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Hernias

Definition

  • Hernia: An abnormal protrusion of an organ or tissue through a defect in its surrounding walls.
    • Derived from the Latin word for "rupture".
  • Commonly involves the abdominal wall, especially the inguinal region.

General Characteristics

  • Occur at sites where aponeurosis and fascia are not covered by striated muscle.
  • Common sites:
    • Inguinal, femoral, umbilical areas
    • Linea alba
    • Semilunar line
    • Sites of prior incisions

Types of Hernias

Reducible vs. Irreducible

  • Reducible Hernia: Contents can be replaced within the surrounding musculature.
  • Irreducible (Incarcerated) Hernia: Cannot be reduced back into place.

Strangulated Hernia

  • Strangulated Hernia: Blood supply to its contents is compromised.
    • Serious and potentially fatal.
    • Occurs more often in large hernias with small orifices.
    • Can lead to intestinal obstruction.

Richter Hernia

  • Richter Hernia: Only a small portion of the antimesenteric wall of the intestine is trapped.
    • Strangulation without intestinal obstruction.

External vs. Internal Hernias

  • External Hernia: Protrudes through all layers of the abdominal wall.
  • Internal Hernia: Protrusion of intestine through a defect within the peritoneal cavity.

Interparietal Hernia

  • Interparietal Hernia: Hernia sac is contained within a musculoaponeurotic layer of the abdominal wall.

Primary Abdominal Wall Hernias (Box 45.1)

Groin

  • Inguinal
    • Indirect
    • Direct
    • Combined
  • Femoral

Anterior

  • Umbilical
  • Epigastric
  • Spigelian

Pelvic

  • Obturator
  • Sciatic
  • Perineal

Posterior

  • Lumbar

    • Superior triangle
    • Inferior triangle

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Inguinal Hernias

Classification

  • Indirect Inguinal Hernia: Sac passes from the internal inguinal ring toward the external inguinal ring and may enter the scrotum.
    • Lateral to the inferior epigastric vessels.
  • Direct Inguinal Hernia: Sac protrudes outward and forward, medial to the internal inguinal ring.
    • Occurs within Hesselbach's triangle.
  • Pantaloon Hernia: Combination of both indirect and direct hernia components.

Incidence

  • 75% of all hernias occur in the inguinal region.
    • Two-thirds are indirect; one-third are direct.
  • Femoral Hernias: Represent 3% of groin hernias.
  • Men: 25 times more likely to have a groin hernia than women.
    • Indirect hernias in men: 2:1 ratio over direct hernias.
  • Women:
    • Indirect inguinal hernia is most common.
    • Femoral hernias: Female-to-male ratio of 10:1.
    • Umbilical hernias: Female-to-male ratio of 2:1.
  • Right-sided Hernias are more common due to developmental factors.

Age Factor

  • Prevalence increases with age.
  • Strangulation risk increases at the extremes of life.
  • Femoral Hernias have the highest rate of strangulation (15%–20%).

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Anatomy of the Groin

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Layers from Anterior to Posterior

  1. Skin and Subcutaneous Tissues
    • Contains superficial vessels: superficial circumflex iliac, superficial epigastric, and external pudendal arteries and veins.
  2. External Oblique Muscle and Aponeurosis
    • Most superficial lateral abdominal muscle.
    • Fibers run inferiorly and medially.
    • Inguinal Ligament (Poupart ligament): Inferior edge extending from the anterior superior iliac spine to the pubic tubercle.
    • External (Superficial) Inguinal Ring: Opening for the spermatic cord.
  3. Internal Oblique Muscle and Aponeurosis
    • Middle layer of lateral abdominal muscles.
    • Fibers run superiorly and laterally.
    • Forms part of the conjoined tendon.
    • Cremaster Muscle arises from this layer.
  4. Transversus Abdominis Muscle and Aponeurosis & Transversalis Fascia
    • Innermost layer.
    • Fibers run horizontally.
    • Transversalis Fascia: Underlies musculature, forming the posterior wall.
  5. Iliopubic Tract
    • Formed by the transversalis fascia and transversus abdominis aponeurosis.
    • Important in hernia repairs.
  6. Pectineal (Cooper) Ligament
    • Formed by periosteum and aponeurotic tissues along the superior ramus of the pubis.
    • Used for anchoring in repairs.
  7. Inguinal Canal
    • Contains the spermatic cord in men, round ligament in women.
    • Boundaries:
      • Anterior: External oblique aponeurosis
      • Posterior: Transversalis fascia
      • Roof: Internal oblique and transversus abdominis muscles
      • Floor: Inguinal ligament

  8. Preperitoneal Space

    • Contains fat, lymphatics, vessels, and nerves.
    • Nerves: Lateral femoral cutaneous nerve and genitofemoral nerve.

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  9. Femoral Canal

    • Boundaries:
      • Anterior: Iliopubic tract
      • Posterior: Cooper ligament
      • Lateral: Femoral vein
    • Site for femoral hernias.

