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Contents
20. PelvicHernias 190
• Obturator Hernia 190
• Howship-Romberg Sign 190
• Demographics and Clinical Presentation 193
• Radiographic Features 194
• Management 194
• Sciatic Hernia 196
• Treatment 196
• Perineal Hernias 198
• Clinical Investigations 203
• Treatment 203
Index 205
xiii
Chapter
Milestones in Hernia Surgery
1
Introduction
Hernia is dened as an abnormal protrusion of viscus
through normal openings in the body. Hernia is a quite
common problem of today’s civilization. It was very
commonly known condition in ancient times too. Before
going to the vast intricate details of the hernia and its
surgery we will take a brief look at the milestones of
hernia surgery. How near perfect surgery has evolved
in these recent years and the creditors of this surgery is
worth noticing.
1. First record of hernia condition: 1500 BC By Greeks.
2. First surgery of inguinal hernia: First century AD by
Celsus involved excision of sac, testis, chord.
3. Paul of Aegina in 700 AD: Complete ligature of sac
and cord at external ring (Fig. 1.1).
4. Guy de Chauliac in 1363 dierentiated inguinal and
femoral hernia.
5. Franco in 1556 described technique to repair the
strangulated hernia to avoid injury to bowel (Fig. 1.2).
6. Casper Stromayr 1559 distinguished between direct
and indirect hernia.
7. Early 19th century correct description of inguinal
anatomy.
8. Dawn of modern surgery by Joseph Lister 1865 in
relation with antiseptic use in surgery (Fig. 1.3).
Fig. 1.1: Paul of Aegina in 700 AD—complete ligature of sac
Fig. 1.2: Franco (1556) described technique to repair the
strangulated hernia to avoid injury to bowel
2
Hernia Surgery Simplied
Fig. 1.3: Dawn of modern surgery by Joseph Lister 1865
in relation with antiseptic use in surgery
Fig. 1.4: Edoardo Bassini (1884) implemented repair of transversalis fascia and reinforcing the posterior wall of inguinal canal
with interrupted silk sutures.He is called father of modern hernia
surgery.It was a herniorrhaphy surgery
Fig. 1.5: Maingot (1941)—advocated oss silk for darning
Fig. 1.6: Shouldice (1953)—multilayered repair
by pure tissue repair
9. Marcy 1871 introduced antiseptic use in hernia
surgery.
10. Lucas in 1881 opened external oblique aponeurosis
and dissected sac.
11. Edoardo Bassini 1884 implemented repair of
transversalis fascia and reinforcing the posterior
wall of inguinal canal with interrupted silk sutures.
He is called father of modern hernia surgery. It was
a herniorrhaphy surgery (Fig. 1.4).
12. George Lotheissen 1898 restructured the inguinal
hernia surgery by repairing the femoral ring and
inguinal defects.
13. McArthur 1901 used pedicle strips of external oblique
aponeurosis interlinked between conjoint tendon
and inguinal ligament.
14. Kirschner 1910 used fascial grafts from thigh.
15. Handley 1918 invented “Darn and Staylace”
procedure.
Milestones in Hernia Surgery
3
16. Ogilvie 1937 nonabsorbable silk lattice repair.
17. Maingot 1941 advocated Floss silk for darning
(Fig. 1.5).
18. Melick 1942 used rst time Braided, multilament
nylon for inguinal hernia.
19. Tanner 1942 Coined the SLIDE operation.
20. Shouldice 1953 multilayered repair by Pure tissue
repair (Fig. 1.6).
21. Usher 1958 rst used knitted polypropylene mesh in
hernia repair.
22. In 1979 rst attempt of laparoscopic hernia repair in
inguinal region.
23. Gilbert 1984 described umbrella plug for inguinal
hernia repair.
24. Read 1985 described relation between smoking and
herniation.
25. Lichtenstein 1986 described the tension free repair
of inguinal hernias.
26. Robbins and Rutkow 1990 coined the concept of
introducing preformed mesh plug in hernia defect.
27. Schultz 1990 rst used a synthetic prosthetic biomaterial in laparoscopic repair of an inguinal hernia.
28. LeBlanc 1991 describes the attempt of laparoscopic
incisional hernia repair.
