37

Inguinal Hernias
Chandan Das, Tahir Jamil, Stephen Stanek,
chapter Ziya Baghmanli, James R. Macho, Joseph Sferra,
and F. Charles Brunicardi

Introduction 1599 Treatment 1608 Complications 1618

History / 1599 Prophylactic Antibiotics / 1609 Hernia Recurrence / 1618
Anatomy / 1600 Open Approach / 1609 Pain / 1619
Pathophysiology / 1604 Laparoscopic Approach / 1613 Cord and Testes Injury / 1620
Diagnosis 1606 Robot-Assisted Inguinal Hernia Laparoscopic Complications / 1620
History / 1606 Repair / 1616 Hematomas and Seromas / 1621
Physical Examination / 1607 Prosthesis Considerations / 1616 Outcomes 1621
Imaging / 1607

INTRODUCTION performed without aseptic technique, and infection and recur-

rence rates were high.
Inguinal herniorrhaphy is one of the most commonly performed
From the late 1700s to the early 1800s, physicians including
operations in the United States.1 Based on estimates made by
Hesselbach, Cooper, Camper, Scarpa, Richter, and Gimbernat
the National Center for Health Statistics, in 2010 nearly 515,000
identified vital components of the inguinal region from cadaveric
inguinal hernia operations were performed in hospitals, and
dissection. This improved understanding of the anatomy and
an additional 450,000 were performed in ambulatory surgery
pathophysiology of inguinal hernias. These findings, coupled
centers.1
with the development of aseptic technique, led surgeons such
Approximately 75% of abdominal wall hernias occur in
as Marcy, Kocher, and Lucas-Championnière to perform sac
the groin. Of inguinal hernia repairs, 90% are performed in
dissection, high ligation, and closure of the internal ring. This
men, and 10% are performed in women. This is thought to be
led to improved outcomes, but recurrence rates remained
because the lifetime risk of inguinal hernia is 27% in men and
unacceptably high.
3% in women.2 The incidence of inguinal hernia in men has a
At around this time, Bassini (1844–1924) pioneered a new
bimodal distribution, with peaks before the first year of age and
method that transformed inguinal hernia repair into a success-
after age 40. Abramson demonstrated the age-dependence of
ful venture with minimal morbidity. The success of the Bassini
inguinal hernias in 1978. Those age 25 to 34 years had a life-
repair over its predecessors ushered in an era of tissue-based
time prevalence rate of 15%, whereas those age 75 years and
repairs. The Bassini repair was then modified into the McVay
over had a rate of 47% (Table 37-1).3 Approximately 70% of
and Shouldice repairs. All three of these techniques, as well as
femoral hernia repairs are performed in women; however, the
modern variations such as the Desarda operation, are currently
most common subtype of groin hernia in men and women is still
practiced.6
the indirect inguinal hernia. Inguinal hernias are five times more
The next major advancement in inguinal hernia repair was
common than femoral hernias.4
in the 1980s. At this time, Lichtenstein applied a piece of mesh
Globally, the inguinal hernia repair has become one of
to the floor of the inguinal canal, allowing for a truly tension-free
the most important procedures in improving quality of life and
repair. This technique demonstrated superior outcomes compared
preventing disability. In one study, an international coopera-
to previous tissue-based repairs. There were several other
tive organization performed over 1033 hernia repairs on 926
advantages of this process. In addition to being truly tension-free,
patients, and their impact was measured in disability adjusted
the mesh could restore the strength of the transversalis fascia,
life years (DALYs). They were able to avoid 5014 DALYs or
and importantly, the technique had a very short learning curve.
5.41 DALYs per patient.5
The superior outcomes have been widely reproduced regardless
History of hernia size and type, and they were achievable among both
Surgical repair of hernias has been documented as far back as in expert and nonexpert hernia surgeons.7
ancient Egyptian and Greek civilizations.4 In the past, early With the advent of minimally invasive surgery, inguinal
management of inguinal hernias often involved a conservative hernia repair underwent its most recent transformation. Laparo-
approach with operative management reserved only for compli- scopic inguinal hernia repair offers an alternative approach,
cations. Surgery often involved routine excision of the testicle, minimizes postoperative pain,8 and improves recovery. Since the
initial description by Ger, the laparoscopic method has become
1 and wounds were closed with cauterization or allowed to
close by secondary intention. These procedures were more sophisticated. Refinements in approach and technique have
 Key Points
1 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 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.
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 on a
2 sound grasp of inguinal anatomy.
Anatomy
The inguinal canal is an approximately 4- to 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 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 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
Table 37-1
Inguinal hernia prevalence by age
AGE (Y) 25–34 35–44
Current prevalence (%) 12 15
Lifetime prevalence (%) 15 19
1600 Current = repaired hernias excluded; lifetime = repaired hernias included.
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.
tubercle. 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
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
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
anterior laminae of the transversalis fascia, and it houses the
45–54 55–64 65–74 75+
20 26 29 34
28 34 40 47
 1601

Medial leaf

Abdominal ring
Interrupted
sutures taken to
suture the medial

CHAPTER 37 INGUINAL HERNIAS

leaf to the inguinal
ligament
Lateral leaf

Pubic tubercle

Spermatic cord

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 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

Reflected
medial leaf after
a strip has been
separated
Internal oblique
muscle seen
through the splitting
Abdominal ring incision made in the
medial leaf

Interrupted Interrupted sutures

sutures taken between the upper
to suture the border of the strip
medial leaf to and conjoined
the inguinal muscle and internal
ligament oblique muscle

Pubic tubercle
Spermatic cord
Lateral leaf

Figure 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.
1602 Table 37-2 A

Nyhus classification system

Type I Indirect hernia; internal abdominal ring normal; D
typically in infants, children, small adults C
B
Type II Indirect hernia; internal ring enlarged without
impingement on the floor of the inguinal
canal; does not extend to the scrotum E

Type IIIA Direct hernia; size is not taken into account F

A - Umbilicus G
Type IIIB Indirect hernia that has enlarged enough to B - Median umbilical ligament
encroach upon the posterior inguinal wall; (urachus)
PART II

indirect sliding or scrotal hernias are usually C - Medial umbilical ligament Bladder
(obliterated umbilical vein)
placed in this category because they are D - Lateral umbilical ligament
commonly associated with extension to the (inferior epigastric vessels)
direct space; also includes pantaloon hernias E - Lateral fossa (indirect hernia)
F - Medial fossa (direct hernia)
SPECIFIC CONSIDERATIONS

Type IIIC Femoral hernia

Type IV Recurrent hernia; modifiers A–D are sometimes
added, which correspond to indirect, direct,
femoral, and mixed, respectively
superior 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, 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
G - Supravesical fossa
Figure 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.)
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

Linea alba Umbilicus

Arcuate line
Rectus muscle
Inferior epigastric vessels

Transversus Superior
abdominis anterior
muscle crus
arch

Direct
hernia site
Spermatic cord
Indirect
hernia site
Femoral canal
Iliopubic
tract
Pubic tubercle Spermatic
Deep vessels
inguinal
ring Cooper’s ligament

External iliac
Obturator vessels
vessels

Figure 37-3. Anatomy of the groin region from the posterior perspective.
 Epigastric vessels 1603

Myopectineal
orifice

CHAPTER 37 INGUINAL HERNIAS

Iliopubic
tract

Iliopsoas muscle
Cooper's ligament
Internal spermatic
Lacunar ligament vessels
External iliac a. and v.
Obturator vessels
Obturator n. Vas deferens

Figure 37-5. Posterior view of the myopectineal orifice of Fruchaud. a. = artery; n. = nerve; v. = vein.

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 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.

Iliohypogastric n.
Ilioinguinal n.

Iliac m.

Lateral femoral
cutaneous n.
Genitofemoral n.

(femoral branch)
Femoral n.
(genital branch)
Inguinal ligament Iliopectinal arch

Pectineal ligament
Iliopubic tract

Lacunar ligament

Figure 37-6. Retroperitoneal view of major inguinal nerves and their courses. m. = muscle; n. = nerve.
1604
PART II
SPECIFIC CONSIDERATIONS

Figure 37-7. Anterior view of the five major nerves of the inguinal region.

Pathophysiology
Inguinal 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-
Iliohypogastric n. ever, there are several other risk-factors that have been studied
Femoral branch of (Table 37-3). Congenital hernias, which make up the majority
genitofemoral n. Genital branch of of pediatric hernias, can be considered a developmental defect
genitofemoral n. rather than an acquired weakness. During the normal course of
Ilioinguinal n.
development, the testes descend from the intra-abdominal space
Lateral femoral into the scrotum in the third trimester. Their descent is guided
cutaneous n.
by the gubernaculum through an evagination of the peritoneum,
Medial and intermediate which protrudes through the inguinal canal and becomes the
femoral cutaneous nn.
processus vaginalis. Between 36 and 40 weeks’ gestation, the
Saphenous n. 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.15
Overall, there is limited data regarding the etiology of
inguinal hernia development. Several studies have documented
strenuous physical activity as a risk factor for acquired
Figure 37-8. Sensory dermatomes of the major nerves in the groin inguinal hernia.16 A case-controlled study of over 1400 male
area. n. = nerve. patients with inguinal hernia revealed that a positive family
history was associated with an eightfold lifetime incidence of
 1605
Deep ring

Medial border: Lateral border:

ductus deferens gonadal vessels

CHAPTER 37 INGUINAL HERNIAS

Iliac artery
Genital branch of
genitofemoral nerve

Iliac vein

A
Posterior border:
peritoneal edge

Inferolateral border:
Deep circumflex iliopubic tract
iliac a. & v.

Lateral border:
reflected
peritoneum

Lat. femoral cutaneous n.

