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Surgery_Schwartz. tumors comparing interruption versus continuation of treatment beyond 1 year: the French Sarcoma Group. J Clin Oncol. 2007;25: 1107-1113. 216. Benjamin RS, Debiec-Rychter M, Le Cesne A, et al. Gastrointestinal stromal tumors II: medical oncology and tumor response assessment. Semin Oncol. 2009;4:302-311. 217. Maleddu A, Pantaleo MA, Nannini M, et al. Mechanisms of secondary resistance to tyrosine kinase inhibitors in gastrointestinal stromal tumours (review). Oncol Rep. 2009;21:1359-1366.Brunicardi_Ch36_p1567-p1598.indd 159501/03/19 6:38 PM 1596SPECIFIC CONSIDERATIONSPART II 218. Chu D, Lacouture ME, Weiner E, et al. Risk of hand-foot skin reaction with the multitargeted kinase inhibitor sunitinib in patients with renal cell and non–renal cell carcinoma: a meta-analysis. Clin Genitourin Cancer. 2009;7:11-19. 219. Zhu X, Stergiopoulos K, Wu S. Risk of hypertension and renal dysfunction with an angiogenesis inhibitor sunitinib: systematic review and meta-analysis. Acta Oncol.


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Surgery_Schwartz. Cancer. 2009;7:11-19. 219. Zhu X, Stergiopoulos K, Wu S. Risk of hypertension and renal dysfunction with an angiogenesis inhibitor sunitinib: systematic review and meta-analysis. Acta Oncol. 2009;48:9-17. 220. Chu TF, Rupnick MA, Kerkela R, et al. Cardiotoxicity asso-ciated with the tyrosine kinase inhibitor sunitinib. Lancet. 2007;370(9604):2011-2009. 221. George S, Wang Q, Heinrich MC, et al. Efficacy and safety of regorafenib in patients with metastatic and/or unresectable GI stromal tumor after failure of imatinib and sunitinib: a multicenter phase II trial. J Clin Oncol. 2012;30(19):2401-2407. 222. Demetri GD, Reichardt P, Kang YK, et al. Efficacy and safety of regorafenib for advanced gastrointestinal stromal tumours after failure of imatinib and sunitinib (GRID): an international, multicentre, randomised, placebo-controlled, phase 3 trial. Lancet. 2013;381(9863):295-302. 223. Boyar MS, Taub RN. New strategies for treating GIST when imatinib fails. Cancer Invest.


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Surgery_Schwartz. international, multicentre, randomised, placebo-controlled, phase 3 trial. Lancet. 2013;381(9863):295-302. 223. Boyar MS, Taub RN. New strategies for treating GIST when imatinib fails. Cancer Invest. 2007;25:328-335. 224. Cassier PA, Dufresne A, Fayette J, et al. Emerging drugs for the treatment of soft tissue sarcomas. Expert Opin Emerg Drugs. 2007;12:139-153. 225. Andtbacka RH, Ng CS, Scaife CL, et al. Surgical resection of gastrointestinal stromal tumors after treatment with imatinib. Ann Surg Oncol. 2007;14:14-24. 226. Desai J, Shankar S, Heinrich MC, et al. Clonal evolution of resistance to imatinib in patients with metastatic gastrointesti-nal stromal tumors. Clin Cancer Res. 2007;13:5398-5405. 227. DeMatteo RP, Maki RG, Singer S, et al. Results of tyrosine kinase inhibitor therapy followed by surgical resection for metastatic gastrointestinal stromal tumor. Ann Surg. 2007;245:347-352. 228. Raut CP, Posner M, Desai J, et al. Surgical management of advanced gastrointestinal


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Surgery_Schwartz. followed by surgical resection for metastatic gastrointestinal stromal tumor. Ann Surg. 2007;245:347-352. 228. Raut CP, Posner M, Desai J, et al. Surgical management of advanced gastrointestinal stromal tumors after treatment with targeted systemic therapy using kinase inhibitors. J Clin Oncol. 2006;24:2325-2331. 229. Gronchi A, Fiore M, Miselli F, et al. Surgery of residual disease following molecular-targeted therapy with imatinib mesylate in advanced/metastatic GIST. Ann Surg. 2007;245:341-346. 230. DeMatteo RP, Ballman KV, Antonescu CR, et al. Placebocontrolled randomized trial of adjuvant imatinib mesylate following the resection of localized, primary gastrointestinal stromal tumor (GIST). Lancet. 2009;373(9669):1097-1104. 231. Joensuu H, Eriksson M, Sundby Hall K, et al. One vs three years of adjuvant imatinib for operable gastrointestinal stromal tumor: a randomized trial. JAMA. 2012;307(12):1265-1272. 232. The ESMO/European Sarcoma Network Working Group. Gastrointestinal


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Surgery_Schwartz. three years of adjuvant imatinib for operable gastrointestinal stromal tumor: a randomized trial. JAMA. 2012;307(12):1265-1272. 232. The ESMO/European Sarcoma Network Working Group. Gastrointestinal stromal tumors: ESMO clinical recommen-dations for diagnosis, treatment and follow-up. Ann Oncol. 2012;23:49-55. 233. Gold JS, Gönen M, Gutiérrez A, et al. Development and validation of a prognostic nomogram for recurrence-free sur-vival after complete surgical resection of localised primary gastrointestinal stromal tumour: a retrospective analysis. Lancet Oncol. 2009;10:1045-1052. 232. Joensuu H, Vehtari A, Riihimäki J, et al. Risk of recur-rence of gastrointestinal stromal tumour after surgery: an analysis of pooled population-based cohorts. Lancet Oncol. 2012;13(3):265-274. 234. Demetri GD, Antonia S, Benjamin RS, et al. Soft tissue sarcoma. J Natl Compr Canc Netw. 2010;8:630-674. 235. van der Zwan SM, DeMatteo RP. Gastrointestinal stromal tumor: 5 years later. Cancer.


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Surgery_Schwartz. GD, Antonia S, Benjamin RS, et al. Soft tissue sarcoma. J Natl Compr Canc Netw. 2010;8:630-674. 235. van der Zwan SM, DeMatteo RP. Gastrointestinal stromal tumor: 5 years later. Cancer. 2005;104:1781-1788. 236. Eisenberg BL, Harris J, Blanke CD, et al. Phase II trial of neoadjuvant/adjuvant imatinib mesylate (IM) for advanced primary and metastatic/recurrent operable gastrointestinal stromal tumor (GIST): early results of RTOG 0132/ACRIN 6665. J Surg Oncol. 2008;99:42-47. 237. McAuliffe JC, Hunt KK, Lazar AJF, et al. A randomized, phase II study of preoperative plus postoperative imatinib in GIST: evidence of rapid radiographic response and tem-poral induction of tumor cell apoptosis. Ann Surg Oncol. 2009;16:910-919. 238. Fiore M, Palassini E, Fumagalli E, et al. Preoperative ima-tinib mesylate for unresectable or locally advanced primary gastrointestinal stromal tumors (GIST). Eur J Surg Oncol. 2009;35:739-745. 239. Emile J, Brahimi S, Coindre J, et al. Frequencies of KIT and PDGFRA


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Surgery_Schwartz. for unresectable or locally advanced primary gastrointestinal stromal tumors (GIST). Eur J Surg Oncol. 2009;35:739-745. 239. Emile J, Brahimi S, Coindre J, et al. Frequencies of KIT and PDGFRA mutations in the MolecGIST prospective population-based study differ from those of advanced GISTs. Med Oncol. 2012;29:1765-1772. 240. Gronchi A, Casali P, Mariani L, et al. Quality of surgery and outcome in extra-abdominal aggressive fibromatosis: a series of patients surgically treated at a single institution. J Clin Oncol. 2003;21:1390-1397. 241. Lev D, Kotilingam D, Wei C, et al. Optimizing treatment of desmoid tumors. J Clin Oncol. 2007;25:1785-1791. 242. Salas S, Dufresne A, Bui B, et al. Prognostic factors influencing progression-free survival determined from a series of sporadic desmoid tumors: a wait-and-see policy according to tumor presentation. J Clin Oncol. 2011;29: 3553-3558. 243. Bonvalot S, Eldweny H, Haddad V, et al. Extra-abdominal primary fibromatosis: aggressive management


