Surg Clin North Am. Dec;78(6) Inguinal hernia repair. The Nyhus posterior preperitoneal operation. Patiño JF(1), García-Herreros LG, Zundel N. A hernia is an outpouching of the parietal peritoneum through a preformed or secondarily established hiatus. If the hernia Table Ib. Nyhus hernia classification. Adapted with permission from Nyhus LM, Klein MS, Rogers FB. Inguinal hernia. Curr Probl Surg ;

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Joachim ConzeUwe Klingeand V. A hernia is an outpouching of the parietal peritoneum through a preformed or secondarily established hiatus. If the hernia extends beyond the abdominal cavity and is thus visible on the surface of the body, it is defined as an hefnia hernia. If the outpouching is limited to peritoneal pockets, it is known as an internal hernia.

An intermediate position is taken by the interparietal hernias of the abdominal wall. Hernias may include intra- and retroperitoneal organs, either permanently or intermittently.

Hernias – Surgical Treatment – NCBI Bookshelf

Depending on the size of the outpouching, we speak of complete total or incomplete partial hernias. Based on their formation, we distinguish between congenital e. The first description of an inguinal hernia appears in the Ebers papyrus B. The first anatomical studies of the inguinal region date back ynhus Galen — A.

Nyhhs the historical precursors of inguinal hernia management by barbers, rupture cutters, and bathing masters, the real history of inguinal hernia surgery begins at the end of the nineteenth century.

The first attempts to reduce the hernial orifice were made by MarcySteeleand Czerny It was Bassini in who introduced and established tactical surgical principles with excellent results by repairing the posterior wall of the inguinal canal and reducing of the hsrnia inguinal ring. It was only in the middle of the twentieth century that Bassini’s concept was improved by Shouldice and McVay and Ansonshowing the importance of the fascia transversalis. The use of fascia grafts to close large hernial orifices and recurrent hernias dates back to HalstedKirschnerRehnand Koontz The use of alloplastic material was introduced by Stock and Usher Preperitoneal mesh-implantation was first described by Rives for unilateral hernias and by Stoppa for bilateral inguinal hernias.

Nyhus and Condon’s Hernia, 5th Edition

Init was Lichtenstein who advocated and used mesh to bolster the repair of both direct and recurrent hernias. The first laparoscopic hernia repair was performed by Gerby simply closing the peritoneal opening with staples without dissection, ligation, or reduction of the sac.

Init was Bogojavalensky to revived this procedure by introducing the mesh-plug technique. The first series of hernnia herniorrhaphies were published by Schultz in Since that time, three laparoscopic procedures have been established: The pathogenesis of hernias is multifactorial.

Congenital hernias are preformed hernial openings caused by incomplete closure of the abdominal wall e. The develop typically in locations where larger blood vessels or the spermatic cord lie, or where previous nyhud were made.

Different etiological factors, such as increased intra-abdominal pressure in pregnancy, intra-abdominal tumors, chronic obstructive lung disease, ascites, chronic intestinal obstruction, and adiposityor pathological changes in connective tissue of the abdominal wall, are blamed, without conclusive significance. New material for understanding the pathogenetics has been provided by recent studies on collagen metabolism disorder, in which an increase of collagen III war proven in patients with hernia.

With overinguinal hernia operations per year in the USA, inguinal hernia repair is the most common operation for general surgeons 6. History, local examination ehrnia inspection and palpation of the hernial opening, auscultation, and diaphanoscopy are employed for hernia diagnosis.

In case of uncertain clinical findings, sonography is the best means for confirming the hernial opening and content. Radiographic diagnosis of hernias is rarely required. Until now, a general classification system that includes all kinds of hernias is not available. To what extent a hernia represents a disease entity rarely depends on the fact of the hernia itself, but rather on the fate of hernial contents.


Giant hernias may cause significant bodily discomfort by weight alone; Nhhus may cause complaints from restriction of physical activity develop surface ulceration, or be herniia on aesthetic and cosmetic grounds alone. But changes in the contents lead more commonly to the hernia’s becoming a true disease entity. Since the first Bassini procedure at the end of the last century, many different operative techniques have been introduced, most recently laparoscopic procedures.

At present, two different major principles of repair are established: Nyyus can be performed using an open approach or laparoscopically with an anterior or posterior approach. Today, there is a great variety of surgical procedures available for the repair of inguinal hernia.

Each procedures has its own advantages and complications. As an open anterior procedure, the Shouldice repair with local anesthesia is the standard mesh-free procedure for uncomplicated primary, unilateral hernias.

Variations in the laparoscopic approach to the preperitoneal space and differences in dissection and fixation techniques reflect that the procedure is still evolving, and there is still no consensus on the best laparoscopic herniorrhaphy. Besides the routine use of general anesthesia and procedure-related increased costs, the cumulating long-term mesh complications as shrinkage, erosion of neighboring structures such as blood vessels, spermatic cord, or bladder, adhesion- and fistula-formation, and a possible reduction of the abdominal wall mobility, make final evaluation of these surgical procedures impossible for the time being.