Ant. femoral cutaneous n. or

other variable branches
Femoral br. of genitofemoral n.
Superomedial border:
gonadal vessels

B Femoral n.
Figure 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 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.18
Epidemiologic 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
1606 Table 37-3 Table 37-4
Presumed causes of groin herniation Connective tissue disorders associated with groin
Coughing herniation
Chronic obstructive pulmonary disease Osteogenesis imperfecta
Obesity Cutis laxa (congenital elastolysis)
Straining Ehlers-Danlos syndrome
Constipation Hurler-Hunter syndrome
Prostatism Marfan’s syndrome
Pregnancy Congenital hip dislocation in children
Birthweight <1500 g Polycystic kidney disease
PART II

Family history of a hernia α1-Antitrypsin deficiency

Valsalva’s maneuver Williams syndrome
Ascites Androgen insensitivity syndrome
Upright position Robinow’s syndrome
SPECIFIC CONSIDERATIONS

Congenital connective tissue disorders Serpentine fibula syndrome

Defective collagen synthesis Alport’s syndrome
Previous right lower quadrant incision Tel Hashomer camptodactyly syndrome
Arterial aneurysms Leriche’s syndrome
Cigarette smoking Testicular feminization syndrome
Heavy lifting Rokitansky-Mayer-Küster syndrome
Physical exertion Goldenhar’s syndrome
Morris syndrome
Gerhardt’s syndrome
elements and hernia formation.20 Although a significant amount
Menkes’ syndrome
of work remains to elucidate the biologic nature of hernias,
Kawasaki disease
current evidence suggests they have a multifactorial etiology
with both environmental and hereditary influences. Pfannenstiel syndrome
Beckwith-Wiedemann syndrome
Rubinstein-Taybi syndrome
Alopecia-photophobia syndrome

Figure 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.
DIAGNOSIS
History
Workup 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 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.
Physical Examination
Physical 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 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
Figure 37-11. Digital examination of the inguinal canal.
Table 37-5 1607
Differential diagnosis of groin hernia
Malignancy
Lymphoma
Retroperitoneal sarcoma
Metastasis
Testicular tumor
Primary testicular
Varicocele
CHAPTER 37 INGUINAL HERNIAS
Epididymitis
Testicular torsion
Hydrocele
Ectopic testicle
Undescended testicle
Femoral artery aneurysm or pseudoaneurysm
Lymph node
Sebaceous cyst
Hidradenitis
Cyst of the canal of Nuck (female)
Saphenous varix
Psoas abscess
Hematoma
Ascites
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.21,22
External 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.
Imaging
In 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 abdominal contents. Movement of these contents
through the canal is essential to making the diagnosis with US,
1608
PART II
SPECIFIC CONSIDERATIONS
Figure 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.24
CT 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.25
MRI 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%, specificity of
96%.26 The expense of MRI precludes its routine use to diag-
nose inguinal hernias.
TREATMENT
Surgical 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
3 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 anesthesia can be safely performed.28
Although the natural history of untreated inguinal hernias is
poorly 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 strategy is safe for minimally symptomatic
inguinal hernia patients.32
Nonoperative 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 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 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 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.
Prophylactic Antibiotics
The 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-
of cases for quality improvement databases have resulted in the 1609
routine administration of prophylactic perioperative antibiotics
in inguinal hernia repairs.
Open Approach
The 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.

CHAPTER 37 INGUINAL HERNIAS

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, 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
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.

Camper’s
Ex. oblique fascia
Scarpa’s
fascia Hemostat

Sp
erm
atic
cor
d

SQ fat
External ring
Inguinal
floor
A Standard groin incision

Illioinguinal
Indirect hernia nerve
sac Repaired
defect in
transversalis
fascia

Direct hernia
sac

Figure 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.
1610 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 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
PART II
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-
SPECIFIC CONSIDERATIONS
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 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 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
Figure 37-14. Anterior open exposure of the inguinal canal. m. =
muscle; n. = nerve; v. = vein.
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 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 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 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 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 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
 Internal abdominal 1611
oblique muscle

External abdominal
oblique aponeurosis

Preperitoneal fat

Transversalis fascia

CHAPTER 37 INGUINAL HERNIAS

A
Spermatic
cord

Poupart's
ligament

EO
B

IO Figure 37-16. Shouldice repair. A. The iliopubic tract is sutured

TA
TF
B
IL
Figure 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.
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.
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

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 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
Cooper’s ligament
is separated from the inguinal floor. Excision of the sac is done
in all cases except in small direct hernias, where it is inverted. Figure 37-17. McVay Cooper’s ligament repair.
1612

1
1
2
4 6
3
2
5 7
PART II

6 4
8
3 5
SPECIFIC CONSIDERATIONS

Figure 37-18. The Desarda repair. A. The medial leaf of the external oblique aponeurosis is sutured to the inguinal ligament. 1 Medial leaf,
2 interrupted sutures taken to suture the medial leaf to the inguinal ligament, 3 pubic tubercle, 4 abdominal ring, 5 spermatic cord, 6 lateral leaf
B. Undetached strip of the external oblique aponeurosis forming the posterior wall. 1 Reflected medial leaf after a strip has been separated,
2 internal oblique muscle seen through the splitting incision made in the medial leaf, 3 interrupted sutures between the upper border of the
strip and conjoined muscle and internal oblique muscle, 4 interrupted sutures between the lower border of the strip and the inguinal ligament,
5 pubic tubercle, 6 abdominal ring, 7 spermatic cord, 8 lateral leaf.

narrow 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
medially up to the pubic symphysis and laterally 1 to 2 cm
beyond the reconstructed abdominal ring.
The free border of the strip of the EOA is now sutured to
the internal oblique or conjoined tendon lying close to it with
1–0 Ethilon or Prolene interrupted sutures. This is followed by
closure of the superficial fascia and the skin as usual.39-41
Prosthetic Repairs. The popularization of tension-free pros-
thetic mesh repairs signified a paradigm shift in the surgical
concept of inguinal hernia pathophysiology. Mesh-based her-
nioplasty is the most commonly performed general surgical
procedure, owing to the technique’s efficacy and improved out-
comes. The techniques of the most commonly performed pros-
thetic repairs are presented in this section.
Lichtenstein Tension-Free Repair The Lichtenstein
technique allows for a tension-free repair of the inguinal floor
by buttressing the floor with a prosthetic mesh (Fig. 37-18).
Initial exposure and mobilization of cord structures is identical
to other open approaches. The inguinal canal is dissected to
expose the shelving edge of the inguinal ligament, the pubic
tubercle, and sufficient area for mesh. The most commonly used
mesh is “flat iron” shaped with a keyhole for cord egress, it is
available in several sizes. It should be noted that when selecting
the size, it must be large enough to extend 2 to 3 cm superior to
Hesselbach’s Triangle. The medial edge of the mesh is affixed to
the anterior rectus sheath such that it overlaps the pubic tubercle
by 1.5 to 2 cm. This refinement to the original Lichtenstein
technique minimizes medial recurrence.42
For fixation of the inferior margin of the mesh, a per-
manent, synthetic, monofilament suture is used taking care to
avoid placing sutures directly into the periosteum of the pubic
tubercle. Fixation is continued along the shelving edge of the
inguinal ligament from medial to lateral, ending at the internal
ring. The upper tail of the mesh is then fixed to the internal
oblique aponeurosis and the medial edge to the rectus sheath
using a synthetic, absorbable suture.
In the case of a femoral hernia, a triangular extension of
the inferior aspect of the mesh is sutured to Cooper’s ligament
medially and to the inguinal ligament laterally. The lateral tails
of the mesh are tailored to fit snugly around the cord at the
internal ring, but not too tight to strangulate it. The tails are then
sutured to the inguinal ligament with an interrupted stitch and
placed beneath the external oblique aponeurosis.
Plug and Patch Technique. A modification of the Lichtenstein
repair, the Plug and Patch technique was developed by Gilbert and
later popularized by Rutkow and Robbins.43 Prior to placing the
prosthetic mesh patch over the inguinal floor, a three-dimensional
prosthetic plug is placed in the space previously occupied by
the hernia sac (Fig. 37-19). In the case of an indirect hernia, the
plug is placed alongside the spermatic cord through the internal
ring. Prosthetic plugs of various sizes are available, and one of
appropriate size is fixed to the margins of the internal ring with
interrupted sutures.44 For direct hernias, the sac is reduced, and the
plug is sutured to Cooper’s ligament, the inguinal ligament, and

Figure 37-19. Lichtenstein tension-free hernioplasty. m. =
muscle; n. = nerve; v. = vein.
the internal oblique aponeurosis. While the technique has good
overall outcomes, there have been some isolated case report series
of complications involving the presence of the plug, including
bowel obstruction and chronic pain.
Wound Closure Once the reconstruction of the inguinal canal is
complete, the cord contents are returned to their anatomic posi-
tion. The external oblique aponeurosis is then reapproximated
continuously from medial to lateral using an absorbable suture.
The external ring should be reconstructed in close apposition
to the spermatic cord to avoid the appearance of recurrence on
future examination. Scarpa’s fascia and skin are appropriately
closed.
Laparoscopic Approach
Laparoscopic inguinal hernia repairs have become increas-
ingly popular given the noninferiority studies, improved aes-
thetics, and increased surgeon experience with the procedure.
Principal endoscopic methods include the transabdominal
preperitoneal (TAPP) repair, the totally extraperitoneal (TEP)
repair, and the less-commonly performed intraperitoneal onlay
mesh (IPOM) repair.
Of note, awake patients do not tolerate abdominal insuffla-
tion well; therefore, laparoscopic repair necessitates the admin-
istration of general anesthesia and its inherent risks. Any patient
with a contraindication to the use of general anesthesia should
not undergo laparoscopic hernia repair. Occasionally, induction
of general anesthesia may result in reduction of an incarcer-
ated or strangulated inguinal hernia. If the surgeon suspects this
might have occurred, the abdomen should be explored for non-
viable tissue either via laparoscopy or upon conversion to an
open laparotomy.
The indications for laparoscopic inguinal hernia repair are
similar to those for open repair. Most surgeons would agree that
the endoscopic approach to bilateral or recurrent inguinal hernias
is superior to the open approach.45 Concurrent inguinal hernia
repair can be considered if a hernia patient is scheduled to undergo
another laparoscopic procedure without gross contamination,
such as prostatectomy.46,47 International Endohernia Society
(IEHS) guidelines offer a grade A recommendation that TEP
and TAPP are preferred alternatives to Lichtenstein repair for 1613
recurrent hernias after open anterior repair.48,49 The possibility of
bilateral repair should be discussed with all patients undergoing
endoscopic inguinal hernia surgery.
The operating room configuration is identical for TAPP,
TEP, and IPOM procedures. The patient is placed in the
Trendelenburg position, and video screens are placed at the foot
of the bed. The surgeon stands contralateral to the hernia, and
the assistant stands opposite the surgeon. The patient’s arms
are tucked to the sides. Figure 37-20 demonstrates a typical
CHAPTER 37 INGUINAL HERNIAS
operating room setup for endoscopic inguinal hernia repair.
The following sections outline the most commonly performed
endoscopic inguinal hernia repair techniques.
Transabdominal Preperitoneal Procedure. The transab-
dominal approach confers the advantage of an intraperitoneal
perspective, which is useful for bilateral hernias, large hernia
defects, and scarring from previous lower abdominal surgery.
The abdominal cavity is accessed using a dissecting trocar or
open Hasson technique. Pneumoperitoneum to a level of 15
mmHg is achieved. Two 5-mm trocars are placed lateral and
slightly inferior to the umbilical trocar, avoiding injury to the
inferior epigastric vessels (Fig. 37-21). The patient is then
placed in the Trendelenburg position, and the pelvis is inspected.
The bladder, median and medial umbilical ligaments,
external iliac, and inferior epigastric vessels are visualized. An
incision is made in the peritoneum at the medial umbilical liga-
ment, 3 to 4 cm superior to the hernia defect, and it is carried lat-
erally to the anterior superior iliac spine. For bilateral inguinal
hernia repair, bilateral peritoneal incisions are advisable, leav-
ing a midline bridge of tissue to avoid injuring a potential patent
urachus. The inferior edge of incised peritoneum is retracted,
and the preperitoneum is dissected to expose the spermatic cord.
If a direct hernia is encountered, the sac is inverted and fixed
to Cooper’s ligament to prevent development of hematoma or
seroma. An indirect hernia sac will usually protrude anterior to
the spermatic cord. In this case, the sac is grasped and elevated
superiorly from the cord and the space below is developed
bluntly to allow for mesh placement. The sac is dissected from
its adhesions, and the cord is skeletonized.
The mesh usually measures 10 × 15 cm to completely
cover the myopectineal orifice (Fig. 37-22). It is rolled length-
wise and placed through the 12-mm trocar. It is unrolled in the
preperitoneal space and secured medially to Cooper’s ligament
using an endoscopic tacker. During this fixation, the surgeon
palpates the end of the tacker from the abdominal surface to
ensure its proper angle and to stabilize the pelvis. The mesh is
then pulled taut and fixed laterally to the anterior superior iliac
spine. Tacks are placed above the iliopubic tract to avoid injury
to the lateral cutaneous nerve of the thigh and the femoral branch
of the genitofemoral nerve. The peritoneal edges are reapproxi-
mated using tacks or intracorporeal sutures as the mesh is sta-
bilized. The peritoneum should be closed completely to avoid
contact between the mesh and the intestine. The abdomen is
desufflated, and the trocars are removed. The fascial defect of
the 12-mm port and the skin incisions are appropriately closed.
Totally Extraperitoneal Procedure. The advantage of the
TEP repair is the access to the preperitoneal space without intra-
peritoneal infiltration. Consequently, this approach minimizes
the risk of injury to intra-abdominal organs and port site hernia-
tion through an iatrogenic defect in the abdominal wall. As with
TAPP, TEP is indicated for repair of bilateral inguinal hernias or
1614
PART II
SPECIFIC CONSIDERATIONS
Figure 37-20. Operating room setup for laparoscopic inguinal hernia repair.
for unilateral hernias when scarring makes the anterior approach
challenging.
A small horizontal incision is made inferior to the umbi-
licus. Subcutaneous tissue is dissected to the level of the ante-
rior rectus sheath, which is then incised lateral to the linea alba.
The rectus muscle is retracted superolaterally, and a dissecting
balloon is advanced through the incision toward the pubic sym-
physis. Under direct visualization with a 30° laparoscope, the
balloon is inflated slowly to bluntly dissect the preperitoneal
space (Fig.  37-23). The dissecting balloon is replaced with a
12-mm balloon trocar, and pneumopreperitoneum is achieved by
insufflation to 15 mmHg. A 5-mm trocar is placed suprapubically
in the midline, and another is placed inferior to the insufflation
port (see Fig. 37-21). The patient is placed in the Trendelenburg
position, and the operation proceeds in an identical fashion to
TAPP. No modifications are necessary to repair bilateral ingui-
nal hernias with the TEP approach. Any peritoneal rents should
be repaired prior to desufflation to prevent mesh from contact-
ing intraperitoneal structures. Following mesh placement, the
preperitoneal space is desufflated slowly under direct vision to
ensure proper mesh positioning. Trocars are removed, and the
anterior rectus sheath is closed with an interrupted suture. If there
 1615