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Surgery_Schwartz. a wait-and-see policy according to tumor presentation. J Clin Oncol. 2011;29: 3553-3558. 243. Bonvalot S, Eldweny H, Haddad V, et al. Extra-abdominal primary fibromatosis: aggressive management could be avoided in a subgroup of patients. Eur J Surg Oncol. 2008;34: 462-468. 244. Fiore M, Rimareix F, Mariani L, et al. Desmoid-type fibromatosis: a front-line conservative approach to select patients for surgical treatment. Ann Surg Oncol. 2009;16: 2587-2593. 245. Constantinidou A, Scurr M, Jones R, et al. Treatment of aggressive fibromatosis with pegylated liposomal doxorubi-cin: The Royal Marsden Hospital experience. J Clin Oncol. (Meeting Abstracts), Abstract 10519, 2009. 246. Gounder MM, Lefkowitz RA, Keohan ML, et al. Activity of sorafenib against desmoid tumor/deep fibromatosis. Clin Cancer Res. 2011;17:4082-4090. 247. Dufresne A, Penel N, Salas S, et al. Updated outcome with long term follow-up of imatinib for the treatment of progres-sive or recurrent aggressive fibromatosis


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Surgery_Schwartz. Cancer Res. 2011;17:4082-4090. 247. Dufresne A, Penel N, Salas S, et al. Updated outcome with long term follow-up of imatinib for the treatment of progres-sive or recurrent aggressive fibromatosis (desmoid tumor): a FNCLCC/French Sarcoma Group phase II trial. Age. 2009;40:59. 248. Chugh R, Wathen JK, Patel SR, et al. Efficacy of imatinib in aggressive fibromatosis: results of a phase II multicenter Sarcoma Alliance for Research through Collaboration (SARC) trial. Clin Cancer Res. 2010;16:4884-4891. 249. Penel N, Le Cesne A, Bui B, et al. Imatinib for progressive and recurrent aggressive fibromatosis (desmoid tumors): an FNCLCC/French Sarcoma Group phase II trial with a long-term follow-up. Ann Oncol. 2011;22:452-457. 250. Criscione VD, Weinstock MA. Descriptive epidemiology of dermatofibrosarcoma protuberans in the United States, 1973 to 2002. J Am Acad Dermatol. 2007;56:968-973. 251. Fiore M, Miceli R, Mussi C, et al. Dermatofibrosarcoma protuberans treated at a single


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Surgery_Schwartz. dermatofibrosarcoma protuberans in the United States, 1973 to 2002. J Am Acad Dermatol. 2007;56:968-973. 251. Fiore M, Miceli R, Mussi C, et al. Dermatofibrosarcoma protuberans treated at a single institution: a surgical disease with a high cure rate. J Clin Oncol. 2005;23:7669-7675. 252. McArthur GA. Molecular targeting of dermatofibrosarcoma protuberans: a new approach to a surgical disease. J Natl Compr Canc Netw. 2007;5:557-562.Brunicardi_Ch36_p1567-p1598.indd 159601/03/19 6:38 PM 1597SOFT TISSUE SARCOMASCHAPTER 36 253. Grovas A, Fremgen A, Rauck A, et al. The National Cancer Data Base report on patterns of childhood cancers in the United States. Cancer. 1997;80:2321-2332. 254. Meyer WH, Spunt SL. Soft tissue sarcomas of childhood. Cancer Treat Rev. 2004;30:269-280. 255. Barr FG, Chatten J, D’Cruz CM, et al. Molecular assays for chromosomal translocations in the diagnosis of pediatric soft tissue sarcomas. JAMA. 1995;273:553-557. 256. Xia SJ, Pressey JG, Barr FG. Molecular


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Surgery_Schwartz. Chatten J, D’Cruz CM, et al. Molecular assays for chromosomal translocations in the diagnosis of pediatric soft tissue sarcomas. JAMA. 1995;273:553-557. 256. Xia SJ, Pressey JG, Barr FG. Molecular pathogenesis of rhabdomyosarcoma. Cancer Biol Ther. 2002;1:97-104. 257. Scrable H, Witte D, Shimada H, et al. Molecular differential pathology of rhabdomyosarcoma. Genes Chromosomes Cancer. 1989;1:23-35. 258. Flamant F, Rodary C, Rey A, et al. Treatment of non-metastatic rhabdomyosarcomas in childhood and adolescence. Results of the second study of the International Society of Paediatric Oncology: MMT84. Eur J Cancer. 1998;34:1050-1062. 259. Crist WM, Anderson JR, Meza JL, et al. Intergroup rhabdomyosarcoma study-IV: results for patients with nonmetastatic disease. J Clin Oncol. 2001;19:3091-3102. 260. Crist WM, Garnsey L, Beltangady MS, et al. Prognosis in children with rhabdomyosarcoma: a report of the intergroup rhabdomyosarcoma studies I and II. Intergroup Rhabdomyo-sarcoma Committee.


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Surgery_Schwartz. WM, Garnsey L, Beltangady MS, et al. Prognosis in children with rhabdomyosarcoma: a report of the intergroup rhabdomyosarcoma studies I and II. Intergroup Rhabdomyo-sarcoma Committee. J Clin Oncol. 1990;8:443-452. 261. Loeb DM, Thornton K, Shokek O. Pediatric soft tissue sarcomas. Surg Clin North Am. 2008;88:615-627, vii.Brunicardi_Ch36_p1567-p1598.indd 159701/03/19 6:38 PM


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Surgery_Schwartz. Inguinal HerniasChandan Das, Tahir Jamil, Stephen Stanek, Ziya Baghmanli, James R. Macho, Joseph Sferra, and F. Charles Brunicardi 37chapterINTRODUCTIONInguinal herniorrhaphy is one of the most commonly performed operations in the United States.1 Based on estimates made by the National Center for Health Statistics, in 2010 nearly 515,000 inguinal hernia operations were performed in hospitals, and an additional 450,000 were performed in ambulatory surgery centers.1Approximately 75% of abdominal wall hernias occur in the groin. Of inguinal hernia repairs, 90% are performed in men, and 10% are performed in women. This is thought to be because the lifetime risk of inguinal hernia is 27% in men and 3% in women.2 The incidence of inguinal hernia in men has a bimodal distribution, with peaks before the first year of age and after age 40. Abramson demonstrated the age-dependence of inguinal hernias in 1978. Those age 25 to 34 years had a life-time prevalence rate of 15%, whereas those age


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Surgery_Schwartz. before the first year of age and after age 40. Abramson demonstrated the age-dependence of inguinal hernias in 1978. Those age 25 to 34 years had a life-time prevalence rate of 15%, whereas those age 75 years and over had a rate of 47% (Table 37-1).3 Approximately 70% of femoral hernia repairs are performed in women; however, the most common subtype of groin hernia in men and women is still the indirect inguinal hernia. Inguinal hernias are five times more common than femoral hernias.4Globally, the inguinal hernia repair has become one of the most important procedures in improving quality of life and preventing disability. In one study, an international coopera-tive organization performed over 1033 hernia repairs on 926 patients, and their impact was measured in disability adjusted life years (DALYs). They were able to avoid 5014 DALYs or 5.41 DALYs per patient.5HistorySurgical repair of hernias has been documented as far back as in ancient Egyptian and Greek civilizations.4 In the


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Surgery_Schwartz. years (DALYs). They were able to avoid 5014 DALYs or 5.41 DALYs per patient.5HistorySurgical repair of hernias has been documented as far back as in ancient Egyptian and Greek civilizations.4 In the past, early management of inguinal hernias often involved a conservative approach with operative management reserved only for compli-cations. Surgery often involved routine excision of the testicle, and wounds were closed with cauterization or allowed to close by secondary intention. These procedures were 1performed without aseptic technique, and infection and recur-rence rates were high.From the late 1700s to the early 1800s, physicians including Hesselbach, Cooper, Camper, Scarpa, Richter, and Gimbernat identified vital components of the inguinal region from cadaveric dissection. This improved understanding of the anatomy and pathophysiology of inguinal hernias. These findings, coupled with the development of aseptic technique, led surgeons such as Marcy, Kocher, and Lucas-Championnière


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Surgery_Schwartz. understanding of the anatomy and pathophysiology of inguinal hernias. These findings, coupled with the development of aseptic technique, led surgeons such as Marcy, Kocher, and Lucas-Championnière to perform sac dissection, high ligation, and closure of the internal ring. This led to improved outcomes, but recurrence rates remained unacceptably high.At around this time, Bassini (1844–1924) pioneered a new method that transformed inguinal hernia repair into a success-ful venture with minimal morbidity. The success of the Bassini repair over its predecessors ushered in an era of tissue-based repairs. The Bassini repair was then modified into the McVay and Shouldice repairs. All three of these techniques, as well as modern variations such as the Desarda operation, are currently practiced.6The next major advancement in inguinal hernia repair was in the 1980s. At this time, Lichtenstein applied a piece of mesh to the floor of the inguinal canal, allowing for a truly tension-free repair.


