– Hernias, Abdomen, and Surgical Technology

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

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)