CHAPTER 37 INGUINAL HERNIAS

A B

Figure 37-21. Trocar placement for (A) transabdominal preperitoneal repair and (B) totally extraperitoneal repair.

Figure 37-22. View of mesh placement in posterior repairs. A Figure 37-23. Balloon dissection of the preperitoneal space in a
large mesh overlaps the myopectineal orifice. totally extraperitoneal inguinal hernia repair.
1616 is violation of the peritoneum during insufflation of the dissec-
tion balloon and subsequent pneumoperitoneum, visualization
can be compromised. To address this, a Veress needle or angio-
catheter can be placed in the LUQ, which will allow desufflation
of the peritoneum and restore visualization.
Intraperitoneal Onlay Mesh Procedure. In contrast to TAPP
and TEP, the IPOM procedure permits the posterior approach
without preperitoneal dissection. It is an attractive procedure in
cases where the anterior approach is unfeasible, in recurrent her-
nias that are refractory to other approaches, or where extensive
preperitoneal scarring would make TEP or TAPP challenging.
PART II
Port placement and inguinal hernia identification are identical to
TAPP. Hernia sac contents are reduced; however, the sac itself
is not inverted from the preperitoneal space. Instead, mesh is
placed directly over the defect and fixed in place with sutures
or spiral tacks. Because these anchors are placed through the
SPECIFIC CONSIDERATIONS
peritoneum without preperitoneal inspection, the lateral cutane-
ous nerve of the thigh and the genitofemoral nerve are especially
prone to injury. Furthermore, intraperitoneal mesh migration is
a documented phenomenon that can lead to postoperative mor-
bidity, recurrence, and reoperation.
Robot-Assisted Inguinal Hernia Repair
Application of a robotic platform to hernia repair has been
adapted by general surgeons across the country. The endowrist
capabilities provides greatly improved manual dexterity and a
relatively short learning curve. Though both total extraperito-
4 neal repair and transabdominal preperitoneal repair can be
adapted to a robotic platform, the latter has gained more
traction among surgeons.
Many papers have explored the efficacy and cost-
effectiveness of robot-assisted herniorraphy. Retrospective data
have had mixed results when comparing robot-assisted surgery
vs. laparoscopy. One recent study has shown longer operative
time,50 another analysis has shown increased cost.51 It should
be noted, however, that there is a decrease in cost with robotic
surgery as the volume of procedures increases at each center,
though it is still unlikely that the costs will ever converge to
that of laparoscopic surgery. A retrospective, single-institution
study has shown greatly reduced complication rates with robotic
assisted surgery in obese patients; however, this was compared
against open inguinal hernia repair (10.8% vs. 3.2%, P = 0.047),
the two groups were covariate matched for preoperative risk.52
Studies have also shown excellent long-term (36-month) quality
of life indicators in robot-assisted TAPP, though this was a
single surgeon survey.53 Further randomized trials will shed
more light into cost issues as surgeons gain more experience
with robotic application that would lead to shorter operative
time and minimize additional instrument use.
Similar to laparoscopy, robot-assisted repair is ideal for
recurrent inguinal hernia patients who had previous anterior
repair and bilateral hernias. Contraindications to robotic her-
nia repair are the same as for laparoscopic repair and include
coagulopathy and/or severe cardiopulmonary disease precluding
induction of general anesthesia and pneumoperitoneum. Previ-
ous preperitoneal repair is a relative contraindication along with
the presence of a large incarcerated inguinal hernia.
Patient evaluation should proceed similarly to workup for
laparoscopic inguinal herniorraphy.
Technique. Patients are instructed to void in preoperative area to
avoid Foley catheter placement, though some surgeons advocate
routine Foley catheter placement. Ideally, the operating table
should have capability of synchronization with robotic arms to
prevent injury to the patient during repositioning during the pro-
cedure. The patient is placed in supine position with arms tucked
at both sides. Appropriate padding of extremities is important
to avoid neuropraxia and trauma from robotic arm movements.
Three trocars are typically used for TAPP repair. Open Hasson
technique is employed for initial trocar placement at umbilicus;
this can be an 8-mm trocar or alternatively a 12-mm with a tele-
scoped 8-mm trochar. Additionally, two 8-mm trocars are placed
in each side of the mid-abdomen, slightly above the level of umbi-
licus. After trocar placement, the robot is docked and targeted,
and the patient is placed in Trendelenburg position. Typically,
the surgeon will use robotic shears attached to electrocautery,
Cadiere forceps, and a needle holder as the primary instruments.
This combination provides optimal cost-effectiveness because the
majority of the cost associated with robotic application is due to
disposable instruments. Exposure starts with incising the parietal
peritoneum from the medial umbilical ligament to the anterior
superior iliac spine. A peritoneal flap is developed by blunt and
sharp dissection with robotic shears in the prepreitoneal space.
Special care is taken to leave the preperitoneal fat pad contain-
ing nerves and vessels with the anterior abdominal wall. Small
vessels can be coagulated with application of electrocautery with
scissors. With the aid of pneumoperitoneum, the preference is first
to perform a lateral dissection in the space of Bogros. Dissection
continues in this plane laterally towards the anterior superior iliac
spine. The generous development of a peritoneal flap will ensure
successful mesh placement at the end. Then the space of Retzius
is entered medially exposing the pubic symphysis. In the absence
of haptic feedback, visual recognition of the pubic symphysis is
crucial as this serves as an important landmark for further dis-
section. Inferior epigastric vessels are readily identified. Next,
an inferior peritoneal flap is developed to avoid rolling of mesh
during closure. Direct, indirect, and femoral spaces are carefully
examined. Cadiere forceps are then used to grasp the hernia sac
to provide traction. Any cord lipoma is carefully dissected free
from the cord structures, and the testicular vessels, pampiniform
plexus, and ductus deferens are separated from hernia sac. These
structures can usually be identified at the neck of sac. Reduction
is successful when the sac stays reduced after traction is released.
The next step is placement of the mesh. Lightweight barbed
mesh and anatomically preshaped mesh are routinely used. Mesh
should be an appropriate size to cover the myopectineal orifice
entirely, and the peritoneal dissection will need to be large enough
to accommodate this size mesh. It is rolled and placed through
one of the ports by the bedside assistant. Then it is unrolled and
placed in the pelvis overlapping the pubic symphysis by several
centimeters medially; this is essential as the majority of recur-
rences occur in this area. Utilization of tacking devices are not
necessary, which helps to reduce procedural cost; however, this
is surgeon preference. Finally, the peritoneal flap is placed back
over the mesh layer and sutured back into place with a running
locking suture that is facilitated by the increased intracorporeal
dexterity of the robotic instruments. Then the fascia of the umbili-
cal trochar site is closed with 0-absorbable suture (Fig 37-24), and
the skin is closed with absorbable monofilament suture.
Prosthesis Considerations
The success of prosthetic repairs has generated considerable
debate about the desirable physical attributes of mesh and their
fixation. An ideal mesh should be easy to handle, flexible,
 1617

