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The Cavernous Direct Inguinal Hernia
35
ThomasPomposelli, GraceLassiter, andOmarYusefKudsi
Introduction
The “cavernous” or “giant” hernia is an informal classication given to large inguinal hernias that extend below the patient’s mid-thigh upon standing [1]. A hernia of
this size poses considerable problems to the patient and to the surgeon tasked with
repair. Morbidities associated with giant hernias cause a signicantly reduced quality of life; these include skin ulceration, infection, difculty urinating, difculties
with mobility, and sexual dysfunction [1]. These patients are also at a greatly
increased risk of morbidity and mortality following repair due to both the technical
difculties of repair and the risk incurred with potential resection of abdominal
viscera which may be contained within the hernia sac. These lesions generally
develop due to years of neglect; the patient population that presents with giant hernias also tends to present with a multitude of other neglected comorbidities as well
[2] (Fig.35.1).
For the surgeon, these patients present incredible challenges that are unique to
their disease process. Foremost is a peculiar form of loss of abdominal domain.
Because these hernias enlarge over the course of many years, the abdomen loses
T. Pomposelli
St. Elizabeth’s Medical Center, Brighton, MA, USA
e-mail: thomas.pomposelli@steward.org
G. Lassiter
Texas A&M College of Medicine, Bryan, TX, USA
e-mail: grace.lassiter@steward.org
O. Y. Kudsi (
Department of Surgery, Tufts University School of Medicine, Boston, MA, USA
Department of General Surgery, Good Samaritan Medical Center, Brockton, MA, USA
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_35
*)
483
484
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Fig. 35.1 Type III direct
inguinal hernia
T. Pomposelli et al.
the anatomical accommodation it provides to the normally congured viscera.
The small bowel and colon with their mesenteries as well as kidneys, ureters, and
bladder have all been seen within these hernia sacs; these hernias are typically
not able to be forcibly reduced [3, 4]. After surgical reduction of the herniated
organs, patients are at risk for developing signicant intra-abdominal hypertension in an unaccommodating abdomen, leading to respiratory failure, circulatory
collapse, and cardiac arrest. Utilizing techniques to increase intra-abdominal
space has become essential to managing cavernous hernias, as oftentimes
extended resection of abdominal viscera will not be tolerated by this patient
population [5].
Although giant hernias are a rare clinical entity, case reports are routinely published, mostly out of remote areas with little access to health care [2]. Because of
the rarity of these lesions, it has not been possible to conduct large-scale comparative studies pertaining to optimal surgical management, and there remains no
accepted standard of repair. Hernia specialists as well as general surgeons in underserved areas should be acquainted with the most up-to-date evidence for dealing
with this challenging clinical entity.
35 The Cavernous Direct Inguinal Hernia
485
Anatomy
A thorough understanding of the inguinal canal as well as the abdominal wall is
critical in the case of giant hernias, as the intra-abdominal domain and the anatomic
landmarks useful in traditional hernia repairs are often obscured. Hesselbach’s triangle is the classic anatomic boundary that differentiates between direct and indirect hernias. This space is delineated by three structures: bordered medially by the
lateral margin of the rectus sheath, superolaterally by the inferior epigastric vessels,
and inferiorly by the inguinal ligament [6]. A hernia that arises through the internal
inguinal ring is classied as an indirect hernia; a hernia that passes through the oor
of the inguinal canal and medial to the inferior epigastric vessels is classied as a
direct hernia [7].
The lower abdominal wall is composed of several distinct layers: (1) skin, (2)
Scarpa’s fascia, (3) innominate fascia, (4) intercrural bers, (5) external oblique
muscle, (6) internal oblique muscle, (7) transversus abdominis muscle, and (8) peritoneum. Although each layer is a distinct anatomic structure, they function together
as a solitary unit to prevent herniation [8].
The anatomic hole located between the false pelvis and ipsilateral lower extremity is known as the myopectineal orice. Originally described by Fruchaud [8], the
myopectineal orice is quadrangular in shape and is divided into a superior and
inferior level by the inguinal ligament [9, 10]. Its role is to allow passage of the
spermatic cord structures superiorly and the femoral vessels inferiorly. The boundaries of the myopectineal orice are the arching ber of the internal oblique superiorly, the rectus abdominis muscle medially, the anterior borders of the iliac bone
inferiorly, and the iliopsoas and iliopectineal arch laterally [6, 8]. This anatomic
hole can be further divided into three anatomic triangles (medial, lateral, and femoral), which are potential sites of groin herniation. Direct hernias form through the
medial triangle (Hesselbach).
Epidemiology
Direct inguinal hernias represent 25–30% of groin hernias; the majority are indirect.
