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200
HerniaSurgerySimplied
Fig. 20.9: Muscles of the female perineum. (Modied from a
drawing by Peter Thompson)
Fig. 20.10: Coronal section of anterior part of pelvis, through
the pubic arch. Seen from in front. (Diagrammatic)
a narrow muscular slip, which passes more or less
transversely across the perineal space in front of the
anus. It arises by tendinous bers from the inner and
forepart of the tuberosity of the ischium, and, running
medialward, is inserted into the central tendinous point
of the perineum, joining in this situation with the muscle
of the opposite side, with the sphincter ani externus
behind, and with the bulbocavernosus in front. In some
cases, the bers of the deeper layer of the sphincter ani
externus decussate in front of the anus and are continued
intothismuscle.Occasionallyitgivesobers,which
join with the bulbocavernosus of the same side.
Variations are numerous. It may be absent or double,
or insert into bulbocavernosus or external sphincter.
Actions: The simultaneous contraction of the two
muscles serves to x the central tendinous point of the
perineum.
e bulbocavernosus (ejaculator urine; accelerator
urine) is placed in the middle line of the perineum, in
front of the anus. It consists of two symmetrical parts,
united along the median line by a tendinous raphé. It
arises from the central tendinous point of the perineum
and from the median raphé in front. Its bers diverge
like the barbs of a quill-pen; the most posterior form
a thin layer, which is lost on the inferior fascia of the
urogenital diaphragm; the middle bers encircle the
bulb and adjacent parts, of the corpus cavernosum
urethrae, and join with the bers of the opposite side, on
the upper part of the corpus cavernosum urethrae, in a
strong aponeurosis; the anterior bers, spread out over
the side of the corpus cavernosum penis, to be inserted
partly into that body, anterior to the ischiocavernosus,
occasionally extending to the pubis, and partly ending in
a tendinous expansion which covers the dorsal vessels of
the penis. e latter bers are best seen by dividing the
muscle longitudinally, and reecting it from the surface
of the corpus cavernosum urethrae.
Actions: is muscle serves to empty the canal of
the urethra, after the bladder has expelled its contents;
during the greater part of the act of micturition its bers
are relaxed, and it only comes into action at the end of
theprocess.emiddlebersaresupposedbyKrause
to assist in the erection of the corpus cavernosum
urethrae, by compressing the erectile tissue of the bulb.
e anterior bers, according to Tyrrel, also contribute to
the erection of the penis by compressing the deep dorsal
vein of the penis as they are inserted into, and continuous
with, the fascia of the penis.
e ischiocavernosus (erector penis) covers the crus
penis. It is an elongated muscle, broader in the middle
than at either end, and situated on the lateral boundary
of the perineum. It arises by tendinous and eshy bers
from the inner surface of the tuberosity of the ischium,
behind the crus penis; and from the rami of the pubis
and ischium on either side of the crus. From these points
eshy bers succeed, and end in an aponeurosis which
PelvicHernias
201
is inserted into the sides and under surface of the crus
penis.
Action: e ischiocavernosus compresses the crus
penis, and retards the return of the blood through the
veins, and thus serves to maintain the organ erect.
Between the muscles just examined a triangular
space exists, bounded medially by the bulbocavernosus,
laterally by the ischiocavernosus, and behind by the
transversus perinei supercialis; the oor is formed by
the inferior fascia of the urogenital diaphragm. Running
from behind forward in the space are the posterior
scrotal vessels and nerves, and the perineal branch of
the posterior femoral cutaneous nerve; the transverse
perineal artery courses along its posterior boundary on
the transversus perinei supercialis.
e deep fascia: e deep fascia of the urogenital
region forms an investment for the transversus perinei
profundus and the sphincter urethrae membranaceae,
but within it lie also the deep vessels and nerves of this
part, the whole forming a transverse septum which is
known as the urogenital diaphragm. From its shape it is
usually termed the triangular ligament, and is stretched
almost horizontally across the pubic arch, so as to close
in the front part of the outlet of the pelvis. It consists
of two dense membranous laminae, which are united
along their posterior borders, but are separated in front
by intervening structures. e supercial of these two
layers, the inferior fascia of the urogenital diaphragm,
is triangular in shape, and about 4 cm in depth. Its apex
is directed forward, and is separated from the arcuate
pubic ligament by an oval opening for the transmission
of the deep dorsal vein of the penis. Its lateral margins
are attached on either side to the inferior rami of the
pubis and ischium, above the crus penis. Its base is
directed toward the rectum, and connected to the central
tendinous point of the perineum. It is continuous with the
deep layer of the supercial fascia behind the transversus
perinei supercialis, and with the inferior layer of the
diaphragmatic part of the pelvic fascia. It is perforated,
about 2.5 cm below the symphysis pubis, by the urethra,
the aperture for which is circular and about 6 mm in
diameter by the arteries to the bulb and the ducts of the
bulbourethral glands close to the urethral orice; by the
deep arteries of the penis, one on either side close to the
pubic arch and about halfway along the attached margin
of the fascia; by the dorsal arteries and nerves of the penis
near the apex of the fascia. Its base is also perforated by
the perineal vessels and nerves, while between its apex
and the arcuate pubic ligament the deep dorsal vein of
the penis passes upward into the pelvis.
