A hernia is defined as an area of weakness or complete disruption of the fibromuscular tissues of the body wall. Structures within the cavity contained by the body wall can pass through, or herniate through, such a defect. While the definition is straightforward, the terminology is often misrepresented or misused. It should be clear that hernia refers to the actual anatomic weakness or defect, and hernia contents describes those structures that pass through the defect.
Inguinal hernias are among the oldest known afflictions of humankind, and surgical repair of the inguinal hernia is the most common general surgery procedure performed today.1 Despite the high incidence, the technical aspects of inguinal hernia repair continue to evolve with new surgical advancements.
The word “hernia” is derived from a Latin term meaning “a rupture.” The earliest reports of abdominal wall hernias date back to 1500 BC. During this early era, abdominal wall hernias were treated with trusses or bandage dressings. The first evidence of operative repair of a groin hernia dates to the first century AD. The original hernia repairs involved wide operative exposures through scrotal incisions requiring orchiectomy on the involved side. Centuries later, around 700 AD, principles of operative hernia repair evolved to emphasize mass ligation and en bloc excision of the hernia sac, cord, and testis distal to the external ring. The first report of groin hernia classification based on the anatomy of the defect (ie, inguinal versus femoral) dates to the 14th century, and the anatomical descriptions of direct and indirect types of inguinal hernia were first reported in 1559.
Bassini revolutionized the surgical repair of the groin hernia with his novel anatomical dissection and low recurrence rates. He first performed his operation in 1884, and published his initial outcomes in 1889.2 Bassini reported 100% follow-up of patients over a 5-year period, with only five recurrences in over 250 patients. This rate of recurrence was unheard of at the time and marked a distinct turning point in the evolution of herniorraphy. Bassini’s repair emphasizes both high ligation of the hernia sac in the internal ring as well as suture reinforcement of the posterior inguinal canal. The operation also utilizes a deep and superficial closure of the inguinal canal. In the deep portion of the repair, interrupted sutures affixing the transversalis fascia medially to the inguinal ligament laterally repair the canal. This requires an incision through the transversalis fascia. The external oblique fascia provides the superficial closure.
In addition to Bassini’s contributions, Lotheissen in 1898 introduced the first true Cooper’s ligament repair, which affixes the pectineal ligament to Poupart’s ligament and thereby repairs both inguinal and femoral hernia defects. McVay further popularized the Cooper’s ligament repair with the addition of a relaxing incision to reduce increased wound tension.
The advances in groin hernia repair in the century following Bassini have shared the primary goal of reducing long-term hernia recurrence rates. To this end, efforts have been directed toward developing a repair that imparts the least tension on the tissues that are brought together to repair the hernia defect. Darn repairs were first introduced in the early 20th century to reduce wound tension by using either autologous tissue or synthetic suture to bridge the gap between fascial tissues. Muscle and fascial flaps were also attempted without consistent success. In 1918, Handley introduced the first use of silk as a prosthetic darn, with nylon following several years later. However, it was found that heavy prosthetic material increased the risk of wound infection, and silk suture ultimately lost its strength over time. The use of autologous or synthetic patches was also attempted in order to reduce wound tension and improve rates of recurrence. The first patches, beginning in the early 20th century, consisted of silver wire filigree sheets that were placed along the inguinal canal. Over time, the sheets suffered from metal fatigue, leading to hernia recurrence. Reports of the wire patches eroding into adjacent inguinal structures and even the peritoneal cavity caused yet more concern with this technique. In 1958, Usher introduced the modern synthetic patch, made of a plastic monofilament polymer (polyethylene). Lichtenstein further popularized this technique after developing a sutureless hernia repair using a plastic mesh placed across the inguinal floor.