CHAPTER 37 INGUINAL HERNIAS

A B

C D

E F

Figure 37-24. Steps in robotic TAPP repair. A. Image of

a direct inguinal hernia. B. There is no visible hernia on the
contralateral side. C. Hernia contents and sac are dissected
and cleared for mesh placement. D. Unrolling and placement
of mesh E. Satisfactory placement of mesh. F. Closure of
peritoneum. G. Completed repair of hernia with comparison
G to contralateral side.
1618 strong, immunologically inert, contraction-resistant, infection-
resistant, and inexpensive to manufacture. 54 The following
section reviews the most common types of mesh and fixatives
currently available.
Synthetic Mesh Material. Polypropylene and polyester are
the most common synthetic prosthetic materials used in her-
nia repair. These materials are permanent and hydrophobic,
and they promote a local inflammatory response that results in
cellular infiltration and scarring with slight contraction in size.
Other synthetic mesh materials are under investigation with the
goals of minimizing postoperative pain and preventing infection
PART II
or recurrence. In selecting mesh material, considerations include
mesh absorbability, thickness, weight, porosity, and strength.
Variations in the fiber diameter and fiber count of mesh
materials categorize them as heavyweight or lightweight in den-
sity, though there does not seem to be a universally agreed upon
SPECIFIC CONSIDERATIONS
set of criteria for either. Commonly used lightweight mesh materi-
als include β-d-glucan, titanium-coated polypropylene, and poly-
propylene–poliglecaprone. These materials have greater elasticity
and less theoretical surface area contact with surrounding tissues
than their heavyweight counterparts.55 They are hypothesized
to reduce scarring and chronic pain without compromising the
strength of the repair. The use of lightweight mesh use in TEP and
TAPP repairs is associated with fewer 3-month cumulative mesh-
related complications.54 A 2012 meta-analysis of 2310 patients
undergoing open or laparoscopic hernia repairs found a lower
incidence of chronic pain (relative risk [RR] 0.61, CI 0.50–0.74)
following use of lightweight mesh versus heavyweight mesh and
no significant difference in rates of recurrence.55
When available, lightweight mesh should be considered for
5 all prosthetic repairs to minimize postoperative chronic pain.
A disadvantage of currently available commercial pros-
theses is their high cost. In settings where resources are limited,
prosthetic repairs are performed using alternative materials.
Polypropylene and polyethylene mosquito nets are inexpensive
and ubiquitous in sub-Saharan Africa and India, and they have
similar mechanical properties to commercially available hernio-
plasty meshes. Meta-analysis of 577 hernioplasties performed
using sterilized mosquito nets demonstrated similar rates of
short-term mesh-related complications (6.1%) and recurrence
(0.17%) to those using commercial meshes.56 Furthermore, the
disability-adjusted life years (DALYs) prevented by inguinal
hernia repair signify a comparable impact to that of vaccination
in sub-Saharan Africa.57,58 Expensive prostheses are not neces-
sarily needed for hernia surgery, whether in resource-limited
or in resource-abundant settings, and the anticipated benefits
should be evaluated with consideration of increased costs.
Biologic Mesh. Although indications for the use of biologic
prostheses have not been absolutely defined, they are commonly
reserved for contaminated cases or when domain expansion is
necessary in the face of high infection risk. This is partially on
account of their high cost and high recurrence rates. There are
numerous biologic materials available with differing properties,
but in general, they have a lower tensile strength and subse-
quently higher rates of rupture than synthetic prostheses.59 They
also have varying degrees of tensile strength and tissue biocom-
patibility between them. In ventral hernia repairs, xenograft
material was associated with a lower rate of recurrence than
allograft material.60 A review of biologic materials concludes
cross-linked graft materials are more durable and less prone
to failure than non–cross-linked grafts.61 Nevertheless, their
diminished ability to remodel adversely affects rates of infec-
tion and incorporation. While new prosthetic materials continue
to be developed, no single biologic warrants routine use. These
materials will continue to evolve, and they remain an important
tool for challenging cases when used judiciously.
Fixation Technique. Independent of prosthesis material, the
method of its fixation remains disputed. Suturing, stapling, and
tacking prostheses entail tissue perforation, which may cause
inflammation, neurovascular injury, and chronic pain devel-
opment. Conversely, improper prosthesis fixation may result
in mesh migration, repair failure, meshoma pain, and hernia
recurrence. Mesh may be fixed with fibrin-derived glue, and
self-gripping mesh has been developed to minimize trauma
to surrounding tissues and to reduce the risk for entrapment
neuropathy. For hernias repaired via a strictly preperitoneal
approach, prosthesis fixation may not be necessary at all.
Fibrin glue fixation is a successful alternative to tack
fixation in hernia repair with a synthetic prosthesis. Recent
studies comparing fibrin glue fixation and suture fixation in
open hernia repair show superior rates of chronic pain with both
Lichtenstein and Plug and Patch techniques.62,63 Meta-analyses
of endoscopic hernia repair determined the incidence of chronic
postoperative pain after tacker fixation was significantly higher
than after fibrin glue fixation, with one showing a relative risk of
4.64 (CI 1.9–11.7). Rates of other postoperative complications
and recurrence were similar between both fixation methods.62,63
Glue fixation is a promising technical refinement, and several
studies have shown long-term benefit; however, its questionable
efficacy in larger hernias and cost remain considerations.
In TEP repairs, fixation of mesh may not be compulsory. A
prospective randomized trial comparing fixation and no fixation
in TEP repairs found a significant increase in new pain and equiv-
alent recurrence rates in the fixation group several months after
repair.64 A 2012 meta-analysis comparing laparoscopic tacker
mesh fixation to no mesh fixation found no statistically signifi-
cant differences in operative duration, pain, mesh-related compli-
cations, recurrence, or length of stay between the two methods.65
Studies of three-dimensional, ergonomically contoured mesh
without fixation, as well as self-gripping meshes, have yielded
similar results.66 In the preperitoneal approach, the reapproxi-
mation of surrounding tissues and physiologic intra-abdominal
pressure hypothetically prevent mesh migration. Due to higher
theoretical risk of mesh migration, repair without fixation is not
recommended for anterior or transperitoneal approaches.
COMPLICATIONS
As with other clean operations, the most common complications of
inguinal hernia repair include bleeding, infection, seroma, urinary
retention, ileus, and injury to adjacent structures (Table  37-6).
Complications specific to herniorrhaphy include hernia
recurrence, chronic inguinal and pubic pain, and injury to the
spermatic cord or testis. The incidence, prevention, and treatment
of these complications are discussed in the ensuing section.
Hernia Recurrence
When a patient develops pain, bulging, or a mass at the site of an
inguinal hernia repair, clinical entities such as seroma, persistent
cord lipoma, and hernia recurrence should be considered. Com-
mon medical issues associated with recurrence include malnu-
trition, immunosuppression, diabetes, steroid use, and smoking.
Technical causes of recurrence include improper mesh size, tissue
Table 37-6
ischemia, infection, and tension in the reconstruction. A focused 1619
physical examination should be performed. As with primary her-
Complications of groin hernia repairs nias, US, CT, or MRI can elucidate ambiguous physical findings.
Recurrence When a recurrent hernia is discovered and warrants reoperation,
Chronic groin pain an approach through a virgin plane facilitates its dissection and
Nociceptive exposure. Extensive dissection of the scarred field and mesh
Somatic may result in injury to cord structures, viscera, large blood ves-
Visceral sels, and nerves. After an initial anterior approach, the posterior
Neuropathic endoscopic approach will usually be easier and more effective
Iliohypogastric than another anterior dissection. Conversely, failed preperitoneal

