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Inguinal Repair Methods
Our Surgeons
Monday, 3 September 2012
New Photo of our Surgical Faculty
Topic: Our Surgeons

Posted by hernia at 1:48 PM ADT
Post Comment | View Comments (1) | Permalink
Sunday, 15 January 2006



This is a sketch of the hernia-vulnerable area of the Right groin (the egg-shaped region near the center of the drawing), and is called the Myopectineal Orifice of Fruchaud(MPO). Note specifically that the MPO is neither fully nor efficiently covered or reinforced by muscle layers, but is simply a layer of non-muscular Connective Tissue called "Transversalis Fascia", which consists of two thin, adherent semi-layers. The MPO is bordered above by the arching fibers of the internal oblique and transversus abdominus muscles. Medially (towards the center or to the right) by the Rectus Abdominus muscle, Inferiorly by Coopers Ligament and Laterally by the Ileopsoas Muscle. The structure running through the center of the MPO, from end to end, is the Inguinal Ligament, and it runs from the anterior-superior iliac spine (on the left of the photo) to the pubic tubercle.
The oval structure in the upper half of the MPO represents the Internal Inguinal Ring.
It is through this internal ring that the structures of the spermatic cord (vas defrens and vessels) penetrate the abdominal wall, coursing downward and centrally through the inguinal canal towards the scrotum. It is also through this internal ring that an Indirect Inguinal Hernia will protrude, widening the ring as it progressively enlarges. To the right of (medial to) the internal ring, is the area of the MPO known as the Medial Triangle (AKA, Direct Space, Hesselbach's Triangle, Hessert's Triangle and Floor of the Inguinal Canal). This is the location through which a "Direct Hernia" develops. Below the Inguinal Ligament lies the portion of the MPO called the Femoral Triangle. On the right side of this area are the two vessels (Femoral artery to your left and Femoral Vein on the right, or the most medially of the two vessels) which are majorly repsonsible for the blood supply to and from the leg. To the left of these vessels (towards the pubic tubercle) lies the Femoral Canal, a thinned and weakend area of Transcersalis Fascia through which Femoral Hernias develop (more common in females because due to the pelvic shape, this area is larger in females than in males). This entire MPO is vulnerable to the development of hernias, partially because of
  • The normal congenital/anatomic gaps that occur in it (i.e., Internal Ring)
  • Significantly because it is not reinforced by adequate muscle layers as is the remainder of the abdominal wall, and
  • Probably in many patients because of an underlying Connective Tissue Disorder (let's call it "Herniosis") which makes the non-reinforced Transversalis Fascia weaker and less able to resist the repetitive intra-abdominal pressure stresses placed upon it leading to progressive bulging, weakness and hernia formation.
Thus an Inguinal "Hernia" is really a Pathologic Hole or Defect within the Transversalis Fascia, that occurs specifically within the area of a poorly reinforced and therefore hernia prone anatomic hole, which is called the MYOPECTINEAL ORIFICE.
> Now lets think of the MPO like a 'frozen lake' (photo at left) at the center of which is a puddle (or Hole)in the ice. Think of a hernia as a 'Hole' in the ice on a frozen lake. Many surgeons' concept of a hernia is simply this, a HOLE in the abdominal wall that must be addressed (i.e., plug it up or sew it closed and that's that!!). But look closely at the Photo. The Puddle, or "Hole", is surrounded by an area of "THIN ICE". So too, a hernia, be it direct or indirect or even femoral, cannot be considered simply as the visable hole. It is always surrounded by an area of weakened, thinned-out, clinically significant and more likely hernia-prone fascia: This is the entire Transversalis Fascia of the MPO.
It is not only the "HOLE" that must be repaired, but the "WHOLE area.
In order to effectively repair an Inguinal Hernia, we strongly believe that this entire area the MPO, MUST also be reinforced. If you only address the HOLE, the surrounding area will be subjected to a 'Pressure Imbalance' whereby normal and at times increased intra-abdominal pressure, now buttressed at the 'hole' will exert a deleterious effect on the surrounding Transversalis Fascia elsewhere in the MPO. Most recurrent hernias are not at the site of the initial repair, but rather adjacent to it, on the THIN ICE area of the weakened and ineffectively reinforced MPO. Physiologically, the best place to reinforce the MPO is behind the Transversalis Fascia where it will lie securely between tissue layers (between the peritoneum and the under-surface of the Transversalis Fascia), being secured by tissue pressure on each side (like a leaf pressed within the pages of a book). It is like the difference between patching a flat tire with a patch on the inside of the tire (i.e., under the Transversalis Fascia), or just placing the patch on the outside of the tire and driving off down the road. Placing simply an overlay mesh, oten too small to fully cover the MPO anyway, (with or without a plug in the hole) risks intra-abdominal pressure lifting the mesh up and off of the MPO as the weakened Transversalis Fascia continues to weaken, resulting in a recurrent hernia.

