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Types of Abdominal Hernia repairs Hernioplasty

Classification of Hernias

The International Classification of Hernias

ď ś By Origin:

1. Congenital Hernia:

2. Acquired Hernia:

(a) umbilical (b) inguinal (c) white line of abdomen (d) umbilical cord hernias (e) gastroschisis

(a) Predestined arise in typical weak places of the abdominal wall. (b) Post-operative (c) Recurrent (d) Traumatic (e) Neuropathic (f ) Artificial rupture

ď ś

By Localisation: Major types: (a) inguinal

(b) femoral (c) umbilical (d) white line of abdomen

ď ś

Clinical Classification : (a) Reducible hernia/ Free hernia (b) Irreducible hernia (c) Strangulated hernia (d) Coprostasis of hernia (e) Inflammation of hernia (f) Traumatic hernia

Anatomical features of Inguinal canal Walls of the inguinal canal:

o Superior wall (roof) : Internal oblique and transverse abdominis muscles o Inferior wall (floor) : Inguinal ligament o Anterior wall : aponeurosis of external oblique aponeurosis of internal oblique (in the lateral third of canal only) Superficial inguinal ring (in the medial third of canal only) o Posterior wall: Fascia of transversalis

Conjoint tendon (in the medial third of canal only) Deep inguinal ring (in the lateral third of canal only)

Contents: in males : the spermatic cord and its coverings + the ilioinguinal nerve. in females : the round ligament of the uterus + the ilioinguinal nerve. The classic description of the contents of inguinal canal in the male are: 3 arteries: artery to vas, testicular artery, cremasteric artery 3 fascial layers: external spermatic,internal spermatic,cremastic 3 other vessels: pampiniform plexus, vas deferens, lymphatics 1 nerve: genital branch of the genitofemoral nerve (L1/2) The ilioinguinal nerve passes through the superficial ring to descend into the scrotum, but does not formally run through the canal.

Principles of Surgical Treatment of Inguinal Hernia The main stages of Herniotomy : There is a great amount of operations on

inguinal hernia, but all of them differ from each other only by the end stage. The stages are:  The first stage : approach to the inguinal canal.  The second stage: isolation of hernial sac out of surrounding tissues and its excision.  The third stage : closure of the inguinal opening up to the normal sizes on its dilatation or destruction.  The fourth stage: inguinal canal plastic repair One of the major causes of recurrence of inguinal hernia is the standard appli-cation one of the techniques of operation without the account of topographical specificity of the inguinal canal, the type of hernia, age of the patient, size of the hernial ring, state of tissues. Such practice is vicious. On the data of native surgeons, standard surgical treatment of inguinal hernias results in recurrences in 6,9-28,5 % of cases. At the same time, in clinics specially engaged in this problem, percent of relapses is reduced to a minimum, averaging from 0 till 3.

INGUINAL HERNIOPLASTY Treatment of inguinal hernia: performed on the general principles of treatment of

hernias, and the basic method of treatment is surgery. The main purpose of the operation – plasty of inguinal canal - that is strengthening the weakness of the abdominal wall, especially inguinal gap. The operation is performed under local anaesthesia or general anaesthesia. Possible both ways like as an open plasty and also minimally invasive endoscopic intervention. As with other localizations plasty of hernias of inguinal canal can be performed with tissue tension (tension hernioplasty) and without (tension free hernioplasty).

Tension hernioplasty in inguinal hernias. Over 150 years, developed various ways of

plastics inguinal canal's own tissues, and to date there are over 300 different techniques. The most suitable fabrics for plastics are the free edge of the internal oblique and transverse abdominal muscles, a strong external oblique muscle aponeurosis, inguinal ligament and the rectus abdomenis muscle sheath. Purpose is many different connections of the anatomical structures forming the diversity of the proposed methods. Dramatically all methods are divided into the plasty of anterior and posterior walls of the inguinal canal. For direct hernias and complex forms of inguinal hernias (indirect with straight channel, sliding, recurrent) should be performed plasty of posterior wall of the inguinal canal. Strengthening the anterior wall with narrowing of the deep ring to normal size may be used in children and young men with small indirect inguinal hernias. All operations are performed from the standard access - an incision in the groin area, parallel to inguinal ligament length of 6-10 cm.

Line for skin incision during surgery of inguinal hernia. Typically, surgery for inguinal hernias is performed under local anaesthesia. General anaesthesia is used only for children and very nervous patients.

Dissection of aponeurosis m. obliqui externi abdominis

Separating hernial sac from the outside flap of aponeurosis of external oblique abdominalis muscles

Separating hernial sac from the elements of the spermatic cord.