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Surgery_Schwartz. next major advancement in inguinal hernia repair was in the 1980s. At this time, Lichtenstein applied a piece of mesh to the floor of the inguinal canal, allowing for a truly tension-free repair. This technique demonstrated superior outcomes compared to previous tissue-based repairs. There were several other advantages of this process. In addition to being truly tension-free, the mesh could restore the strength of the transversalis fascia, and importantly, the technique had a very short learning curve. The superior outcomes have been widely reproduced regardless of hernia size and type, and they were achievable among both expert and nonexpert hernia surgeons.7With the advent of minimally invasive surgery, inguinal hernia repair underwent its most recent transformation. Laparo-scopic inguinal hernia repair offers an alternative approach, minimizes postoperative pain,8 and improves recovery. Since the initial description by Ger, the laparoscopic method has become more sophisticated.


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Surgery_Schwartz. hernia repair offers an alternative approach, minimizes postoperative pain,8 and improves recovery. Since the initial description by Ger, the laparoscopic method has become more sophisticated. Refinements in approach and technique have Introduction1599History / 1599Anatomy / 1600Pathophysiology / 1604Diagnosis1606History / 1606Physical Examination / 1607Imaging / 1607Treatment1608Prophylactic Antibiotics / 1609Open Approach / 1609Laparoscopic Approach / 1613Robot-Assisted Inguinal Hernia Repair / 1616Prosthesis Considerations / 1616Complications1618Hernia Recurrence / 1618Pain / 1619Cord and Testes Injury / 1620Laparoscopic Complications / 1620Hematomas and Seromas / 1621Outcomes1621Brunicardi_Ch37_p1599-p1624.indd 159929/01/19 2:02 PM 1600Key Points1 Conservative management of asymptomatic inguinal hernias is recommended.2 A thorough understanding of groin anatomy is essential to successful surgical treatment of inguinal hernias.3 Elective repair of inguinal hernias can be


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Surgery_Schwartz. asymptomatic inguinal hernias is recommended.2 A thorough understanding of groin anatomy is essential to successful surgical treatment of inguinal hernias.3 Elective repair of inguinal hernias can be undertaken using a laparoscopic, robotic, or open approach.4 Robotic-assisted hernia surgery is quickly becoming adopted by general surgeons because of its better ergonomics and visualization.5 The use of prosthetic mesh as a reinforcement significantly improves recurrence rates, whether the repair is open or laparoscopic.6 Recurrence, pain, and quality of life are the metrics by which hernia repair outcomes are measured.7 Laparoscopic inguinal hernia repair results in less pain; how-ever, mastery of this technique has a longer learning curve.led to the development of the intraperitoneal onlay mesh,9,10 the transabdominal preperitoneal (TAPP) repair,11 and the totally extraperitoneal (TEP) repair.12 Irrespective of the approach, suc-cessful surgical treatment of inguinal hernias depends


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Surgery_Schwartz. mesh,9,10 the transabdominal preperitoneal (TAPP) repair,11 and the totally extraperitoneal (TEP) repair.12 Irrespective of the approach, suc-cessful surgical treatment of inguinal hernias depends on a sound grasp of inguinal anatomy.AnatomyThe inguinal canal is an approximately 4to 6-cm long cone-shaped region situated in the anterior portion of the pelvic basin (Fig. 37-1). The canal begins on the posterior abdominal wall, where the spermatic cord passes through a hiatus in the transver-salis fascia also known as the deep (internal) inguinal ring. The canal concludes medially at the superficial (external) inguinal ring, the point at which the spermatic cord crosses a defect in the external oblique aponeurosis. The boundaries of the ingui-nal canal are the external oblique aponeurosis anteriorly, the internal oblique muscle laterally, the transversalis fascia and transversus abdominis muscle posteriorly, the internal oblique and transversus abdominis muscle superiorly, and the


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Surgery_Schwartz. anteriorly, the internal oblique muscle laterally, the transversalis fascia and transversus abdominis muscle posteriorly, the internal oblique and transversus abdominis muscle superiorly, and the inguinal (Poupart’s) ligament inferiorly. The spermatic cord traverses the inguinal canal, and it contains three arteries, three veins, two nerves, the pampiniform venous plexus, and the vas deferens. It is enveloped in three layers of spermatic fascia.Additional important structures surrounding the inguinal canal include the iliopubic tract, the lacunar ligament, Cooper’s ligament, and the conjoined tendon (Fig. 37-2). The iliopubic tract is an aponeurotic band that begins at the anterior superior iliac spine and inserts into Cooper’s ligament from above. It forms on the deep inferior margin of the transversus abdominis and transversalis fascia. The shelving edge of the inguinal ligament is a structure that connects the iliopubic tract to the inguinal ligament. The iliopubic tract helps form


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Surgery_Schwartz. transversus abdominis and transversalis fascia. The shelving edge of the inguinal ligament is a structure that connects the iliopubic tract to the inguinal ligament. The iliopubic tract helps form the inferior margin of the internal inguinal ring as it courses medially, where it continues as the anteromedial border of the femoral canal. The lacunar ligament, or ligament of Gimbernat, is the triangular fanning of the inguinal ligament as it joins the pubic 2tubercle. Cooper’s (pectineal) ligament is the lateral portion of the lacunar ligament that is fused to the periosteum of the pubic tubercle. The conjoined tendon is commonly described as the fusion of the inferior fibers of the internal oblique and transversus abdominis aponeurosis at the point where they insert on the pubic tubercle.Inguinal hernias are generally classified as direct, indirect, or femoral based upon the site of herniation relative to surround-ing structures. Indirect hernias protrude lateral to the inferior


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Surgery_Schwartz. hernias are generally classified as direct, indirect, or femoral based upon the site of herniation relative to surround-ing structures. Indirect hernias protrude lateral to the inferior epigastric vessels, through the deep inguinal ring. Direct hernias protrude medial to the inferior epigastric vessels, within Hesselbach’s triangle. The borders of the triangle are the ingui-nal ligament inferiorly, the lateral edge of rectus sheath medi-ally, and the inferior epigastric vessels superolaterally. Femoral hernias protrude through the small and inflexible femoral ring. They traverse the empty space between the femoral vein and the lymphatic channels. The borders of the femoral ring include the iliopubic tract and inguinal ligament anteriorly, Cooper’s liga-ment posteriorly, the lacunar ligament medially, and the femoral vein laterally. The Nyhus classification categorizes hernia defects by location, size, and type (Table 37-2).Laparoscopic inguinal hernia repair requires a thorough


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Surgery_Schwartz. medially, and the femoral vein laterally. The Nyhus classification categorizes hernia defects by location, size, and type (Table 37-2).Laparoscopic inguinal hernia repair requires a thorough knowledge of inguinal anatomy from a posterior perspective (Fig. 37-3). Intraperitoneal points of reference are the five peritoneal folds, bladder, inferior epigastric vessels, and psoas muscle (Fig. 37-4). Two potential spaces exist within the pre-peritoneum. Between the peritoneum and the posterior lamina of the transversalis fascia is Bogros’s (preperitoneal) space. This area contains preperitoneal fat and areolar tissue. The most medial aspect of the preperitoneal space, that which lies superior to the bladder, is known as the space of Retzius. The posterior perspective also allows visualization of the myopectineal orifice of Fruchaud, a relatively weak portion of the abdominal wall that is divided by the inguinal ligament (Fig. 37-5).The vascular space is situated between the posterior and