Posted by hernia at 2:38 PM MNT
Tuesday, 16 November 2004
An article in the New England Journal of Medicine, Volume 343:392-398 August 10, 2000 Number 6 (Abstract, Full Article) concluded that in "patients with midline abdominal incisional hernias, Mesh Repair is superior to suture repair with regard to the recurrence of hernia, regardless of the size of the hernia".

Among the 154 patients with primary hernias and the 27 patients with first-time recurrent hernias who were eligible for the study, 56 had recurrences during the follow-up period. The three-year cumulative rates of recurrence among patients who had suture repair and those who had mesh repair were 43 percent and 24 percent, respectively, with repair of a primary hernia (P=0.02; difference, 19 percentage points; 95 percent confidence interval, 3 to 35 percentage points). The recurrence rates were 58 percent and 20 percent with repair of a first recurrence of hernia (P=0.10; difference, 38 percentage points; 95 percent confidence interval, -1 to 78 percentage points). The risk factors for recurrence were suture repair, infection, prostatism (in men), and previous surgery for abdominal aortic aneurysm. The size of the hernia did not affect the rate of recurrence.
James A. Goodyear, MD

Saturday, 13 November 2004
Open vs Laparoscopic Inguinal Hernia Repairs-Comparison
Topic: Inguinal Repair Methods
An article in the New England Journal of Medicine (April 2004) concluded that the open method of repair was superior to the laparoscopic method for the repair of primary inguinal hernias. [FULL ARTICLE]
Via Reuters: Findings from a new report suggest that hernia recurrence is more likely following laparoscopic repair than more traditional "open" repair. Lead author Dr. Leigh Neumayer of the VA Medical Center in Salt Lake City, Utah said "Right now, we're trying to tease out why recurrence rates were higher with laparoscopic repair. I think part of it is that it's just a harder procedure to learn and it takes a lot of experience to get good at it." The rate of immediate postoperative complications was higher in the laparoscopic group, at 24.6 percent, compared with rate in the open group, at 19.4 percent. Although rare, complications during surgery and life-threatening complications were also more frequent in the laparoscopic group. In contrast, the rate of long-term complications was similar in each group. Pain immediately following surgery and two weeks later was lower in the laparoscopic group, but this only hastened the return to normal activities by one day. Over 10 years ago, the surgeons at the North Penn Hernia Institute abandoned the laparoscopic method of repair feeling that not only were the results less effective thant an open approach, but perhpas more significantly, the complication rates, both minor and severe, were far higher as well. James A. Goodyear, MD

Posted by hernia at 4:05 PM MNT
Updated: Sunday, 14 November 2004 12:58 PM MNT
Friday, 12 November 2004
WELCOME to the North Penn Hernia Institue Blog. This Blog will cover all aspects of hernias and hernia surgery and will list recent and advances in Hernia Surgery, as well as offer responsible guests an opportunity to post entries reguarding questions or concerns. Enjoy

James A. Goodyear, MD

Posted by hernia at 2:28 PM MNT
Updated: Thursday, 18 November 2004 12:50 PM MNT

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