Opening of hernial sac

Reposition of the contents of hernial sac into the abdominal cavity

Suturing the neck of the hernial sac

Cutting the peripheral part of hernial sac

Plasty of inguinal canal by the method of Girard. suturing m. obliquus internus abdominis, and m. transversus abdominis to lig. inguinale. Plastic anterior wall of the inguinal canal by the way Bobrov-Girard :-Suturing by individual sutures internal oblique and transverse abdominal muscles to the inguinal ligament in front of the spermatic cord with the formation of duplicate aponeurosis of external oblique muscle

Plasty of inguinal canal by Spasokukotsky. Suturing of inner flap of aponeurosis of m. obliqui externi abdominis, m. obliquus internus abdominis, and m. transversus abdominis to lig. Inguinale Plasty of anterior wall of the inguinal canal by the method of Girard-Spasokukotsky :-The method is a modification method of Bobrov - Girard, and differs from it only by the fact that the inguinal ligament at the same time (with single suture) is stitched to the internal oblique and transverse abdominalis muscles, along with the top flap of aponeurosis external oblique abdominal muscles.

Plastic inguinal canal. Seam MA Kimbarovskogo. Above the inner flap is filed outer aponeurosis flap Plasty of anterior wall of the inguinal canal by the method of Girard-Spasokukotsky with modification of Kimbarovskogo :- with a special sutures upper edge of external oblique aponeurosis muscles is wrapped to the edge of the internal oblique and transverse abdominal muscles, then with the same thread is sutured the inguinal ligament by putting 4-5 interrupted sutures, providing matching of similar tissues and more thorough healing

Original Bassini operation. The canal's posterior wall is opened Plasty of posterior wall of the inguinal canal in Bassinis method :-cross-linking of the internal oblique and transverse abdominal muscles (Conjoined tendon) to the inguinal ligament behind the spermatic cord, which eliminates the inguinal gap

Halsted operation or Postempskogo operation The external oblique aponeurosis is closed under the spermatic cord thereby sacrificing the step-down effect of the canal. Plasty of inguinal canal by the way Postempskogo or Halsted’s :-complete elimination of the inguinal canal and inguinal gap by matching all the tissues behind the spermatic cord and forming a new channel by placing the spermatic cord in the subcutaneous tissue.

Shouldice repair. The posterior wall is imbricated to be reconstructed and reinforced in 4 layers

Plasty of inguinal canal in the way by Shouldice :-using a thin steel wire is formed duplicate transverse fascia and filed edge of the internal oblique and transverse abdominal muscles to the inguinal ligament behind the spermatic cord, and then over the cord is formed duplicate external oblique muscle aponeurosis, thus securely reinforce anterior and posterior walls of inguinal canal

Shouldice repair

Cooper ligament or McVay repair. Approximation of the transversus arch to the superior pubic ligament creates more sutureline tension than any other pure tissue repair. A transition stitch must be used to avoid injury to the femoral vein Technique according to McVay:- On its basis also lay the nar-rowing of the deep inguinal ring and reconstruction of the posterior wall of the inguinal canal. Suturing of the transversal fascia forms the deep inguinal ring. Before restoration of the posterior wall of the inguinal canal, on musculus rectus abdominalis sheath, the large relief incision with the length of 4-5 cm for the greater mobility of muscular layers and the conjoined tendon is made; then a transverse fascia together with the conjoined tendon of in-ternal oblique and transversal muscles is sewed by close stitches to the Cooper's ligament. The author categorically objected to use for this purpose the inguinal ligaments. He considered essentially important to fix the posterior wall to the place of its natural attach-ment, i.e. to the Cooper's ligament. The stitches are placed on all extent from the ligamentum Gimbernati up to the femoral vessels. The spermatic cord is packing up, and aponeurotic edges of the external oblique muscle are sutured by duplicating. This technique is recommended to be applied to the com-plex forms of hernias. Technically it is difficult. There is a danger of damage of femoral vessels; therefore they should be previously exposed. The author of this technique, having applied it in 562 patients with various, including recurring inguinal, hernias has reduced the amount of relapses up to 0,6 %.

Plasty of inguinal canal by the way of Kukudzhanova :removal of the inguinal gap by suturing divided transverse fascia to inguinal ligament and the outer edge of the rectus abdominis muscle sheath, together with the free edges of the internal oblique and suturing the transverse muscles - to lacunar /coopers ligament and upper pubic ligaments behind the spermatic cord, while creating duplicate external oblique muscle aponeurosis over the spermatic cord - that simultaneously strengthens the anterior and posterior wall of the inguinal canal.

