Surg Clin North Am. Dec;78(6) Inguinal hernia repair. The Nyhus posterior preperitoneal operation. Patiño JF(1), García-Herreros LG, Zundel N. The Nyhus Posterior Preperitoneal Operation The repair of inguinofemoral hernias constitutes the most widely performed general surgical procedure. Adapted with permission from Nyhus LM, Klein MS, Rogers FB. Inguinal hernia. Curr Probl Surg ;
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This is a corrected version of the article that appeared in print. Hernias usually present as swelling accompanied by pain or a dragging sensation in the groin.
Most hernias can be diagnosed based on the history and clinical examination, but ultrasonography may be useful in differentiating a hernia from other causes of groin swelling. Surgical repair is usually advised because of the danger of incarceration and strangulation, particularly with femoral hernias.
Three major types nyhs open repair are currently used, and laparoscopic techniques are also employed. The choice of technique depends on several factors, including the type of hernia, anesthetic considerations, cost, period of postoperative disability and the surgeon’s hsrnias. Following initial herniorrhaphy, complication and recurrence rates are generally low. Laparoscopic techniques make it possible for patients to return to normal activities more quickly, but nyhhus are more costly than open procedures.
In addition, they require general anesthesia, and the long-term hernia recurrence rate with these procedures is unknown. Inguinal and femoral hernias are the most common problems primary care physicians encounter that require surgical intervention.
Postoperative convalescence also contributes to absence from the work force. A clear understanding of the epidemiology and anatomy of inguinal hernias provides a solid foundation for timely diagnosis and care. Since inguinal herniorrhaphy can be performed using a variety of techniques, the approach can be individualized.
This article reviews the available surgical options for herniorrhaphy and the possible complications of these procedures.
In the United States, approximately 96 percent of groin hernias are inguinal and 4 percent are femoral. Inguinal hernias are bilateral in as many as 20 percent of affected adults. The most common hernia in both sexes is the indirect inguinal hernia. The male-to-female ratio is 9: While inguinal hernias occur fairly equally across adult age groups, femoral hernias tend to occur more often in elderly women.
The lifetime risk of inguinal herniation is approximately 10 percent. Nhyus hernias are broadly classified as indirect or direct, designations that refer to the relation of the herniation to the inferior epigastric arteries on the abdominal wall and the Hesselbach’s triangle. The anatomic region known as Hesselbach’s triangle is defined laterally by the inferior epigastric artery, medially by the lateral border of the rectus muscle and inferiorly by the inguinal ligament Figure 1.
An indirect hernia passes lateral to the inferior epigastric vessels and thus is outside of Hesselbach’s triangle Figure 2while henrias direct hernia is medial to the herniws vessels and therefore within the confines of this space Figure 3.
This anatomic landmark is bounded by the rectus abdominis muscle medially, the inguinal ligament inferiorly and the inferior epigastric vessels laterally. The triangle is outlined in red.
Route of an indirect hernia. Note that the hernia sac passes outside of the boundaries of Hesselbach’s triangle and follows the course of the spermatic cord.
Route of a direct hernia. The hernia sac passes directly hfrnias Hesselbach’s triangle and may disrupt the floor of the inguinal canal.
Inguinal hernia repair. The Nyhus posterior preperitoneal operation.
An indirect hernia is generally believed to have a congenital component. The development of this type of hernia requires a potential hernia sac, which is provided by the processus vaginalis.
After the fetal testis has descended into the scrotum from the retroperitoneum, the processus vaginalis normally obliterates, thereby removing this potential for herniation. Thus, an indirect hernia is the result of two conditions: Direct inguinal hernias are not generally congenital. Instead, they are acquired nyhhus the development of tissue deficiencies of the transversus abdominis muscle, which makes up the floor of the inguinal canal.
Thus, these hernias protrude directly through a defect in the inguinal canal floor, rather than indirectly following the potential space of the processus vaginalis and the path of the spermatic cord. The development of femoral herniation is not well understood. A femoral hernia can occur as a result of elevated intra-abdominal pressure. In this circumstance, preperitoneal fat can protrude through the femoral ring, with its accompanying pelvic peritoneum.
The hernial sac can then migrate down along the femoral vessels into the anterior thigh. Women may be predisposed to femoral herniation due to weakness of the pelvic floor musculature from previous childbirth Figure 4. Route of a femoral hernia. The hernia sac follows the potential space along herniss femoral vessels. It may be palpable near the femoral ring or in the medial thigh. An understanding of the innervation of the inguinal region is important, because injury to the nerves in this area may cause significant problems.
The major nerves in the inguinal region are the ilioinguinal, iliohypogastric and genitofemoral nerves. The ilioinguinal nerve hednias the inguinal canal near the external inguinal ring and provides unilateral sensory innervation to the pubic region and the upper portion of the scrotum or the labia majora. This is the nerve most commonly injured during open herniorrhaphy. The iliohypogastric nerve passes superior to nyhue internal inguinal ring and provides sensory innervation to the skin superior to the pubis.