Diagnosis

Clinical Presentation

  • Bulge in the inguinal region.
  • Pain or vague discomfort.
  • Paresthesias due to nerve compression.

Physical Examination

  • Inspect and palpate the groin with the patient standing and supine.
  • Ask the patient to cough or perform a Valsalva maneuver.
  • Place a fingertip over the inguinal canal or invaginate the scrotum.
  • Indirect Hernia: Bulge moves lateral to medial.
  • Direct Hernia: Bulge moves from deep to superficial.
  • Femoral Hernia: Bulge below the inguinal ligament.

Imaging

  • Ultrasonography: High sensitivity and specificity for detecting occult hernias.

Classification of Groin Hernias (Box 45.3)

Nyhus Classification

  • Type I: Indirect hernia with normal internal ring (e.g., pediatric hernia).
  • Type II: Indirect hernia with dilated internal ring; posterior wall intact.
  • Type III: Posterior wall defect.
    • A: Direct inguinal hernia.
    • B: Indirect hernia encroaching on Hesselbach triangle (e.g., sliding hernia).
    • C: Femoral hernia.
  • Type IV: Recurrent hernia.
    • A: Direct.
    • B: Indirect.
    • C: Femoral.
    • D: Combined.

Treatment

Nonoperative Management

  • Watchful Waiting: Safe for asymptomatic or minimally symptomatic men.
    • Low risk of incarceration (0.3%).
    • Most patients eventually require surgery due to symptom progression.
  • Truss Use: May alleviate symptoms but can have complications.
  • Not Recommended for femoral hernias due to high strangulation risk.

Operative Repair

Anterior Repairs

  • Common approach for inguinal hernias.

Tissue Repairs (Rarely Used)

  • Iliopubic Tract Repair: Approximates the transversus abdominis to the iliopubic tract.

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  • Shouldice Repair: Multilayered imbricated repair of the posterior wall.
  • Bassini Repair: Suturing transversus abdominis and internal oblique to the inguinal ligament.
  • McVay (Cooper Ligament) Repair: Secures transversus abdominis to Cooper ligament.

Tension-Free Anterior Repairs

  • Standard Practice using mesh prosthesis.

  • Lichtenstein Repair:

    • Mesh placed over the inguinal floor.
    • Slit in mesh accommodates the spermatic cord.

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  • Plug and Patch Technique:

    • Mesh plug inserted into the hernia defect.
    • Overlying patch covers the inguinal canal.
  • Sandwich Technique:
    • Bilayered device with underlay patch, connector, and onlay patch.

Preperitoneal Repair

  • Useful for recurrent, sliding, femoral, and some strangulated hernias.
  • Accesses the hernia from behind the abdominal wall.

Laparoscopic Repair

  • Advantages: Less pain, quicker recovery, better visualization.

  • Techniques:

    • Totally Extraperitoneal (TEP):

      • Dissection begins in the preperitoneal space without entering the peritoneal cavity.

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    • Transabdominal Preperitoneal (TAPP):

      • Accesses the preperitoneal space via the peritoneal cavity.
    • Considerations:
    • Requires general anesthesia.
    • Higher recurrence with inexperienced surgeons.
    • Not ideal for patients with extensive prior abdominal surgery.

Robotic Repair

  • Similar to TAPP but utilizes robotic technology.
  • Benefits:
    • Enhanced 3D visualization.
    • Improved instrument mobility.
    • Suturing may reduce postoperative pain.

Complications and Results

Mortality

  • Low for elective repairs.
  • Higher in strangulated hernias due to patient comorbidities.

Recurrence Rates

  • Tissue Repairs: Higher recurrence rates.
  • Tension-Free Mesh Repairs: Lower recurrence rates.
    • Lichtenstein Repair: Recurrence is 25% that of non-mesh repairs.
  • Laparoscopic Repairs:
    • Similar recurrence rates to open mesh repairs when performed by experienced surgeons.
    • Higher recurrence with surgeon inexperience.

Other Complications

  • Chronic Groin Pain: Less common with tension-free repairs.
  • Visceral or Vascular Injury: Approximately 0.3% risk in laparoscopic repairs.

Femoral Hernias

Definition

  • Femoral Hernia: Occurs through the femoral canal, bounded by:
    • Superiorly: Iliopubic tract
    • Inferiorly: Cooper ligament
    • Laterally: Femoral vein
    • Medially: Junction of the iliopubic tract and Cooper ligament (lacunar ligament)
  • Presentation: Produces a mass or bulge below the inguinal ligament.
    • May occasionally present over the inguinal canal but still exits inferior to the inguinal ligament.
  • Association with Inguinal Hernias:
    • 50% of men with a femoral hernia also have a direct inguinal hernia.
    • Only 2% of women with a femoral hernia have this association.

