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Indirect Inguinal Hernia

Important points about Indirect Inguinal hernia

  • In Indirect inguinal hernia the contents of the abdomen enter the deep inguinal ring and traverse the whole length of the inguinal canal to come out through the superficial inguinal ring.
  • It is the most common of all forms of hernia.
  • It is most common in the young (cf. a direct hernia is most common in the olD.
  • More common in males (-20 times)
  • It is more common on the right side.
  • It is bilateral in 12% of cases.
  • Indirect inguinal hernia usually occurs when there is a partially or completely patent processus vaginalis (although multiple other factors are responsible for formation of indirect inguinal hernia, patent processus vaginalis seems to be the prime factor)
  • "If both sides are explored in an infant presenting with one hernia, the incidence of a patent processus vaginalis on the other side is 60%"
  • Indirect Inguinal hernias are classified into 3 types
  1. Bubonocele: in this case the hernia is limited in the inguinal canal.
  2. Funicular : here the processus vagina lis is closed at its lower end just above the epididymis. The contents of the hernial sac can be felt separately from the testis which lies below the hernia.
  3. Complete (or Vaginal): here the processus vaginalis is "Patent throughout. The hernial sac is continuous with the tunica vagina lis of the testis. The hernia descends down to the bottom of scrotum and it is difficult to differentiate the testis from the hernia.
  • Surgery is the treatment of choice
  • Inguinal hernias are of 2 types
- Indirect
- Direct: here the contents protrude through the posterior wall of the inguinal canal medial to the inferior epigastric vessels (through the Hesselback's trianglE.
  • Indirect inguinal hernia is -20 times more common in ma es.
  • Direct inguinal is practically never seen in females.  
  • Indirect inguinal hernia is much more common on the right side than on left (This is associated with the late descent of the right testis) [Direct inguinal hernias have no side predilection]
  • As the neck of the direct inguinal hernia is wide, it rarely gets strangulated.
  • Femoral hernia are more common in females. F : M ratio being 4:1





Through Posterior Wall Of Inguinal Canal (Hesselbach’s Triangle)

Through Dir

LOCATION in relation to the Inferior Epigastric vessels.



Age Predisposition



Extent Into Scrotum

Usually absent

May be present

Most groin hernias are clinically important and should be repaired electively. LA is preferred for open hernia repair.

