External abdominal oblique fascia – forms the inguinal ligament (shelving edge) at inferior portion of the inguinal canal
Internal abdominal oblique – forms cremasteric muscles
Transversalis muscle – along with the conjoined tendon, forms inguinal canal floor
Conjoined tendon – composed of the aponeurosis of the internal abdominal oblique and transversalis muscles
Inguinal ligament (Poupart’s ligament) – from external abdominal oblique fascia, runs from anterior superior iliac spine to the pubis; anterior to the femoral vessels
• Lacunar ligament – where the inguinal ligament splays out to insert in the pubis
Cooper’s ligament – pectineal ligament; posterior to the femoral vessels; lies against bone
Vas deferens – runs medial to cord structures
Hesselbach’s triangle – rectus muscle, inferior inguinal ligament, and inferior epigastrics
• Direct hernias are inferior/medial to the epigastric vessels
• Indirect hernias are superior/lateral to the epigastric vessels
Indirect hernias – most common; from persistently patent processus vaginalis
Direct hernias – lower risk of incarceration; rare in females, higher recurrence than indirect
Pantaloon hernia – direct and indirect components
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Risk factors for inguinal hernia in adults: age, obesity, heavy lifting, COPD (coughing), chronic constipation, straining (BPH), ascites, pregnancy, peritoneal dialysis
Incarcerated hernia – can lead to bowel strangulation; should be repaired emergently
Sliding hernias – retroperitoneal organ makes up part of the hernia sac
• Females – ovaries or fallopian tubes most common
• Males – cecum or sigmoid most common
• Bladder can also be involved
Females with ovary in canal
• Ligate the round ligament
• Return ovary to peritoneum
• Perform biopsy if looks abnormal
Hernias in infants and children
• Just perform high ligation (nearly always indirect)
• Open sac prior to ligation
Lichtenstein repair = mesh; recurrence ↓ with use of mesh (↓ tension)
Bassini repair – approximation of the conjoined tendon and transversalis fascia (superior) to the free edge of the inguinal ligament (shelving edge, inferior)
Cooper’s ligament repair – approximation of the conjoined tendon and transversalis fascia (superior) to Cooper’s ligament (pectineal ligament, inferior)
• Needs a relaxing incision in the external abdominal oblique fascia
• Can use this for femoral hernia repair
Laparoscopic hernia repair – indicated for bilateral or recurrent inguinal hernia
Urinary retention – most common early complication following hernia repair
Wound infection – 1%
Recurrence rate – 2%
Testicular atrophy – usually secondary to dissection of the distal component of the hernia sac causing vessel disruption
• Thrombosis of spermatic cord veins
• Usually occurs with indirect hernias
Pain after hernia – usually compression of ilioinguinal nerve
• Tx: local infiltration can be diagnostic and therapeutic
Ilioinguinal nerve injury – loss of cremasteric reflex; numbness on ipsilateral penis, scrotum, and thigh
• Nerve is usually injured at the external ring; nerve runs on top of cord
Genitofemoral nerve injury – usually injured with laparoscopic hernia repair
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