Treatment

  • Surgical repair is recommended for all femoral hernias due to high risk of strangulation.
  • Repair Techniques:
    • Cooper Ligament Repair
      • Preferred if the bowel is compromised because mesh is contraindicated.
    • Preperitoneal Approach
    • Laparoscopic Approach

Surgical Principles

  • Dissection and reduction of the hernia sac.
  • Obliteration of the femoral canal defect by:
    • Approximating the iliopubic tract to Cooper ligament.
    • Placement of prosthetic mesh (if bowel is not compromised).
  • Dividing the lacunar ligament can assist when hernia contents cannot be reduced.
  • Anterior Approach Tips:
    • Expose the anterior reflection of the inguinal ligament by dissecting subcutaneous fat from the external oblique aponeurosis.
    • Palpate the femoral artery to locate the femoral canal.
    • Mobilize and reduce the hernia sac.
    • Insert a small prosthetic plug into the femoral canal, suturing it to surrounding structures.
      • Avoid suture fixation near the femoral vein to prevent injury.

Recurrence and Incidence

  • Femoral hernias occur in conjunction with inguinal hernias in 0.3% of patients.
  • After inguinal hernia repair, the occurrence of a femoral hernia is 15 times higher than expected.
    • Unclear if due to missed femoral hernia or new development post-repair.
  • Recurrence Rate after femoral hernia operation: 2%
  • Re-recurrence Rate after femoral hernia repair: About 10%

Special Problems

Sliding Inguinal Hernia

Definition

  • Sliding Hernia: An internal organ forms part of the hernia sac wall.
    • Commonly involved organs:
      • Colon
      • Urinary bladder

Characteristics

  • Typically a variant of indirect inguinal hernias.
  • Can also be femoral or direct sliding hernias.

Risks

  • Failure to recognize the visceral component may lead to injury to the bowel or bladder during surgery.

Treatment

  • Reduce the sliding organ back into the peritoneal cavity.
  • Ligate and divide any excess hernia sac.
  • Repair the hernia using standard techniques previously described.

Recurrent Inguinal Hernia

Challenges

  • Higher incidence of secondary recurrence.
  • Technical difficulty due to scarring and altered anatomy.

Treatment

  • Prosthetic mesh is usually required for successful repair.
  • Alternative Surgical Approaches:
    • Laparoscopic approach
    • Open posterior approach
      • Preferred after previous anterior mesh repair to avoid scar tissue and reduce complications.

Considerations

  • Avoid repeating the same surgical approach used in the initial repair.

Strangulated Inguinal Hernia

Definition

  • Strangulated Hernia: Hernia with compromised blood supply to its contents.

Treatment

  • Preperitoneal approach is preferred.
    • Allows direct visualization of hernia contents.
    • Assess viability of entrapped organs through a single incision.
  • Incise the constricting ring to reduce the hernia safely.
  • Resection of strangulated intestine can be performed if necessary without additional incisions.

Bilateral Inguinal Hernias

Approach

  • Simultaneous repair of both hernias is common.
  • Recurrence rates are similar to unilateral repairs.
  • Preferred Techniques:
    • Giant Prosthetic Reinforcement of the Visceral Sac (Stoppa Repair)
    • Laparoscopic Repair

Complications and Results

General Complications

  • Overall complication rate: Approximately 10%
  • Types of Complications:
    • General: Related to patient health and anesthesia.
    • Technical: Related to surgical procedure and surgeon experience.
      • More frequent in recurrent hernia repairs due to scarring and altered anatomy.

Surgical Site Infection

Incidence

  • 1%–2% after open repair.
  • Slightly less with laparoscopic repair.

Risk Factors

  • Associated patient diseases (e.g., diabetes, immunosuppression).
  • Previous infections or chronic skin conditions.

Prevention

  • Proper surgical technique.
  • Antiseptic skin preparation.
  • Appropriate hair removal.
  • Antimicrobial Prophylaxis:
    • Generally not needed for low-risk patients.
    • Indicated for patients with significant underlying disease (ASA score ≥3).
      • Cefazolin 2–3 g IV preoperatively.
      • Clindamycin 900 mg IV for penicillin-allergic patients.

Treatment

  • Superficial Infections: Open incision, local wound care, heal by secondary intention.
  • Deep Infections/Mesh Involvement: May require mesh explantation.

Nerve Injuries and Chronic Pain Syndromes

Affected Nerves

  • Open Repair:
    • Ilioinguinal nerve
    • Iliohypogastric nerve
    • Genital branch of the genitofemoral nerve
  • Laparoscopic Repair:
    • Lateral femoral cutaneous nerve
    • Genitofemoral nerve

Symptoms

  • Transient Neuralgias:
    • Temporary sensory disturbances.
    • Usually resolve within weeks.
  • Persistent Neuralgias:
    • Chronic pain and hyperesthesia.
    • May interfere with daily activities.