If the inferior fascia of the urogenital diaphragm be
detached on either side, the following structures will be
seen between it and the superior fascia: the deep dorsal
vein of the penis; the membranous portion of the urethra;
the transversus perinei profundus and sphincter urethrae
membranaceae muscles; the bulbourethral glands and
their ducts; the pudendal vessels and dorsal nerves of the
penis; the arteries and nerves of the urethral bulb, and a
plexus of veins.
e superior fascia of the urogenital diaphragm is
continuous with the obturator fascia and stretches
across the pubic arch. If the obturator fascia be traced
medially after leaving the obturator internus muscle, it
will be found attached by some of its deeper or anterior
bers to the inner margin of the pubic arch, while its
supercial or posterior bers pass over this attachment
to become continuous with the superior fascia of the
urogenital diaphragm. Behind, this layer of the fascia is
continuous with the inferior fascia and with the fascia of
Colles; in front, it is continuous with the fascial sheath of
the prostate, and is fused with the inferior fascia to form
the transverse ligament of the pelvis.
e transversus perinei profundus arises from the
inferior rami of the ischium and runs to the median line,
where it interlaces in a tendinous raphé with its fellow of
the opposite side. It lies in the same plane as the sphincter
urethrae membranaceae; formerly the two muscles were
described together as the constrictor urethrae.
The sphincter urethrae membranaceae surrounds
the whole length of the membranous portion of the
urethra, and is enclosed in the fasciae of the urogenital
diaphragm. Its external bers arise from the junction of
the inferior rami of the pubis and ischium to the extent
of 1.25 to 2 cm and from the neighboring fasciae. ey
arch across the front of the urethra and bulbourethral
glands, pass around the urethra, and behind it unite with
the muscle of the opposite side, by means of a tendinous
raphé. Its innermost bers form a continuous circular
investment for the membranous urethra.
Nerve supply: e perineal branch of the pudendal
nerve supplies this group of muscles.
Actions: e muscles of both sides act together as a
sphincter, compressing the membranous portion of the
urethra. During the transmission of uids, they like the
bulbocavernosus, are relaxed, and only come into action
at the end of the process to eject the last drops of the uid.
202
HerniaSurgerySimplied
The Muscles of the Urogenital Region
in the Female (See Fig. 20.9)
• Transversusperineisupercialis.
• Ischiocavernosus.
• Bulbocavernosus.
• Transversusperineiprofundus.
• Sphincterurethraemembranaceae.
The transversus perinei superficialis (transversus
perinei; supercial transverse perineal muscle) in the
female is a narrow muscular slip, which arises by a small
tendon from the inner and forepart of the tuberosity of
the ischium, and is inserted into the central tendinous
point of the perineum, joining in this situation with the
muscle of the opposite side, the sphincter ani externus
behind, and the bulbocavernosus in front.
Action: The simultaneous contraction of the two
muscles serves to x the central tendinous point of the
perineum.
e bulbocavernosus (sphincter vagina) surrounds
the orice of the vagina. It covers the lateral parts of the
vestibular bulbs, and is attached posteriorly to the central
tendinous point of the perineum, where it blends with
the sphincter ani externus. Its bers pass forward on
either side of the vagina to be inserted into the corpora
cavernosa clitoridis, a fasciculus crossing over the body
of the organ so as to compress the deep dorsal vein.