They usually occur in men over 40years of age [6]. Due to the rarity of giant inguinal hernias, there is no reliable data on the incidence of these lesions; however, there
continues to be published case reports of these lesions on a regular basis, albeit
infrequently.
Etiology/Pathogenesis
Direct hernias are generally considered to be acquired lesions. They protrude
through the abdominal wall as the muscles and fascia naturally weaken with age due
to normal biomechanical stresses, which is why this type of hernia is generally seen
486
e.
T
reduction contraindicated.
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T. Pomposelli et al.
in the middle-aged and elderly. Risk factors for direct inguinal hernia include obesity, heavy lifting, straining, coughing, or pregnancy. However, the greatest risk
factor for developing a direct hernia is being male, which confers a tenfold predisposition to the lesion compared with females [6].
The current standard of care once an asymptomatic hernia is diagnosed is conservative management, as the risk of strangulation is roughly 2% per year [11].
When a hernia becomes symptomatic or interferes with the patient’s activities of
daily living, then operative repair is suggested. Due to the natural tendency of the
abdominal wall to progressively weaken with age, direct inguinal hernias have the
propensity to increase in size over time. While it is rare for hernias to attain a giant
size before intervention is sought, cavernous hernias are still seen in modern
practice.
An inguinal hernia is classied as “giant” when it extends below the midpoint of
the thigh upon standing [12]. Trakarnsagna etal. proposed a further classication
scheme based on the optimal type of operative repair: (a) Type I extending up to
mid-thigh, (b) Type II extending midway between mid-thigh level and the suprapatellar line, and (c) Type III extending below the suprapatellar line [12] (Fig.35.2).
For Type I lesions, forced reduction and hernioplasty are feasible, but only with
close monitoring of thoracic and abdominal pressures. For Type II cavernous hernias, some resection of hernia contents is usually required, as well as a procedure
for increasing intra-abdominal volume. For Type III lesions, some resection of
Hernioplasty with forced reduction is feasibl
Intra-abdominal and intra-thoracic pressure
monitoring are required.
ype I
Type II
Type III
Fig. 35.2 Classication scheme for cavernous direct inguinal hernia
Hernioplasty with forced reduction is unlikely.
Most cases demand resection of content or
increased intraabdominal volume
procedures.
Resection of the contents or increased
intraabdominal volume procedures are
indicated. Hernioplasty with forced
35 The Cavernous Direct Inguinal Hernia
487
hernia contents is always required, and the operation must include a procedure for
increasing intra-abdominal volume [12].
Often resection of hernia contents and hernioplasty are not possible in the
case of giant inguinal hernias, as the content of the hernia sac is quite variable
and many patients cannot tolerate extended resection of abdominal viscera.
Simple forced reduction of the hernia in an attempt to spare extensive resection
is usually not possible due to the risk of intra-abdominal hypertension (IAH).
Due to the loss of intra- abdominal accommodation, the increased pressure in the
abdomen is translated to multiple organ systems, increasing systemic vascular
resistance; decreasing preload, thus affecting gut perfusion; and hindering respiration through direct pressure on the diaphragm [13]. Iatrogenic IAH may progress to multiple organ dysfunction and death quite rapidly in this already tenuous
patient population who may present with poor baseline physiologic reserve. The
fact that patients with giant hernias are so vulnerable to developing this syndrome was rst recognized by Moreno in 1947, when he proposed increasing the
abdominal space to accommodate reduction and repair of giant hernias [14]. The
importance of expanding the intra-abdominal space in patients that won’t tolerate resection is now recognized as an important step for repairing Type II and
Type III lesions [12].
Appropriate preoperative workup is mandatory. Informed consent must cover all
possible operative procedures including visceral resection. Oftentimes the nal
decisions are made intraoperatively, and so we favor the wording of “hernia repair,
proceed as indicated.” All potential decisions and outcomes must be adequately
explained to the patient as well as their family members beforehand [12]. A thorough delineation of the hernia contents should also be performed in the preoperative
period utilizing a contrast-enhanced CT scan [15]. There is a high likelihood that the
hernia contains portions of the colon with the necessity of resection during repair [2,
11]. A thorough bowel prep should also be considered in all cases, especially in
patients where the hernia sac extends beyond the imaginary line between superior
borders of patellar bone [12].
Repair ofCavernous Direct Hernias
There is no gold standard for the surgical management of cavernous direct hernias;
these lesions are rare and highly heterogenous in presentation. Because of the high
risk of recurrence (up to 30%) as well as the risks of intra-abdominal hypertension
with respiratory failure and circulatory collapse, operative strategy must be carefully considered on a case-by-case basis [6]. Currently, there exist two strategies
described that surgeons have used with success: resecting the hernia contents and/or
increasing intra-abdominal capacity.