CHAPTER 37 INGUINAL HERNIAS

Ilioinguinal repairs should be approached using an open anterior repair.
Genitofemoral
Lateral cutaneous Pain
Femoral Pain after inguinal hernia repair is classified into acute or
Cord and testicular chronic manifestations of three mechanisms: nociceptive
Hematoma (somatic), neuropathic, and visceral pain. Nociceptive pain is
Ischemic orchitis the most common of the three. Because it is usually a result of
Testicular atrophy ligamentous or muscular trauma and inflammation, nociceptive
Dysejaculation pain is reproduced with abdominal muscle contraction. Treat-
Division of vas deferens ment consists of rest, nonsteroidal anti-inflammatory drugs
Hydrocele (NSAIDs), and reassurance as it resolves spontaneously in most
Testicular descent cases. Neuropathic pain occurs as a result of direct nerve dam-
Bladder injury age or entrapment. It may present early or late, and it mani-
Wound infection fests as a localized, sharp, burning, or tearing sensation. It may
respond to pharmacologic therapy and to local steroid or anes-
Seroma
thetic injections when indicated. Visceral pain refers to pain
Hematoma
conveyed through afferent autonomic pain fibers. It is usually
Wound
poorly localized and may occur during ejaculation as a result of
Scrotal
sympathetic plexus injury.
Retroperitoneal
Chronic postoperative pain remains an important measure
Osteitis pubis
of clinical outcome that has been reported in as many as 63% of
Prosthetic complications inguinal hernia repair cases.67-69 Despite the significant anatomic
Contraction
variation in the three inguinal nerves, literature reviews suggest
Erosion
identification of all three nerves is possible in 70% to 90% of
Infection
cases.70 Meticulous nerve identification may prevent injury that
Rejection
results in debilitating chronic postoperative pain syndromes.
Fracture
Notwithstanding, moderate-to-severe pain adversely affects
Laparoscopic
physical activity, social interactions, health care utilization,
Vascular injury
employment, and productivity in 6% to 8% of patients.67,68,71-74
Intra-abdominal
Pain in this subset of patients comprises a tremendous individ-
Retroperitoneal
ual and societal burden.
Abdominal wall
Postherniorrhaphy inguinodynia is a debilitating chronic
Gas embolism
complication. Its incidence is independent of the method of her-
Visceral injury
nia repair.73 Selective ilioinguinal, iliohypogastric, and genito-
Bowel perforation
femoral neurolysis/neurectomy, removal of mesh and fixation
Bladder perforation
material, and revision of the repair are the three most common
Trocar site complications
Hematoma options for treatment. Nevertheless, anatomic variation and
Hernia cross-innervation of the inguinal nerves in the retroperitoneum
Wound infection and inguinal canal make selective neurectomy less reliable.75-78
Keloid When inguinodynia is refractory to pharmacologic and interven-
Bowel obstruction tional measures, triple neurectomy with removal of meshoma is
Trocar or peritoneal closure site hernia routinely performed with acceptable outcomes in the majority
Adhesions of patients.74,76,77,79-84 Refractory inguinodynia with concurrent
Miscellaneous orchialgia also requires resection of the paravasal nerves.84
Diaphragmatic dysfunction A relatively newly described technique that has cited good
Hypercapnia outcomes is the laparoscopic triple neurectomy. This involves
General laparoscopic approach to and division of the main trunks of the
Urinary ilioinguinal and iliohypogastric nerves and additional division
Paralytic ileus of the genitofemoral nerve in the lumbar plexus.84,85 Several
Nausea and vomiting studies with moderate numbers of patients treated showed dura-
Aspiration pneumonia ble reduction in pain scores.
Cardiovascular and respiratory insufficiency Other chronic pain syndromes include local nerve
entrapment, meralgia paresthesia, and osteitis pubis. At greatest
1620 risk of entrapment are the ilioinguinal and iliohypogastric nerves
in anterior repairs and the genitofemoral and lateral femoral
cutaneous nerves in endoscopic repairs. Clinical manifestations
of nerve entrapment mimic acute neuropathic pain, and they
occur with a dermatomal distribution. Injury to the lateral
femoral cutaneous nerve results in meralgia paresthesia, a
condition characterized by persistent paresthesia of the lateral
thigh. Initial treatment of nerve entrapment consists of rest, ice,
NSAIDs, physical therapy, and possible local corticosteroid
and anesthetic injection. This can be followed by a trial of
gabapentin86 or its analogues. Osteitis pubis is characterized
by inflammation of the pubic symphysis and usually presents
PART II
as medial groin or symphyseal pain that is reproduced by
thigh adduction. Avoiding the pubic periosteum when placing
sutures and tacks reduces the risk of developing osteitis pubis.
CT scan or MRI excludes hernia recurrence, and bone scan is
confirmatory for the diagnosis. Initial treatment is identical to
SPECIFIC CONSIDERATIONS
that of nerve entrapment; however, if pain remains intractable,
orthopedic surgery consultation should be sought for possible
bone resection and curettage. Irrespective of treatment, the
condition often takes six months to resolve.87
Cord and Testes Injury
Injury to spermatic cord structures may result in ischemic
orchitis or testicular atrophy. Ischemic orchitis is most com-
monly caused by injury to the pampiniform plexus and not to
the testicular artery. It usually manifests within 1 week of ingui-
nal hernia repair as an enlarged, indurated, and painful testis,
and it is almost certainly self-limited. It occurs in <1% of pri-
mary hernia repairs; however, this figure is larger for recurrent
inguinal hernia repairs.88 US will demonstrate testicular blood
flow to differentiate between ischemia and necrosis. Emergent
orchiectomy is only necessary in the case of necrosis. Injury to
the testicular artery itself may lead to testicular atrophy, which
is manifest over a protracted period but does not always lead to
testicular necrosis. This is because despite compromise of the
artery, there is collateral flow from the inferior epigastric, vesi-
cal, prostatic, and scrotal arteries that supply the testes, and in
the case of insufficiency, there is atrophy. Treatment for isch-
emic orchitis most frequently consists of reassurance, NSAIDs,
and comfort measures. Intraoperatively, proximal ligation of
large hernia sacs to avoid cord manipulation minimizes the risk
of injury.
Injury to the vas deferens within the cord may lead to
infertility. In open inguinal hernia repairs, isolating the vas
deferens along with the cord structures using digital manipulation
may cause injury or disruption. In endoscopic approach, grasping
the vas may result in a crush injury. Transections of the vas
deferens should be addressed with a urologic consult and early
anastomosis, if possible. Historically, surgeons and their patients
speculated that synthetic material would increase the risks of
mesh rejection, carcinogenesis, and inflammation; however,
as mesh became used more frequently, these concerns did not
manifest. Nevertheless, one study found prosthetic mesh may
exert long-term deleterious effects upon the vas deferens, causing
azoospermia.89 Similar studies report varied results, though. A
recent prospective study from the Swedish Hernia Registry
discovered no difference in rates of patient-reported infertility
between the general population and patients who underwent either
mesh or tissue-based inguinal hernia repair.90 Chronic scarring
may lead to vas deferens obstruction, resulting in decreased
fertility rates and a dysejaculation syndrome. Pain and burning
during ejaculation are usually self-limited, and more common
causes, such as sexually transmitted diseases, should be excluded.
In females, the round ligament is the analog to the sper-
matic cord, and it maintains uterine anteversion. Injury to the
artery of the round ligament does not result in clinically signifi-
cant morbidity.
Laparoscopic Complications
In general, the risks of the TEP technique mirror those of open
anterior repairs, as the peritoneal space is not violated. Com-
plications of transabdominal laparoscopy include urinary reten-
tion, paralytic ileus, visceral injuries, vascular injuries, and less
commonly, bowel obstruction, hypercapnia, gas embolism, and
pneumothorax. The most common complications of endoscopic
inguinal hernia repair are presented in this section.
Urinary Retention. The most common cause of urinary reten-
tion after hernia repair is general anesthesia, which is routine
in endoscopic hernia repairs. Among 880 patients undergoing
inguinal hernia repair with local anesthesia only, 0.2% devel-
oped urinary retention, while the rate of urinary retention was
13% among 200 patients undergoing repair with general or
spinal anesthesia.91 Overall, the risk of development of postop-
erative urinary retention is 2% to 3%.92-95 Other risk factors for
postoperative urinary retention include pain, narcotic analgesia,
and perioperative bladder distention. Initial treatment of urinary
retention requires decompression of the bladder with short-term
catheterization. Patients will generally require an overnight
admission and trial of normal voiding before discharge. Failure
to void normally requires reinsertion of the catheter for up to a
week. Chronic requirement of a urinary catheter is rare, though
older patients may require prolonged catheterization. Risk of
urinary retention can be minimized by ensuring voiding prior to
surgery and minimization of perioperative fluid administration.96
Ileus and Bowel Obstruction. The laparoscopic transab-
dominal approach is associated with a higher incidence of ileus
than other modes of repair. This complication is self-limited;
however, it necessitates sustained inpatient observation, intra-
venous fluid maintenance, and possibly nasogastric decom-
pression. Abdominal imaging may be helpful to confirm the
diagnosis and to exclude bowel obstruction. Prolonged absence
of bowel function, in conjunction with a suspicious abdominal
series, should raise concern for obstruction. In this case, CT of
the abdomen is helpful to distinguish anatomic sites of obstruc-
tion, inflammation, and ischemia. In TAPP repairs, obstruction
occurs most commonly secondary to herniation of bowel loops
through peritoneal defects or large trocar insertion sites; how-
ever, the use of smaller trocars and the preponderance of TEP
repairs have reduced the frequency of this complication. True
obstruction warrants reoperation.
Visceral Injury. Small bowel, colon, and bladder are at risk
for injury in laparoscopic hernia repair. The presence of intra-
abdominal adhesions from previous surgeries may predispose to
visceral injuries. Direct bowel injuries may also result from tro-
car placement. In reoperative abdominal surgery, open Hasson
technique and direct visualization of trocars are recommended
to reduce the likelihood of visceral injury. Bowel injury may
also occur secondary to electrocautery and instrument trauma
outside of the camera field. Missed bowel injuries are associated
with increased mortality. If injury to the bowel is suspected, its
entire length should be examined, and conversion to open repair
may be necessary.
 Bladder injuries are less common than visceral injuries,
and they are usually associated with perioperative bladder dis-
tention or extensive dissection of perivesical adhesions. As with
bladder injuries encountered in open surgery, cystotomies must
be repaired in several layers with 1 to 2 weeks of Foley catheter
decompression. A confirmatory cystogram may be performed
before catheter removal to confirm healing of the injury.
Vascular Injury. The most severe vascular injuries usually
occur in iliac or femoral vessels, either by misplaced sutures
in anterior repairs, endoscopic tacker use, or by trocar injury or
direct dissection in laparoscopic repairs. In these cases, exsan-
guination may be swift. Conversion to an open approach may be
necessary, and bleeding should be temporarily controlled with
mechanical compression until vascular control is obtained.
The most commonly injured vessels in laparoscopic hernia
repair include the inferior epigastrics and external iliac arter-
ies. Although apparent upon initial approach, these vessels may
be obscured during mesh positioning, and tacks or staples may
injure them. Oftentimes, due to tamponade effect, injury to the
inferior epigastric vessels is not apparent until the adjacent tro-
car is removed. If injured, the inferior epigastrics may be ligated
with a percutaneous suture passer or endoscopic vessel clips.
If the tissue pressure exerted by pneumoperitoneum is
greater than an injured vessel’s hydrostatic intraluminal pres-
sure, bleeding will not manifest until pneumoperitoneum is
released. The presentation of an inferior epigastric vein injury
is often delayed because of this effect, and it may result in a
significant rectus sheath hematoma. Accordingly, the surgeon
should be aware of this intraoperative consideration.
Hematomas and Seromas
Hematomas may present as localized collections or as dif-
fuse bruising over the operative site. Injury to spermatic cord
vessels may result in a scrotal hematoma. Although they are
self-limited, characteristic dark blue discoloration of the entire
scrotum may alarm patients. Intermittent warm and cold com-
pression aids in resolution. Hematomas may also develop in the
incision, retroperitoneum, rectus sheath, and peritoneal cavity.
The latter three sites are more frequently associated with lapa-
roscopic repair. Bleeding within the peritoneum or preperitoneal
space may not be readily apparent on physical examination. For
this reason, close monitoring of subjective complaints, vital
signs, urine output, and physical parameters is necessary.
Seromas are fluid collections that most commonly develop
within one week of synthetic mesh repairs. Large hernia sac
remnants may fill with physiologic fluid and mimic seromas.
Patients often mistake seromas for early recurrence. Treatment
consists of reassurance and warm compression to accelerate
resolution. To avoid secondary infection, seromas should not
be aspirated unless they cause discomfort or they restrict activ-
ity for a prolonged time.
OUTCOMES
The incidence of recurrence is the most-cited measure of post-
operative outcome following inguinal hernia repair. In evaluat-
ing the various available techniques, other salient signifiers of
outcome include complication rates, operative duration, hospital
stay, and quality of life. The following section summarizes the
6 evidence-based outcomes of the various approaches to
inguinal hernia repair.
Among tissue repairs, the Shouldice operation is the 1621
most commonly performed technique, and it is most frequently
executed at specialized centers. A 2012 meta-analysis from the
Cochrane database demonstrated significantly lower rates of
hernia recurrence (OR 0.62, CI 0.45–0.85) in patients undergoing
Shouldice operations when compared with other open tissue-
based methods.97 In experienced hands, the overall recurrence
rate for the Shouldice repair is about 1%.98 Although it is an
elegant procedure, its meticulous nature requires significant
technical expertise to achieve favorable outcomes, and it is
CHAPTER 37 INGUINAL HERNIAS
associated with longer operative duration and longer hospital
stay. One study found the recurrence rate for Shouldice repairs
decreased from 9.4% to 2.5% after surgeons performed the repair
six times.99 Compared with mesh repairs, the Shouldice technique
resulted in significantly higher rates of recurrence (OR 3.65,
CI 1.79–7.47); however, it is the most effective tissue-based
repair when mesh is unavailable or contraindicated.97
Hernia recurrence is drastically reduced as a result of the
Lichtenstein tension-free repair.100 Compared with open elective
tissue-based repairs, mesh repair is associated with fewer recur-
rences (OR 0.37, CI 0.26–0.51) and with shorter hospital stay
and faster return to usual activities.101,102 In a multi-institutional
series, 3019 inguinal hernias were repaired using the Lichten-
stein technique, with an overall recurrence rate of 0.2%.103
Among other tension-free repairs, the Lichtenstein technique
remains the most commonly performed procedure worldwide.
Meta-analysis demonstrates no significant differences in out-
comes between the Lichtenstein and the Plug and Patch tech-
niques; however, intra-abdominal plug migration and erosion
into contiguous structures occurs in approximately 6% of
cases.101,104,105 The Stoppa technique results in longer operative
duration than the Lichtenstein technique. Nevertheless, postop-
erative acute pain, chronic pain, and recurrence rates are similar
between the two methods.106 Perhaps the most compelling advan-
tage of the Lichtenstein technique is that nonexpert surgeons
rapidly achieve similar outcomes to their expert counterparts.
Guidelines issued by the European Hernia Society recommend
the Lichtenstein repair for adults with either unilateral or bilat-
eral inguinal hernias as the preferred open technique.102 Com-
pared to open approaches, endoscopic primary inguinal hernia
repair produces equivalent recurrence rates and improved recov-
ery time, pain prevention, and return to normal activities.107 In a
study of 168 patients randomized to either TEP or Lichtenstein
repair, the 5-year recurrence rates were extremely low in both
groups.108,109 Similarly, a study of 200 male patients randomized
to either ambulatory TEP or Lichtenstein repair demonstrated no
recurrences in either group after one year.110 Because endoscopic
surgery requires specialized instruments and longer operative
times, its cost is higher than conventional open repair; however,
the potential financial benefit of shorter recovery and
7 decreased pain may offset these costs in the long-term.
Perhaps the most salient difference between open and endo-
scopic techniques is the number of cases needed to develop techni-
cal proficiency. In a randomized controlled trial performed by the
VA Cooperative Study, two-year recurrence rates were 10.1% in
patients undergoing endoscopic repair and 4.9% in those undergo-
ing open repair, and the outcomes of endoscopic repairs improved
after each surgeon performed at least 250 cases.111 More recently,
Lal and colleagues found that surgeons sustained a decrease from
9% to 2.9% in postoperative recurrences after performing 100
TEP operations.112 Other studies also suggest surgeons develop
proficiency in these endoscopic techniques after performing 30
1622 to 100 cases; however, this estimate has decreased precipitously
since laparoscopic technique was first introduced.111,113,114
Although controversy persists regarding the utility of TEP
versus TAPP, reviews to date find no significant differences in
operative duration, length of stay, time to recovery, or short-term
recurrence rate between the two approaches. In TAPP repair, the
risk of intra-abdominal injury is higher than in TEP repair. This
finding prompted the IEHS to recommend TAPP should only be
attempted by surgeons with sufficient experience.49 A Cochrane
systematic review found rates of port-site hernias and visceral
injuries were higher for the TAPP technique, while TEP may
be associated with a higher rate of conversion to an alternative
PART II
approach; however, neither finding was sufficiently compelling
to recommend one technique over the other.114
The frequency with which the aforementioned ingui-
nal hernia repair techniques are performed reinforces the
importance of broad experience. The authors recommend that
SPECIFIC CONSIDERATIONS
surgeons become proficient in several techniques to address dif-
ferent manifestations of inguinal hernias. Surgeons should tailor
this experience to optimize outcomes for each patient.
REFERENCES
Entries highlighted in bright blue are key references.
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Discharge Survey and National Survey of Ambulatory
Surgery, 2010 . Available at: https://www.cdc.gov/nchs/index
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2. Abramson JH, Gofin J, Hopp C, et al. The epidemiology of
inguinal hernia. A survey in western Jerusalem. J Epidemiol
Community Health. 1978;32(1):59-67.
3. Rutkow IM. Epidemiologic, economic, and sociologic aspects
of hernia surgery in the United States in the 1990s. Surg Clin
North Am 1998;78(6):941-951, v-vi.
4. Johnson J, Roth JS, Hazey JW, et al. The history of open
inguinal hernia repair. Curr Surg. 2004;61(1):49-52.
5. Gil J, Rodriguez JM, Hernandez Aguera Q, et al. The usefulness
of international cooperation in the repair of inguinal hernias in
Sub-Saharan Africa. World J Surg. 2015;39(11):2622-2629.
6. Shulman AG, Amid PK, Lichtenstein IL. A survey of non-
expert surgeons using the open tension-free mesh patch repair
for primary inguinal hernias. Int Surg. 1995;80(1):35-36.
7. Spaw AT, Ennis BW, Spaw LP. Laparoscopic hernia repair: the
anatomic basis. J Laparoendosc Surg. 1991;1(5):269-277.
8. Scheuermann U, Niebisch S, Lyros O, Jansen-Winkeln B,
Gockel I. Transabdominal preperitoneal (TAPP) versus
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systematic review and meta-analysis of randomized controlled
trials. BMC Surg. 2017;17(1):55.
9. Fitzgibbons RJ, Jr, Salerno GM, Filipi CJ, Hunter WJ,
Watson P. A laparoscopic intraperitoneal onlay mesh
technique for the repair of an indirect inguinal hernia. Ann
Surg. 1994;219(2):144-156.
10. Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a
prospective multicenter trial evaluating the ePTFE peritoneal
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11. Arregui ME, Davis CJ, Yucel O, Nagan RF. Laparoscopic
mesh repair of inguinal hernia using a preperitoneal approach:
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etiology of indirect inguinal hernias: congenital and/or
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17. Lau H, Fang C, Yuen WK, Patil NG. Risk factors for
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18. Ruhl CE, Everhart JE. Risk factors for inguinal hernia
among adults in the US population. Am J Epidemiol.
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20. Franz MG. The biology of hernias and the abdominal wall.
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can direct and indirect inguinal hernias be distinguished?
Br Med J. 1980;280(6220):1039-1040.
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24. Jamadar DA, Jacobson JA, Morag Y, et al. Sonography of
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185-190.
25. Burkhardt JH, Arshanskiy Y, Munson JL, Scholz FJ. Diagnosis
of inguinal region hernias with axial CT: the lateral crescent sign
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Detection of groin hernia with physical examination,
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ful waiting vs repair of inguinal hernia in minimally symp-
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285-292.
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surgical repair of an asymptomatic groin hernia appropriate?
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34. Gallegos NC, Dawson J, Jarvis M, Hobsley M. Risk of
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35. Nilsson H, Stylianidis G, Haapamäki M, Nilsson E,
Nordin P. Mortality after groin hernia surgery. Ann Surg.
2007;245(4):656-660.
 30
The Appendix
Fadi S. Dahdaleh, David Heidt, and Kiran K. Turaga
chapter