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Surgery_Schwartz. of the myopectineal orifice of Fruchaud, a relatively weak portion of the abdominal wall that is divided by the inguinal ligament (Fig. 37-5).The vascular space is situated between the posterior and anterior laminae of the transversalis fascia, and it houses the Table 37-1Inguinal hernia prevalence by ageAGE (Y)25–3435–4445–5455–6465–7475+Current prevalence (%)121520262934Lifetime prevalence (%)151928344047Current = repaired hernias excluded; lifetime = repaired hernias included.Brunicardi_Ch37_p1599-p1624.indd 160029/01/19 2:02 PM 1601INGUINAL HERNIASCHAPTER 37Abdominal ringLateral leafPubic tubercleSpermatic cordInterrupted sutures taken to suture the medial leaf to the inguinal ligament Interrupted sutures between the upper border of the strip and conjoined muscle and internal oblique muscleInternal oblique muscle seen through the splitting incision made in the medial leafReflected medial leaf after a strip has been separatedFigure 37-2. Ligaments that contribute to the


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Surgery_Schwartz. oblique muscleInternal oblique muscle seen through the splitting incision made in the medial leafReflected medial leaf after a strip has been separatedFigure 37-2. Ligaments that contribute to the inguinal canal include the inguinal ligament, Cooper’s ligament, and the lacunar ligament. The iliopubic tract originates and inserts in a similar fashion to the inguinal ligament, but in a deeper position. m. = muscle.Abdominal ringLateral leafMedial leafPubic tubercleSpermatic cordInterrupted sutures taken to suture the medial leaf to the inguinal ligament Figure 37-1. Location and orientation of the inguinal canal within the pelvic basin. Boundaries of the canal include: transversus abdominus and transversalis fascia posterior; internal oblique muscle superior; external oblique aponeurosis anterior; inguinal ligament inferior. m. = muscle.inferior epigastric vessels. The inferior epigastric artery supplies the rectus abdominis. It is derived from the external iliac artery, and it


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Surgery_Schwartz. anterior; inguinal ligament inferior. m. = muscle.inferior epigastric vessels. The inferior epigastric artery supplies the rectus abdominis. It is derived from the external iliac artery, and it anastomoses with the superior epigastric, a continuation of the internal thoracic artery. The epigastric veins course paral-lel to the arteries within the rectus sheath, posterior to the rectus muscles. Inspection of the internal inguinal ring will reveal the deep location of the inferior epigastric vessels.Nerves of interest in the inguinal region are the ilioin-guinal, iliohypogastric, genitofemoral, and lateral femoral cutaneous nerves (Figs. 37-6 and 37-7). The ilioinguinal and iliohypogastric nerves arise together from the first lumbar nerve (L1). The ilioinguinal nerve emerges from the lateral border of the psoas major and passes obliquely across the quadratus lumborum. At a point just medial to the anterior Brunicardi_Ch37_p1599-p1624.indd 160129/01/19 2:02 PM 1602SPECIFIC


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Surgery_Schwartz. the lateral border of the psoas major and passes obliquely across the quadratus lumborum. At a point just medial to the anterior Brunicardi_Ch37_p1599-p1624.indd 160129/01/19 2:02 PM 1602SPECIFIC CONSIDERATIONSPART IIInferior epigastric vesselsCooper’s ligamentPubic tubercleArcuate lineUmbilicusLinea albaRectus muscleDeepinguinalringIliopubictractExternal iliacvesselsIndirecthernia siteDirecthernia siteObturatorvesselsTransversusabdominismusclearchSuperioranteriorcrusSpermatic cordSpermatic vesselsFemoral canalFigure 37-3. Anatomy of the groin region from the posterior perspective.AA UmbilicusB Median umbilical ligament (urachus)C Medial umbilical ligament (obliterated umbilical vein)D Lateral umbilical ligament (inferior epigastric vessels)E Lateral fossa (indirect hernia)F Medial fossa (direct hernia)G Supravesical fossaBEFBladderGCDFigure 37-4. Posterior view of intraperitoneal folds and associated fossa: A. Umbilicus. B. Median umbilical ligament. C. Medial


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Surgery_Schwartz. hernia)F Medial fossa (direct hernia)G Supravesical fossaBEFBladderGCDFigure 37-4. Posterior view of intraperitoneal folds and associated fossa: A. Umbilicus. B. Median umbilical ligament. C. Medial umbilical ligament (obliterated umbilical vein). D. Lateral umbilical ligament (inferior epigastric vessels). E. Lateral fossa (indirect hernia). F. Medial fossa (direct hernia). G. Supravesical fossa. (Modified with permission from Rowe JS, Skandalakis JE, Gray SW: Multiple bilateral inguinal hernias, Am Surg. 1973 May;39(5):269-270.)Table 37-2Nyhus classification systemType IIndirect hernia; internal abdominal ring normal; typically in infants, children, small adultsType IIIndirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotumType IIIADirect hernia; size is not taken into accountType IIIBIndirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are


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Surgery_Schwartz. scrotumType IIIADirect hernia; size is not taken into accountType IIIBIndirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to the direct space; also includes pantaloon herniasType IIICFemoral herniaType IVRecurrent hernia; modifiers A–D are sometimes added, which correspond to indirect, direct, femoral, and mixed, respectivelysuperior iliac spine, it pierces the transversus and internal oblique muscles to enter the inguinal canal and exits through the superficial inguinal ring. It supplies somatic sensation to the skin of the upper and medial thigh. In males, it also inner-vates the base of the penis and upper scrotum. In females, it innervates the mons pubis and labium majus. The iliohypo-gastric nerve arises from T12–L1. After it pierces the deep abdominal wall, it courses between the internal oblique and transversus abdominis,


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Surgery_Schwartz. innervates the mons pubis and labium majus. The iliohypo-gastric nerve arises from T12–L1. After it pierces the deep abdominal wall, it courses between the internal oblique and transversus abdominis, supplying both. It then divides into lat-eral and anterior cutaneous branches. A common variant is for the iliohypogastric and ilioinguinal nerves to exit around the superficial inguinal ring as a single entity. The genitofemoral nerve arises from L1 to L2, courses along the retroperitoneum, and emerges on the anterior aspect of the psoas. It then divides into genital and femoral branches. The genital branch enters the inguinal canal lateral to the inferior epigastric vessels, and it courses ventral to the iliac vessels and iliopubic tract. In males, it travels through the superficial inguinal ring and sup-plies the ipsilateral scrotum and cremaster muscle. In females, it supplies the ipsilateral mons pubis and labium majus. The Brunicardi_Ch37_p1599-p1624.indd 160229/01/19 2:02 PM


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Surgery_Schwartz. ring and sup-plies the ipsilateral scrotum and cremaster muscle. In females, it supplies the ipsilateral mons pubis and labium majus. The Brunicardi_Ch37_p1599-p1624.indd 160229/01/19 2:02 PM 1603INGUINAL HERNIASCHAPTER 37Epigastric vesselsInternal spermaticvesselsIliopsoas muscleIliopubictractMyopectinealorificeExternal iliac a. and v.Vas deferensObturator n.Obturator vesselsLacunar ligamentCooper's ligamentFigure 37-5. Posterior view of the myopectineal orifice of Fruchaud. a. = artery; n. = nerve; v. = vein.Ilioinguinal n.Iliohypogastric n.Iliac m.Lateral femoralcutaneous n.Femoral n.Inguinal ligamentGenitofemoral n.(femoral branch)(genital branch)Iliopectinal archPectineal ligamentIliopubic tractLacunar ligamentFigure 37-6. Retroperitoneal view of major inguinal nerves and their courses. m. = muscle; n. = nerve.femoral branch courses along the femoral sheath, supply-ing the skin of the upper anterior thigh. The lateral femoral cutaneous nerve arises from L2 to L3, emerges


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Surgery_Schwartz. courses. m. = muscle; n. = nerve.femoral branch courses along the femoral sheath, supply-ing the skin of the upper anterior thigh. The lateral femoral cutaneous nerve arises from L2 to L3, emerges lateral to the psoas muscle at the level of L4, and crosses the iliacus mus-cle obliquely toward the anterior superior iliac spine. It then passes inferiorly to the inguinal ligament where it divides to supply the lateral thigh (Fig. 37-8).The preperitoneal anatomy seen in laparoscopic hernia repair led to characterization of important anatomic areas of interest, known as the triangle of doom, the triangle of pain, and the circle of death (Fig. 37-9).7 The triangle of doom is bordered medially by the vas deferens and laterally by the vessels of the spermatic cord. The contents of the space include the external iliac vessels, deep circumflex iliac vein, femoral nerve, and gen-ital branch of the genitofemoral nerve. The triangle of pain is a region bordered by the iliopubic tract and gonadal


