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478
M. Śmetański and K .A. LeBlanc
References
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incision. An evaluation of postoperative flank bulge. Arch Surg.
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2. LeBlanc KA. Proper mesh overlap is a key determinant in hernia
recurrence following laparoscopic ventral and incisional hernia
repair. Hernia. 2016;20(1):85–9.
3. Hoffman RS, Smink DS, Noone R, et al. Surgical repair of the
abdominal bulge: correction of a complication of the flank incision
for retroperitoneal surgery. J Am Coll Surg. 2004;199:5.
4. Adamson RJW. A case of bilateral hernia through Petit’s triangle
with two associated abnormalities. Br J Surg. 1958;46:88–9.
5. Myers RN, Shearburn EW. The problem of recurrent inguinal hernia. Surg Clin N Am. 1973;53:555–8.
6. Watson LF. Hernia: anatomy, etiology, symptoms, diagnosis, differential diagnosis, prognosis, and the operative and injection treatment. 2nd ed. London: Harry Kimpton; 1938.
7. Geis WP, Saletta JD. Lumbar hernia. In: Nyhus LM, Condon RE,
editors. Hernia. 3rd ed. Philadelphia: Lippincott; 1989.
8. Stumpf M, Conze J, Prescher A, et al. The lateral incisional hernia:
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9. Yavuz N, Ersoy YE, Demirkesen O, et al. Laparoscopic incisional
lumbar hernia repair. Hernia. 2009;13:281–6.
10. Kretschmer HL. Lumbar hernia of the kidney. J Urol. 1851;65:
944–8.
11. Esposito TJ, Fedorak I. Traumatic lumbar hernia. Case report and
review of the literature. J Trauma. 1994;37:123–6.
12. McCarthy MC, Lemmon GW. Traumatic lumbar hernia: a seat belt
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14. Bathla L, Davies E, Fitzgibbons RJ, et al. Timing of traumatic lumbar hernia repair: is delayed repair safe? Report of two cases review
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Radiol Anat. 1999;21:1–5.
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Girela E, Aguayo-Albasini JL. Open vs laparoscopic repair of secondary lumbar hernias. Surg Endosc. 2005;19:184–7.
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Hernias of the Pelvic Wall
Michael S. Kavic, Suzanne M. Kavic, Mary K. Hanissee,
and Stephen M. Kavic
37
There are several large openings in the bony pelvic girdle,
including its floor that can allow for intestine or viscera to
pass through and develop a hernia. However, the near vertical walls of the pelvis mitigate against the development of
hernia—mitigate—but not completely deny hernia formation. Although rare, hernias of the deep pelvic structures can
occur and cause debilitating symptoms.
Unfortunately, physicians often ignore these symptoms
because hernias in the pelvic areas are difficult to see and to
palpate. For the most part, pelvic wall hernia is not even considered in females with vague abdominal or pelvic symptoms. Nonetheless, general surgeons need a thorough
knowledge of pelvic anatomy, particularly, potential hernia
sites in women, to avoid inadequate diagnostic workup and
examination. Patients, usually older female patients, suffer
the consequences of our inattention.
A good example of disease neglected by the general surgeons is chronic pelvic pain in females. Chronic pelvic pain
is a common problem in women accounting for 10–30% of
all gynecological visits. It is considered the principle indication for 20% of hysterectomies performed for benign disease
and approximately 40% of gynecological laparoscopies [1].
About 78,000 hysterectomies are performed each year in the
United States for chronic pelvic pain [2]. It has been estimated that 70% of female patients who have chronic pelvic
M.S. Kavic, MD (*)
Department of Surgery, St. Elizabeth Health Center,
Youngstown, OH, USA
Northeast Ohio Medical University, College of Medicine,
Rootstown, OH, USA
e-mail: Mkavic@aol.com; mkavic@sls.org
S.M. Kavic, MD
Loyola University Medical Center 630-953- 6669,
Maywood, IL 60153, USA
M.K. Hanissee, MD
Department of Surgery, University of Maryland Medical Center,
Baltimore, MD, USA
S.M. Kavic, MD
University of Maryland School of Medicine, Baltimore, MD, USA
pain have disease in the reproductive genital tract; however,
10% of patients with chronic pelvic pain had gastrointestinal
tract disorders, 8% had musculoskeletal neurologic disease,
7% had myofascial abnormalities, and 5% had urologic
causes of chronic pelvic pain [3]. Chronic pelvic pain can
have many etiologies, and the general surgeon must not shirk
from actively participating in the evaluation of these patients.