29. Popp 1991 described a method to dissect the
peritoneum away from abdominal wall prior to the
incision of the peritoneum in TAPP repair.
At a Glance
Theodor Billroth (1878) envisaged prostheses before
Bassini’s sutured cure (1887) (Fig. 1.7). Phelps (1894)
reinforced with silver coils. Metals were replaced by
plastic (Aquaviva 1944). Polypropylene (Usher 1962),
resisting infection, became popular. Usher instituted
tensionless, overlapping preperitoneal repair. Spermatic
cord was parietalized, to obviate keyholing. Stoppa
(1969) championed the sutureless Cheatle-Henry
approach encasing the peritoneum. His technique,
“La grande prosthese de renforcement du sac visceral”
(GPRVS), was adopted by laparoscopists. Newman (1980)
and Lichtenstein (1986) pioneered subaponeurotic
positioning. Kelly (1898) inserted a plug into the femoral
canal; Lichtenstein and Shore (1974) followed. Gilbert
(1987) plugged the internal ring, and Robbins and
Rutkow (1993) treated all groin herniae thus. Incisional
herniation has been controlled by prefascial, retrorectus
prosthetic placement (Rives-Flament 1973). ePTFE
(Sher et al. 1980) is useful intraperitoneally, since it
evokes few adhesions. Here, laparoscopy (Ger 1982)
is competitive. Beginning in 1964 (Wirtschafter and
Bentley) experimental and clinical studies have shown
herniation may be associated with aging and genetic or
acquired (smoking, etc.) systemic disease of connective
tissue. ese data, with prospective trials, all but mandate
tensionless prosthetic repair.
Fig. 1.7: Theodor Billroth (1878)—envisaged prostheses
before Bassini’s sutured cure (1887)
History of the Procedure
Hippocrates used the Greek hernios for bud or bulge to
describe abdominal hernias. Statues of the era portray
this condition. e Ebers papyrus, from approximately
1550 BCE, detailed the use of a truss. Celsius used
transillumination to differentiate a hernia from a
hydrocele and advocated gradual pressure (taxis) in the
management of incarcerated hernia. e earliest recorded
surgical efforts were to reduce the hernia through a
scrotal incision, to remove the sac and the testis, and to
close the area with sutures that spontaneously extruded.
As the church forbade physicians from surgical
procedures, nonphysicians (barbers) began developing
therapy for surgical problems. De Chauliac advocated
escharotics with gradual cicatrization accompanied
by prolonged bed rest as the solution for inguinal
hernias. Parë followed the operation of Gerald of Metz
using a cerclage wire of gold to retard further intestinal
protrusion into the scrotum.
4
Hernia Surgery Simplied
In 1700, Littre reported an omphalomesenteric duct
trapped in a hernia. Richter described an incarcerated
but nonobstructing hernia in 1785. Hunter, in 1756,
detailed the embryological origin of the indirect inguinal
hernia. De Gimbernat advocated cutting the ligament
that is eponymically associated with him in management
of incarcerated femoral hernia. Teale reported the rst
prevascular femoral hernia in 1846.
Other eponyms associated with inguinal hernias relate
to anatomical descriptions by Camper (fascia) (1801),
Cooper (ligament) (1804), Cloquet (hernia) (1817),
Grynfeltt (hernia) (1866), Hesselbach (triangle) (1814),
Laugier (hernia) (1833), Nuck (canal) (1650-1692), Petit
(hernia) (1783), and Scarpa (fascia) (1814). Scarpa also
previously described a sliding hernia and a Spiegelian
hernia in 1645.
e advent of antisepsis by Lister in 1865 paved the way
for a more precise surgical approach to hernia. Finally,
physicians could expect success of an operation not being
disrupted by infection. In 1871, Marcy felt that closure
of the fascia adjacent to the internal ring would provide
a reliable repair of the inguinal hernia. Over a decade
later, Bassini (1884) formulated an approach to hernia
repair that remains the foundation of the modern hernia
repair, namely, reconstruction of the oor of the inguinal
canal. In the last century, Cheatle used a properitoneal
approach in 1920, while McVay (1948) made popular the
use of Cooper’s iliopectineal ligament in repair.