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Surgery_Schwartz. the external iliac vessels, deep circumflex iliac vein, femoral nerve, and gen-ital branch of the genitofemoral nerve. The triangle of pain is a region bordered by the iliopubic tract and gonadal vessels, and it encompasses the lateral femoral cutaneous, femoral branch of the genitofemoral and femoral nerves. The circle of death is a vascular continuation formed by the common iliac, internal iliac, obturator, inferior epigastric, and external iliac vessels.Brunicardi_Ch37_p1599-p1624.indd 160329/01/19 2:03 PM 1604SPECIFIC CONSIDERATIONSPART IIFigure 37-7. Anterior view of the five major nerves of the inguinal region.Femoral branch ofgenitofemoral n.Ilioinguinal n.Lateral femoralcutaneous n.Medial and intermediatefemoral cutaneous nn.Saphenous n.Iliohypogastric n.Genital branch ofgenitofemoral n.Figure 37-8. Sensory dermatomes of the major nerves in the groin area. n. = nerve.PathophysiologyInguinal hernias may be congenital or acquired. Most adult inguinal hernias are considered


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Surgery_Schwartz. n.Figure 37-8. Sensory dermatomes of the major nerves in the groin area. n. = nerve.PathophysiologyInguinal hernias may be congenital or acquired. Most adult inguinal hernias are considered acquired defects in the abdomi-nal wall. There is however, a known hereditary association that is not well understood.13 The most likely risk factor for inguinal hernia is weakness in the abdominal wall musculature; how-ever, there are several other risk-factors that have been studied (Table 37-3). Congenital hernias, which make up the majority of pediatric hernias, can be considered a developmental defect rather than an acquired weakness. During the normal course of development, the testes descend from the intra-abdominal space into the scrotum in the third trimester. Their descent is guided by the gubernaculum through an evagination of the peritoneum, which protrudes through the inguinal canal and becomes the processus vaginalis. Between 36 and 40 weeks’ gestation, the processus vaginalis closes


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Surgery_Schwartz. through an evagination of the peritoneum, which protrudes through the inguinal canal and becomes the processus vaginalis. Between 36 and 40 weeks’ gestation, the processus vaginalis closes and eliminates the peritoneal open-ing at the internal inguinal ring.14 Failure of the peritoneum to close results in a patent processus vaginalis (PPV). In preterm babies, indirect inguinal hernias as a result of PPV is very high (Fig. 37-10). However, overall, the risk of developing a symp-tomatic hernia during childhood in the presence of a known PPV is relatively low.15Overall, there is limited data regarding the etiology of inguinal hernia development. Several studies have documented strenuous physical activity as a risk factor for acquired inguinal hernia.16 A case-controlled study of over 1400 male patients with inguinal hernia revealed that a positive family history was associated with an eightfold lifetime incidence of Brunicardi_Ch37_p1599-p1624.indd 160429/01/19 2:03 PM 1605INGUINAL


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Surgery_Schwartz. patients with inguinal hernia revealed that a positive family history was associated with an eightfold lifetime incidence of Brunicardi_Ch37_p1599-p1624.indd 160429/01/19 2:03 PM 1605INGUINAL HERNIASCHAPTER 37Inferolateral border:iliopubic tractDeep circumflexiliac a. & v.Lateral border:reflected peritoneumLat. femoral cutaneous n.Ant. femoral cutaneous n. or other variable branchesFemoral br. of genitofemoral n.Femoral n.Superomedial border:gonadal vesselsLateral border:gonadal vesselsGenital branch ofgenitofemoral nerveIliac veinIliac arteryMedial border:ductus deferensPosterior border:peritoneal edgeDeep ringABFigure 37-9. Borders and contents of the (A) triangle of doom and (B) triangle of pain. a. = artery; Ant. = anterior; br. = branch; Lat. = lateral; n. = nerve; v. = vein. (Modified with permission from Colborn GL, Skandalakis JE: Laparoscopic cadaveric anatomy of the inguinal area, Probl Gen Surg. 1995;12(1):13-20.)inguinal hernia.17 Chronic obstructive pulmonary disease


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Surgery_Schwartz. with permission from Colborn GL, Skandalakis JE: Laparoscopic cadaveric anatomy of the inguinal area, Probl Gen Surg. 1995;12(1):13-20.)inguinal hernia.17 Chronic obstructive pulmonary disease also significantly increases the risk of direct inguinal hernias, thought to be due to repeated instances of intra-abdominal pressure during coughing.18 Several studies have suggested a protective effect of obesity. In a large, population-based prospective study of American individuals (First National Health and Nutrition Examination Survey), the risk of inguinal hernia development in obese men was only 50% that of normal-weight men, while the risk in overweight men was 80% that of nonobese men. A possible explanation is the increased difficulty in detecting inguinal hernias in obese individuals.18Epidemiologic studies have identified risk factors that may predispose to a hernia. Microscopic examination of skin of inguinal hernia patients demonstrated significantly decreased ratios of type I to


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Surgery_Schwartz. studies have identified risk factors that may predispose to a hernia. Microscopic examination of skin of inguinal hernia patients demonstrated significantly decreased ratios of type I to type III collagen. Type III collagen does not contribute to wound tensile strength as significantly as type I collagen. Additional analyses of similar skin revealed disaggregated collagen tracts with decreased collagen fiber density.19 Collagen disorders such as Ehlers-Danlos syndrome are also associated with an increased incidence of hernia formation (Table 37-4). Recent studies have found an association between concentrations of extracellular matrix Brunicardi_Ch37_p1599-p1624.indd 160529/01/19 2:03 PM 1606SPECIFIC CONSIDERATIONSPART IITable 37-3Presumed causes of groin herniationCoughingChronic obstructive pulmonary diseaseObesityStraining Constipation ProstatismPregnancyBirthweight <1500 gFamily history of a herniaValsalva’s maneuverAscitesUpright positionCongenital connective tissue


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Surgery_Schwartz. obstructive pulmonary diseaseObesityStraining Constipation ProstatismPregnancyBirthweight <1500 gFamily history of a herniaValsalva’s maneuverAscitesUpright positionCongenital connective tissue disordersDefective collagen synthesisPrevious right lower quadrant incisionArterial aneurysmsCigarette smokingHeavy liftingPhysical exertionFigure 37-10. Varying degrees of closure of the processus vagi-nalis (PV). A. Closed PV. B. Minimally patent PV. C. Moderately patent PV. D. Scrotal hernia.Table 37-4Connective tissue disorders associated with groin herniationOsteogenesis imperfectaCutis laxa (congenital elastolysis)Ehlers-Danlos syndromeHurler-Hunter syndromeMarfan’s syndromeCongenital hip dislocation in childrenPolycystic kidney diseaseα1-Antitrypsin deficiencyWilliams syndromeAndrogen insensitivity syndromeRobinow’s syndromeSerpentine fibula syndromeAlport’s syndromeTel Hashomer camptodactyly syndromeLeriche’s syndromeTesticular feminization syndromeRokitansky-Mayer-Küster


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Surgery_Schwartz. insensitivity syndromeRobinow’s syndromeSerpentine fibula syndromeAlport’s syndromeTel Hashomer camptodactyly syndromeLeriche’s syndromeTesticular feminization syndromeRokitansky-Mayer-Küster syndromeGoldenhar’s syndromeMorris syndromeGerhardt’s syndromeMenkes’ syndromeKawasaki diseasePfannenstiel syndromeBeckwith-Wiedemann syndromeRubinstein-Taybi syndromeAlopecia-photophobia syndromeDIAGNOSISHistoryWorkup for inguinal hernia begins with a detailed history. The most common symptom of inguinal hernia is a groin mass that protrudes while standing, coughing, or straining. It is sometimes described as reducible while lying down. Symptoms that are extrainguinal such as a change in bowel habits or urinary symptoms are far less common but should be recognized as having the potential to be ominous. The pain is thought to be due to compression of the nerves by the sac, causing generalized pressure, localized sharp pain, or referred pain. Referred pain may involve the scrotum, tes-ticle, or