In the search for a technical means to reduce recurrence, emphasis was also placed on a meticulous dissection that would avoid placement of a prosthetic mesh. The most popular version was the Shouldice technique, initially introduced in 1958, which was in essence a modification of the Bassini operation. This technique involves precise dissection of the entire inguinal floor and closure of the inguinal canal in four layers. The transversalis fascial layer itself is closed in two running layers, as opposed to the single layer of interrupted suture advocated by Bassini. While the operation can be technically challenging to the beginner, it has been associated with excellent long-term outcomes and the lowest reported recurrence rates for non-mesh repairs.
Today, laparoscopic and robotic techniques have been validated as safe and effective in the treatment of groin hernias and as a result, have become commonplace. The laparoscopic approaches were initially developed in the early 1990s when laparoscopic techniques diffused throughout other specialties of general surgery. Robotic inguinal hernia repair has become an area of significant growth in the recent past and continues to grow in volume yearly.
Seventy-five percent of all abdominal wall hernias are found in the groin, making it the most common location for an abdominal wall hernia. Of all groin hernias, 95% are hernias of the inguinal canal, with the remainder being femoral hernia defects. Inguinal hernias are nine times more common in men than in women. Although femoral hernias are found more often in women, the inguinal hernia is still the most common hernia in women.3 The overall lifetime risk of developing a groin hernia is approximately 27% in males and 3% in females.4 There is also clearly an association between age and hernia diagnosis. After an initial peak in the infant, the prevalence of groin hernias increases with advancing age. On average, the prevalence of hernias is 1.3% for all ages, but increases to 3% in those over the age of 45. In the same way, the complications of hernias (incarceration, strangulation, and bowel obstruction) are found more commonly at the extremes of age. Interestingly, the incidence of inguinal hernia repair actually decreases over the age of 80 for both men of women.5 It is hypothesized that this is likely due to the increase in comorbidities that supersede the need for hernia repair.
Currently in this country, approximately 800,000 operations for inguinal hernia repair are performed annually.6 Overall, the lifelong cumulative incidence of an initial unilateral or bilateral inguinal hernia repair in adults is 42.5% for men and 5.8% for women.5 Nevertheless, in the retrospective review by Zendejas, it was seen that the incidence of inguinal hernia repair is downtrending over time. The etiology of this pattern requires more investigation, but is theorized to be due to a multitude of factors such as the popularization of watchful waiting, as described later, and the increased use of mesh repair which decreases recurrences and need for reoperation.
A thorough classification system has been developed to assist in the proper diagnosis and management of the inguinal hernia. All hernias can be broadly classified as congenital or acquired. It is thought that the vast majority of inguinal hernias are congenital in nature. Acquired groin hernias develop after surgical incision and manipulation of the involved abdominal wall tissues. Given the paucity of primary groin incisions utilized in modern general surgery, acquired hernias of the inguinal or femoral region are rare.
Inguinal hernias are further divided by anatomical location into direct and indirect types. This differentiation is based on the location of the actual hernia defect in relation to the inferior epigastric vessels. The inferior epigastric vessels are continuous with the superior epigastric vessels that originate from the internal mammary artery cephalad and ultimately course caudally to become the common femoral artery and vein. These vascular structures make up the lateral axis of Hesselbach’s triangle, which includes the lateral border of the rectus sheath as its medial border and the inguinal (Poupart’s) ligament itself as the inferior border. Hernias that develop lateral to the inferior epigastric vessels are termed indirect inguinal hernias, and those that develop medial to the vessels are direct inguinal hernias. In this way, direct hernia defects are found within Hesselbach’s triangle. Hernias of the femoral type are located caudal or inferior to the inguinal ligament and medial to the femoral vessels.