Table 2.1
Anatomical discoveries
Vesalius (Flemish) and Fallopius (Italy)
Poupart (France)
Described the inguinal ligament
Heister First to describe direct hernias (1724)
Po (England) Anatomy of congenital hernias; methods of incarceraon
Camper (Holland) Described the supercial subcutaneous fascia
Scarpa (Italy) Described deep subcutaneous fascia; anatomic and surgical importance of sliding hernias (En Glissade) (1814)
Sir Ashley Cooper (England) Described anatomy and surgical treatment of crural and umbilical hernias; anatomy of the groin including the
superior pubic (Cooper) ligament; cremasteric fascia and the transversalis fascia
Hunter Emphasized the role of the processus vaginalis
Morton Described the conjoined tendon
Cloquet Noted postnatal closure of the processus vaginalis; made observaons of the iliopubic tract
Hesselbach (Germany) Dened iliopubic tract; described importance of the medial triangle of the groin (included the femoral canal).;
described the “corona mors” (arterial circle formed by the deep epigastric and obturator arteries)
De Gimbernat Described medial ligament of the femoral canal (lacunar ligament), and division of that ligament in the treat-
ment of strangulated femoral hernias
Richter (Germany) Described paral obstrucon and incarceraon of a wall of the bowel in a hernia defect
Chapter
Surgical Anatomy of Hernia Sites
2
Surgical Anatomy of Hernia Sites
“e anatomy of the inguinal region is misunderstood by
surgeons of all levels of seniority.” Robert E Condon, MD.
Success of hernia repair is measured primarily by the
permanence of the operation, fewest complications,
minimal costs, and earliest return to normal activities. is
success depends largely on the surgeon’s understanding
of the anatomy and physiology of the surgical area as
well as a knowledge of how to use most eectively the
currently available techniques and materials.
e surgeon who seeks to make a success of hernia
repairs should fully understand the anatomical variations
in the hernia site. Today it is mandatory for the surgeon
to individualize the surgery according to the anatomy
encountered.
Anatomy of the Abdomen and Groin
Much of what we know about the anatomy of the
abdomen and groin comes from the work of the early
anatomists and surgeons. A thorough understanding of
these and later anatomical “discoveries” is essential to
successful hernia repair (Table 2.1).
Original drawing:
detailing the triangular area bordered by the deep
Hesselbach’s original (1814) drawing
6
Hernia Surgery Simplied
Fig. 2.1: Original drawing–Hesselbach’s original (1814) drawing
detailing the triangular area bordered by the deep epigastric
vessels, the lateral border of the rectus muscle, and the superior
pubic ligament (Cooper)
External Anatomy of Abdominal
Wall—The Surface Markings
Anterior Abdominal Wall Anatomy
e anatomical layers of the abdominal wall include
skin, subcutaneous tissue, superficial fascia, deep
fascia, muscle, extraperitoneal fascia, and peritoneum.
This anatomy may vary with respect to the different
topographic regions of the abdomen. e major source
of structural integrity and strength of the abdominal
wall is provided by the musculofascial layer. The
main paired abdominal muscles include the external
oblique muscles, internal oblique muscles, transversus
abdominis muscles, and rectus abdominis muscles and
their respective aponeuroses, which are interdigitated
with each other, and provide core strength and protection
to the abdominal wall viscera. The integrity of the
abdominal wall is essential not only to protect the visceral
structures but also to stabilize the trunk and to aid trunk
movement and posture.
Surface Anatomy
epigastric vessels, the lateral border of the rectus muscle,
and the superior pubic ligament (Cooper) (Fig. 2.1).
Current interpretation:
triangle substitutes the inguinal ligament for the superior
pubic ligament (Fig. 2.2).
Current version of the Hesselbach’s
Fig. 2.2: Current interpretation–current version of the Hesselbach’s triangle substitutes
the inguinal ligament for the superior pubic ligament
e abdomen can be divided into quadrants or nine
abdominal regions (Fig. 2.3). e midline in the sagittal
plane is the linea alba. e lateral edge of the rectus
sheath is the linea semilunaris. e lower costal margin,
the iliac crest and pubic tubercle can be palpated.