History 1331 Complicated Appendicitis / 1335 Outcomes and Postoperative

Embryology, Anatomy,
and Histology
Acute Appendicitis
Clinical Diagnosis
History / 1332
Physical Examination / 1332
Laboratory Findings / 1332
Imaging / 1332
Differential Diagnosis / 1335
Management of Appendicitis
Uncomplicated Appendicitis / 1332
Operative Intervention 1335
1331 Preoperative Preparation / 1335
1331 Operative Technique / 1336
Novel Techniques / 1336
1332
Negative Exploration / 1336
Incidental Appendectomy / 1336
Special Circumstances 1337
Appendicitis in Children / 1337
Appendicitis in Older Adults / 1338
1335 Appendicitis in Pregnancy / 1338
Chronic or Recurrent Appendicitis / 1338
Course 1338
Stump Appendicitis / 1338
Appendiceal Neoplasms / 1338
Gastroenteropancreatic Neuroendocrine
Tumors (GEP-NETs or Carcinoid) / 1338
Goblet Cell Carcinomas / 1339
Lymphomas / 1339
Adenocarcinoma / 1339
Appendiceal Mucoceles and Mucinous
Neoplasms of the Appendix / 1339
Pseudomyxoma Peritonei
Syndrome / 1340

HISTORY appendix. The appendix is a true diverticulum of the cecum as

Although anatomists such as Vesalius and Leonardo Da Vinci
had written about the appendix, Claudius Amyand in the early
18th century was the first surgeon to describe a successful
appendectomy.1 In subsequent centuries, significant progress
was made in the diagnosis and management of appendicitis,
especially after Chester McBurney advocated for early appen-
dectomy in his 1889 publication.2 Famously, the magician Harry
Houdini died of a ruptured appendix after suffering a blow to
his abdomen. Following the introduction and widespread use
of antibiotics in the 1940s, mortality rates improved further. In
1982, Kurt Semm, a gynecologist, reported on the first laparo-
scopic appendectomy, which is now the most widely adopted
technique.
EMBRYOLOGY, ANATOMY, AND HISTOLOGY
Previously considered a vestigial organ, the appendix is now
linked to the development and preservation of gut-associated
lymphoid tissue (GALT) and to the maintenance of intestinal
flora. It has been suggested that appendectomy is associated with
increased Clostridium difficile infections and increased subse-
quent cancer (colon, esophageal) as a result of microbial altera-
tion, although this is currently unproven.3 The protective effect of
an early appendectomy against development of ulcerative colitis
has been proposed to be mechanistically linked to the release of
dimeric forms of IgA from plasma B cells and the Th2 response
mediated by IL-13–producing natural killer T cells.4
The appendix, along with the ileum and the colon, devel-
ops from the midgut and first appears at 8 weeks of gestation.
As the gut rotates medially, the cecum becomes fixed in the
right lower quadrant, thus determining the final position of the
it contains all the histological layers of the colon, although cer-
tain differences in the irregularity of crypts remain. The average
appendix measures 6 to 9 cm and derives its blood supply from
the appendicular branch of the ileocolic artery. Visceral innerva-
tion occurs along the superior mesenteric plexus (T10-L1) and
the vagus nerves. The appendix is intraperitoneal and retrocecal
in location, but it can be pelvic (30%) and retroperitoneal (7%).5
Grossly, the appendiceal base can be identified by tracing the
convergence of the cecal taeneia.
ACUTE APPENDICITIS
Inflammation of the appendix is a significant public health prob-
lem with a lifetime incidence of 8.6% in men and 6.7% in
1 women, with the highest incidence occurring in the second
and third decade of life.6 While the rate of appendectomy in
developed countries has decreased over the last several decades,
it remains one of the most frequent emergent abdominal
operations.7
The etiology of appendicitis is perhaps due to luminal
obstruction that occurs as a result of lymphoid hyperplasia in
pediatric populations; in adults, it may be due to fecaliths, fibro-
sis, foreign bodies (food, parasites, calculi), or neoplasia.5,8-10
Early obstruction leads to bacterial overgrowth of aerobic
organisms in the early period, and subsequently, it leads to
mixed flora. Obstruction generally leads to increased intralumi-
nal pressure and referred visceral pain to the periumbilical
region.10 It is postulated that this leads to impaired venous drain-
age, mucosal ischemia leading to bacterial translocation, and
subsequent gangrene and intraperitoneal infection. Escherichia
coli and Bacteroides fragilis are the most common aerobic
and anaerobic bacteria isolated in perforated appendicitis.11,12
 Key Points
1 Inflammation of the appendix is a significant public health
problem with a lifetime incidence of 8.6% in men and 6.7%
in women, with the highest incidence in the second and third
decade of life.6 While the rate of appendectomy in devel-
oped countries has decreased over the last several decades,
it remains one of the most frequent emergent abdominal
operations.
2 The natural history of appendicitis is unclear, but it appears
that progression to perforation is not predictable and that
spontaneous resolution is common, suggesting that nonper-
forated and perforated appendicitis may, in fact, be different
diseases.
3 C-reactive protein, bilirubin, Il-6, and procalcitonin have all
been suggested to be helpful in the diagnosis of appendicitis,
specifically in predicting perforated appendicitis.
4 Perforated appendicitis can be managed either operatively or
nonoperatively. Immediate surgery is necessary in patients
that appear septic, but this is usually associated with higher
complications, including abscesses and enterocutaneous fis-
tulae, due to dense adhesions and inflammation.
5 Single incision appendectomy has not been shown to improve
outcomes, including cosmetic outcomes, in prospective
This sequence is not inevitable, however, and some episodes of
acute appendicitis may resolve spontaneously. Due to differ-
ences in epidemiology, nonperforated and perforated
2 appendicitis are considered different diseases.13 Addition-
ally, since not all nonperforated appendicitis progresses to per-
forations, it is suggested that the pathogenesis of the two
conditions may be different.
CLINICAL DIAGNOSIS
History
It is important to elicit an accurate history from the patient and/
or family, in the case of pediatric patients. Inflammation of the
visceral peritoneum usually progresses to the parietal perito-
neum, presenting with migratory pain, which is a classic sign
of appendicitis (likelihood ratio+, 2.06 [1.63–2.60]).14 Inflam-
mation can often result in anorexia, nausea, vomiting, and fever
(Table 30-1). Regional inflammation can also present with an
ileus, diarrhea, small bowel obstruction, and hematuria. Perti-
nent negative history (including menstrual) must be obtained to
rule out other etiologies of abdominal pain.
Physical Examination
Most patients lay quite still due to parietal peritonitis. Patients
are generally warm to the touch (with a low-grade fever,
∼38.0°C [100.4°F]) and demonstrate focal tenderness with
guarding. McBurney’s point, which is found one-third of the
distance between the anterior superior iliac spine and the umbili-
cus, is often the point of maximal tenderness in a patient with an
anatomically normal appendix. Certain physical signs with their
respective eponyms can be helpful in discerning the location
of the appendix: Rovsing’s sign, pain in the right lower quad-
rant after release of gentle pressure on left lower quadrant (nor-
1332 mal position); Dunphy’s sign, pain with coughing (retrocecal
randomized studies and has been suggested to have a higher
incisional hernia rate.
6 While there is no evidence clearly evaluating long-term out-
comes of patients undergoing incidental appendectomy with
an asymptomatic appendix, the risk of adhesions and future
complications after an appendectomy has been suggested to
be higher than the risk of future appendicitis and increased
economic costs. An incidental appendectomy is currently not
advocated.
7 Older adult patients are at a higher risk for complications due
to their premorbid conditions, and it is prudent to obtain
definitive diagnostic imaging prior to taking patients to the
operating room.
8 Patients with uncomplicated appendicitis do not require fur-
ther antibiotics after an appendectomy, while patients with
perforated appendicitis are treated with 3 to 7 days of
antibiotics.
9 The most common mode of presentation for appendiceal car-
cinoma is that of acute appendicitis. Patients also may pres-
ent with ascites or a palpable mass, or the neoplasm may be
discovered during an operative procedure for an unrelated
cause.
appendix); obturator sign, pain with internal rotation of the hip
(pelvic appendix); iliopsoas sign, pain with flexion of the hip
(retrocecal appendix). In addition, pain with rectal or cervical
examinations is also suggestive of pelvic appendicitis.
Laboratory Findings
Patients with appendicitis usually have leukocytosis of 10,000
cells/mm3, with a higher leukocytosis associated with gangrenous
and perforated appendicitis (∼17,000 cells/mm3). C-reactive pro-
tein, bilirubin, Il-6, and procalcitonin have all been sug-
3 gested to help in the diagnosis of appendicitis, specifically
in predicting perforated appendicitis.14,15 The authors believe
that a white blood cell (WBC) count and a C-reactive protein are
two appropriate lab tests to obtain in the initial work up of
appendicitis; a pregnancy test is also essential in women of
childbearing age. Lastly, a urinalysis can be valuable in ruling
out nephrolithiasis or pyelonephritis.
Imaging
Imaging is often utilized to confirm a diagnosis of appendici-
tis because a negative operation rate is acceptable in <10% of
male patients and <20% of female patients. Routine use of cross-
sectional imaging somewhat reduces the rate of negative laparot-
omies. Imaging studies are most appropriate for patients in whom
a diagnosis of appendicitis is unclear or who are at high risk from
operative intervention and general anesthesia, such as pregnant
patients or patients with multiple comorbidities. Commonly
utilized imaging modalities include computerized tomography
(CT), ultrasound (US), and magnetic resonance imaging (MRI).
CT Scan. A contrast-enhanced CT scan has a sensitivity of
0.96 (95% confidence interval [CI] 0.95–0.97) and specificity of
0.96 (95% CI 0.93–0.97) in diagnosing acute appendicitis.16,17
Features on a CT scan that suggest appendicitis include
enlarged lumen and double wall thickness (greater than 6 mm),
Table 30-1 1333