The indirect inguinal hernia develops at the site of the internal ring, or the location where the spermatic cord in men and the round ligament in women enters the abdomen. While these may present at any age, indirect inguinal hernias are thought to be congenital in etiology. The accepted hypothesis is that these hernias arise from the incomplete or defective obliteration of the processus vaginalis during the fetal period. The processus is the peritoneal layer that covers the testicle or ovary as it passes through the inguinal canal and into the scrotum in men or the broad ligament in women. During development, the internal ring closes, and the processus vaginalis becomes obliterated following the migration of the testicle into the inguinal canal. The failure of this closure provides an environment for the indirect inguinal hernia to develop. In this way, the remnant layer of peritoneum forms a sac at the internal ring through which intra-abdominal contents may herniate, thereby resulting in a clinically detectable inguinal hernia. Anatomically, the internal ring is lateral to the external ring and the remainder of the inguinal canal, thus explaining the lateral relationship of the indirect inguinal hernia to the inferior epigastric vessels. It is noteworthy that indirect inguinal hernias develop more frequently on the right, where descent of the gonads occurs later during fetal development.
Direct inguinal hernias, in contrast, are found medial to the inferior epigastric artery and vein, and within Hesselbach’s triangle. These hernias are acquired and only rarely found in the youngest age groups. They are thought to develop from an acquired weakness in the fibromuscular structures of the inguinal floor, so that the abdominal wall in this region can no longer adequately contain the intra-abdominal contents. The exact relationship between direct inguinal hernias and heavy lifting or straining remains unclear, and some studies suggest that the incidence of direct hernias is no greater in people in professions that routinely involve heavy manual labor.7
While femoral hernias account for less than 10% of all groin hernias, their presentation can be more acute in nature. In fact, it is estimated that up to 40% of femoral hernias present as emergencies with hernia incarceration or strangulation.3 In this way, femoral hernias may also present as bowel obstructions. The empty space through which a femoral hernia forms is medial to the femoral vessels and nerve in the femoral canal and adjacent to the major femoral lymphatics. The inguinal ligament forms the cephalad border of the empty space. However, while the empty space is inferior to the inguinal ligament, the herniated contents may present superior to the ligament, thereby making an accurate diagnosis difficult.
Femoral hernias are much more common in females than males, although inguinal hernias are still the most common hernia in women. The predilection for femoral hernias in women may be secondary to less bulky groin musculature or weaknesses in the pelvic floor tissues from previous childbirth. It has also been shown that previous inguinal hernia repair may be a risk factor for the subsequent development of a femoral hernia.3
Despite the pervasiveness of groin hernias and repairs, there lacks standardization regarding classification of groin hernias. There exist many various classification and grading systems describing inguinal hernias. Early classifications were first seen in the 1960s, and then modified by various groups, including Rutkow and Robbins, Lichtenstein, Nyhus, Zollinger, and Stoppa. Given the variations between individual classifications, the European Hernia Society (EHS) published a simplified yet comprehensive classification based on the Aachen classification.8 The EHS grading system describes three characteristics of hernias: whether the hernia is primary or recurrent; the size from 0 to 3, with 0 as no hernia, 1 as <1.5 cm (one finger-width), 2 as <3 cm (two finger-widths), 3 as >3 cm (more than two finger-widths), and × as not investigated; and anatomic location, with L being lateral or indirect, M being medial or direct, and F being femoral. While no consensus exists among surgeons regarding a preferred classification system, it is recommended that the EHS classification be used as a standard to allow for better comparison of hernias and their treatments among various institutions.9
The boundaries of the inguinal canal must be understood to comprehend the principles of hernia repair. In the inguinal canal, the anterior boundary is the external oblique aponeurosis; the posterior boundary is composed of the transversalis fascia with some contribution from the aponeurosis of the transversus abdominis muscle; the inguinal and lacunar ligaments impart the inferior border; and the superior boundary is formed by the arching fibers of the internal oblique musculature.
The internal (or deep) inguinal ring is formed by a normal defect in the transversalis fascia through which the spermatic cord in men and the round ligament in women passes into the abdomen from the extraperitoneal plane. The external (or superficial) ring is inferior and medial to the internal ring and represents an opening of the aponeurosis of the external oblique. The spermatic cord passes from the peritoneum through the internal ring and then caudally into the external ring before entering the scrotum in males.