Chronic pelvic pain has three main dimensions: (1) duration, pelvic pain lasting 6 months or more; (2) anatomic, pain
in the pelvis defined by physical findings at laparoscopy; and
(3) affective/behavioral, pelvic pain accompanied by significant alterations in physical activity such as work, recreation,
and sex, as well as changes in mood related to the chronic
pain [3]. Most standard laboratory and imaging studies such
as complete blood count, abdominal and pelvic ultrasound,
and computed tomographic studies are often within normal
limits.
Frequently dismissed as “female trouble,” chronic pelvic
pain has resisted intensive efforts to determine its cause.
Chronic pelvic pain can have many etiologies, and a multidisciplinary approach is frequently necessary for proper
patient evaluation [4]. Nevertheless, chronic pelvic pain is a
real entity, and it is now appreciated that obscure, rare conditions such as sciatic, obturator, supravesical, and perineal
hernia may cause chronic pain in women. A case in point is
the seldom diagnosed sciatic hernia.
Sciatic Hernia
Sciatic hernia, one of the rarest of abdominal and pelvic wall
hernias, was first described by Verdier in 1753 [5, 6]. It is the
protrusion of peritoneal sac and content through the greater
or lesser sciatic foramen. The hernia may occur superior to
the piriformis muscle (suprapiriformis), inferior to the piriformis (infrapiriformis), or through the lesser sciatic notch
(subspinous) (Fig. 37.1). Known variously as sacrosciatic
hernia, ischiatic hernia, ischiocele, hernia incisurae ischiadicae, or gluteal hernia, the hernia sac may contain the ovary,
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_37
479
480
Fig. 37.1 Sciatic hernia. The
hernia may occur superior to
the piriformis muscle
(suprapiriformis), inferior to
the piriformis
(infrapiriformis), or through
the lesser sciatic notch
(subspinous)
M.S. Kavic et al.
tube, or intestine. Entrapment of these organs may cause
chronic pelvic pain or bowel obstruction.
There were only 39 cases of sciatic hernia reported in the
world literature up to 1958 [5, 6]. However, in 1998, Miklos
and colleagues reported 20 cases of sciatic hernia diagnosed
in a series of 1100 female patients who had diagnostic laparoscopy for chronic pelvic pain. All of these cases had the
ipsilateral ovary alone or fallopian tube contained within the
hernia sac. If this incidence of sciatic hernia in patients who
required diagnostic laparoscopy for chronic pelvic pain
(1.8%) is carried over into the general population, sciatic
hernia cannot be as rare as previously thought [7].
Anatomy
The sacrospinous ligament converts the greater sciatic notch
into the greater sciatic foramen which is filled with the piriformis muscle. In addition to the piriformis muscle, the
greater sciatic foramen transmits the gluteal vessels and
nerves, internal pudendal vessels and nerve, and nerves to
the obturator internus and quadratus femoris muscles. Above
the piriformis muscle, the suprapiriformis area allows for
passage of the superior gluteal artery, vein, and nerve. Below
the piriformis muscle lies the infrapiriformis space which
transmits the inferior gluteal vessels, posterior femoral cutaneous nerve, nerve to the obturator internus, internal pudendal vessels and nerves, and sciatic nerve.
The lesser sciatic notch is transformed into a foramen by
the sacrospinous ligament superiorly and the sacrotuberous
ligament inferiorly. The lesser sciatic foramen transmits the
tendon of the obturator internus, its nerve, and the internal
pudendal vessels [5]. In females, the abdominal opening of a
sciatic hernia is posterior to the broad ligament. In males, the
opening lies in the lateral pelvis between the urinary bladder
and rectum. Hernias below the sacrotuberous ligament are
considered to be perineal hernias [8].