Chronic Groin Pain

  • Affects ~10% of patients post-surgery.
  • Defined as pain lasting >3 months after operation.
  • 2%–4% report significant impact on daily life.

Prevention

  • Identify and preserve nerves during surgery.
  • Avoid nerve entrapment with sutures or mesh fixation.
  • Minimize tissue disruption, especially of cremasteric fibers.
  • Use absorbable sutures when appropriate.

Management

  • Initial Treatment:
    • Anti-inflammatory medications
    • Analgesics
    • Local anesthetic nerve blocks
  • Persistent Pain Strategies:
    • Local Interventions: Mesh or tack removal near the repair site.
    • Nerve-related Interventions: Neurectomy (open or minimally invasive).
      • May trade chronic pain for numbness or paresthesia.

Ischemic Orchitis and Testicular Atrophy

Ischemic Orchitis

  • Cause: Thrombosis of veins in the pampiniform plexus within the spermatic cord.
  • Symptoms:
    • Swelling and tenderness of the testis 2–5 days post-surgery.
    • May progress over 6–12 weeks.
  • Treatment:
    • Anti-inflammatory agents
    • Analgesics
    • Orchiectomy is rarely required.

Prevention

  • Avoid unnecessary dissection of the spermatic cord.
  • Prefer posterior approach in recurrent hernias or large sacs.

Testicular Atrophy

  • Result of prolonged ischemic orchitis.
  • More common after recurrent hernia repairs.
  • Incidence increases with each subsequent recurrence.

Injury to the Vas Deferens and Viscera

Causes

  • Unrecognized sliding hernias.
  • Large hernias displacing the vas deferens before it enters the spermatic cord.

Prevention

  • Identify and protect the vas deferens during surgery.
  • Recognize and properly manage sliding hernias to avoid organ injury.

Inguinal Hernia Recurrence

Causes

  • Technical Factors:
    • Excessive tension on the repair.
    • Missed hernias during initial surgery.
    • Inadequate musculoaponeurotic margins.
    • Improper mesh size or placement.
  • Other Factors:
    • Failure to close a widened (patulous) internal inguinal ring.
    • Elevated intraabdominal pressure (e.g., chronic cough).
    • Deep incisional infections.
    • Poor collagen formation affecting wound healing.

Prevention

  • Assess internal inguinal ring size at surgery's end and close if necessary.
  • Use relaxing incisions to reduce tension.
  • Investigate for femoral hernias during recurrence repairs.

Treatment

  • Prosthetic mesh repair is typically required.
  • Alternate Surgical Approach:
    • Using a posterior approach avoids scar tissue.
  • Re-recurrences may require larger prosthetics or different techniques.

Outcomes

  • Mesh Repairs:
    • Reduce recurrence by ~60% compared to non-mesh repairs.
  • Recurrence Rates:
    • Higher after multiple repairs.
    • Re-recurrence increases with each surgery.
    • Complications also increase with subsequent repairs.

Quality of Life

Postoperative Pain

  • Tension-free and laparoscopic mesh repairs:
    • Less painful than traditional non-mesh repairs.
  • Laparoscopic repairs:
    • Offer the least postoperative pain.
    • May slightly reduce time off work.

Return to Work

  • Mesh-based repairs generally allow for quicker return to normal activities.
  • Laparoscopic approach may offer a marginal advantage.

Ventral Hernias

Definition

  • Ventral Hernia: Protrusion through the anterior abdominal wall.
    • Categories:
      • Spontaneous (e.g., umbilical, epigastric hernias).
      • Acquired (e.g., incisional hernias).

Types by Location

  • Epigastric Hernias: Between the xiphoid process and the umbilicus.
  • Umbilical Hernias: Occur at the umbilicus.
  • Hypogastric Hernias: Rare, occur below the umbilicus in the midline.
  • Incisional Hernias: Occur at sites of previous surgical incisions.

Diastasis Recti

  • Not a true hernia.
  • Definition: Stretching of the linea alba, causing bulging at the medial margins of the rectus muscles.
  • Treatment: Generally avoided unless significantly symptomatic.

Incidence

  • Incisional Hernias:
    • Account for 15%–20% of abdominal wall hernias.
    • Twice as common in women.
    • Up to 41% incidence 2 years after oncologic resection.
  • Umbilical and Epigastric Hernias:
    • Constitute 10% of hernias.
  • Annual Repairs: Estimated 350,000–500,000 ventral hernia repairs in the U.S.

Risk Factors

  • Technical Factors: Suture technique may influence hernia formation.
  • Patient-Related Factors:
    • Obesity
    • Older age
    • Male gender
    • Sleep apnea
    • Emphysema
    • Prostatism
  • Wound Infection: Linked to hernia formation.
  • Surgical Technique:
    • Suture-to-Wound Length Ratio: A ratio of 4:1 reduces incisional hernia rates.

