GROIN HERNIA REPAIR

INGUINAL HERNIA Fig. 24.10

Indirect Hernia  Fig 24.10a

Ingural incision half an inch above and paratel to the inguinal ligament

Inguinal Hernia

Cut skin and subcutaneous tissue

Open external oblique aponeurosis in the same line

Identify the cord and free it by blunt dissection.

Open the cremaster muscle the indirect sac is identified and opened finger introduced to enter the neck and peritoneal cavity.

Sac separated from cord structure by blunt and sharp dissection

The contents reduced sac twisted and ligated as high as possible. Sac excised.

Repair defect in transverselis fashia

If the posterior wall is weak a Bassini repair of the posterior wall is done by plication

The conjoint tendon can also be sutured to the inguinal ligament

External oblique is closed

DIRECT INGUINAL HERNIA

This  hernia is due to a diffuse bulge of the posterior  wall  of

the  inguinal  canal  and it is this wall that  needs repair  and

reinforcement with mesh after the sac has been excised.

Direct Hernia

The incision is the same as for indirect hernia

The incision is depended to cut subcutaneous tissue

External oblique identified and cut along the line of incision

The inguinal canal is now open

Identify the cord and free it by blunt dissection

The direct hernia bulge will be seen behind find the cord

Placation of the tranversalis muscle ligament

A Bassini repair of the posterior wall

Conjoint tendon is sutured to the inguinal ligament

In some cases a marlex mesh is sutured behind the cord to reinforce the posterior wall

The external oblique and skin are closed.

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Groin hernia symptoms

HERNIA SYMPTOMS

A hernia may be a  symptomatic or may be discovered  incidentally

(asymptomatic)during a routine physical examination.If noticed by 

the patient, except for the bulge,  the  usual  reducible  hernia

produces  no symptoms other than a dull pain. The degree of  pain

vary  from  one individual to another.  This pain occurs  when  a

sudden  enlargement occurs and allows descent of a loop of  small

gut  into  the  hernial sac.  The pain may then  develop  due  to

pressure and is of a visceral origin.

With groin hernia, the location of the mass should be helpful  in

distinguishing  the  femoral hernia.   The  clinical  distinction

between  direct  and indirect hernia by physical  examination  is

required  scince.  The operative procedure for the repair of  the

defects  have to be different.  A thumb placed over the  internal

inguinal  ring  should keep an indirect hernia reduced  when  the

patient strains while permitting a direct hernia to appear.

The  predominant  finding with an  incarcerated  or  strangulated

hernia is a tender mass at one of the hernial sites.

TREATMENT

The non-operative treatment of a hernia involves the use of  some

external  device or turss to maintain hernial reduction.  In  the

groin,  a  truss  is  ineffective  in  maintaining   satisfactory

reduction.  A properly fitting corset may be an exellent  remedy,

however, for a ventral hernias, particularly when a large  defect

develops  in an abdominal wound which becomes infected  following

laparotomy.

PRINCIPLES OF SURGICAL REPAIR

The essential steps to the repair of hernias are:

1. The  separation  and  excision of  the  peritoneal  sac  after

   reduction of its contents, and

2. The repair of the fascial defect through which the hernia  has

   appeared

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Groin Hernias 3 Clinical

4.5 Clinical

All  these  hernias  present  with a  vague  pain  or  discomfort

associated with a bulge in the groin.

Clinical  diagnosis is made on the basis of the  relationship  of

the hernia to the pubic tubercle. Inguinal hernias are lateral  to

the tubercle femoral hearnia is medial to the tubercle.

Inguinal  hernias also need to be differentiated from  a  scrotal

hydrocele,   spermatocele,   orchitis,  testicular   tumours  and

hydrocele of the cord.

75% of all hernias occur in the groin half of these are  indirect

hernias and a 25% direct only 3% are femoral hernia

4.6 DIFFERENTIAL DIAGNOSIS

All hernia patients are examined supine and standing.

A scrotal hydrocele is not reducible.

There  is  no  cough  impulse and is  situated  entirely  in  the

scrotum,  the  testis  may not be palpable seprately  but  it  is

possible  to  get  above  the hydrocele  and  to  feel  the  cord

seperately. The hydrocele is also transilluminant. 

A  spermatocele is a distension of the epididymis and  is  filled

with fluid and sperms.

The clinical features are similar to those of a hydrocele  except

the swelling is smaller and situated above and behind the  testes

which is palpable separately.

An  orchitis  presents as a firm and tender scrotal  swelling  of

recent  onset  accompanied  with fever.  The  cord  may  also  be

tender (funniculitis).

A  testicular  tumour is a painless usually  symptomless  scrotal

swelling  which  is  firm in feel and heavy.   There  may  be  an

accompanying secondary hydrocele.

A  hydrocele of the cord is an unobilaterated portion  of  tunica

vaginalis.   The  cyst  is  palpable, along  the  course  of  the

spermatic  cord and may be in the inguinal canal or  scrotum,  it

moves  with  a pull on the cord and there is no  reducibility  or

cough impulse.

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