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Surgery_Schwartz. The pain is thought to be due to compression of the nerves by the sac, causing generalized pressure, localized sharp pain, or referred pain. Referred pain may involve the scrotum, tes-ticle, or inner thigh.Important considerations of the patient’s history include the duration and timing of symptoms. Sudden onset symp-toms are more concerning. Questions should also be directed to characterize whether the hernia is reducible. Patients will often reduce the hernia by pushing the contents back into the abdomen, thereby providing temporary relief. As the defect size increases and more intra-abdominal contents fill the hernia sac, the hernia may become harder to reduce and incarcerate, prompting urgent surgical intervention.Certain elements of the review of systems such as chronic constipation, cough, or urinary retention should prompt the sur-geon to perform a thorough workup to rule out any underlying malignancy.elements and hernia formation.20 Although a significant amount of work


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Surgery_Schwartz. cough, or urinary retention should prompt the sur-geon to perform a thorough workup to rule out any underlying malignancy.elements and hernia formation.20 Although a significant amount of work remains to elucidate the biologic nature of hernias, current evidence suggests they have a multifactorial etiology with both environmental and hereditary influences.Brunicardi_Ch37_p1599-p1624.indd 160629/01/19 2:03 PM 1607INGUINAL HERNIASCHAPTER 37Figure 37-11. Digital examination of the inguinal canal.Table 37-5Differential diagnosis of groin herniaMalignancy Lymphoma Retroperitoneal sarcoma Metastasis Testicular tumorPrimary testicular Varicocele Epididymitis Testicular torsion Hydrocele Ectopic testicle Undescended testicleFemoral artery aneurysm or pseudoaneurysmLymph nodeSebaceous cystHidradenitisCyst of the canal of Nuck (female)Saphenous varixPsoas abscessHematomaAscitesPhysical ExaminationPhysical examination is essential to the diagnosis of inguinal hernia. The patient should be


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Surgery_Schwartz. of the canal of Nuck (female)Saphenous varixPsoas abscessHematomaAscitesPhysical ExaminationPhysical examination is essential to the diagnosis of inguinal hernia. The patient should be examined in a standing position to increase intra-abdominal pressure, with the groin and scro-tum fully exposed. Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the scrotum. If an obvious bulge is not detected, palpation is per-formed to confirm the presence of the hernia.Palpation is performed by advancing the index fin-ger through the scrotum towards the external inguinal ring (Fig. 37-11). This allows the inguinal canal to be explored. The patient is then asked to perform a Valsalva maneuver to increase intraabdominal pressure. These maneuvers will reveal an abnor-mal bulge and allow the clinician to determine whether the her-nia is reducible or not. Examination of the contralateral side affords the clinician the opportunity to compare the


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Surgery_Schwartz. will reveal an abnor-mal bulge and allow the clinician to determine whether the her-nia is reducible or not. Examination of the contralateral side affords the clinician the opportunity to compare the presence and extent of herniation between sides. This is especially useful in the case of a small hernia. In addition to inguinal hernia, a number of other diagnoses may be considered in the differential of a groin bulge (Table 37-5).While very difficult to ascertain, there are certain physi-cal examination maneuvers that can be performed to help distinguish direct vs. indirect inguinal hernias. The inguinal occlusion test entails the examiner blocking the internal ingui-nal ring with a finger as the patient is instructed to cough. A controlled impulse suggests an indirect hernia, while persistent herniation suggests a direct hernia. Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an impulse palpated on the dorsum of the finger implies a direct


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Surgery_Schwartz. herniation suggests a direct hernia. Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an impulse palpated on the dorsum of the finger implies a direct hernia. When results of physical examination are com-pared against operative findings, there is a probability some-what higher than chance (i.e., 50%) of correctly diagnosing the type of hernia.21,22External groin anatomy is difficult to assess in obese patients, making the physical diagnosis of inguinal hernia chal-lenging. A further challenge to the physical examination is the identification of a femoral hernia. Femoral hernias should be palpable below the inguinal ligament, lateral to the pubic tubercle. In obese patients, a femoral hernia may be missed or misdiagnosed as a hernia of the inguinal canal. In contrast, a prominent inguinal fat pad in a thin patient, otherwise known as a femoral pseudohernia, may prompt an erroneous diagnosis of femoral hernia.ImagingIn the case of an ambiguous


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Surgery_Schwartz. canal. In contrast, a prominent inguinal fat pad in a thin patient, otherwise known as a femoral pseudohernia, may prompt an erroneous diagnosis of femoral hernia.ImagingIn the case of an ambiguous diagnosis, radiologic investigations may be used as an adjunct to history and physical examination. Imaging in obvious cases is unnecessary. The most common radiologic modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Each technique has certain advantages over physical examination alone; however, each modality is associated with potential limitations.US is the least invasive technique and does not impart any radiation to the patient. Anatomic structures can be more easily identified by the presence of bony landmarks; however, because there are few bones in the inguinal canal, other structures such as the inferior epigastric vessels are used to define groin anatomy. Positive intra-abdominal pressure is used to elicit the herniation of


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Surgery_Schwartz. are few bones in the inguinal canal, other structures such as the inferior epigastric vessels are used to define groin anatomy. Positive intra-abdominal pressure is used to elicit the herniation of abdominal contents. Movement of these contents through the canal is essential to making the diagnosis with US, Brunicardi_Ch37_p1599-p1624.indd 160729/01/19 2:03 PM 1608SPECIFIC CONSIDERATIONSPART IIFigure 37-12. Computed tomography scan depicting a large right inguinal hernia (arrow). A smaller left inguinal hernia is also visualized.and lack of this movement may lead to a false negative. A recent meta-analysis demonstrated that ultrasound detects inguinal hernia with a sensitivity of 86%, specificity of 77%.23 In thin patients, normal movement of the spermatic cord and posterior abdominal wall against the anterior abdominal wall may lead to false-positive diagnoses of hernia.24CT and MRI provide static images that are able to delin-eate groin anatomy, to detect groin hernias, and to


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Surgery_Schwartz. wall against the anterior abdominal wall may lead to false-positive diagnoses of hernia.24CT and MRI provide static images that are able to delin-eate groin anatomy, to detect groin hernias, and to exclude potentially confounding diagnoses (Fig. 37-12). Meta-analysis determined standard CT detects inguinal hernia with a sensitiv-ity of 80%, specificity of 65%. Although direct herniography has a higher sensitivity and specificity than CT, its invasiveness and limited availability restrict its routine use.23 As CT imaging increases in resolution, its sensitivity in detecting inguinal her-nia is expected to expand; however, this has yet to be clinically confirmed by surgical correlation.25MRI is most commonly utilized in cases where physical examination detects a groin bulge, but where ultrasonography is inconclusive. In a 1999 study of 41 patients with clinical find-ings of inguinal hernia, laparoscopy revealed that MRI was an effective diagnostic test with a sensitivity of 95%,


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Surgery_Schwartz. ultrasonography is inconclusive. In a 1999 study of 41 patients with clinical find-ings of inguinal hernia, laparoscopy revealed that MRI was an effective diagnostic test with a sensitivity of 95%, specificity of 96%.26 The expense of MRI precludes its routine use to diag-nose inguinal hernias.TREATMENTSurgical repair of hernias can be performed open, laparoscopic, or with robotic assistance. Surgical repair is the definitive treat-ment of inguinal hernias. The most common reason for elective repair is pain. Incarceration and strangulation are the primary indications for urgent repair. Symptomatic hernias should be operated on electively, and minimally symptomatic or asymptomatic hernias should undergo watchful waiting.27 Repair of minimally symptomatic inguinal hernia in patients with significant medical comorbidities surgery should be deferred and the patient medically optimized. If despite optimal management of comorbidities, the patient remains high-risk, open repair under local


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Surgery_Schwartz. medical comorbidities surgery should be deferred and the patient medically optimized. If despite optimal management of comorbidities, the patient remains high-risk, open repair under local anesthesia can be safely performed.28 Although the natural history of untreated inguinal hernias is 3poorly defined, the rates of incarceration and strangulation are low in the asymptomatic population. As a result, nonoperative management is an appropriate consideration in minimally symp-tomatic patients. Prospective studies and meta-analyses have demonstrated no difference in intention-to-treat outcomes, qual-ity of life, or cost-effectiveness between watchful waiting and elective repair among healthy inguinal hernia patients.27,29 A 2012 systematic review found that 72% of asymptomatic ingui-nal hernia patients developed symptoms and had surgical repair within 7.5 years of diagnosis.30 Nevertheless, the complication rates of immediate and delayed elective repair are equivalent.29,31 A nonoperative