  1. Anesthesia: General anaesthesia is a preferred anaesthesia for Lap. Hernia repair. Q
  2. Local anesthesia; Regional anesthesia: Subarachnoid block or spinal anesthesia; for open Hernia repair
  3. Other options: Such as caudal anesthesia or paravertebral block. General anesthesia provides complete relaxation and calms the patient's fears however.
  4. The Evolution of Hernia Repair Q
  1. Edoardo Bassini: The Father of Modern Day Hernia Surgery
  2. Bassini's operation epitomized the essential steps for an ideal tissue repair. He opened the external oblique aponeurosis through the external ring, and then resected the cremasteric fascia to expose the spermatic cord. Q
  3. He then divided the canal's posterior wall to expose the preperitoneal space and did a high dissection and ligation of the peritoneal sac in the iliac fossa.
  4. Bassini then reconstructed the canal's posterior wall in 3 layers. He approximated the medial tissues, including the internal oblique muscle, transversus abdominus muscle and transversalis fascia to the shelving edge of the inguinal ligament with interrupted sutures. Q
  5. He then placed the cord against that newly constructed wall and closed the external oblique aponeurosis over it, thereby restoring the step-down effect of the canal and reforming the external inguinal ring. Q
  6. There have been numerous modifications of Bassini's original technique eg.  Introduction of relaxing incisions by surgeons such as Wolfer, Halsted, Tanner, and McVay.
  7. Annandale described a posterior approach to groin hernia repair in 1876. Stoppa used the posterior approach to implant an impermeable barrier around the entire peritoneal bag, demonstrating that permanent repair of groin hernias does not require closure of the abdominal wall defect per se. Q
  8. Without having stated it, their repair used a tension-free technique In Stoppa's approach, the mesh is held in place by intra-abdominal pressure, an application of Pascal's principle. 
  1. Contemporary Classical Repairs
    Among the most notable contemporary classic hernia repairs are the Bassini, Halsted, Shouldice and, McVay (Cooper Ligament) repairs.
    1. Modified Bassini. Bassini's original repair yielded outstanding results for a pure tissue technique, but, as noted above, problems occurred when surgeons failed to open the posterior wall.
    2. This operation became known as the "modified" or "North American" Bassini. By not opening the posterior wall, the wall tissue was damaged in its most medial portion by sutures placed under tension, and recurrences resulted, primarily in the pubic tubercle area. Q
    3. Shouldice repair: It applies the principle of an imbricated posterior wall closure with continuous monofilament suture.
    4. At the Shouldice hospital, continuous stainless-steel wire is used for all layers of the repair. The Shouldice repair remains an excellent option, however, and has produced the best and most enduring results of any other pure tissue repair.
  2. Tension-Free Hernia Repair
    1. The most important advance in hernia surgery has been the development of tension-free repairs. QUsher opened the posterior wall and sutured a swatch of Marlex mesh to the undersurface of the medial margin of the defect (which he described as the transversalis fascia and the conjoined tendon) and to the shelving edge of the inguinal ligament. 
    2. The most common prosthetic open repairs done today are the Kugel patch repair, the Lichtenstein onlay patch repair, the PerFix plug and patch repair, and the PROLENE Hernia System bilayer patch repair.
    3. The Stoppa-Rives giant prosthetic repair of the visceral sac is also an important tension-free technique done through an open posterior approach. Q
    4. Complications Associated With Hernia Surgery
      1. Infection
      2. Seroma: A seroma is a collection of serum in a surgical wound. The size of the collection relates to the amount of dissection done between tissue planes and the amount of dead space remaining in the wound.
        The wound appears raised but is not inflamed or tender. The mass is fluctuant and the fluid ballotable.
        Ultrasonography confirms the clinical diagnosis. Treatment consists primarily of observation and expectation.
        Aspiration is rarely necessary, and in most cases the seroma will completely reabsorb in 2 to 3 weeks. Early aspiration is futile, as the fluid will reaccumulate within a day or 2.
      3. Hematoma: Opening the wound, evacuating the hematoma, and allowing it to close by secondary intention best treats bleeding into the wound.
      4. Postoperative Neuralgia: Symptoms are pain or a burning sensation in the inguinal region, which may radiate to the genitalia and the upper thigh.    
        It is aggravated by activity and relieved by hip flexion. Tinel's sign helps in identifying a trigger point causing the problem. Q
        If localized anesthetic blocks confirm the diagnosis of a specific postoperative neuralgia. treatment is resection of the nerve trunk carried as far proximal as possible.
  3. Pediatric Inguinal Hernias
    1. Inguinal hernias in the pediatric age group are almost always indirect, the result of persistent patency of the processus vaginalis
    2. The processus vaginalis is still open in most newborns. It normally becomes fibrosed during infancy, and by age 2 most are completely obliterated. The persistent processus in itself does not indicate the presence of a hernia. Q
    3. Bowel or other intra-abdominal contents must come into the processus for it to clinically become a hernia. The processus may close inconsistently, leading to a funicular hernia, a scrotal hernia, or, a hydrocele.
    4. The persistence of the processus vaginalis seems to be more common on the right side.
    5. Once the diagnosis of an inguinal hernia is made in a child it should be repaired, there is a higher incidence of incarceration or strangulation in these young children. Q
    6. Repair of Pediatric Hernias
      1. Repair of most pediatric hernias requires ligation of the true neck of the sac through the internal ring.
      2. The sac should be examined to rule out the presence of a sliding component. This is especially important in female patients, as it may contain a Fallopian tube or ovary that could inadvertently be ligated. Q
      3. In general, prosthetics should not be used in small children. However, hernias in full-grown teenagers can be safely repaired with mesh.
  4. Laparoscopic Hernia Repair
    1. Triangle of doom
      1. Medially – Van deferens
      2. Laterally Gonadal vessels
      3. Inferior Inferiorly reflect peritoneum
    2. Triangle of pain
      1. Genito femoral nerve
      2. LFCN (Lat. Femoral cutaneous NervE. Most common nerve damaged in lap hernia repair)
    3. Trapezoid of disaster
      1. Abnormal obturator artery (Corona Mortis)
  5. Intraperitoneal onlay mesh technique (IPOM):
    1. The IPOM technique focused on the placement of an intra-abdominal piece of a prosthetic biomaterial fixed with some type of stapling device;
    2. The repair did not involve the dissection of the peritoneum. The advantages of this repair were the lack of significant dissection of the preperitoneal space and the rapid placement of the prosthesis. The recurrence rate, however, was somewhat higher that that of the more widely adopted repairs developed later. Q
    3. Trans abdominal preperitoneal (TAPP) repair method: In this approach, the preperitoneal tissue is removed from the fascial layer by directly entering the intra-abdominal cavity.
    4. This is similar to the IPOM approach, except that TAPP involves more dissection of the preperitoneal space.
    5. With TAPP, the prosthesis is placed into the preperitoneal space following dissection, fixed with a stapling device or a spiral tacking device, and covered.
    6. Totally extraperitoneal approach (TEP) Q:  The TEP approach generally employs a preperitoneal dissection balloon that is introduced via a subumbilical incision.
      The balloon is inflated, creating the preperitoneal space for the hernia repair. Q
      Two or 3 additional working ports are then placed to complete the necessary surgical dissection in which to adequately expose the inguinal floor and the myopectineal orifice.
      Once the hernia defects are visualized, a polypropylene biomaterial is then inserted and secured to the transversalis fascia and/or Cooper's ligament with tacks or staples.
  6. Other terminology and types of hernias.
    1. Maydel’s hernia (Hernia in W): Strangulated loop of W lies within the abdomen and local symptoms of strangulation are not marked.
    2. Sliding hernia (Hernia en gissadE.: The posterior wall of sac is also formed by cecum (right), Sigmoid colon (left) or by a portion of bladder (either sidE..
    3. Spigelian hernia: Occurs commonly at the level of arcute line.
    4. Lumbar hernia: Exits through inferior lumber triangle of Petit (formed by iliac crest; external oblique and latissimus dorsi), or rarely through superior lumber triangle (formed by sacrospinalis; lower border of 12th rib and posterior border of internal obliquE..
    5. Obturator hernia: it occurs through the obturator canal. Swelling is covered by pectineus but becomes more apparent on flexion abduction and external rotation of the limb.
    6. Gleuteal hernia: passes through greater sciatic foramina either above or below the piriformis.
    7. Schiatic hernia: passes through the lesser schiatic foramen.
    8. Incisional hernia occurs in a previous scar and it is the most common hernia in a female.  
    9. Velpeau hernia: A hernia in the groin in front of the femoral blood vessels. Named for the 19th-century Paris surgeon Alfred Armand Louis Marie Velpeau (1795-1867).
    10. Holthouse’s hernia: An inguinal hernia with extension of the loop of the intestine along the inguinal ligament.

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