From superficial to deep, the surgeon first encounters Scarpa’s fascia after incising the skin and subcutaneous tissue. Deep to Scarpa’s layer is the external oblique aponeurosis, which must be incised and spread to identify the cord structures. The inguinal ligament represents the inferior extension of the external oblique aponeurosis, and extends from the anterior superior iliac spine to the pubic tubercle. The medial extension of the external oblique aponeurosis forms the anterior rectus sheath. The iliohypogastric and ilioinguinal nerves, which provide sensation to the skin, penis, and the upper medial thigh, lie deep to the external oblique aponeurosis in the groin region. The internal oblique aponeurosis is more prominent cephalad in the inguinal canal, and its fibers form the superior border of the canal itself. The cremaster muscle, which envelops the cord structures, originates from the internal oblique musculature. The transversus abdominis muscle and its fascia represent the true floor of the inguinal canal. Deep to the floor is the preperitoneal space, which houses the inferior epigastric artery and vein, the genitofemoral and lateral femoral cutaneous nerves, and the vas deferens, which traverses this space to join the remaining cord structures at the internal inguinal ring.
The indirect inguinal hernia, the most common form of groin hernia across all ages and genders, is thought to be congenital in etiology. The processus vaginalis is the pocket of peritoneum that forms around the testicle as it descends through the internal ring and along the inguinal canal into the scrotum during the 28th week of gestation. The primary etiology behind the indirect inguinal hernia is believed to be a patent processus vaginalis, which in essence represents a hernia sac. In this way, the hernia defect is the internal ring itself, and the sac is preformed but never closed at the end of gestation. Once intra-abdominal contents find their way into the sac, an indirect inguinal hernia is formed.
However, not every person with a patent processus vaginalis develops an inguinal hernia during his or her lifetime. Thus, other predisposing factors must aid in indirect inguinal hernia formation. It is commonly thought that repeated increases in intra-abdominal pressure contribute to hernia formation; hence, inguinal hernias are commonly associated with pregnancy, chronic obstructive pulmonary disease, abdominal ascites, patients who undergo peritoneal dialysis, laborers who repeatedly flex abdominal wall musculature, and individuals who strain from constipation. It is also thought that collagen formation and structure deteriorates with age, thus explaining increased hernia formation in older individuals.
Several inborn errors of metabolism can lead to hernia formation. Specifically, conditions such as Ehlers–Danlos syndrome, Marfan syndrome, Hunter syndrome, and Hurler syndrome can predispose to defects in collagen formation, resulting in weaknesses in the abdominal wall. There is also evidence that cigarette smoking is associated with connective tissue disruption, and not surprisingly, hernia formation is more commonly found in the chronic smoker.
The groin hernia can present in a variety of ways, from the asymptomatic hernia to frank peritonitis in a strangulated hernia. Many hernias are found on routine physical examination or on focused examination for an unrelated complaint. These groin hernias are usually fully reducible and chronic in nature. Such hernias are still referred for repair since they invariably develop symptoms, and asymptomatic hernias still have an inherent risk of incarceration and strangulation, albeit low.10,11
The most common presenting symptomatology for a groin hernia is a bulge associated with a dull feeling of discomfort or heaviness in the groin region that is exacerbated by straining the abdominal musculature, lifting heavy objects, or defecating. These maneuvers worsen the feeling of discomfort by increasing the intra-abdominal pressure and forcing the hernia contents through the hernia defect. Pain develops as a tight ring of fascia outlining the hernia defect compresses intra-abdominal structures with a visceral neuronal supply. With a reducible hernia, the feeling of discomfort resolves as the pressure is released when the patient stops straining the abdominal muscles. The pain is often worse at the end of the day, and patients in physically active professions may experience the pain more often that those who lead a sedentary lifestyle.