Actions: e bulbocavernosus diminishes the orice
of the vagina. The anterior fibers contribute to the
erection of the clitoris, as they are inserted into and are
continuous with the fascia of the clitoris, compressing the
deep dorsal vein during the contraction of the muscle.
e ischiocavernosus (erector clitoridis) is smaller
than the corresponding muscle in the male. It covers
the unattached surface of the crus clitoridis. It is an
elongated muscle, broader at the middle than at either
end, and situated on the side of the lateral boundary of
the perineum. It arises by tendinous and eshy bers
from the inner surface of the tuberosity of the ischium,
behind the crus clitoridis; from the surface of the crus;
and from the adjacent portion of the ramus of the
ischium. From these points eshy bers succeed, and
end in an aponeurosis, which is inserted into the sides
and under surface of the crus clitoridis.
Actions: e ischiocavernosus compresses, the crus
clitoridis and retards the return of blood through the
veins, and thus serves to maintain the organ erect.
e fascia of the urogenital diaphragm in the female
is not so strong as in the male. It is attached to the public
arch, its apex being connected with the arcuate pubic
Fig. 20.11: Perineal hernias
ligament. It is divided in the middle line by the aperture
of the vagina, with the external coat of which it becomes
blended, and in front of this is perforated by the urethra.
Its posterior border is continuous, as in the male, with the
deep layer of the supercial fascia around the transversus
perinei supercialis.
Like the corresponding fascia in the male, it consists of
two layers, between which are to be found the following
structures: the deep dorsal vein of the clitoris, a portion of
the urethra and the constrictor urethra muscle, the larger
vestibular glands and their ducts; the internal pudendal
vessels and the dorsal nerves of the clitoris; the arteries
and nerves of the bulbi vestibuli, and a plexus of veins.
e transversus perinei profundus arises from the
inferior rami of the ischium and runs across to the side
of the vagina. e sphincter urethrae membranaceae
(constrictor urethrae), like the corresponding muscle
on the male, consists of external and internal bers. e
external bers arise on either side from the margin of
the inferior ramus of the pubis. ey are directed across
the pubic arch in front of the urethra, and pass around
it to blend with the muscular bers of the opposite side,
between the urethra and vagina. e innermost bers
encircle the lower end of the urethra.
Nerve supply: e muscles of this group are supplied
by the perineal branch of the pudendal.
Spontaneousdevelopmentofperinealherniasisavery
rare condition and many techniques have been described
for repairing the pelvic oor defect.
Occurrence: Posteriorprimaryperineal herniasare
very unusual ndings and they may be congenital or
acquired. ey occur most commonly between the ages
of 40 and 60 years and are ve times more common in
females than in males, due to the broader female pelvis
and attenuation of the pelvic oor during pregnancy.
Clinically
Signsand symptomsareconned tocomplaintsof a
mass in the perineum or buttock, which may cause some
discomfort when sitting. e classic signs of hernia, such
as perineal bulging, size that varies when abdominal
pressure is applied, tympanites and peristalsis, allow
diagnosis to be made. However, perineal hernias may be
mistaken for other diseases of the perineum and adjacent
organs, such as lipomas, bromas, rectocele, cystocele
and prolapse of the rectum. One particular condition
from which perineal hernias must be distinguished
is sciatic hernia. However, when a perineal hernia is
reduced, the direction of reduction together with the
palpable defect in the pelvic oor identies the hernia
as perineal rather than sciatic.
Investigations: Radiographic demonstration of
such hernias via plain lm or barium had already been
reported before the advent of CT/MRI scanning (Figs
20.12 and 20.13). ey can show that the herniation of
PelvicHernias
Fig. 20.13: MRI perineal hernias
the sigmoid colon is adjacent to the distal rectum and
going into the buttock. In the normal pelvis, CT scans
are adequate to display the muscle anatomy of the pelvic
oor, thereby allowing the identication of any muscle
perineal defect.
Treatment
203
Fig. 20.12: Barium enema shows a perineal hernia with loop
of sigmoid colon in sac
Simpleclosureofthepelvicdefectbybringingtogether
the levator ani muscles along the midline is occasionally
feasible, the pelvic oor is usually decient and requires
support using autogenous or prosthetic materials.
e perineal approach is usually dicult in the repair
of perineal hernias, unless these are accompanied by an
abdominal access.
A new laparoscopic approach for repairing postoperative perineal hernias, involving the use of synthetic
mesh, has recently been reported and regarded as safe
andeective.