Because these hernias are typically diseases of neglect, patients often present
with a multitude of other comorbidities. Although performing visceral resection
would typically be the safest strategy to minimize the risk of recurrence, this patient
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T. Pomposelli et al.
population often lacks the physiologic reserve necessary to tolerate this type of
repair. Most hernia specialists advocate a procedure to expand intra-abdominal volume as a critical component [16].
One method of repair of the Type III hernia was described by Kovachev etal.,
who elected to perform their repair in a staged manner by rst introducing progressive pneumoperitoneum to increase intra-abdominal space [12]. Using local
anesthesia, a catheter with a stop cock was inserted in the right lower quadrant,
and a total of 20,000mL of air was then instilled gradually over the course of a
week. The authors instilled approximately 6000mL of air every 3days. After the
nal insufation, the catheter was removed. All procedures were performed in
the operating room using sterile technique. After this maneuver to increase intraabdominal accommodation, they were able to successfully reduce the hernia contents back into the abdomen. The repair was performed utilizing the Stoppa
technique, in which a large piece of synthetic mesh was sutured as a retromuscular sublay that covered the entire myopectineal orice. Once the hernia contents
were reduced, an incision was made in the peritoneum and a plane developed
between the posterior sheath and the rectus abdominis. This dissection was carried lateral to medial until the epigastric perforator vessels were encountered,
and care was taken to preserve this blood supply. The mesh was then placed in
this plane, and the posterior sheath was closed primarily [12, 17]. This extended
procedure, while successful, requires the patient to be hospitalized for a week
preoperatively.
Merrett etal. reported repair of giant inguinal hernia via rotational musculocutaneous aps. Preoperative progressive pneumoperitoneum was undertaken.
The peritoneum was initially entered through a midline abdominal incision, and
the abdomen was found to be almost completely devoid of bowel. They were able
to reduce the hernia, which contained the entire small bowel and right colon.
After redelivery of the bowel, the defect was repaired by suturing a Marlex mesh
between the posterior edge of the inguinal ligament and the conjoint tendon, but
once the repair was complete, they were unable to close the laparotomy.
Inguinoscrotal skin aps were raised, rotated to cover the midline defect, and
sutured in place. The patient did well and returned 3months later for resection of
redundant skin. The authors reported no further complications from the procedure [
16].
Hamad etal. presented their hybrid technique utilizing laparoscopic component
separation to increase abdominal domain [5]. Their patient’s hernia contained most
of the colon and small bowel with only the rectum, proximal jejunum, and duodenum lying within the abdomen. After a midline laparotomy, the hernia was reduced
with great difculty, requiring division of the lower end of the left rectus abdominis.
The hernia defect was then repaired extraperitoneally using a large polypropylene
mesh extending from the anterior superior iliac spine to the symphysis pubis. Both
the inguinal ligament and rectus abdominis muscle were repaired. Subsequently, a
laparoscopic bilateral component separation was performed, with mass closure of
the laparotomy incision [5].
35 The Cavernous Direct Inguinal Hernia
489
Laparoscopic Robotic-Assisted Transabdominal Preperitoneal
(TAPP) Approach
Our group has utilized a laparoscopic robotic-assisted transabdominal preperitoneal
(TAPP) approach with success [8, 13, 15]. Pneumoperitoneum is achieved via
Veress needle placement in the left upper quadrant (Palmer’s point). Three 8.5-mm
trocars are introduced in a horizontal line 4cm above the umbilicus; each lateral
trocar is positioned in the midclavicular line, and the center trocar is positioned just
off the midline. All trocars are separated by at least 8cm. The patient is then placed
in the Trendelenburg position (30°), and the robot is docked at the patient’s side at
30°. To avoid visceral injury in cavernous direct irreducible hernias, neither adhesiolysis nor reduction is performed at the beginning of the case; rather, these procedural steps are taken during preperitoneal dissection and mobilization of the hernia
contents.
A peritoneal incision is made 4–6cm above the inguinal canal from the anterior
superior iliac spine to the median umbilical ligament, and the ap is developed with
dissection in the preperitoneal space. The medial extent of dissection is carried out
roughly 2–4cm beyond the symphysis pubis to the contralateral side. The cranial
extent of the dissection is carried out 4cm above the transversalis arch. The lateral
extent is the anterior superior iliac spine. The caudal extent is 4cm below the iliopubic tract at the level of the psoas muscle and 2cm below Cooper’s ligament. The
peritoneal hernia sac and associated adipose tissue from the hernia (pre-, extra-, and
retroperitoneal fat tissue) are reduced toward the middle of the psoas muscle (parietalization) (Fig.35.3), taking into consideration the importance of preserving the
spermatic fascia and lumbar fascia to protect the vas deferens, nerves, and vessels.