Clinical Presentation
Sciatic hernias are rarely noted on physical examination as the
large gluteal muscles cover and overlap the sciatic foramen. To
further complicate matters, openings in the sciatic foramen are
small, and many of these cases present with incarceration and
obstruction. Frequently, the diagnosis is only revealed at laparotomy. Even so, the pain of chronic sciatica may call attention
to the gluteal area where physical examination may suggest a
gradually increasing infragluteal bulge or a bulge that is more
pronounced on standing and can cause pain with sitting [9].
Compression of the sciatic nerve can cause muscle weakness
of the lower leg with pain radiating down the posterior thigh
made worse with dorsiflexion. Herniography can be helpful in
delineating a sciatic hernia; however, a computerized tomography (CT) scan is the initial diagnostic imaging of choice.
Treatment
Sciatic hernias have been repaired by a transabdominal or
transgluteal approach [10, 11]. A transabdominal approach
is usually recommended as these hernias are difficult to diagnose, and most surgeons are more comfortable performing
an exploration for possible bowel obstruction in an open
manner. Laparoscopic access, however, can offer satisfactory
visualization of a sciatic hernia [7] (Fig. 37.2).
After the abdomen has been opened or pneumoperitoneum established for laparoscopic access, a thorough intraabdominal examination is performed. The liver, gallbladder,
stomach, intestine, appendix, uterus, tubes, ovaries, and peri-
37 Hernias of the Pelvic Wall
Fig. 37.2 Laparoscopic view of a sciatic hernia
481
Fig. 37.4 Mesh repair of a sciatic hernia
Obturator Hernia
An obturator hernia is an abnormal protrusion of preperitoneal fat or intestine through the obturator canal. These hernias are rarely visualized and are usually not found
preoperatively unless a palpable bulge is noted on rectal or
bimanual pelvic examination [13, 14]. An obturator hernia
may contain a “pilot tag” of preperitoneal tissue, large or
small bowel, appendix, uterus, tube, or ovary [15]. Herniation
through the obturator canal is rare, occurring in 0.073% of
all hernias in one series [16]. Two broad groups of patients
have been described who most frequently suffer obturator
hernia [15–17]:
Fig. 37.3 Sciatic hernia sac reduction
toneal surfaces are examined [12]. The entire pelvis is
inspected for hernias, adhesions, and endometriosis.
If a sciatic hernia is found, its content is reduced. Dusky
bowel should be observed for 5–10 min to see that adequate
circulation is reestablished. Nonviable bowel should be
resected with primary anastomosis. If the bowel is viable, a
preperitoneal incision is made superior to the hernia defect
and the hernia sac reduced (Fig. 37.3). The sciatic foramen is
visualized and completely covered with nonabsorbable synthetic mesh. There should be a 2.5–3.0 cm overlap of the
hernia defect with mesh circumferentially. The mesh is
secured with endohernia tacks or fasteners to the obturator
internus fascia laterally and coccygeus medially (Fig. 37.4).
The area is reperitonealized by closing the peritoneal incision with intracorporeal suture, tacks, or fasteners. The laparoscopic trocar sites or abdominal incision is then closed in
the standard manner.
1. Elderly patients, usually women, with a history of chronic
disease, weight loss, increased intra-abdominal pressure,
and attenuation of the obturator membrane
2. Women of childbearing age
Anatomy
The obturator foramen is the largest bony foramen in the
human body (Fig. 37.5). It is roughly circular in shape and
shielded by the obturator membrane. The internal opening
of the obturator canal is about 1 cm diameter and sited in
the superior midsection of the obturator membrane. The
obturator canal itself is a fibro-osseous tunnel about 2–3 cm
in length whose roof is formed by the obturator sulcus of
the pubic bone and its floor by the internal and external
obturator muscles and their fascia. The obturator nerve,
artery, and vein pass through the obturator canal with the
nerve typically superior to the artery and vein (Fig. 37.6).