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Surgery_Schwartz. patients developed symptoms and had surgical repair within 7.5 years of diagnosis.30 Nevertheless, the complication rates of immediate and delayed elective repair are equivalent.29,31 A nonoperative strategy is safe for minimally symptomatic inguinal hernia patients.32Nonoperative inguinal hernia treatment targets pain, pres-sure, and protrusion of abdominal contents in the symptomatic patient population. The recumbent position aids in hernia reduc-tion via the effects of gravity and a relaxed abdominal wall. Trusses externally confine hernias to a reduced state and inter-mittently relieve symptoms in up to 65% of patients; however, they do not prevent complications, and they may be associated with an increased rate of incarceration.33 The risks of incarcera-tion and strangulation appear to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of protruding tissue in an


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Surgery_Schwartz. to decrease over the first year, likely because gradual enlargement of the abdominal wall defect facilitates spontaneous reduction of hernia contents. The sheer volume of protruding tissue in an inguinal hernia does not nec-essarily signify severe morbidity.Femoral and symptomatic inguinal hernias carry higher complication risks, and so surgical repair is performed earlier for these patients. Irrespective of symptoms, one study found the 3-month and 2-year cumulative incidences of strangulation were 2.8% and 4.5%, respectively, for inguinal hernias and 22% and 45%, respectively, for femoral hernias.34 Data from the Swedish Hernia Registry demonstrates that emergent operation is associ-ated with a sevenfold increase in all-cause mortality over that of elective surgery among 107,838 groin hernia repairs.35 For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible.Incarceration occurs when hernia contents fail to


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Surgery_Schwartz. hernia repairs.35 For this reason, it is recommended that femoral hernias and symptomatic inguinal hernias be electively repaired, when possible.Incarceration occurs when hernia contents fail to reduce; however, a minimally symptomatic, chronically incarcerated hernia may also be treated nonoperatively. Taxis should be attempted for incarcerated hernias without sequelae of strangulation, and the option of surgical repair should be discussed prior to the maneuver. To perform taxis, analgesics and light sedatives are administered, and the patient is placed in the Trendelenburg position. The hernia sac is elongated with both hands, and while slight countertraction is maintained, reduction of the contents is attempted circumferentially in a small stepwise fashion to ease their reduction into the abdomen.The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangu-lation of hernia contents is a surgical emergency. Clinical signs that


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Surgery_Schwartz. the abdomen.The indication for emergent inguinal hernia repair is impending compromise of intestinal contents. As such, strangu-lation of hernia contents is a surgical emergency. Clinical signs that indicate strangulation include tenderness, fever, leukocy-tosis, and hemodynamic instability. The hernia bulge is usu-ally warm, tender, and the overlying skin is often erythematous or discolored. Symptoms of bowel obstruction in patients with sliding or incarcerated inguinal hernias may also indicate stran-gulation. Taxis should not be performed when strangulation is suspected, as reduction of potentially gangrenous tissue into the abdomen may result in an intra-abdominal catastrophe. Preop-eratively, the patient should receive fluid resuscitation, naso-gastric decompression, and prophylactic intravenous antibiotics.Brunicardi_Ch37_p1599-p1624.indd 160829/01/19 2:03 PM 1609INGUINAL HERNIASCHAPTER 37Prophylactic AntibioticsThe debate as to whether or not to administer preoperative


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Surgery_Schwartz. intravenous antibiotics.Brunicardi_Ch37_p1599-p1624.indd 160829/01/19 2:03 PM 1609INGUINAL HERNIASCHAPTER 37Prophylactic AntibioticsThe debate as to whether or not to administer preoperative prophylactic antibiotics in elective inguinal hernia repair still remains controversial as elective hernia repair is considered a clean procedure and as such are exempt from SCIP surgical prophylaxis guidelines. A Cochrane review of 17 randomized controlled trials in 2012 revealed an overall decrease in infec-tion rates (3.1% vs. 4.5%, odds ratio [OR] 0.64, 95% confi-dence interval [CI] 0.50–0.82) when prophylactic antibiotics are administered in patients. In subgroup analyses, the differ-ence was smaller in patients without mesh placement (3.5% vs. 4.9%, OR 0.71, 95% CI 0.51–1.00) than in those with mesh placement (2.4% vs. 4.2%, OR 0.56, 95% CI 0.38–0.81). However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result,


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Surgery_Schwartz. with mesh placement (2.4% vs. 4.2%, OR 0.56, 95% CI 0.38–0.81). However, with inguinal hernia repair, overall wound infection rates were higher than those expected for clean operations, as a result, they were unable to definitively recommend for or against antimicrobial prophylaxis.36,37 Although there is no uni-versal guideline regarding the administration of prophylactic antibiotics for open elective hernia repair, the routine indexing of cases for quality improvement databases have resulted in the routine administration of prophylactic perioperative antibiotics in inguinal hernia repairs.Open ApproachThe most commonly performed type of hernia operation still remains the open inguinal hernia repair. These repairs can be performed tension-free with mesh or by reconstruction of the floor with tissue. Tissue repairs are less common and are pri-marily indicated in infected fields.Exposure of the anterior inguinal region is common to the open approaches. An oblique or horizontal incision


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Surgery_Schwartz. tissue. Tissue repairs are less common and are pri-marily indicated in infected fields.Exposure of the anterior inguinal region is common to the open approaches. An oblique or horizontal incision is performed over the groin (Fig. 37-13). The incision begins two fingerbreadths inferior and medial to the anterior superior iliac spine. It is then extended medially for approximately 6 to 8 cm. The subcutaneous tissue is dissected using electrocautery. Scarpa’s fascia is divided to expose the external oblique aponeurosis. A small incision is made in the external oblique aponeurosis parallel to the direction of the muscle fibers. Standard groin incisionEx. obliqueSpermatic cordCamper’sfasciaScarpa’sfasciaHemostatExternal ringInguinalfloorSQ fatARepaireddefect intransversalisfasciaDirect herniasacIndirect herniasacIllioinguinal nerveBFigure 37-13. A. Layers of the abdominal wall in the anterior open approach to hernia repair. B. Identification of indirect and direct hernia sacs with


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Surgery_Schwartz. herniasacIndirect herniasacIllioinguinal nerveBFigure 37-13. A. Layers of the abdominal wall in the anterior open approach to hernia repair. B. Identification of indirect and direct hernia sacs with retraction of the spermatic cord and ilioinguinal nerve. Ex. = external; SQ = subcutaneous.Brunicardi_Ch37_p1599-p1624.indd 160929/01/19 2:03 PM 1610SPECIFIC CONSIDERATIONSPART IIFigure 37-14. Anterior open exposure of the inguinal canal. m. = muscle; n. = nerve; v. = vein.Metzenbaum scissors are introduced and spread beneath the fibers to sweep away the underlying ilioinguinal nerve. The scissors are then used to incise the aponeurosis superior to the inguinal ligament, splitting the external inguinal ring.The flaps of the external oblique aponeurosis are elevated with Hemostat clamps. The internal oblique fibers are dissected bluntly from the overlying external oblique flaps. Dissection of the inferior flap reveals the shelving edge of the inguinal ligament. The iliohypogastric and


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Surgery_Schwartz. internal oblique fibers are dissected bluntly from the overlying external oblique flaps. Dissection of the inferior flap reveals the shelving edge of the inguinal ligament. The iliohypogastric and ilioinguinal nerves are iden-tified and preserved. Effort should be made to avoid remov-ing nerves from their natural bed and disrupting the protective investing fascia. The pubic tubercle is identified, and the cord structures are dissected off of the pubis, encircled, and elevated with a Penrose drain. The cord is elevated 2 cm over the pubic symphysis in an avascular plane, and cremasteric fibers are pre-served to avoid injuring cord structures (Fig. 37-14).An indirect hernia sac will generally be found on the antero-medial surface of the spermatic cord after division of the crem-asteric muscle in the direction of its fibers. The genital nerve is visualized along the inferolateral surface of the cord adjacent to the external spermatic vein. The floor of the inguinal canal is fully