Surgicalrepaircanbedoneeitherthroughatransabdo-
minal approach or transperineally.
index
Page numbers followed by f refer to gure and t refer to table
A
Abdomen 7f
Abdominal
inguinal ring 159f
surgery 81
wall defects 42
Abnormal protrusion of viscus 1
Acellular porcine collagen 49f
Advantages of local anesthesia 83
AlloDerm 49
mesh 49, 50f
tissue matrix 49f
Anatomical layers of abdominal wall 6
Anatomy of
abdomen 5
female inguinal canal 120t
femoral canal 134f
groin 5
Anesthesia for
hernia repairs 83
inguinal incision in hernia repair 86f
Annulus inguinalis subcutaneous 153
Anterior abdominal wall
anatomy 6
in cadaveric dissection 8f
Anterolateral muscles of abdomen 151
Aponeurotic and fascial senescence 40
Arcuate line 16, 17f
Areawise occurrence of umbilical hernia
34f
Arteries in femoral canal 137f
Atrophy of left gluteal muscles 197f
B
Balloon
dissection 109
dissector and trocars 107
for making properitoneal space 109f
Bard
3D max mesh 61f
Visilex mesh 62, 62f
Barium swallow for hiatus hernia 79
Bassini
repair 88, 89f
sutured cure 3f
Bilateral inguinal hernias 107
Bilocular
interstitial hernia 72f
properitoneal hernia 72f
Blood supply 19
of inguinal canal 19t, 20f
of posterior abdominal wall 22, 24f
Bochdalek hernia 73
Bogros’ space 13, 15f
C
Cadaveric dissection 10f
Calcitonin gene-related peptide 124
Camper’s fascia 7
Causes of
delayed wound healing 82
femoral hernia 45, 135
loss of musculofascial tissue 48
umbilical hernia 43, 44
Central tendon 29
Choice of mesh 169
Classication of
abdominal hernia 64
groin hernias 64
hernia 64
inguinal hernia for total extraperitoneal
repair 65
ventral hernia 65
Cloquet’s lipoma theory 37
Closure of
external oblique aponeurosis 100f
peritoneum 168
Collagen
containing mesh 48
diseases 40
Complete ligature of sac 1f
Completely descended testis 39f
Complications of
epigastric hernia operation 162
ventral hernia repair 175
Congenital
abdominal wall defects 44, 73
diaphragmatic hernia 74f
Conjoint tendon 24, 26f
Connective tissue disease 42
Contents of hernia 190
Cooper’s
hernia 66
iliopectineal ligament 4
ligament 92f, 104, 115
Coronal section of abdomen posterior
abdominal wall 22f
Corrugator cutis ani 198
Coverings of femoral hernia 135
Creating peritoneal ap 115
Cremaster 156f
Crura
of supercial inguinal ring 22
tendon 29
Crural arch 135f
Current guidelines in hernia surgery 81
D
Deep
circumex iliac arteries 19
epigastric arcade 18
fascia 6, 8, 198
inguinal ring 23
layer of transversalis fascia 13
lymphatic vessels 21
Denervation theory 38
Deployment of prolene hernia system 100f
Desarda’s theory 38
Descent of testis in embryonic life 38f
Development of preperitoneal space 99f
Device
for inguinal hernioplasty 54
on abdominal wall 61f
Diagnosis of hernia 68
Diaphragmatic hernia 66, 72
Diastasis recti 48, 71
Direct inguinal hernia 76
Disadvantages of local anesthesia 84
Dissecting hernia sac 115
Dissection of femoral space 92f
Division of external oblique aponeurosis
99f
E
Endoscopy for hiatus hernia 79
Enlarged prostate 40
Entering intra-abdominal cavity 114
Epidemiology of inguinal hernia survey
results 35
Epigastric hernia 34, 34f, 66, 70, 150
surgery 161
Esophageal hiatus 30
Etiological factors of incisional hernia 164
European pelvis 40f
Examination of adult groin hernia 68f
External
abdominal ring 153
anatomy of abdominal wall 6
oblique 11f
206
Hernia Surgery Simplied
aponeurosis 95f
muscle 10f, 181f
sphincter ani 198
Extraperitoneal
fascia 6
operation 142
F
Fascia 4
of Camper 152
of Colles 152
of Scarpa 152
transversalis 11
Father of modern hernia surgery 2f
Female inguinal hernia 120, 121, 121f
Femoral
canal 25, 133
repair 139
hernia 33, 45, 45f, 67, 76, 76f, 133, 133f,
138, 134