After passing through the obturator canal, the obturator
nerve divides into an anterior and posterior branch. The
482
Fig. 37.5 Obturator anatomy
Fig. 37.6 Obturator nerve, artery, and vein
anterior branch courses over the superior border of the
obturator externus muscle to supply the adductor longus,
gracilis, and adductor brevis muscles. The posterior branch
pierces the obturator externus muscle to supply the adductor magnus and adductor brevis. Obturator hernia sacs that
follow the anterior division of the obturator nerve pass
between the pectineus and above the obturator externus
muscle. Hernia sacs that follow the posterior division of the
obturator nerve pass through the obturator externus
muscle.
M.S. Kavic et al.
Clinical Presentation
Historically, obturator hernia has been associated with four
signs or symptoms [15]:
1. Intestinal obstruction (elderly females, frequently
intermittent)
2. Howship-Romberg sign
3. History of previous attacks
4. Palpable mass (rare)
Although the first two are the most common signs, the
nature of intestinal obstruction is usually unclear and the
Howship-Romberg sign only recalled after exploration has
revealed the presence of obturator hernia. Upon exploration,
up to 50% can be associated with gangrenous bowel, resulting in high perioperative morbidity and mortality. The hernia
can also present with a medial thigh mass [18], but the most
common symptoms are crampy abdominal pain and obstructive symptoms [9]. The absence of bowel motion and a high
serum urea level at the time of operation have been shown to
be independent factors for mortality [19].
A palpable mass is occasionally noted on rectal or pelvic
examination. However, since obturator hernia is rarely considered in a differential diagnosis of vague abdominal pain,
the presence of a mass in the obturator region is rarely
sought.
John Howship first noted the pain characteristic of obtura-
tor hernia in 1840. He described this pain as extending down
the inner surface of the involved thigh, exacerbated by thigh
extension, adduction or medial rotation [20] (Fig. 37.7).
Howship’s sign was independently described by Moritz
Romberg in 1848 [21]. Although the Howship-Romberg sign
is pathognomonic of obturator hernia, by no means is it
invariably present. About 50% of patients will complain of
this radicular pain or paresthesia down the inner aspect of
their thigh caused by compression of the cutaneous branch of
the obturator nerve in the narrow confines of the obturator
canal [15, 22]. Karasaki described that the HowshipRomberg sign is present in 67% of anterior obturator hernias
and only 30% of posterior [23].
Some have suggested that an obturator hernia develops
over several stages. It first begins as a prehernia with a plug
of preperitoneal connective tissue or “pilot tag” entering the
obturator canal [15] (Fig. 37.8). This concept was supported
by a post mortem study of female cadavers. In this report, a
“pilot tag” was found in 64% of female cadavers that were
examined [24]. The second stage of obturator hernia formation continues with dimpling of the peritoneum over the
obturator canal and progresses to invagination of a peritoneal
sac (Fig. 37.9). Finally in the evolution of an obturator her-
37 Hernias of the Pelvic Wall
483
Fig. 37.9 Reduction of an obturator canal hernia
nia, bowel, uterus, tube, or ovary may enter the peritoneal
sac and pass along the obturator canal.
Chronic pelvic pain can result from incarceration of tube
or ovary in the obturator hernia. Symptomatic intestinal
obstruction can result from incarceration of small or large
bowel in the obturator canal [25]. Delay of diagnosis, however, is common as an obturator hernia is usually not visible
or even palpable because of its deep location between the
pectineus and adductor longus muscles.
More recently, computerized tomography has developed
into a reliable diagnostic tool for evaluation of patients with
possible obturator hernia. In two small series, CT scans
detected the presence of an obturator hernia in 87 and 100%
of the cases studied [13, 14]. Gas below the superior pubic
ramus on plain film is diagnostic [18].
Fig. 37.7 Palpation of the obturator hernia
Fig. 37.8 Obturator canal pilot tag
Treatment
Despite advances in imaging technology, the mainstay of
diagnoses and treatment remains abdominal exploration.
Exploration may be via open laparotomy or with laparoscopic visualization. Literature supports that laparoscopy is a
safe and effective surgical option and has even been associated with decreased complications and hospital days
[26–28].