Currently, the most common method of tensioning plasty of inguinal canal in Europe and the U.S. is by Shouldice method. But in Russia, there is no unity in the surgical treatment of hernias, but the most common and reliable enough to all the proposed methods is the by Kukudzhanova method. In any case, recurrence of hernia after a tension hernioplasty ranges from 4 to 20%, so the above benefits are shown only for young people with small hernial entities. To reduce the recurrence rate of hernia a new plasty was introduced

Tension free hernioplasty Tension free hernioplasty - a closure of the defects and weaknesses of the abdominal wall using prosthetic materials without tension of own tissue(alloplasty), which ensures the absence of additional trauma , ischemia and violation of tropism, the best conditions for recovery, less risk of relapse. For tension free hernioplasty used a variety of synthetic prostheses, with various configurations (flat and three-dimensional grid, plugs, patches, etc.), which depends on the anatomic location of hernia, method of plasty and technical solutions (open or endoscopic surgery). Today tension free hernioplasty using special synthetic prostheses successfully replacing traditional methods of closure of hernial ring. This is due to the great advantages of this type of plasty:  significantly lower risk of recurrence of hernia  less tissue trauma, result in lower discomfort and less pain in the postoperative period  more rapid recovery, reduced period of hospitalization and rehabilitation  possibility of operation under local anaesthesia  The operation can be performed both open and endoscopic approach (through the punctures).

ď‚— I.L.Lichtenstein uses traditional

access and plasty of the inguinal canals posterior wall with 2dimensional polypropylene or Teflon mesh implant. Relapses are about 1%. Plasty by using Mesh.The method involves the use of tension free hernioplasty complex 3dimensional prosthesis consisting of suprafascial flap, connector, subfascial flap. Pursue their traditional access to the inguinal canal. The inner flap prosthesis formed, is introduced through the internal inguinal ring and crushes in preperitoneal space under the transverse fascia. The outer flap is formed; ensuring the passage of the spermatic cord was fixed in the same plasty of Liechtenstein. Lichtenstein patch. Mesh is sutured from the transversus arch to the shelving edge of the inguinal ligament creating a "tension-free" repair.


Femoral canal  The femoral sheath has three compartments. The lateral compartment contains the femoral artery, the intermediate compartment contains the femoral vein, and the medial and smallest compartment is called the femoral canal. The femoral canal contains efferent lymphatic vessels and a lymph node embedded in a small amount of areolar tissue. It is conical in shape and is about 2 cm long.

The femoral canal is bordered:  Anteriorly by the inguinal ligament  Posteriorly by the pectineal ligament  Medially by the lacunar ligament  Laterally by the femoral vein  The entrance to the femoral canal is the femoral ring, through which bowel can sometimes enter, causing a femoral hernia.  It contains the lymph nodes of Cloquet or Rosenmuller. It should not be confused with the nearby adductor canal.

Contents  It is important as a number of vital structures pass through it, right under the skin. The following structures are contained within the femoral triangle (from lateral to medial):     

terminal part of the femoral nerve and its branches femoral sheath femoral artery and its branches femoral veins and its tributaries deep inguinal lymph nodes (snell, 8th edition)

Femoral triangle Boundaries

It is bounded by:  superiorly the inguinal ligament  medially the medial border of adductor longus muscle  laterally the medial border of sartorius muscle  Its floor is formed (medial to lateral) by adductor longus, pectineus and iliopsoas. Its roof is formed by the fascia lata.

The femoral ring is bounded by: Medially ; Concave knife like edge of lacunar (Gimbernat)’s ligament) Laterally ; A thin septum separating it from the femoral vein. Anteriorly ; inguinal ligament (Poupart's ligament). Posteriorly ; Iliopectineal (Astly Cooper's) ligament

Treatment Method Bassini : incision is made parallel to the inguinal ligament and below it over the hernial protrusion. Hernial ring is closed by stitching the groin and upper pubic ligaments.Impose a 3-4 sutures. Second line closing sutures between the margins of the broad ligament fascia of the thigh and pectinate ligament fascia stitching of the femoral canal. Method Ruddi - Parlavechchio: make the cut, as in inguinal hernia. Reveal external oblique aponeurosis abdominal muscles. Identify the inguinal gap. Cut through the transverse fascia in the longitudinal direction. Move the preperitoneal tissue, highlighting the neck of the hernial sac. Hernial sac moved out from the femoral canal, exposed, stitched and removed. Hernial orifice closed by matching the internal oblique, transverse muscles, & the upper edge of the transverse fascia with upper pubic and inguinal ligaments. Plasty of the anterior wall of the inguinal canal done by duplication of aponeurosis of external oblique abdominal muscles.

