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)

•  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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