Signs and symptoms of appendicitis

TRUE POSITIVE 95% CONFIDENCE TRUE NEGATIVE 95% CONFIDENCE
  LIKELIHOOD RATIO INTERVAL LIKELIHOOD RATIO INTERVAL
Duration of symptoms (hours)
>9 1.01 0.97–1.05 0.94 0.62–1.42
>12 0.96 0.90–1.04 1.19 0.87–1.63
>24 0.65 0.47–0.90 1.47 1.14–1.90

CHAPTER 30 THE APPENDIX

>48 0.49 0.36–0.67 1.20 1.08–1.34
Fever 1.64 0.89–3.01 0.61 0.49–0.77
Gastrointestinal dysfunction
Anorexia 1.27 1.14–1.41 0.59 0.45–0.77
Nausea 1.15 1.04–1.36 0.72 0.57–0.91
Vomiting 1.63 1.45–1.84 0.75 0.69–0.80
Pain
Pain migration 2.06 1.63–2.60 0.52 0.40–0.69
Pain progression 1.39 1.29–1.50 0.46 0.27–0.77
Direct tenderness 1.29 1.06–1.57 0.25 0.12–0.53
Indirect tenderness 2.47 1.38–4.43 0.71 0.65–0.77
Psoas sign 2.31 1.36–3.91 0.85 0.76–0.95
Rebound 1.99 1.61–2.45 0.39 0.32–0.48
Percussion tenderness 2.86 1.95–4.21 0.49 0.37–0.63
Guarding 2.48 1.60–3.84 0.57 0.48–0.68
Rigidity 2.96 2.43–3.59 0.86 0.72–1.02
Temperature (degrees centigrade)
>37.7 1.57 0.90–2.76 0.65 0.31–1.36
>38.5 1.87 0.66–5.32 0.89 0.71–1.12
White blood cells (109/L)
≥10 4.20 2.11–8.35 0.20 0.10–0.41
≥15 7.20 4.31–12.00 0.66 0.56–0.78
C-reactive protein (mg/L)
>10 1.97 1.58–2.45 0.32 0.20–0.51
>20 2.39 1.67–3.41 0.47 0.28–0.81
Conclusions: Individually, disease history, clinical findings, and laboratory tests are weak. But when combined, they yield high discriminatory power.
Data from Andersson RE: Meta-analysis of the clinical and laboratory diagnosis of appendicitis, Br J Surg. 2004 Jan;91(1):28-37.

wall thickening (greater than 2 mm), periappendiceal fat
stranding, appendiceal wall thickening, and/or an appendicolith
(Fig. 30-1). While there remains a concern of ionizing radia-
tion exposure with a CT scan, typical low-dose CT scans result
Figure 30-1. McBurney’s point. 1 = anterior superior iliac spine;
2 = umbilicus; x = McBurney’s point.
in exposure of 2 to 4 mSv, which is not significantly higher
than background radiation (3.1 mSv).18 Recent trials have also
suggested that although low-dose CT scans of 2 mSv do not
generate high-resolution images, using these lower resolution
images does not affect clinical outcomes.19 Intravenous contrast
is generally preferred in these studies, but it can be avoided in
patients with allergies or low estimated glomerular filtration rate
(less than 30 mL/minute for 1.73 m2). Several meta-analyses
have suggested that CT scan is more sensitive and specific than
ultrasound in diagnosing appendicitis.
Ultrasound. Ultrasonography has a sensitivity of 0.85 (95%
CI 0.79–0.90) and a specificity of 0.90 (95% CI 0.83–0.95).20
Graded compression ultrasonography is used to identify the
anteroposterior diameter of the appendix. An easily compressible
appendix <5 mm in diameter generally rules out appendicitis.
Features on an ultrasound that suggest appendicitis include
a diameter of greater than 6 mm, pain with compression,
presence of an appendicolith, increased echogenicity of the fat,
and periappendiceal fluid.21 Ultrasound is cheaper and more
readily available than CT scan, and it does not expose patients to
ionizing radiation, but it is user-dependent and has limited util-
ity in obese patients. In addition, graded compression is usually
 SPECIFIC CONSIDERATIONS PART II