ring 133
sheath 133
vessels 14f
Fibrae intercrurales 153
Final position of prolene hernia system
mesh 100f
Floor of canal 55
Foley catheter 107
Fortaperm mesh 50f
Fossa ischiorectalis 198
Fruchaud’s theory 37
G
General cavity of abdomen 26
Gilbert classication 65f
Grynfeltt’s hernia 66
Grynfeltt-Lesshaft hernia 71
H
Hannington-Ki sign 194
Hematoma 111
Hemostasis 81
Hernia 1, 4
of superior lumbar triangle 177
repair 82, 83
technique 59
surgery 83
Hernial sac ligation 112f
Herniography 29, 74
technique 74
surgery 2f
Hesselbach’s
original drawing 5
triangle 6, 25, 42
Hiatal hernia 34, 66, 70, 79f
Hiatus hernia 54f
Howship-Romberg sign 78, 190, 194
I
Iliohypogastric nerves 20
Ilioinguinal nerves 20
Iliopubic tract 104
Incarcerated hernia 69
Incarceration technique 173f
Incisional hernia 66, 70, 79, 163, 166
repair 165
Indications of umbilical hernia surgery 147
Indirect inguinal hernia 76, 76f
Inferior epigastric
artery and vein complex 103
vessels 115
Inguinal
and lacunar ligaments 154f
canal 121
dissection 90
hernia 25f, 39, 40, 42, 68, 75, 138
in adults 32
in children 32, 33f, 123, 125
in males 33f
surgery in girls 129
ligament 23, 25f
Inlay mesh repair 169, 170
Intercolumnar bers 153
Internal oblique muscle 10f
Interparietal hernia 71
Intersection tendineae 151f
Interstitial hernia 72
Intra-abdominal injury 111
Intraperitoneal onlay mesh 103, 106, 188
Irreducible hernia 69, 126
K
Keith’s theory 38
L
Langer’s lines 17, 18f
in hernia surgery 16
Laparoscopic
classication of hernia 65
hernia repair 88
incisional hernia repair 169
inguinal
anatomy 104
hernia repairs 102
repair for femoral hernia 143
retroperitoneal repair 184
surgery for spigelian hernia 188
ventral hernia repair 171
Large pores 51
Lateral
abdominal wall
dissection 110
muscles 9f
hernias 165, 165f
muscles 9
ventral hernia 69
Layers and anatomy of pediatric inguinal
canal 128f
Le Suspenseur De L’abdomen 24
Left lumbar hernia 180f
Ligament 4
Ligamentum inguinale 151f
Linea
alba 16, 151f
semilunaris 16
Lines of incision for Bassini’s repair of
inguinal hernia 89f
List of causes of inguinal hernia 40
Littre’s hernia 66
Local anesthesia
for hernias 83
to inguinal area 85f
Locations of port placement 108f
Lockwood’s infrainguinal approach 139
Loss of fascial strength 48
Lotheissen’s transinguinal approach 142
Lumbar hernia 66, 177, 180
Lymph nodes 138
Lymphatic drainage 20
Lytle and Marcy repair 88
M
Major
muscles of posterior abdominal wall 21
nerves of posterior abdominal wall 21t
Management of
femoral hernias 138
of hernia strangulation 131
of incarcerated hernia 130
of umbilical hernia 131
Manual reduction of incarcerated hernia
130
Marcy repair 88
Mayo’s procedure for umbilical hernia 147
McEvedy’s high approach 142
Mechanism of hernia of groin 39
Medial
inguinal fossa 29f
side of mesh 95f
Mesh
and folding of mesh 117f
deployment and xation 110
strap 61f
Metal prosthetic graft material 47t
Milestones in hernia surgery 1
Modied Bassini 89, 90f
Monolocular
interstitial hernia 73f
properitoneal hernia 71, 72
Morgagni hernia 73
Multilayered repair 2f
Multiple hernia defects 166f
Index
207
Muscle
and fasciae of abdomen 151
of anal region 198
of female perineum 200f
of male perineum 199f
of urogenital region in
female 202
male 199
rectus abdominis 151f
transversus abdominis 151f
Muscular bers 29t
Musculofascial layer 9
Musculo-tendino-aponeurotic dystrophy
40
N
Negro pelvis 39f
Nerve injury 111
Nonmetal synthetic prosthesis 47t
O
Obesity 40
Obliquus externus abdominis 152, 155f
Obturator hernia 66, 71, 78
Onlay mesh repair 169
Open
anterior repair of inguinal hernia in
adult 88
prosthetic incisional hernia repair 167
Openings in diaphragm 30, 30f, 31t
Operating room setup 108t