All tension-free hernia repair techniques with mesh have shown excellent results without statistical proof of the superiority of any single method. But, aside from low recurrence rates, long-term consequences of the mesh-related risks, such as mesh migration, and persistent chronic inflammation at the interface still remain open. Further long follow-up as well as larger studies comparing the results of open and laparoscopic repairs are needed 48.

Hernias occur five times more often in boys than in girls. This persistence does not imply the presence of a hernia, but means simply a potential for hernia formation.

The main management procedure is nynus ligation of the hernial sac. In girls, the hernial sac should be sutured under nyuhs obliquus internus muscle for fixation of the rotundum ligament. Five to seven percent of all hernias are femoral hernias. Here, the herniation passes under the inguinal ligament through the lacuna vasorum medially of the v.

Management involves operative therapy by crural, inguinal, or preperitoneal approach for direct fixation of the inguinal ligament to heria fascia pectinea of the pubic bone. Of late, reinforcement with mesh is advised. This type of hernia presents herniation into preformed defects of the linea alba between xiphoid and umbilicus. First description was made by Arnaud de Villeneuve inbut it was not until that the term epigastric hernia was introduced by Leveille.

Usually, the hernia sac content is preperitoneal fatty tissue. There is a male predominance with a male to female ration of at least 3: Defects of the fascia may vary in diameter from several centimeters to only a few millimeters. The larger ones usually readily reducible, whereas the smaller ones often became in-carcerated.

Vague upper abdominal pain and nausea associated with epigastric henia may be present. Incarceration is common, especially in smaller hernias, but strangulation is unusual. Operative management heernia at reposition of the hernia sac contents and direct closure of the hernial opening with a continuous suture.

Surgical Options in the Management of Groin Hernias – – American Family Physician

Due to high recurrence rates, tension-free hernia repair with mesh is becoming more common. The umbilicus is a natural hernial opening in the abdominal wall.


It can develop a hernia at any age. In children, umbilical hernias are the third most common disorder after hydroceles and inguinal hernias. The hernia is present in about one to every five birth, the incidence in black infants being up to eight hdrnia higher than in white infants.

Predisposing factors are a low birth weight and prematurity. In children most umbilical hernias are asymptomatic beside the obvious cosmetic defect. The spontaneous resolution appears nyhsu be directly influenced by the size of the umbilical ring. Defects with an umbilical ring larger than 1.

Indication for surgical repair are occurrence of complaints and complications or a persistence of the hernia beyond the age of 2 years. If the fascial defect is less then 1. Umbilical hernla in adults are indirect herniations through the umbilical canal, and there have a high tendency to incarce-rate and strangulate and do not resolve spontaneously.

Most of these patients are women. Management includes operative therapy with repositioning of the hernial content and continuous suture, using local anesthesia in elective repair in adults or general anesthesia in herhia or in an emergency situation.

An exception are acquired umbilical hernias, that may occur in patients with acute abdominal distension. Reasons nyhhus an acute elevation of the intra-abdominal njhus include ascites from cirrhosis, nyhs heart failure or nephrosis. Patients undergoing peritoneal dialysis also have a high incidence of these hernias. As the majority of these patients have serious underlying problems, a surgical repair is not indicated unless complications, such as incarceration or spontaneous rupture, occur.

Hernias of the linea semilunaris occur usually at the intersection with the linea semicircularis arcuata. They are always acquired, occurring between the fourth and seventh decade, with a female to male ratio of 4: The symptoms vary considerably, including abdominal pain, a mass in the anterior abdominal wall or signs of incarceration with or without intestinal obstruction.

Today there are approximately cases are reported in the literature. The therapy is always surgical. Obturator hernias are internal herniations through the obturator foramen, bordered by the obturator vessels and nerve. It was first described by Roland Arnaud de Ronsil in They are acquired, occurring predominantly in females female to male ratio of 6: Typical symptoms are intestinal obstruction and the Henria sign pain extending down the inner surface of a thigh to the knee relieved by flexion of the thigh and a history of previous attacks.

When they case symptoms, they are almost always incarcerated, usually on the right side and often combined with a femoral hernial. Management includes a transperitoneal or preperitoneal approach and hernia orifice closure with direct suture or mesh. Perineal hernias are primary or secondary herniations of the pelvic floor that appear para- or retrorectally between the levator hetnia and coccygeal muscles.

Primary hernias occur mostly in females, secondary hernias nhhus both females and males and rarely with an incarceration. Management includes transperitoneal or combined abdominal and perineal approaches and direct suture or mesh. Hernia lumbalis presents abdominal wall or retroperitoneal outpouchings between the 12th rib and the iliac crest.

The hernial orifice is in the muscles of the lumbar area. They present with a flank protrusion, that rarely results in a strangulation, but increases in herjia and therefore should undergo surgical repair at the time of discovery.

Today there are less than herina described in the literature worldwide.