their hernia so they might present promptly to their physician in cases in which an adverse event takes place. Definitive data that this recommendation is safe is not available and it is for this reason that standard surgical texts continue to recommend surgical repair of all inguinal hernias at diagnosis. However, a randomized controlled trial is currently underway which should shed some light on this subject in the next few years.


The modern era of herniorrhaphy has seen a progressive decrease in recurrence rate because of improvement in surgical technique and prosthetics. It is apparent that the abdominal wall does not always heal satisfactorily after primary closure and that an irreducible percentage of recurrences is inevitable if one were to insist on pure tissue repairs. The only reasonable solution is the use of a structure that can bridge a defect in certain cases.

Prosthetic Materials

It has now been proven that mesh herniorrhaphy can decrease the recurrence rate by approximately 50 percent when compared to nonmesh repairs. Chronic post herniorrhaphy groin pain occasionally occurs after prosthetic repair and is relieved by prosthesis removal. However, the overall incidence of chronic post herniorrhaphy groin pain is less with a prosthetic repair. The materials that have emerged as suitable for routine use in hernia surgery include polypropylene, either monofilament (Marlex, Prolene) or polyfilament (Surgipro), Dacron (Mersilene)

and expanded polytetrafluoroethylene (e-PTFE) (Gore-Tex).


Most inguinal herniorrhaphies can be performed under local or regional anesthesia. Laparoscopic herniorrhaphy is the exception, as general endotracheal anesthesia is primarily mandated by the pneumoperitoneum. This is one of the strongest arguments for conventional herniorrhaphy when compared to laparoscopic herniorrhaphy. Despite this, the best available evidence suggests that the majority of conventional herniorrhaphies are performed under a general anesthetic with local and regional techniques, finding their greatest popularity in specialty clinics. Nevertheless, local anesthesia, when used in adequate doses and far enough in advance of the initial incision, proves very effective when combined with the newer, short-acting amnesic and anxiolytic agents.


Before discussing specific conventional herniorrhaphies, several steps will be described because they are common to all of the conventional operations.

Initial Incision: Classically an oblique skin incision is made between the anterior superior iliac spine and the pubic tubercle. Many surgeons now use a more horizontally placed skin incision in the natural skin lines for cosmetic reasons. Regardless, it is deepened through the Camper and Scarpa fascia and the subcutaneous tissue to expose the external oblique aponeurosis. This structure is incised medially down to and through the external inguinal ring. Mobilization of the cord structures. The superior flap of the external oblique aponeurosis is bluntly dissected off the internal oblique muscle laterally and superiorly. The iliohypogastric nerve is identified at this time. It can be left in-situ or freed from the surrounding tissue and isolated from the operative field by passing a hemostat under the nerve and grasping the upper flap of the external oblique aponeurosis. Routine division of this nerve along with the ilioinguinal nerve is practiced by some surgeons but not advised by most. The cord structures are then separated from the inferior flap of the external oblique aponeurosis by blunt dissection exposing the shelving edge of the inguinal ligament and the iliopubic tract. The cord structures are lifted enmasse with the fingers of one hand at the pubic tubercle so that the index finger can be passed underneath to meet the index finger of the other hand. Blunt dissection is used to complete mobilization of the cord structures and a Penrose drain is placed around them for retraction during the course of the procedure.

Division of the cremasteric muscle. Complete division of the cremasteric muscle, especially when dealing with an indirect hernia, has been common practice. The purpose is to facilitate sac identification and to lengthen the cord for better visualization of the inguinal floor. However, adequate exposure usually can be obtained by a longitudinal opening of the muscle, which lessens the likelihood of damage to cord structures and avoids the complication of testicular descent. It is probably best not to divide the cremasteric muscle unless the surgeon cannot obtain adequate visualization of the inguinal floor any other way. High ligation of the sac. The term “high ligation of the sac” will be used frequently as its historical significance has ingrained it in the description of most of the older operations. By convention, high ligation should be considered equivalent to reduction of the sac into the preperitoneal space without excision. Both methods work equally well and are highly effective. Sac inversion, in lieu of excision, does protect intraabdominal viscera in cases of unrecognized incarcerated sac contents or a sliding hernia. Management of inguinal scrotal hernia sacs. Complete excision of all indirect inguinal hernia sacs is felt to be important by some. The downside to this practice is an excessive rate of ischemic orchitis caused by trauma to the testicular blood supply, especially the delicate venous plexuses. Testicular atrophy is the logical further sequelae although the relationship has not been conclusively proven. A better approach is to divide indirect inguinal hernia sacs in the mid inguinal canal, once confident the hernia is not sliding and there are no abdominal contents. The distal sac is not dissected but the anterior wall is opened as far distally as is convenient. Contrary to popular opinion in the urological literature, this does not result in an excessive rate of postoperative hydrocele formation.

Wound closure. The external oblique fascia is closed, serving to reconstruct the superficial (external) ring. The external ring must be loose enough to prevent strangulation of the cord structures yet tight enough to avoid an inexperienced examiner from confusing a dilated ring with a recurrence. The later is sometimes referred to as an “industrial” hernia because historically it has at times been a problem during a preemployment physical. The Scarpa fascia and the skin are closed to complete the operation.