Operation theater layout 113
Original Bassini operation 90f
Oxidized regenerated cellulose 57
P
Pantaloon hernia 66
Paraumbilical hernia 66, 70
Parietex mesh 53f, 54f
Peacock’s theory 38
Pediatric inguinal hernia 123, 123f
Pelvic
hernias 190
musculature 191f, 192f
Penrose drain 99f
Perineal hernia 66, 71, 198, 202f
Peritoneography 74
Peritoneum 25, 28f
Petit’s hernia 66, 71
Phases of wound healing 81
Placement of prosthetic mesh 82
Pneumoperitoneum in TAPP 114f
Polypropylene
hernia system 54f, 97f, 98f
prosthetic mesh 52
Polytetrauoroethylene 60
Ponka’s system 64
Port positions 114f
Posterior abdominal wall 21, 178f
Poupart’s ligament 26f
Pregnancy 40
Preparation of mesh 169
Presentation of hernia 68
Preshaped mesh device for inguinal hernia
60
Prevalence of hernia 32
Principles of hernia repair 81
Prolene
3D patch 56
hernia system 100, 149f
mesh 51f, 52
polypropylene hernia system 54
Properitoneal hernia 66
Prosthesis used in hernioplasty 46
Prosthetic
for inguinal hernia repair 48
mesh 82
with absorbable barriers 60
without barrier 60
Pure tissue repair 2f
Pyramidalis 16, 16f
R
Ratio of inguinal hernia 32f
in children 33f
Rectus
abdominis 8, 15f, 157
muscle 6f
sheath 8
Recurrent inguinal hernia 65f, 106
Reducible hernia 69
Reliable treatment for paraesophageal and
hiatal hernia 54
Repair
of pediatric inguinal hernia 128
technique 94
with prolene hernia system 149
Retzius’ space 13
Richter’s hernia 66
Right inguinal hernia 75f
Russell’s theory 37
S
Sac
closure and excision 139
of incisional hernia 168f
Scarpa fascia 7
Sciatic
hernia 67, 71, 196
nerve 197f
Scrotal hernia 77
with bowel loops 77f
Separation of hernial sac 112
Seroma formation 111
Shouldice repair 90
Silk
glove sign 127f
sign 68
Single hernia defect 166f
Skin
incision 99f
sutured with staplers 171f
Sliding hernia 66
Small pores 51f
Space dissection 109f
Spermatic cord 24, 115
Spigelian hernia 67, 69, 76, 77f, 185, 185f,
188f
Spina iliaca antero-superior 151f
Sports hernia 67
Stages of
hernia formation 193
pelvic hernia formation 193f
Standard technique of transabdominal
preperitoneal hernia repair 113
Strangulated hernia 69
Subcostal nerves 20
Subcutaneous
inguinal ring 153f
tissue 6
Subserous and peritoneal fascia 8
Supercial
circumex iliac arteries 19
epigastric arteries 19
fascia 6, 7, 152, 198
fatty layer 7
hernia 72
inguinal ring 22, 24, 25
lymphatic vessels 20
Superior
epigastric arteries 19
pubic ligament 6, 6f
triangle of Grynfeltt and Lesshaft 177
Supravesical hernia 80f
Surgical anatomy of hernia sites 5
Synthetic absorbable suture 58
T
Technique of
hernia repair 88, 122f
open anterior inguinal hernia repair 88
eories for hernia formation 37
oracoabdominal nerves 19
Toxicity of local anesthetic agents 86
Transabdominal preperitoneal
hernia repair 112, 113f
repair 102, 103, 188
Transversalis
fascia 12, 14f, 159
muscle 155
208
Hernia Surgery Simplied
Transversus abdominis 11, 157f
muscle 10, 10f, 13
Trendelenburg position 90f
Triangle of
doom 104f
pain 104f
Trocar
placement 109
in preperitoneal space 109f
positioning 114f
Types of
abdominal hernia 66
lumbar hernia surgery 177
repair 167
U
Uglavasky theory 38
Ultrapro hernia system 55f
Umbilical
hernia 34, 43, 56, 70, 144, 145f
hernia repair 146f
Upper gastrointestinal endoscopy depicting
hiatus hernia 70f
Use of prosthesis in hernia repair 46, 48
V
Vagina muscle recti abdominis 151f
Valsalva maneuver 75
Vas deferens and spermatic veins 112f
Vascular supply of abdomen 17
Veins of femoral canal 136f
Velpeau hernia 67
Ventral
abdominal wall hernia 79f
hernia 54f, 163f
surgery 163
W
Walk’s theory 38
Wide female pelvis 38
Wound
complications 175
healing 82
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