Anatomy of the Anterior Abdominal Wall

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Musculature

  1. External Oblique Muscle
    • Most superficial lateral muscle.
    • Fibers run inferomedially ("hands in pockets").
    • Forms the anterior layer of the rectus sheath.
  2. Internal Oblique Muscle
    • Lies deep to the external oblique.
    • Fibers run superomedially.
    • Contributes to both anterior and posterior rectus sheaths.
  3. Transversus Abdominis Muscle
    • Deepest lateral muscle.
    • Fibers run horizontally.
    • Forms part of the posterior rectus sheath above the arcuate line.

Rectus Sheath and Linea Alba

  • Rectus Abdominis Muscle: Runs longitudinally along the anterior abdominal wall.
  • Linea Alba: Midline structure formed by the fusion of the rectus sheaths.
  • Arcuate Line:
    • Located 3–6 cm below the umbilicus.
    • Below this line, the posterior rectus sheath is absent.

Innervation

  • Intercostal Nerves 7–12 and L1–L2:
    • Innervate lateral muscles, rectus muscle, and overlying skin.
    • Travel between the transversus abdominis and internal oblique muscles.

Blood Supply

  • Lateral Muscles:
    • Lower intercostal arteries
    • Deep circumflex iliac artery
    • Lumbar arteries
  • Rectus Abdominis:
    • Superior epigastric artery (from internal mammary artery)
    • Inferior epigastric artery (from external iliac artery)
    • Anastomose near the umbilicus.
  • Periumbilical Area:
    • Contains critical perforator vessels.

Classification of Ventral Hernias

Umbilical Hernia

  • Children:
    • Congenital, often close spontaneously by age 2.
    • More common in individuals of African descent.
  • Adults:
    • Acquired, more common in women.
    • Associated with conditions increasing intraabdominal pressure:
      • Pregnancy
      • Obesity
      • Ascites
  • Complications:
    • Strangulation is unusual but can occur with ascites.
    • Spontaneous rupture can lead to peritonitis and death.

Epigastric Hernia

  • Occur between the xiphoid process and the umbilicus.
  • Incidence: 3%–5% of the population.
  • More common in men (2–3 times).
  • Characteristics:
    • Small defects, often multiple.
    • 80% occur in the midline.
  • Symptoms:
    • Pain disproportionate to size due to incarcerated preperitoneal fat.

Incisional Hernia

  • Result from excessive tension and inadequate healing of a previous incision.
  • Risk Factors:
    • Obesity
    • Advanced age
    • Malnutrition
    • Ascites
    • Pregnancy
    • Chronic pulmonary disease
    • Diabetes mellitus
    • Medications (e.g., corticosteroids, chemotherapeutic agents)
    • Wound infection

Loss of Abdominal Domain

  • Occurs when abdominal contents no longer reside in the abdominal cavity.
  • Complications:
    • Respiratory dysfunction
    • Bowel edema
    • Venous stasis
    • Urinary retention
    • Constipation
    • Abdominal compartment syndrome upon visceral return.

Classification Systems

  • No universal system due to complexity.
  • Factors:
    • Defect size
    • Location
    • Loss of domain
    • Patient comorbidities
    • Presence of contamination
    • History of prior repairs

  • Proposed Staging (Table 45.2):

    • Stage I: Small (<10 cm), clean wounds.
    • Stage II: Medium (10–20 cm) or small contaminated wounds.
    • Stage III: Large (≥20 cm) or contaminated wounds.

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  • Outcomes (Table 45.3):

    • Surgical site occurrence (SSO) and recurrence rates increase with stage.

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Treatment: Operative Repair

Indications

  • Primary Repair:
    • Small defects (≤2–3 cm).
    • Viable surrounding tissue.
  • Mesh Repair:
    • Larger defects (>2–3 cm).
    • Prosthetic materials used to reinforce repair.

Prosthetic Materials

Permanent Synthetic Materials

  • Polypropylene Mesh:
    • Macroporous, allows tissue ingrowth.
    • Available in lightweight and heavyweight variants.
    • Lightweight Mesh:
      • May reduce postoperative pain.
      • Controversial regarding long-term durability.
  • Polyester Mesh:
    • Hydrophilic, macroporous.
    • Requires further long-term studies.
  • Expanded Polytetrafluoroethylene (ePTFE):
    • Microporous on visceral side, macroporous on fascial side.
    • Not incorporated into tissue; encapsulated.
    • Risk of infection; removal often necessary if infected.
  • Composite Meshes:
    • Combine polypropylene with PTFE or absorbable barriers.
    • Designed to promote tissue ingrowth and reduce adhesions.

Biologic Materials

  • Derived from human, porcine, or bovine sources.
  • Acellular collagen matrices.
  • Advantages:
    • May be used in contaminated fields.
    • Provide a scaffold for neovascularization and collagen deposition.
  • Limitations:
    • High cost.
    • Variable long-term durability.
    • Best used as fascial reinforcement, not as a bridge.