Overwhelming or focal pain from a groin hernia is unusual and should raise the suspicion for hernia incarceration or strangulation. An incarcerated hernia occurs when the hernia contents are trapped in the hernia defect so that the contents cannot be reduced back into the abdominal cavity. The tight circumferential pressure applied by the hernia defect serves to impede the venous outflow from the hernia contents, resulting in congestion, edema, and tissue ischemia. Ultimately, the arterial inflow to the hernia contents is compromised as well, resulting in tissue loss and necrosis, termed strangulation of the hernia.
All types of groin hernias are at risk for incarceration and strangulation, although the femoral hernia seems to be predisposed to this complication. Incarceration and strangulation of a groin hernia may present as a bowel obstruction when the tight hernia defect constricts the lumen of the viscus. Hence, all patients presenting with bowel obstruction require a thorough physical examination of the groin region for inguinal and femoral hernias.
The physical exam differs between an incarcerated and a strangulated hernia. The incarcerated hernia may be mildly tender due to venous congestion from the tight defect. If there is no bowel in the hernia sac, an incarcerated groin hernia may alternatively present as a hard, painful mass that is tender to palpation. The strangulated hernia will be tender and warm and may have surrounding skin erythema secondary to the inflammatory reaction from the ischemic bowel. The patient with the strangulated hernia may have a fever, hypotension from early bacteremia, and a leukocytosis. The incarcerated hernia requires operation on an urgent basis within 6 to 12 hours of presentation. If the operation is delayed for any reason, serial physical exams are mandated to follow any change in the hernia site indicating the onset of tissue loss. The strangulated hernia clearly requires emergent operation immediately following diagnosis.
It may also be difficult to differentiate fat from bowel contents in the hernia sac; incarcerated omental fat alone can produce significant pain and tenderness on physical exam, similar to incarcerated bowel.
Not surprisingly, groin hernias during pregnancy may become symptomatic. This is related to the increased intra-abdominal pressure from the growing fetus and enlarging uterus. The symptomatic groin discomfort may become positional later in pregnancy as the uterus shifts location with movement. While the risks of complications of groin hernias still exist during pregnancy, the enlarging uterus may in theory protect against incarceration by physically blocking the intra-abdominal contents from the inlet of the defect.
In general, elective repair of groin hernias during pregnancy is not recommended, even if they become increasingly symptomatic. However, emergent repair of the incarcerated or strangulated hernia is undertaken as needed.
As with any hernia, the groin hernia should be properly examined with the patient in the standing position. This allows the hernia contents to fill the hernia sac and make the hernia more obvious on physical examination. Some hernias, however, may be easily identifiable in the supine position. It should be noted that the exact anatomical classification of the inguinal hernia (ie, indirect versus direct) is difficult to accurately predict based on physical exam alone, and likely not clinically relevant, as all repair techniques should address both direct and indirect inguinal hernias.
In the male patient, using the second or third finger, the examiner should invaginate the scrotum near the external ring and direct the finger medially toward the pubic tubercle. The examiner’s finger will thus lie on the spermatic cord with the tip of the finger within the external ring. The patient is then asked to cough or perform a Valsalva maneuver. A true inguinal hernia will be felt as a silk-like sensation against the gloved finger of the examiner. This is the infamous “silk glove” sign.
The female patient does not have the long and stretched spermatic cord to follow with the examiner’s finger during the physical examination. Instead, two fingers can be placed along the inguinal canal, and the patient is asked to cough or strain. If present, the examiner should feel the sensation of the hernia sac against the gloved finger. Particular attention in the female patient should be paid to the location of the sensation. Femoral hernia sacs will present medial and just inferior to the lower border of the inguinal ligament, while inguinal hernias will present superior to the lower border of the inguinal ligament.
While the physical examination does not differ in the infant, it can be more challenging to elicit the hernia impulse given the compressed groin anatomy of the young child. It is well known that a groin hernia can be more readily diagnosed in the infant who is actively crying and hence increasing the intra-abdominal pressure through flexion of the abdominal wall musculature.