Surface lines:
viscera and of reference to morbid conditions of the
For convenience of description of the
Surgical Anatomy of Hernia Sites
7
contained parts, the abdomen is divided into nine
regions, by imaginary planes, two horizontal and two
sagittal, the edges of the planes being indicated by lines
drawn on the surface of the body. In the older method the
upper, or subcostal, horizontal line encircles the body at
the level of the lowest points of the tenth costal cartilages;
the lower, or intertubercular, is a line carried through
the highest points of the iliac crests seen from the front,
i. e. through the tubercles on the iliac crests about 5 cm
behind the anterosuperior spines. An alternative method
is that of Addison, who adopts the following lines:
(1) An upper transverse, the transpyloric, halfway
between the jugular notch and the upper border of
the symphysis pubis; this indicates the margin of the
transpyloric plane, which in most cases cuts through
the pylorus, the tips of the ninth costal cartilages and
the lower border of the rst lumbar vertebra; (2) a lower
transverse line midway between the upper transverse and
the upper border of the symphysis pubis; this is termed
the transtubercular, since it practically corresponds to
that passing through the iliac tubercles; behind, its plane
cuts the body of the fth lumbar vertebra.
By means of these horizontal planes the abdomen
is divided into three zones named from above, the
subcostal, umbilical, and hypogastric zones. Each of
these is further subdivided into three regions by the
two sagittal planes, which are indicated on the surface
by a right and a left lateral line drawn vertically through
points halfway between the anterosuperior iliac spines
and the middle line. e middle region of the upper zone
is called the epigastric, and the two lateral regions the
right and left hypochondriac. e central region of the
middle zone is the umbilical, and the two lateral regions
the right and left lumbar. e middle region of the lower
zone is the hypogastric or pubic, and the lateral are the
right and left iliac or inguinal. e middle regions, viz.,
epigastric, umbilical, and pubic, can each be divided
into right and left portions by the middle line. In the
following description of the viscera the regions marked
out by Addison’s lines are those referred to.
The Fascia
Fig. 2.3: Abdomen can be divided into quadrants
or nine abdominal regions
Below the skin the supercial fascia is divided into a
supercial fatty layer, Camper’s fascia, and a deeper
brous layer, Scarpa’s fascia. e deep fascia lies on the
abdominal muscles. Inferiorly Scarpa’s fascia blends with
the deep fascia of the thigh. is arrangement forms a
plane between Scarpa’s fascia and the deep abdominal
fascia extending from the top of the thigh to the upper
abdomen (Figs 2.4A and B). Below the innermost layer
of muscle, the transversus abdominis muscle, lies the
transversalis fascia. e transversalis fascia is separated
from the parietal peritoneum by a variable layer of fat,
subcutaneous tissue.
Supercial Fascia
e supercial fascia of the abdominal wall is divided
into a supercial and a deep layer. It may be as thin
as half an inch or less or as thick as 6 inches or more.
Above the umbilicus, the supercial fascia consists of a
single layer. Below the umbilicus, the fascia divides into
two layers: the Camper fascia (a supercial fatty layer)
and the Scarpa fascia (a deep membranous layer). e
supercial epigastric neurovascular bundle is located
between these two layers. e abdominal subcutaneous
fat, which is separated by the Scarpa fascia, is highly
variable in thickness.
8
Hernia Surgery Simplied
A B
Figs 2.4 and B: Anterior abdominal wall in cadaveric dissection
Deep Fascia
e deep fascia is a thin, tough layer that surrounds and
is adherent to the underlying abdominal muscles. Each
abdominal muscle has an aponeurotic component that
contributes to the deep fascia. e individual abdominal
muscles are described below:
Subserous and Peritoneal Fascia
The subserous fascia is also known as extraperitoneal
fascia and serves to bond the peritoneum to the deep
fascia of the abdominal wall or to the outer lining
of the gastrointestinal tract. It may receive different
names depending on its location (i.e. transversalis
fascia when it is deep to that muscle, psoas fascia when
it is next to that muscle, iliac fascia, and so on). The
peritoneum is a thin (one cell thick) membrane that
lines the abdominal cavity. It is useful in reconstructive
efforts because it provides a layer between the bowel
and mesh.