Absorbable Synthetic Materials

  • Polyglactin Mesh:
    • Rapidly absorbable (8–9 weeks).
    • Used in contaminated fields.
  • Longer-term Absorbable Meshes:
    • Examples include poly-4-hydroxybutyrate.
    • Resorb over 12–18 months.
    • Not recommended in contaminated situations due to infection risk.

Operative Techniques

Mesh Placement Options

  1. Onlay Technique:
    • Mesh placed over the anterior fascia.
    • Disadvantages:
      • Large subcutaneous dissection.
      • Increased seroma formation.
      • Higher infection risk.
  2. Interposition Repair:
    • Mesh bridges the fascial defect without overlap.
    • High recurrence rates; generally not recommended.
  3. Sublay Technique:
    • Mesh placed below the fascial layers.
    • Positions:
      • Intraperitoneal
      • Preperitoneal
      • Retrorectus (Retromuscular)

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Laparoscopic Ventral Hernia Repair

  • Procedure:
    • Trocar placement laterally.
    • Reduction of hernia contents.
    • Adhesiolysis as needed.
    • Mesh placement:
      • Barrier-coated mesh to prevent adhesions.
      • At least 4 cm overlap beyond defect margins.
      • Secured with transfascial sutures and fixation devices.
  • Advantages:
    • Fewer wound complications.
    • Avoids large incisions and subcutaneous dissection.

Myofascial Release Techniques

Posterior Rectus Sheath Incision with Retromuscular Mesh

  • Technique:
    • Incise posterior rectus sheath.
    • Place mesh in retromuscular space.
    • Mesh extends 5–6 cm beyond defect.
  • Advantages:
    • Avoids mesh contact with viscera.
    • Lower recurrence rates in long-term studies.

Posterior Component Separation/Transversus Abdominis Release (TAR)

  • Procedure:
    • Incise the posterior rectus sheath near the linea semilunaris.
    • Incise the transversus abdominis muscle.
    • Extend dissection laterally for additional advancement.
  • Benefits:
    • Allows placement of large prosthetic mesh.
    • Reduced wound morbidity compared to anterior component separation.

Anterior Component Separation

  • Method:
    • Create subcutaneous flaps above external oblique fascia.
    • Incise external oblique aponeurosis lateral to linea semilunaris.
    • Advance muscle layers medially for midline closure.
  • Considerations:
    • Risk of lateral bulges or herniation.
    • Recurrence rates of up to 20% even with mesh reinforcement.

Robotic Ventral Hernia Repairs

Robotic Intraperitoneal Mesh Placement

  • Procedure similar to laparoscopic repair but uses robotic assistance.
  • Mesh fixation using sutures instead of tacks.
  • Potential Benefits:
    • Less postoperative pain.
    • Shorter hospital stay.
    • Reduced surgical site occurrences.

Robotic Retromuscular Repair with TAR

  • Indications:
    • Patients with risk factors for wound morbidity.
    • Defects 10–15 cm in width.
  • Technique:
    • Robotic ports placed laterally.
    • Retrorectus dissection with posterior component separation.
    • Midline closure of posterior and anterior rectus sheaths.
    • Mesh placed in retromuscular space without fixation.

Robotic Extended TEP Technique

  • Ideal for defects <10–12 cm.
  • Approach:
    • Enter retrorectus space via optical port.
    • Dissect preperitoneal plane to opposite side.
    • Close hernia defect and place mesh in retromuscular space.
  • Advantages:
    • Avoids laparotomy and adhesiolysis.
    • Can be performed as same-day surgery.

Results of Incisional Hernia Repairs

  • Comparative Studies:
    • Laparoscopic repairs tend to have fewer complications and lower recurrence rates for small to medium defects.
  • Surgeon Expertise:
    • Choice of open vs. laparoscopic repair often depends on surgeon preference and experience.
  • Need for Further Research:
    • Larger, adequately powered prospective randomized trials are needed.
    • Guidance on the most appropriate hernia size for each approach is required.

Unusual Hernias

Overview

Unusual hernias are less common types of hernias that occur in specific anatomical locations or have unique characteristics. Understanding these hernias is crucial for accurate diagnosis and appropriate surgical management.

Types of Unusual Hernias

Spigelian Hernia

Definition

  • A Spigelian hernia occurs through the Spigelian fascia, which is the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally.

Anatomy

  • Location: Almost all Spigelian hernias occur at or below the arcuate line.
  • Characteristics:
    • Often interparietal, with the hernia sac dissecting posterior to the external oblique aponeurosis.
    • Typically small (1–2 cm in diameter).
    • Develop during the fourth to seventh decades of life.

Diagnosis

  • Clinical Presentation:
    • Localized pain in the area.
    • Bulge may not be present due to intact external oblique aponeurosis.
  • Imaging:
    • Ultrasound or Computed Tomography (CT) scans are useful for diagnosis.
    • Dynamic Abdominal Sonography for Hernia (DASH) can help localize the hernia.