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Surgery_Schwartz. muscle in the direction of its fibers. The genital nerve is visualized along the inferolateral surface of the cord adjacent to the external spermatic vein. The floor of the inguinal canal is fully assessed for direct hernias. If a hernia is not visualized upon entry into the inguinal canal, the preperitoneal space should be explored for a femoral hernia. In addition to sac identification, the vas deferens and vessels of the spermatic cord must be identi-fied to allow dissection of the sac from the cord. Blunt dissection facilitates dissection of the sac from the cord. The dissection is carried proximally toward the deep inguinal ring.In cases where the viability of sac contents is in question, the sac should be incised, and hernia contents should be evalu-ated for signs of ischemia. The defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents resected. In elective cases, the sac may be


Surgery_Schwartz

Surgery_Schwartz. defect should be enlarged to augment blood flow to the sac contents. Viable contents may be reduced into the peritoneal cavity, while nonviable contents resected. In elective cases, the sac may be amputated at the internal inguinal ring or inverted into the preperitoneum. Both methods are effective; however, patients undergoing sac exci-sion had significantly increased postoperative pain in a prospec-tive trial.38 Dissection of a densely adherent sac may result in injury to cord structures and should be avoided; however, sac ligation at the internal inguinal ring is necessary in these cases. A hernia sac that extends into the scrotum may require division within the inguinal canal as extensive dissection and reduction risks injury to the testicular blood supply, resulting in testicular swelling, orchitis, and atrophy.At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of


Surgery_Schwartz

Surgery_Schwartz. swelling, orchitis, and atrophy.At this point, the inguinal canal is reconstructed, either with native tissue or with prostheses. The following sections describe the most commonly performed types of tissue-based and prosthetic-based reconstructions.Tissue Repairs. Tissue-based herniorrhaphy is a suitable alter-native when prosthetic materials cannot be used safely. Indica-tions for tissue repairs include operative field contamination, emergency surgery, and when the viability of hernia contents is uncertain.Bassini Repair The Bassini repair was a historic advancement in operative technique. Its current use is limited as modern tech-niques reduce recurrence. The original repair includes dissection of the spermatic cord, dissection of the hernia sac with high liga-tion, and extensive reconstruction of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal


Surgery_Schwartz

Surgery_Schwartz. of the floor of the inguinal canal (Fig. 37-15). After exposing the inguinal floor, the transversalis fascia is incised from the pubic tubercle to the internal inguinal ring. Preperitoneal fat is bluntly dissected from the upper margin of the posterior side of the transversalis fascia to permit adequate tissue mobilization. A triple-layer repair is then performed. The internal oblique, transversus abdominis, and transversalis fascia are fixed to the shelving edge of the inguinal ligament and pubic periosteum with interrupted sutures. The lateral aspect of the repair reinforces the medial border of the internal inguinal ring.Shouldice Repair The Shouldice repair recapitulates principles of the Bassini repair, and its distribution of tension over several tissue layers results in lower recurrence rates (Fig. 37-16). Dur-ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the


Surgery_Schwartz

Surgery_Schwartz. rates (Fig. 37-16). Dur-ing dissection of the cord, the genital branch of the genitofemoral nerve is routinely divided, resulting in ipsilateral loss of sensation to the scrotum in men or the mons pubis and labium majus in women. With the posterior inguinal floor exposed, an incision in the transversalis fascia is made between the pubic tubercle and internal ring. Care is taken to avoid injury to preperitoneal struc-tures, which are bluntly dissected to mobilize the upper and lower fascial flaps. At the pubic tubercle, the iliopubic tract is sutured to the lateral edge of the rectus sheath using a synthetic, nonab-sorbable, monofilament suture. This continuous suture progresses laterally, approximating the edge of the inferior transversalis flap to the posterior aspect of the superior flap. At the internal inguinal ring, the suture continues back in the medial direction, approxi-mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At


Surgery_Schwartz

Surgery_Schwartz. At the internal inguinal ring, the suture continues back in the medial direction, approxi-mating the edge of the superior transversalis fascia flap to the shelving edge of the inguinal ligament. At the pubic tubercle, this suture is tied to the tail of the original stitch. The next suture begins at the internal inguinal ring, and it continues medially, apposing the aponeuroses of the internal oblique and transversus abdominis to the external oblique aponeurotic fibers. At the pubic tubercle, the suture doubles back through the same structures lat-erally towards the tightened internal ring.McVay Repair The McVay repair addresses both inguinal and femoral ring defects. This technique is indicated for femoral hernias and in cases where the use of prosthetic material is contraindicated (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of


Surgery_Schwartz

Surgery_Schwartz. (Fig. 37-17). Once the spermatic cord has been isolated, an incision in the transversalis fascia permits entry into the preperitoneal space. The upper flap is mobilized by gentle blunt dissection of underlying tissue. Cooper’s ligament is bluntly dissected to expose its surface. A 2 to 4 cm relaxing incision is made in the anterior rectus sheath vertically from the Brunicardi_Ch37_p1599-p1624.indd 161029/01/19 2:03 PM 1611INGUINAL HERNIASCHAPTER 37SpermaticcordPoupart'sligament Internal abdominaloblique muscleExternal abdominaloblique aponeurosisPreperitoneal fatTransversalis fasciaABEOTATFILIOFigure 37-15. Bassini repair. A. The transversalis fascia is opened. B. Reconstruction of the posterior wall by suturing the transver-salis fascia (TF), the transversus abdominis muscle (TA), and the internal oblique muscle (IO) medially to the inguinal ligament (IL) laterally. EO = external oblique aponeurosis.ABFigure 37-16. Shouldice repair. A. The iliopubic tract is sutured to the


Surgery_Schwartz

Surgery_Schwartz. and the internal oblique muscle (IO) medially to the inguinal ligament (IL) laterally. EO = external oblique aponeurosis.ABFigure 37-16. Shouldice repair. A. The iliopubic tract is sutured to the medial flap of the transversalis fascia and the internal oblique and transverse abdominis muscles. B. The second of the four suture lines, reversing toward the pubic tubercle approximating the inter-nal oblique and transversus muscles to the inguinal ligament. Two more suture lines affix the internal oblique and transversus muscles medially.Cooper’s ligamentFigure 37-17. McVay Cooper’s ligament repair.pubic tubercle. This incision is essential to reduce tension on the repair; however, it may result in increased postoperative pain and higher risk of ventral abdominal herniation. Using either interrupted or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin-ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral


Surgery_Schwartz

Surgery_Schwartz. or continuous suture, the superior transversalis flap is then fastened to Cooper’s ligament, and the repair is contin-ued laterally along Cooper’s ligament to occlude the femoral ring. Lateral to the femoral ring, a transition stitch is placed, affixing the transversalis fascia to the inguinal ligament. The transversalis is then sutured to the inguinal ligament laterally to the internal ring.Desarda Repair The Desarda hernia repair was recently described in 2001, and it consists of a mesh-free repair utilizing a strip of external oblique aponeurosis.An oblique skin incision is made, and dissection is carried down to the external oblique fascia. The integrity of the fascia is preserved as much as possible. The cremasteric muscle is then incised, and the spermatic cord along with the cremasteric muscle is separated from the inguinal floor. Excision of the sac is done in all cases except in small direct hernias, where it is inverted.The medial leaf of the external oblique aponeurosis is


Surgery_Schwartz

Surgery_Schwartz. muscle is separated from the inguinal floor. Excision of the sac is done in all cases except in small direct hernias, where it is inverted.The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament from the pubic tubercle to the abdominal ring using 1–0 Ethilon or Prolene interrupted sutures. The first two sutures are taken at the junction of the anterior rec-tus sheath and EOA. The last suture is taken so as to sufficiently Brunicardi_Ch37_p1599-p1624.indd 161129/01/19 2:03 PM 1612SPECIFIC CONSIDERATIONSPART IInarrow the abdominal ring without constricting the spermatic cord (Fig. 37-18). Each suture is passed first through the ingui-nal ligament, then the transversalis fascia, and then the EOA. The index finger of the left hand is used to protect the femo-ral vessels and retract the cord structures laterally while taking lateral sutures. A splitting incision is then taken in the EOA, partially separating a strip. This splitting incision is extended