Regardless of the method used to obtain access, the entire
pelvis must be examined and evaluated. If bilateral obturator
defects are found, both hernias should be repaired.
After an obturator hernia has been identified, contents of
the sac are reduced and a preperitoneal dissection is done to
expose the internal obturator opening and obturator canal. At
this point, the internal opening of the obturator canal can be
closed with permanent monofilament suture securing periosteum of the symphysis pubis to fascia of the internal obtura-
484
M.S. Kavic et al.
tor muscle. It is necessary to take care not to injure the
obturator nerve or obturator vessels. An alternative method
to repair obturator hernia is to use permanent synthetic mesh
to secure the breach in the obturator membrane.
Polypropylene, polyester, or expanded polytetrafluoroethylene mesh can be used. Mesh must cover the entire defect
with a 2.5–3.0 cm overlap circumferentially and secured
with adequate fixation. In addition to the obturator opening,
it is usual to cover the entire myopectineal orifice—femoral
and inguinal orifices—with mesh (Fig. 37.10).
After the mesh has been secured, the operative area is
reperitonealized. Typically, the peritoneal incision is closed
with an intracorporeal running suture of 2-0 absorbable
suture; polydioxanone or polyglactin 910 are suitable choices
(Fig. 37.11).
Perineal Hernia
Perineal hernias are very rare hernias that insinuate themselves through muscle and fascia of the pelvic floor (pelvic
diaphragm) into the perineum (Fig. 37.12). The first report of
a perineal hernia was documented in 1743 by de Garangeot.
Moscowitz was the first to treat a perineal hernia surgically
in 1916. Perineal hernias have also been called ischiorectal
hernias, subpubic hernias, pudendal hernias, posterior labial
hernias, hernias of the pouch of Douglas, and vaginal hernias. Perineal hernias are commonly found in women and are
true hernias with a distinct peritoneal sac.
Congenital perineal hernias are very rare, with only nine
cases being reported in the literature [29]. Acquired (incisional) perineal hernias occur in both males and females
after abdominoperineal resection of the rectum and after pelvic operations for genital malignancy (radical prostatectomy
and gynecological exenteration), though still being very rare
with rates of less than 1% and 3–7%, respectively [30].
Factors thought to contribute to perineal hernia include
the broad female pelvis, childbirth, injuries incident to childbirth, obesity, exenteration procedures for pelvic cancer,
abdominal perineal resection, and, in men, perineal prostatectomy. Perineal hernias may present anterior or posterior to
the superficial perineal muscle, through the levator ani, or
between the levator ani and coccygeus muscle.
Fig. 37.10 Obturator hernia mesh repair with tacks
Fig. 37.11 Closure of the peritoneum in obturator hernia repair
Anatomy
A pudendal hernia is an anterior perineal hernia that occurs
only in females. This hernia is also known as a labial hernia
and may protrude into the labium majus as an overt mass. A
pudendal hernia exits the pelvis through a triangle bounded
by the bulbocavernosus, ischiocavernosus, and transversus
perineal muscles [24]. A posterior perineal hernia may
emerge between fibers of the levator ani or between the levator ani and coccygeus muscles [31, 32]. Hernia contents can
be intraperitoneal or extraperitoneal, and contents usually
include the bowel and omentum, though unusual contents
such as bladder diverticulum and leiomyoma have been
reported [29].
Presentation
Perineal hernias are bounded by compliant muscle and soft
tissue and, as such, rarely cause intestinal obstruction. They
can, however, cause chronic pelvic pain. Typically, perineal
hernias present as a palpable, soft bulge in the perineum that
37 Hernias of the Pelvic Wall
Fig. 37.12 Location of
perineal hernias
485
Fig. 37.13 Perineal herniography (Note: the arrow is an X-ray mark
and is irrelevant to the present discussion)
is easily reducible or reduces itself when the patient is
recumbent. If an overt perineal bulge is not evident, herniography with intra-abdominal instillation of radiopaque
dye may be used to further refine a diagnosis of perineal
hernia (Figs. 37.13, 37.14, 37.15, and 37.16). A contrasted
CT scan is also helpful in identifying these hernias.