The examination for the femoral hernia in both genders involves palpation of the femoral canal just below the inguinal ligament in the upper thigh. In this way, the most easily palpable landmark is the femoral artery, which is located lateral in the canal. Medial to the femoral artery is the femoral vein, and the femoral empty space is just medial to the vein. This area can be located easily, palpated with two fingers, and then examined closely while the patient coughs or strains. In general, a focused groin hernia examination should involve the investigation for both inguinal and femoral hernias in both genders.
The treatment of all hernias, regardless of their location or type, is surgical repair. Elective repair is performed to alleviate symptoms and to prevent the significant complications of hernias, such as incarceration or strangulation. While the limited data available on the natural history of groin hernias show that these complications are rare, the complications are associated with a high rate of morbidity and mortality when they do occur. At the same time, the risks of elective groin hernia repair, even in the patient with a complicated medical history, are exceedingly low. Outcomes of surgical repair are generally excellent with minimal morbidity and relatively rapid return to baseline health.
The major risk with delayed surgical repair is the risk of incarceration and/or strangulation. It is not possible to reliably identify those hernias that are at an increased risk for these complications. It is known that the risk of incarceration of a hernia is greatest soon after the hernia manifests itself. This is likely due to the fact that at the early stage of the hernia, the defect is small and fits tightly around the hernia sac; therefore, any contents that fill the sac may quickly become trapped within the hernia. Over time, the hernia defect stretches due to the tissue that enters and leaves the sac with changes in intra-abdominal pressure. After 6 months, the risk of hernia incarceration decreases from 5% per year to 1% to 2% per year. In general, the larger the palpable defect on physical examination, the lower the risk of incarceration. Clearly, all risks of tissue loss aside, elective hernia repair is still preferred over emergent repair.
While elective hernia repair is recommended, for those with minimal symptoms who do not wish to undergo surgical intervention, watchful waiting is a reasonable and safe option. In the watchful waiting trial, 720 men with minimally symptomatic or asymptomatic inguinal hernias were enrolled and randomized to either watchful waiting or open surgical repair.10 The study showed that watchful waiting is a safe alternative to surgery. After 4 years, only two patients required emergent operation for either acute incarceration without strangulation or bowel obstruction and only a total of three patients required emergency operations at 7 years.10,11 This changed the traditional idea that all groin hernias should be repaired immediately. Nevertheless, it should be noted that while watchful waiting is safe with low risk of need for emergent surgery, 68% of patients who waited eventually underwent surgical repair, most commonly due to worsening hernia-related pain. It was also seen that men older than 65 years of age had increased rates of surgical repair than younger men for pain (79% crossover to surgical repair vs 62%). Therefore, while watchful waiting is a safe option, the majority of patients will likely experience progression of symptoms that may require surgical repair. As a result, elective hernia repair still remains the preferred treatment and should be offered to all surgical candidates.
Groin hernia repair can be performed using a variety of anesthesia options, including general, regional (such as spinal or epidural), and local anesthesia.12 Laparoscopic repairs usually require general anesthesia in order to provide the complete muscle relaxation needed to achieve insufflation of the preperitoneal or peritoneal space.
Open groin hernia repairs are frequently performed using either regional or local anesthesia. Local anesthesia with controlled intravenous sedation, referred to as monitored anesthesia care, is often preferred in the repair of the reducible inguinal hernia. Its advantages include the ease of induction and awakening, the short postanesthesia recovery period, and the fact that its intensity can easily be titrated up or down based on patient comfort levels intraoperatively. The only major disadvantage to this approach is in patients who experience considerable pain during repairs of large groin hernias.
In groin hernia repair, local anesthesia can be administered either as a direct infiltration of the tissues to be incised or as a local nerve block of the ilioinguinal and iliohypogastric nerves. The latter is associated with improved local pain control, but may be difficult to achieve. The local nerve block also spares the soft tissue edema from diffuse infiltration of local anesthesia.
