What are the different types of hernias requiring open surgical repair?

Updated: Apr 16, 2020
  • Author: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS; Chief Editor: Kurt E Roberts, MD  more...
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Answer

An indirect hernia is defined as a defect protruding through the internal or deep inguinal ring, whereas a direct hernia is a defect protruding through the posterior wall of the inguinal canal. To put it in a more anatomic way, an indirect hernia is lateral to the inferior epigastric artery and vein, whereas a direct hernia is medial to these vessels. The Hesselbach triangle is the zone of the inguinal floor through which direct hernias protrude, and its boundaries are the epigastric vessels laterally, the rectus sheath medially, and the inguinal ligament inferiorly. [8]

An incomplete hernia is confined to the inguinal canal, whereas a complete hernia comes out of the inguinal canal through the external or superficial ring into the scrotum. Direct hernias are always incomplete, whereas indirect hernias can also be complete.

A sliding inguinal hernia is one in which a portion of the wall of the hernia sac is made up of an intra-abdominal organ. As the peritoneum is stretched and pushed through the hernia defect and becomes the hernia sac, retroperitoneal structures such as the colon or bladder are dragged along with it and thus come to make up one of its walls.

Bilateral pediatric hernias are most commonly indirect hernias and arise because of the patency of the processus vaginalis. Simple ligation of the hernia sac (herniotomy) alone is enough. Surgical treatment of indirect hernias in adults, unlike that in children, requires more than simple ligation of the hernia sac. This is because the patent processus is only part of the story. With time, the internal ring dilates, leaving an adult with what can be a sizable defect in the floor of the inguinal canal; this must be closed in addition to division or reduction of the indirect hernia sac.

A hydrocele is a commonly encountered pathology related to hernias. A communicating hydrocele is, by definition, a form of indirect hernia, albeit with an extremely small defect through which only peritoneal fluid enters the sac but no viscus (eg, omentum or bowel) comes out.


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