Repairing these types of hernias without addressing the cavity often leads to seroma
Fig. 35.3 Direct defect containing hernia sac
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Fig. 35.4 Placing sutures in Cooper’s ligament
T. Pomposelli et al.
Fig. 35.5 Transversalis fascia to Cooper’s ligament
formation which could impact the recovery period [1, 18]. We favor suturing the
weakened transversalis fascia to Cooper’s ligament via running 3-0 absorbable
sutures in order to address the dead space (Figs.35.4 and 35.5). This is to decrease
postoperative seroma, as well as to have the mesh placed against the tissue rather
than the cavity. It is important to avoid approaches to direct defect closure utilizing
repair under tension, as this could harbor a chance of chronic groin pain due to the
possibility of nerve entrapment [13] (Fig.35.6).
We have thus far performed a total of 82 direct hernia repairs as described above with
no groin pain. Complete dissection of the pelvic oor ensured at placement of the
mesh, which covered the entire myopectineal orice without folding. We believe that
35 The Cavernous Direct Inguinal Hernia
Fig. 35.6 Immediately
post-op following TAPP
repair
491
ProGrip™ laparoscopic self-xating mesh (Covidien, New Haven, CT, USA) is advantageous due to the benets of xation across the whole surface. One could potentially
also consider medium-weight mesh with either suturing or surgical glue on the medial
side at numerous points such as Cooper’s ligament and medial to the inferior epigastric
vessels. Depending on the size of the hernia, we commonly use 12× 16 cm mesh or
15×20cm. Our practice is to place the mesh in the peritoneal ap without using tacks
or sutures, as in our experience, we have seen an improvement in postoperative pain.
After adequate positioning of the mesh is ensured, the peritoneal ap is closed using a
3-0 absorbable, barbed suture. Local anesthetic (1% bupivacaine hydrochloride,
Marcaine) is inltrated at the trocar sites prior to skin closure. We generally utilized four
robotic instruments in dealing with large cavernous hernias: bipolar non-crushing
grasper, non-crushing grasper, monopolar scissors, and needle driver (Fig.35.7).
Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair
What follows is a description of the laparoscopic totally extraperitoneal (L-TEP)
approach that our group has also utilized with success [19]. A fascial incision is
made into the anterior rectus sheath, and the rectus muscle is retracted laterally to
gain entry to the preperitoneal space. A 12-mm blunt-tip trocar is placed with an
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Fig. 35.7 Mesh covering myopectineal orice with adequate medial overlap
T. Pomposelli et al.
oval dissection balloon to help delineate the anatomy of the inguinal space and dissect within the preperitoneal space. Two 5-mm trocars are then placed in the same
vertical line, taking care to prevent peritoneal entry. We ensure that dissection
extends superiorly to the level of the umbilical area, inferiorly to the space of
Retzius, inferolaterally to the psoas muscle and the space of Bogros until the anterior superior iliac spine is reached, and medially at least 2cm beyond the midline.
In a similar fashion to the R-TAPP repair, complete exposure of the myopectineal
orice of Fruchaud is achieved. The direct hernia is reduced to the level of the psoas
muscle; complete parietalization of the vas deferens and the testicular vessels is
then achieved; and complete dissection of the pelvic oor is carried out to ensure
at placement of the mesh without folding or curling.
Reduction of the hernia sac occasionally presents a signicant challenge, and the
surgeon may not be able to properly assess the intraperitoneal organs. With this
being the case, our group favors placing a 5-mm port at the conclusion of the case
to evaluate the peritoneum. The transversalis is sutured to Cooper’s ligament, and
the mesh is placed in a similar fashion as described above.
The 12-mm balloon trocar incision is closed with a gure of 8-0 absorbable braided
suture. Skin closure is performed only at the 5-mm ports. Local anesthetic (1% bupivacaine hydrochloride, Marcaine) is inltrated at the trocar sites. In cases of peritoneal
entry, we attempt to close the peritoneum with a 5-mm metallic clip, and in cases
where this is unsuccessful, we place a left upper quadrant 5-mm port to decompress
the peritoneal cavity, thus facilitating the completion of the L-TEP repair.
Conclusion
Cavernous direct inguinal hernias are an increasingly rare entity in modern times
but when encountered present signicant challenges to the surgeon as well as to
the patient. As with all hernia repairs, a thorough knowledge of the anatomy and
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