Rectus Abdominis and Rectus Sheath
e rectus muscle extends from the xiphoid process of
the sternum and 5, 6, 7th costal cartilages to the pubic
symphysis and pubic crest. e muscle is enclosed within
the rectus sheath formed by the aponeuroses of the lateral
abdominal muscles (Fig. 2.5). Along the length of this strap
muscle there are three brous intersections separating
the muscle into four segments. e brous intersections
are attached to the anterior surface of the rectus sheath,
but not to the posterior surface. is allows the superior
and inferior epigastric vessels to pass along the posterior
surface of the muscle without encountering a barrier.
The most important feature from the surgical
perspective is that the bers of the rectus sheath run
from side-to-side. Vertical incisions divide bers while
horizontal incisions down closure with sutures encircling
bers rather that between bers (Fig. 2.6).
e posterior rectus sheath has a similar trilaminar
criss-cross pattern above the umbilicus, where it is
composed of the posterior lamina of the internal oblique
and the aponeurosis of the transverses abdominis muscle
from either side.
Lateral Muscles
e lateral muscles arise from the lower part of the rib
cage, the lumbar fascia and the iliac crest.
e external oblique muscle arises from the lower
eight ribs. The fibers run downwards and forwards
to form an aponeurosis anteriorly. The aponeurosis
passes anteriorly to the rectus muscle to insert into
the aponeurosis from the other side at the linea alba.
Inferiorly the aponeurosis inserts into the anterosuperior
iliac spine and stretches over to the pubic tubercle,
forming the inguinal ligament.
e internal oblique muscle arises from the lumbar
fascia, the iliac crest and the lateral two-thirds of the
inguinal ligament and runs upwards and forwards
to form an aponeurosis. Above the arcuate line the
aponeurosis splits to enclose the rectus muscle. Below the
arcuate line the aponeurosis passes anterior to the rectus
muscle. e inferior part of the aponeurosis inserts into
the symphysis pubis. At this insertion the aponeurosis is
fused with the aponeurosis of the transversus abdominis
muscle to form the conjoint tendon.
e transversus abdominis muscle arises from the
lower six costal cartilages, the lumbar fascia and the iliac
crest. e bers run forwards to form an aponeurosis.
Superiorly the aponeurosis passes behind the rectus
muscle. Below the arcuate line the aponeurosis passes
anterior to the muscle. The inferior fibers of the
aponeurosis are fused with those of the internal oblique
to form the conjoint tendon.
Musculofascial Layer
e abdominal wall includes 5 paired muscles (3 at
muscles, 2 vertical muscles). The 3 flat muscles are
the external oblique, internal oblique, and transversus
abdominis. The 3-layered structure, combined with
extensive aponeuroses, works in a synkinetic fashion not
only to protect the abdominal viscera but also to increase
abdominal pressure, which facilitates defecation,
micturition, and parturition. e 2 vertical muscles are
the rectus abdominis and pyramidalis. Fusion of the
fascial layers of these muscles forms 3 distinct fascial
lines: the linea alba and 2 semilunar lines. e linea
alba is formed by the fusion of both rectus sheaths at
the midline, while the semilunar lines are formed by
Surgical Anatomy of Hernia Sites
Fig. 2.5: Lateral abdominal wall muscles
the union of the external oblique, internal oblique, and
transversus abdominis aponeuroses at the lateral border
of the rectus abdominis muscle (Figs 2.8A to C).
External Oblique (Fig. 2.9)
e external oblique muscle is the largest and thickest
of the at abdominal wall muscles. It originates from
the lower 8 ribs, interlocks with slips of latissimus dorsi
and serratus anterior, and courses inferior-medially,
attaching via its aponeurosis centrally at the linea alba.
Inferiorly, the external oblique aponeurosis folds back
upon itself and forms the inguinal ligament between
the anterior superior iliac spine and the pubic tubercle.
Medial to the pubic tubercle, the external oblique
aponeurosis is attached to the pubic crest. Traveling
superior to the medial part of the inguinal ligament, an
opening in the aponeurosis forms the supercial inguinal
ring. e innervation to the external oblique is derived
from the lower 6 thoracic anterior primary rami and the
rst and second lumbar anterior primary rami.
Internal Oblique (Figs 2.6 and 2.10)
e internal oblique muscle originates from the anterior
portion of the iliac crest, lateral half to two-thirds of the
inguinal ligament, and posterior aponeurosis of the
9
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