Fig. 37.14 Perineal herniography
Treatment
The only definitive treatment for perineal hernia is surgical
repair. Access to a perineal hernia can be obtained via a perineal incision, or transabdominally using open laparotomy or
laparoscopic techniques. Traditionally, these hernias have
486
M.S. Kavic et al.
Fig. 37.15 Perineal herniography. If an overt perineal bulge is not evident, herniography with intraabdominal instillation of radiopaque dye
may be used to further refine a diagnosis of perineal hernia
Fig. 37.16 Perineal herniography: X-ray fluoroscopy over 1 h
to fix the mesh, and the operative area is reperitonealized
closing the peritoneal incision with intracorporeal absorbable suture.
Supravesical Hernia
Supravesical hernias are herniation of abdominal content
through a supravesical fossa of the anterior abdominal wall.
They are classified as either external or internal supravesical
hernias [32]. External supravesical hernias pass inferiorly
through the supravesical fossa to present medially as direct
inguinal hernias or intraparietal hernias of the anterior inferior abdominal wall. Internal supravesical hernias pass
downward to enter the retropubic space of Retzius
(Fig. 37.17).
The diagnosis of supravesical hernias that exit through the
posterior inguinal wall or femoral canal may be obvious.
However, an internal supravesical hernia that passes into the
retropubic space of Retzius is usually more difficult to diagnose. Although a small bowel series, ultrasound, or computed tomography may aid in the workup, diagnosis is
usually made at abdominal exploration.
Management of supravesical hernia is that of operative
repair. Hernias that present as external supravesical hernias
(i.e., as direct hernias) may be managed with traditional Bassini
or Shouldice herniorrhaphy techniques or Lichtenstein anterior
hernioplasty with mesh. A laparoscopic repair is also feasible.
Hernia in the retropubic space of Retzius—internal supravesical hernia—may be better served with a transabdominal laparoscopic approach that permits a complete visualization of
abdomen and pelvis. As with other hernias of the abdomen and
pelvic wall, a preperitoneal dissection is performed after reduction of hernia content. Hernioplasty with appropriate synthetic
mesh and adequate overlap of hernia margins is followed by
reperitonealization of the operative site.
been repaired by closure of the perineal defect with nonabsorbable suture and the patient’s own tissues. This procedure, while grounded in the principles of classic open
surgery, has the disadvantage of using attenuated muscle and
fascia to secure the repair.
Another approach that is gaining favor for the evaluation
of abdominal and pelvic wall hernias has been that of laparoscopy [12]. A transabdominal laparoscopic examination
offers the benefit of minimal access with maximum visualization of potential hernia sites in the abdominal and pelvic
cavities. Once a perineal hernia has been visualized, its contents are reduced and a preperitoneal dissection carried out to
define the borders of the hernia defect. Permanent synthetic
mesh is used to cover and overlap the hernia defect with a
3 cm margin. Laparoscopic suture, staples, or tacks are used
Conclusion
In years past, diagnosis of hernia was only seriously
entertained when a mass was seen or a bulge was palpable
at a hernia’s point of presentation. This mindset did not
include the possibility of non-visualized, non-palpable
symptomatic hernias that were evident only at their site of
origin [33–36]. All the same, nonpalpable, clinically significant occult hernias do exist and in one series constituted 8% of those hernia cases repaired [33].
Occult symptomatic abdominal and pelvic wall hernias can be visualized at their site of origin with advanced
imaging and during laparoscopic exploration. The use of
laparoscopic visualization allows for the diagnosis and
repair of common and rare abdominal and pelvic wall
hernias at their site of origin rather that at their point of
presentation. A principle of hernia repair that was first
37 Hernias of the Pelvic Wall
Fig. 37.17 Supravesical
retropubic hernia
487
clearly articulated by Henri Fruchaud in his 1956 insightful discussion of groin anatomy and description of an
abdominal myopectineal orifice [36].
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Principles and practice. 6th ed. Mosby Yearbook Inc: St. Louis;
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3. Carter JE. Surgical treatment for chronic pelvic pain. JSLS.
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