OTHER REPAIRS (I) The Low Operation (Lockwood) * Incision in the thigh below the inguinal ligament. * Excise the sac then suture inguinal ligament to iliopectineal line. (II) The high "Lotheissen's Operation" * Incision is similar to that of inguinal hernia. * Fascia transversalis is opened and the sac extracted & excised. * Then suture conjoined tendon to iliopectineal line. (III) The "Mc Evedy's Operation" * Incision is vertical over the femoral canal extending above inguinal ligament (in skin & s. c. tissue) * Then do 2 incisions, one above the ingunal ligament & one below it, to dissect and excise the sac. * Then suture conjoined tendon to iliopectineal line The infra-inguinal approach is the preferred method for elective repair. The trans-inguinal approach involves dissecting through the inguinal canal and carries the risk of weakening the inguinal canal. McEvedy’s approach is preferred in the emergency setting when strangulation is suspected. This allows better access to and visualisation of bowel for possible resection. In any approach, care should be taken to avoid injury to the urinary bladder which is often a part of the medial part of the hernial sac. Repair is either performed by suturing the inguinal ligament to the pectineal ligament using strong nonabsorbable sutures or by placing a mesh plug in the femoral ring. With either technique care should be taken to avoid any pressure on the femoral vein.

UMBLICAL HERNIA REPAIR Autotransplantation of abdominal wall by the method Sapezhko or Mayo. Method Sapezhko: interrupted sutures, starting from one side margin of aponeurosis of white line of the stomach and on the other hand - posterior-medial portion of the rectus abdominis muscle sheath, creating duplicate of musculo-aponeurotic flaps in the longitudinal direction. This flap which is located superficially is sutured to the bottom in the form of duplicate. Method Mayo: Two transverse parallel cross-sections skin is excised along with the umbilicus. After isolation and excision of the hernial sac hernial ring is dialated in the transverse direction with the help of two cuts through the white line of the abdomen and the anterior wall of the tunica vaginalis of the rectus muscle to their inner margins. Inferior flap of the aponeurosis is sutured by Đ&#x;-shaped sutures are sutured under the superior, which is in the form of duplicate is sutured as interrupted sutures to the inferior flap.

Alloplastic techniques at post-operative ventral hernias in

each case provide all the possibilities for application of natural tissues of the patient (muscles, aponeuroses, fasciae, scar tissues, sites of the hernial sac). There are several ways of transplant ap-placation.

Onlay patch repair 

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This is the simplest method, placing a patch anterior to the aponeurosis and the defect, which may or may not have been sutured. Polypropylene mesh is most suitable as it is rapidlyincorporated in scar tissue. It should extend 4 cm beyond the edge of the defect. Secure the edge of the mesh with interrupted 2/0 polypropylene sutures at 2-cm intervals, reinforced with a continuous over-and-over stitch. Place another continuous suture to fix the mesh where it lies over the edge of the defect. This is important to prevent herniation of bowel beneath the mesh.

Three alternative levels for placement of mesh in incisional hernia repair: (a) onlay; (b) extraperitoneal; (c) intraperitoneal. Transverse section through abdominal wall, i, interrupted sutures; c, continuous suture; u, 'U’ sutures.

Extraperitoneal mesh repair (Inlay Technique)  This is suitable for midline hernias.  The peritoneum, plus the posterior rectus sheath if above the arcuate line, is dissected off the posterior aspect of the rectus muscle laterally and from the aponeurosis in the midline, for about 3 cm.  Polypropylene mesh will incorporate more rapidly but polyester is easier to position as it can deform on the bias.  Cut a piece of mesh 2 cm larger than the defect at each margin.  The mesh is drawn into the space deep to the abdominal wall by interrupted 'U' sutures of 2/0 polypropylene at 2-cm inter-vals. Each passes in through the anterior rectus sheath and rectus, picks up the edge of the mesh and returns to be tied externally.  The margin of the defect is then sutured to the surface of the mesh with a continuous over-and-over suture. Intraperitoneal mesh repair (Sublay Technique)  The sac is opened and any adhesions for 4 cm around the rim are freed.  Cut a piece of polyester mesh 2 cm larger than the defect in each direction (polypropylene is liable to cause dense intestinal adhesions).  Draw the margin of the mesh under the rim of the defect with a series of 'IT sutures of 2/0 polypropylene. These penetrate the peritoneum 2-3 cm from the rim. First place four cardinal sutures and hold them with forceps, adjusting the size of the mesh so that it fits the opening. Then insert more 'U' sutures at 1-cm intervals between one pair of cardinal sutures and tie these. Repeat this for the other three sections.  Pick up the mesh and the overlying rim with a continuous over-and-over suture, taking care to avoid the bowel.