^ Specific Herniorrhaphies


Reconstruction of the posterior wall by suturing the transversalis fascia, the transversus abdominis muscle, the internal oblique muscle (Bassini’s famous “triple layer”) medially to the inguinal ligament laterally and possibly the iliopubic tract. Following the initial dissection and reduction or ligation of the sac, attention turns to reconstructing the inguinal floor. Bassini began this part of the operation by opening the transversalis fascia (some prefer to use the term posterior inguinal wall) from the internal inguinal ring to the pubic tubercle, exposing the preperitoneal fat which was bluntly dissected away from the under surface of the superior flap of the transversalis fascia. This allowed him to properly prepare the deepest structure in his famous triple layer (transversalis fascia, transversus abdominis muscle and internal oblique muscle). The first stitch in the repair includes the triple layer superiorly and the periosteum of the medial side of the pubic tubercle along with the rectus sheath. Most surgeons now try to avoid the periosteum of the pubic tubercle to decrease the incidence of osteitis pubis. The repair is continued laterally with nonabsorbable suture securing the triple layer to the reflected inguinal ligament (Poupart ligament). These sutures are continued until the internal ring has been closed on its medial

side. A relaxing incision was not part of the original description but is commonly added now.


Local anesthesia with sedation is the rule, and epinephrine is empirically avoided in the event it might contribute to ischemic orchitis. The initial approach is similar to the Bassini repair with particular importance placed on freeing the cord from its surrounding adhesions, resection of the cremaster muscle, high dissection of the hernia sac and division of the transversalis fascia. Continuous nonabsorbable suture is used to repair the floor. Traditionally, this has been monofilament steel wire. The Shouldice surgeons feel a continuous suture distributes tension evenly and prevents defects that could potentially occur between interrupted sutures resulting in a recurrence. The repair is started at the pubic tubercle by approximating the iliopubic tract laterally to the undersurface of the lateral edge of the rectus muscle. The suture is continued laterally, approximating the iliopubic tract to the medial flap that is made up of the transversalis fascia, the internal oblique and transverse abdominis muscles. Eventually four suture lines are developed from the medial flap. The running suture is continued to the internal ring where the lateral stump of the cremaster muscle is picked up, forming a new internal ring. The direction of the suture is reversed back toward the pubic tubercle, approximating the medial edge of the internal oblique and transversus abdominis muscle to Poupart ligament and the wire is tied to itself. Thus, there are two suture lines formed by the first suture. The second wire suture is started near the internal ring and approximates the internal oblique and transversus muscles to a band of external oblique aponeurosis superficial and parallel to the inguinal ligament, in effect creating a second artificial inguinal ligament. This forms the third suture line that ends at the pubic crest. The suture is then reversed and a fourth suture line is constructed in a similar manner, superficial to the third line. At the Shouldice Clinic, the cribriforms fascia always is incised in the thigh, parallel to the inguinal ligament, to make the inner side of the lower flap of the external oblique aponeurosis available for these multiple layers. This step commonly is omitted in general practice.

The Anterior Approach

Read-Rives. This operation starts like a classical Bassini, including opening

the inguinal floor. The inferior epigastric vessels are identified and the preperitoneal

space completely dissected. The spermatic cord is “parietalized” by

separating the ductus deferens from the spermatic vessels. A 12- . 16-cm

piece of mesh is positioned in the preperitoneal space deep to the inferior epigastric

vessels and secured with three sutures; one each to the pubic tubercle,

a Cooper ligament and the psoas muscle laterally. The transversalis fascia is

closed over the prosthesis and the cord structures replaced. The rest of the

closure is as described above for the Bassini repair.

^ Complications of operations:


Chronic Groin Pain


A) Somatic

B) Visceral


A) Iliohypogastric

B) Ilioinguinal

C) Genitofemoral

D) Lateral Cutaneous

E) Femoral

Cord and testicular

A) Hematoma

B) Ischemic orchitis

C) Testicular atrophy

D) Dysejaculation

E) Division of vas deferens

F) Hydrocele

G) Testicular descent

Bladder Injury

Wound Infection



A) Wound

B) Scrotal

C) Retroperitoneal

Osteitis pubis

Prosthetic Complications

A) Contraction

B) Erosion

C) Infection

D) Rejection

E) Fracture


Vascular injury

A) Intra-abdominal

B) Retroperitoneal

C) Abdominal wall

D) Gas embolism

Visceral injury

A) Bowel perforation

B) Bladder perforation

Trocar Site Complications

A) Hematoma

B) Hernia

C) Wound infection

D) Keloid

Bowel Obstruction

A) Trocar or peritoneal closure site hernia

B) Adhesions


A) Diaphragmatic dysfunction

B) Hypercapnia



Paralytic ileus

Nausea and vomiting

Aspiration pneumonia


Respiratory insufficiency


External abdominal hernias iconExternal abdominal hernias
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External abdominal hernias iconThe auricle and the external aгditory meatus comprises: +the external ear

External abdominal hernias icon25 The peritoneum !1 The superior wall of the abdominal cavity, separating it

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External abdominal hernias icon33. External Carotid artery, subclavian artery !1 The external carotid artery has the following groups of

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External abdominal hernias iconPetrov eu external relations law lecture 8

External abdominal hernias iconPetrov eu external relations law system 1

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