Spinal or continuous epidural anesthesia allows the surgeon greater freedom to maneuver within the operative field since the anesthetized region is larger than in local anesthesia. However, these modes of anesthesia carry their own infrequent risks such as urinary retention, prolonged anesthetic effect, hypotension, and spinal headache. They may also be associated with longer in-hospital recovery times on the day of surgery.
A randomized trial of local, regional, and general anesthesia in 616 adult patients undergoing open inguinal hernia repair in 10 hospitals found that local anesthesia was superior in the early postoperative period.13 Compared to those who received regional or general anesthesia, patients who received local anesthesia had less postoperative pain and nausea, shorter time spent in the hospital, and fewer unplanned overnight admissions (3% vs 14% and 22%, respectively).
Successful surgical repair of a hernia depends on a tension-free closure of the hernia defect to attain the lowest possible recurrence rate. Previous efforts to simply identify the defect and suture it closed resulted in unacceptably high recurrence rates of up to 15%. Modern techniques have improved upon this recurrence rate by utilizing the placement of mesh over the hernia defect, or in the case of laparoscopic repair, behind the hernia defect. One exception to this rule is the classic Shouldice repair, which uses meticulous dissection and closure without mesh placement to obtain a consistently low recurrence rate. Another benefit of the tension-free closure is that it has been shown to cause significantly less pain and discomfort in the short-term postoperative period.
Figure 11-1 illustrates the essential steps to the modern open inguinal hernia repair. All of the open anterior herniorraphy techniques begin with a transversely-oriented, slightly curvilinear skin incision of approximately 6 to 8 cm, positioned one to two fingerbreadths above the inguinal ligament. Dissection is carried down through the subcutaneous and Scarpa’s layers. The external oblique aponeurosis is identified and cleaned so that the external ring is identified inferomedially. Being careful to avoid injury to the iliohypogastric and ilioinguinal nerves, the aponeurosis is incised sharply and opened along its length through the external ring with fine scissors. The nerves underlying the external oblique fascia are then identified and preserved without mobilization to decrease the risk of post-herniorraphy inguinodynia. Additionally, the iliohypogastric nerve and the genital branch of the genitofemoral nerve should be identified and preserved without mobilization in order to retain their protective investing fascial layers. The soft tissue is cleared off the posterior surface of the external oblique aponeurosis on both sides and the spermatic cord is mobilized. Using a combination of blunt and sharp dissection, the cremaster muscle fibers enveloping the cord are separated from the cord structures and the cord itself is isolated. At this point, it is possible to accurately define the anatomy of the hernia. An indirect hernia will present with a sac attached to the cord in an anteromedial position extending superiorly through the internal ring. A direct inguinal hernia will present as a weakness in the floor of the canal posterior to the cord. A pantaloon defect will present as both a direct and indirect defect in the same inguinal canal.
Figure 11-1
Adult hernia incision and dissection. A. Transverse incision. B. Curved skin crease incision. C. The aponeurosis of the external oblique is incised along the direction of its fibers. D. The inguinal canal is exposed and the spermatic cord mobilized. E. The spermatic cord has been skeletonized, and the internal ring and posterior wall of the canal (the transversalis fascia) have been defined. F. A medium-sized sac has been dissected free of the cord elements. G. The sac has been invaginated. H. A long or complete sac is being dissected free close to the internal ring. I. The sac has been transected.
The specifics of the common modern techniques for hernia repair will be discussed further.
The Shouldice technique is commonly used for open repair of inguinal hernias and is the most popular pure tissue hernia repair. It is in essence the modern evolution of the Bassini repair performed in a multilayered fashion. Both operations use a tightening of the internal ring and closure of the transversalis fascia to the inguinal ligament as their primary tenets of hernia repair.14
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