The genital branch of the genitofemoral nerve travels within the spermatic cord to provide sensation to the scrotum and the medial thigh. The femoral branch of this nerve supplies sensation to the skin of the anterior thigh 2 Figure 5. Global anatomy of the pelvis and inguinal trigone.
Surgical Options in the Management of Groin Hernias
Note the lush innervation of this region. Both the ilioinguinal nerve and the genitofemoral nerve traverse the usual hernia-repair operative field. The femoral vein also runs just deep to the inguinal floor laterally. Most early inguinal hernias can be diagnosed by careful physical examination. Except for pain or a dull dragging sensation in the groin, the common reducible inguinal hernia usually does not cause significant symptoms.
Sonography may be useful in diagnosing inguinal hernias in patients who report symptoms but do not have a palpable defect. Ultrasound examination of the inguinal region with the patient in the supine and upright positions and with the Valsalva maneuver has been reported nuhus have a hhernias sensitivity and specificity of greater than 90 percent.
In the extremely rare patient with inguinal pain but no physical or sonographic evidence of inguinal herniation, computed tomographic scanning can be used to evaluate the pelvis for the presence of an obturator hernia. Preoperatively, it is often difficult to differentiate the common indirect hernia from the less common direct defect. Even skilled examiners may be incorrect in up to 30 percent of cases. However, indirect and direct hernias need to be differentiated during surgery, because the approach to repair depends on the defect type.
A hernia that is not repaired appropriately is more likely henrias recur. Diagnosing inguinal hernias in children can be very difficult. Surgical consultation is usually warranted if the parent or other caregiver reports that the child has had a groin bulge. The diagnosis nyhhs recurrent herniation is generally straightforward. However, it may be difficult to identify this problem in patients with scarring from a hernixs repair.
In patients who have symptoms suggestive of recurrent herniation but no clinical findings, the diagnosis can usually be obtained through sequential serial examinations and the judicious use of imaging modalities.
Classification systems for groin hernias range from simple schemes to more complex systems with up to 20 categories. Most classification systems take into account the location of the defect direct, indirect or femoralthe size of the defect and whether or not the herniation is recurrent.
While it is often difficult to differentiate hernial types preoperatively, a consistent approach to classifying hernias during surgery can provide information that will allow institutions to compare the outcomes achieved with different types of hernia repair. If one system is universally used to classify hernias, surgeons will be able to perform individualized procedures for specific anatomic defects based on sound outcome data.
While a broad consensus on the best classification system has not been achieved, the Nyhus classification system Table 1 4 is often referred to in the literature. Internal inguinal ring normal i. Dilated internal inguinal ring with posterior inguinal wall intact. Curr Probl Surg ; Almost all groin hernias should be surgically repaired.
When the potential complications of incarceration and strangulation are weighed against the minimal risks of hernia repair particularly when local anesthesia is usedthe early repair of groin hernias is clearly justified. This is especially true in the case of femoral hernias, since the rigid borders of the femoral canal increase the risk of incarceration.
Nyhus and Condon’s Hernia | JAMA Surgery | JAMA Network
Surgical repair of a hernia is not warranted in terminally ill patients with no evidence of incarceration. Patients with ascites generally should not undergo elective herniorrhaphy until their ascites is controlled.
While some surgeons believe that heenias direct hernias do not need to be repaired, the uncertainty of determining the status of a hernia preoperatively argues against this practice. The presence of incarceration or strangulation usually mandates urgent operative repair.
Based on operative intent and approach, the many different herniorrhaphy techniques can be grouped into four nyyhus categories. Group 1 hernia repairs Bassini, McVay and Shouldice techniques involve opening the external oblique aponeurosis and freeing the spermatic cord. Nghus transversalis fascia is then opened, facilitating inspection of the inguinal canal, the indirect space and the direct space.
The hernia sac is usually ligated, and the canal floor is subsequently reconstructed Figure 6. McVay open anterior repair. This repair reconstructs the inguinal canal without using a mesh prosthesis. The techniques in the open anterior repair group differ somewhat in their approach to reconstruction, but they all use permanent sutures to approximate the surrounding fascia and repair the floor of the inguinal canal.
When performed by skilled surgeons, these repairs provide reliable, satisfactory results and have similar recurrence rates. With very large defects or with fascia of marginal quality, the tension of the sutures can lead to recurrence. Posterior repair iliopubic tract repair and Nyhus technique is performed by dividing the layers of the abdominal wall superior to the internal ring and entering the properitoneal space. Dissection then continues behind and deep to the entire inguinal region.
Like the anterior approach, the posterior approach provides excellent visualization of the areas of concern in herniorrhaphy. Excellent results have been reported for the posterior techniques, but problems related to suture tension remain. Posterior repair is often used for hernias with multiple recurrences, because the approach avoids scar tissue from previous surgeries.
It is probably best performed with the patient receiving regional or general anesthesia.