Treatment

  • Surgical Repair is recommended due to the risk of incarceration.
  • Techniques:
    • Open Repair:
      • Transverse incision over the defect.
      • Dissection through the external oblique aponeurosis.
      • Hernia sac is opened, dissected, and either excised or inverted.
      • Defect closure:
        • Small defects: Closed transversely with sutures.
        • Larger defects: Repaired with mesh prosthesis.
      • Closure of the external oblique aponeurosis.
    • Laparoscopic Repair:
      • Useful, especially for patients with higher wound risk.
      • Ensure complete reduction of hernia contents before repair.

Obturator Hernia

Definition

  • An obturator hernia protrudes through the obturator canal, a space formed by the union of the pubic bone and ischium.

Anatomy

  • Obturator Canal:
    • Covered by a membrane with an opening for the obturator nerve and vessels.
  • Hernia Formation:
    • Weakening of the obturator membrane leads to enlargement of the canal.
    • Formation of a hernia sac can lead to intestinal incarceration and strangulation.

Clinical Presentation

  • Symptoms:
    • Pain in the anteromedial thigh due to obturator nerve compression (Howship-Romberg sign).
    • Pain relieved by thigh flexion.
  • Bowel Obstruction:
    • 50% present with complete or partial intestinal obstruction.

Diagnosis

  • Imaging:
    • CT Scan of the abdomen can establish the diagnosis.

Treatment

  • Surgical Repair is necessary due to high risk of complications.
  • Approach:
    • Posterior Approach (open or laparoscopic) is preferred.
      • Provides direct access to the hernia.
  • Procedure:
    • Reduction of hernia sac and contents.
    • Obturator Foramen Repair:
      • Use of prosthetic mesh to close the defect.
      • Avoid injury to the obturator nerve and vessels.
  • Compromised Bowel:
    • May require laparotomy and possible bowel resection.

Lumbar Hernia

Definition

  • Lumbar hernias occur in the posterior abdominal wall through defects in the lumbar region.
  • Types:
    • Superior Lumbar Triangle Hernia (Grynfeltt Hernia): More common.
    • Inferior Lumbar Triangle Hernia (Petit Hernia): Less common.

Anatomy

  • Superior Lumbar Triangle: [G-RIQ]
    • Boundaries:
      • Medial: Quadratus lumborum muscle.
      • Lateral: Internal oblique muscle.
      • Superior: 12th rib.
  • Inferior Lumbar Triangle: [P-ILE]
    • Boundaries:
      • Medial: Latissimus dorsi muscle.
      • Lateral: External oblique muscle.
      • Inferior: Iliac crest.
  • Cause:
    • Weakness of the lumbodorsal fascia leads to herniation.

Diagnosis

  • Symptoms:
    • Asymptomatic in small hernias.
    • Back pain in larger hernias.
  • Imaging:
    • CT Scan is useful for diagnosis.

Treatment

  • Surgical Repair is recommended.
  • Technique:
    • Prosthetic Mesh Placement:
      • Mesh is sutured beyond the hernia margins.
      • Anchored to available fascia over the bone.
  • Approach:
    • Both open and laparoscopic repairs are effective.
  • Suture Repair:
    • Often difficult due to immobile bone margins.

Interparietal Hernia

Definition

  • An interparietal hernia is one where the hernia sac lies between layers of the abdominal wall.
  • Common Sites:
    • Often occurs in areas of previous incisions.
    • Spigelian hernias are typically interparietal.

Diagnosis

  • Clinical Presentation:
    • May present with intestinal obstruction.
    • Difficult to diagnose preoperatively.
  • Imaging:
    • CT Scan aids in diagnosis.

Treatment

  • Surgical Repair:
    • Large Hernias:
      • Require prosthetic mesh for closure.
    • Component Separation Technique:
      • May be used when prosthetic repair is not feasible.
      • Utilizes natural tissues to close the defect.

Sciatic Hernia

Definition

  • A sciatic hernia occurs through the greater sciatic foramen.
  • Rarity: Extremely uncommon and often asymptomatic until complications arise.

Clinical Presentation

  • Symptoms:
    • Gluteal mass or discomfort.
    • Sciatic nerve pain (rare cause of sciatic neuralgia).
  • Complications:
    • May present with intestinal obstruction.

Treatment

  • Surgical Repair:
    • Transperitoneal Approach is preferred if obstruction is suspected.
    • Procedure:
      • Reduction of hernia contents with gentle traction.
      • Prosthetic Mesh Repair to close the defect.
    • Transgluteal Approach:
      • Alternative if diagnosis is certain and hernia is reducible.
      • Less commonly used due to surgeon familiarity.

Perineal Hernia

Definition

  • A perineal hernia involves protrusion of intra-abdominal contents through the pelvic diaphragm.
  • Types:
    • Primary: Rare, often in older multiparous women.
    • Secondary: Occur after surgeries like abdominoperineal resection or perineal prostatectomy.

Clinical Presentation

  • Symptoms:
    • Bulge or mass in the perineal area.
    • Worsens with sitting or standing.
    • May be detected on bimanual rectal-vaginal examination.

Treatment

  • Surgical Repair:
    • Approach:
      • Transabdominal or combined transabdominal and perineal.
    • Procedure:
      • Reduction of hernia contents.
      • Defect Closure:
        • Small defects: Closed with nonabsorbable sutures.
        • Large defects: Require prosthetic mesh repair.

Loss of Domain Hernias

Definition

  • Loss of domain refers to massive hernias where the herniated contents have been outside the abdominal cavity for so long that they cannot be easily returned.

Classification

  • With or Without Preoperative Contamination.
  • Categories:
    • Small Defect, Massive Hernia Sac: E.g., large inguinoscrotal hernias.
    • Large Defect, Massive Hernia Sac: E.g., open abdomen with skin graft.

Preoperative Considerations

  • Patient Evaluation:
    • Weight reduction.
    • Smoking cessation.
    • Nutritional optimization.
    • Glucose control.
  • Risks:
    • Increased intra-abdominal pressure post-repair.
    • Potential for abdominal compartment syndrome and respiratory failure.

Treatment

  • Techniques:
    • Progressive Pneumoperitoneum:
      • Insufflation of air into the abdominal cavity over 1–3 weeks.
      • Gradual stretching of abdominal wall muscles.
    • Staged Repair with Mesh:
      • Initial placement of ePTFE dual mesh to close the defect.
      • Serial excisions of mesh over time to approximate fascia.
      • Final closure with component separation and possible biologic mesh.

Parastomal Hernia Repair

Definition

  • A parastomal hernia is a hernia occurring adjacent to an abdominal stoma, such as a colostomy or ileostomy.

Incidence

  • Highest with colostomies.
  • Occurs in up to 50% of stoma patients.
  • Most patients remain asymptomatic.

Indications for Repair

  • Symptoms of bowel obstruction.
  • Pouching difficulties.
  • Cosmetic concerns.

Treatment Options

  1. Primary Fascial Repair:
    • Reduction of hernia contents.
    • Fascial reapproximation through a peristomal incision.
    • High recurrence rate; reserved for patients not tolerating laparotomy.
  2. Stoma Relocation:
    • Creation of a new stoma at a different site.
    • Requires laparotomy.
    • Risk of developing another parastomal hernia.
  3. Prosthetic Repair:
    • Mesh Placement:
      • Onlay Patch.
      • Intraperitoneal Mesh (e.g., Sugarbaker technique).
      • Retrorectus Mesh Placement.
    • Considerations:
      • Risk of mesh-related complications like erosion and obstruction.
      • Use of prosthetic mesh can lower recurrence rates.

Sugarbaker Technique

  • Method:

    • Intraperitoneal mesh is placed over the hernia defect.
    • Stoma is lateralized as it exits the abdomen.
    • Mesh overlaps the fascial defect without a keyhole.

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Complications

Mesh Infection

Overview

  • Serious complication requiring prompt attention.
  • Types:
    • Acute Infection with Sepsis.
    • Chronic Indolent Infection.

Management

  • Acute Infections:
    • Hospital admission.
    • Intravenous antibiotics.
    • Surgical debridement and mesh removal.
  • Chronic Infections:
    • Percutaneous drainage of fluid collections.
    • Antibiotic suppression based on cultures.
    • Mesh Salvage:
      • Success depends on patient factors (e.g., smoking cessation, diabetes control).
      • Type of Mesh:
        • ePTFE Mesh: Often requires removal if infected.
        • Polypropylene Mesh: More amenable to salvage efforts.

Seromas

Overview

  • Accumulation of serous fluid in the space created by hernia repair.
  • Common after both open and laparoscopic repairs.

Management

  • Preventive Measures:
    • Drains in open repairs (though may risk contamination).
  • Postoperative Care:
    • Observation: Many seromas resolve spontaneously.
    • Aspiration:
      • Reserved for symptomatic or persistent seromas (after 6–8 weeks).

Enterotomy

Overview

  • Intestinal injury during adhesiolysis can be severe.
  • Risk: Particularly high during ventral hernia repairs.

Management

  • Options:
    • Abort the hernia repair.
    • Primary tissue repair.
    • Use of biologic mesh in contaminated fields.
    • Delayed repair with prosthetic mesh (after 3–4 days).
  • Considerations:
    • Segment of intestine injured (small vs. large bowel).
    • Degree of contamination.

Note: This summary is based on provided content and aims to offer clear and detailed explanations of unusual hernias, their diagnosis, treatment options, and associated complications for educational purposes.