2
yses comparing CT scan and US outcomes

  AUTHOR

  TERASAWA WESTON DORIA AL-KHAYAL VAN RANDEN SUMMARY

  2004 2005 2006 2007 2008  
ies   22 21 57 25 6  
ents CT 1172 NR NR NR NR  
US 1516 NR NR NR NR
Total 2688 5039 13697 13046 671
CT 94% (CI: 91%–95%) 97% (CI: 95%–98%) 94% (CI: 92%–97%) 93% (CI: 92%–95%) 91% (CI: 84%–95%) CT more s
US 86% (CI: 83%–88%) 87% (CI: 85%–89%) 88% (CI: 86%–90%) 84% (CI: 82%–85%) 78% (CI: 67%–86%) than US
five met
CT 95% (CI: 93%–96%) 95% (CI: 93%–96%) 94% (CI: 94%–96%) 93 (CI: 92%–94%) 90% (CI: 85%–94%) CT more s
US 81% (CI: 78%–84%) 93% (CI: 92%–94%) 93% (CI: 90%–96%) 96 (CI: 95%–96%) 83% (CI: 76%–88%) US in fo
meta-an
edictive CT NR 94% (CI: 92%–95%) NR 90% (CI: 89%–92%) NR CT has sup
US NR 89% (CI: 87%–90%) NR 90% (CI: 89%–91%) NR positive
value in
meta-an
redictive CT NR 97% (CI: 96%–98%) NR 96% (CI: 95%–97%) NR CT has sup
US NR 92% (CI:91%–93%) NR 93% (CI: 92%–94%) NR negative
value in
meta-an
CT NR NR NR 94% (CI: 93%–94%) NR CT is more
US NR NR NR 92% (CI: 92%–96%) NR in the on
reporting
nce interval; CT = computed tomography; NR = not reported; US = ultrasonography.
painful for patients with peritonitis. A comparison of the effi-
cacy of ultrasound v. CT scan is found in Table 30-2.
MRI. MRI of the abdomen has a sensitivity of 0.95 (95% CI
0.88–0.98) and specificity of 0.92 (95% CI 0.87–0.95) for iden-
tification of acute appendicitis.22 MRI is an expensive test that
requires significant expertise to perform and interpret and is
usually recommended in patients for whom the risk of ionizing
radiation outweighs the relative ease of obtaining a contrast
CT scan, i.e., pregnant or pediatric patients.
Differential Diagnosis
Causes of acute abdominal pain that are often confused with
acute appendicitis include acute mesenteric adenitis, cecal
diverticulitis, Meckel’s diverticulitis, acute ileitis, Crohn’s dis-
ease, acute pelvic inflammatory disease, torsion of ovarian cyst
or graafian follicle, and acute gastroenteritis. Frequently, no
organic pathology is identified. Obtaining an antecedent history
of a viral infection (mesenteric adenitis or gastroenteritis) and
a cervical exam in women (exquisite tenderness with motion in
pelvic inflammatory disease) are essential before planning any
intervention. Detailed menstrual history can distinguish mittel-
schmerz (no fever or leukocytosis, mid-menstrual cycle pain)
and ectopic pregnancies.
MANAGEMENT OF APPENDICITIS
Uncomplicated Appendicitis
The preferred approach to manage patients with uncomplicated
appendicitis is an appendectomy. Several recent randomized
trials and cohort studies have examined the role of nonopera-
tive management of adult patients with appendicitis.23,24,25 In
each of these well-designed studies with noninferiority as the
endpoint, patients were randomized to either receiving antibiot-
ics or undergoing an appendectomy, which was frequently per-
formed open. A majority of the patients in the nonoperative arm
received intravenous antibiotics for a short course followed by
a course of a fluoroquinolone and metronidazole, or oral amoxi-
cillin/clavulanic acid.23,26,27 Meta-analysis of the published data
found that 26.5% of patients in the nonoperative group required
an appendectomy within 1 year. In addition, the rate of adverse
events following antibiotics therapy was higher (relative risk
[RR] 3.18, 95% CI 1.63–6.21, P = 0.0007), and patients who
recurred presented more frequently with complicated appen-
dicitis (RR 2.52, 95% CI 1.17–5.43, P = 0.02).28,29 Currently,
conservative management can be offered to informed patients
using techniques of shared decision-making, but it is not the
standard modality of management of appendicitis, except in
patients with significant phobia of surgery.30 Societal costs and
long-term implications of the conservative strategy have not yet
been completely evaluated.
Timing of Surgery. Emergent surgery is often performed in
patients with appendicitis, but studies have evaluated the perfor-
mance of urgent surgery (waiting less than 12 hours) in a semi-
elective setting after administering antibiotics upon admission.
The studies did not reveal any significant difference in outcomes,
except for a slightly longer hospital stay in those undergoing
urgent surgery.31-33 Currently, delaying surgery less than 12 hours
is acceptable in patients with short duration of symptoms (less
than 48 hours) and in nonperforated, nongangrenous appendicitis.
Approach of Surgery. Numerous meta-analyses comparing
laparoscopic to open appendectomy have demonstrated relative
equivalence of the techniques, with laparoscopic appendec- 1335
tomy resulting in a shorter length of stay (LOS), faster return to
work, and lower superficial wound infection rates, especially
in obese patients.34,35 Open appendectomy results in shorter
operative times and lower intra-abdominal infection rates.36
Costs of the two techniques are relatively similar because of
the offset of costs in laparoscopic techniques by shorter LOS.
In the United States, laparoscopic appendectomies are increas-
ingly utilized.37
Complicated Appendicitis
CHAPTER 30 THE APPENDIX
Perforated and gangrenous appendicitis and appendicitis with
abscess or phlegmon formation are considered complicated
conditions. Patients with perforated appendicitis usually pres-
ent after 24 hours of onset, although 20% of patients present
within 24 hours. Such patients are often acutely ill and dehy-
drated and require resuscitation. Usually, the perforated abscess
is walled off in the right lower quadrant, although retroperito-
neal abscesses including psoas abscess, liver abscesses, fistu-
las, and pylephlebitis (portal vein inflammation) can also occur
when left untreated.
Perforated appendicitis can be managed either operatively
or nonoperatively. Immediate surgery is necessary in
4 patients that appear septic, but this is usually associated
with higher complications, including abscesses and enterocuta-
neous fistulae due to dense adhesions and inflammation.
The management of long-duration, complicated appendici-
tis is often staged.38,39 Patients are resuscitated and treated with
IV antibiotics.40,41 Patients with longstanding perforation are
better treated with adequate percutaneous image-guided drain-
age.42 This strategy is successful in 79% of patients who achieve
complete resolution, which occurs more often in lower-grade
abscesses, transgluteal drainage, and with CT- (vs. ultrasound-)
guided drainage43 Operative intervention is performed in patients
who fail conservative management and in patients with free intra-
peritoneal perforation.
Interval Appendectomy. The majority of patients with perfo-
rated appendicitis (80%) have resolution of their symptoms with
drainage and antibiotics. There remains debate about the value
of performing an interval appendectomy 6 to 8 weeks after the
original inflammatory episode.44-46 Proponents of this approach
cite the incidence of recurrent appendicitis (7.4%–8.8%) and the
presence of appendiceal neoplasms detected on the appendec-
tomy (relevant benign lesions 0.7%, malignant lesions 1.3%).47
Opponents cite the high incidence of no future events after a
median follow-up of 34 months in 91% of patients. Currently,
shared decision-making is necessary before proceeding with an
interval appendectomy.39
OPERATIVE INTERVENTION
Preoperative Preparation
Once the decision to proceed with surgical intervention is made,
patients can be taken to the operating room rather expeditiously.
While resuscitative efforts are important in patients who pres-
ent with significant dehydration or in a compromised host, the
majority of patients can be taken to the operating room within
a short interval. Placement of a Foley catheter is optional but
not necessary while performing an appendectomy. Preopera-
tive antibiotics must be administered at least 30 to 60 minutes
prior to skin incision. The choice of antibiotics include cefoxi-
tin, ampicillin/sulbactam, and cefazolin plus metronidazole for
1336 uncomplicated appendicitis. Patients with ß-lactam allergies can
be given clindamycin in combination with a fluoroquinolone,
gentamicin, or aztreonam. Postoperative antibiotics are usually
not necessary.
In patients with perforated appendicitis undergoing opera-
tive intervention, preoperative antibiotics are necessary to cover
gram-negative bacteria and anaerobes. Monotherapy with piper-
acillin/tazobactam or combination of cephalosporin with metro-
nidazole are reasonable choices. The duration of postoperative
antibiotics is generally less than 4 days once complete source
control has been achieved (STOP-IT trial).48 Patients with
incomplete drainage, persistent catheters, complications from
PART II
surgery, and uncertain resolution of inflammation might need a
longer duration of antibiotics.49
Operative Technique
Open Appendectomy. An open appendectomy is usually per-
SPECIFIC CONSIDERATIONS
formed under general anesthesia, although regional anesthesia
can be used. After wide prep and drape, an incision is usually
made on McBurney’s point either in an oblique fashion (McBur-
ney’s incision) or transverse incision (Rocky-Davis incision).
A lower midline laparotomy incision is more appropriate for
perforated appendicitis with a phlegmon. A muscle-splitting
approach can be utilized to access the peritoneum in patients
that are well paralyzed. The bed is positioned in Trendelen-
burg’s with the left side down. The appendix is usually readily
identified, but if necessary, it can be found by tracing the ante-
rior taenia (taenia Liberia) of the cecum distally. We generally
ligate the mesentery early to allow better exposure. If the base
of the appendix is viable, ligating the appendix is acceptable.
This can be imbricated with a Z-stitch or purse string configura-
tion, or alternatively the mucosa can be fulgurated. In the event
of retraction of the appendiceal artery or unexpected bleeding,
the incision can be extended medially (Fowler extension).
Skin closure is usually performed in a layered fashion, but in
cases with significant abscess or contamination, closure by sec-
ondary intention or delayed primary closure has been consid-
ered. Recent trials have suggested no difference in surgical site
infection rates between primary and delayed primary closure.50
Placement of surgical drains has not been proven to be benefi-
cial in multiple clinical trials for either complicated or uncom-
plicated appendicitis.51,52
Laparoscopic Appendectomy. Patients undergoing laparo-
scopic appendectomy are positioned supine with the left arm
tucked for better access. Monitors and assistants are positioned
appropriately. Access to the peritoneum can be obtained using
either the Hasson technique in a periumbilical fashion or with
a Verees or optical trocar in the left upper quadrant 3 cm below
the costal margin in the midclavicular line. Five-mm ports are
usually placed in the suprapubic and left lower quadrant areas.
It is also technically feasible to place the third port in the right
upper quadrant. The bed is positioned in Trendelenburg, with
the left side down to sweep the bowel away. The appendix is
grasped and elevated upwards to identify the window between
the mesoappendix and the cecum (Fig. 30-2). Occasionally, it
is essential to release the mesenteric attachments of the cecum
to mobilize a retrocecal or pelvic appendix to obtain this
view. Using a Maryland grasper, the window is created, and
the mesoappendix is divided with cautery, clip, or a bipolar
energy source. The base of the appendix is divided either with
an endoscopic stapler or after placing an endoloop. In the case
of a nonviable appendix base, a staple line through the cecum
that avoids the ileocecal valve might be sufficient, unless sig-
nificant inflammation is present. The appendix is retrieved
through the midline port in a specimen bag, especially if an
appendiceal lesion is suspected. If a periappendiceal phlegmon
is encountered or if the operation is being performed for perfo-
rated appendicitis, careful sweeping of the bowel with a blunt
dissector can release the appendix. It is important to carefully
separate adjacent bowel, which can be friable in such settings.
Conversion to open surgery should be considered for failure to
progress. Typically, once the base of the appendix is identified,
it is generally more helpful to divide the stump first. An endo-
scopic stapler or endoloop can be used for the base, provided
the base is viable. Occasionally, an ileocecectomy is necessary
when resection of the base of the appendix or cecum is likely to
impinge on the ileocecal valve. The mesoappendix is similarly
divided with either a stapler with thin leg length staples, a clip,
cautery, or energy device.
Novel Techniques
Three novel techniques have been investigated in the performance
of an appendectomy: single incision appendectomy, natural orifice
transluminal endoscopic surgery (NOTES), and robotic appendec-
tomy. Single incision appendectomy has not been shown to
improve outcomes, including cosmetic outcomes, in pro-
5 spective randomized studies and has been suggested to have
a higher incisional hernia rate.53 NOTES surgery has been shown
to have better cosmetic outcome and less postoperative pain in a
meta-analysis of NOTES procedures including appendectomies,
although only 40 patients were included in the analysis.54 The risk
of luminal contamination and closure of enteral or vaginal mucosa
remain suboptimal; for this reason, there has not been widespread
dissemination of this technique.55 Robotic appendectomy allows
flexible motions of intraperitoneal instruments and is therefore
superior in ergonomics for the surgeon.56 However, it is extremely
expensive and requires larger ports based on most of the current
platforms; thus, this technique is also not utilized widely.
Negative Exploration
Upon performing a laparoscopy or laparotomy for suspected
appendicitis, if one finds no evidence of appendicitis, a thor-
ough exploration of the peritoneum must be performed to
rule out contributing pathology. A normal appendix is often
removed to reduce future diagnostic dilemma.57 Management
of incidentally found common conditions is summarized in
Table 30-3.
Incidental Appendectomy
The practice of prophylactic appendectomy has been considered
during other operations to prevent the future risk of appendici-
tis.6,58 It is routinely performed in children undergoing chemo-
therapy, compromised hosts with an unclear physical exam,
patients with Crohn’s disease with a normal cecum, patients
traveling to remote places with no urgent care, and in patients
undergoing cytoreductive operations for ovarian malignancies.59
While there is no evidence clearly evaluating long-term out-
comes of patients undergoing incidental appendectomy
6 with an asymptomatic appendix, the risk of adhesions and
future complications after an appendectomy has been suggested
to be higher than the risk of future appendicitis and increased
economic costs. For these reasons, an incidental appendectomy
is currently not advocated.
 1337

Anesthesiologist

CHAPTER 30 THE APPENDIX

Assistant

Surgeon

Figure 30-2. Operating room setup.

SPECIAL CIRCUMSTANCES
Table 30-3
Appendicitis in Children
Management of Intraoperative Findings Mimicking
Almost 1 in 8 children undergo a workup for the diagnosis of
appendicitis.60,61 Of these, infants and young children are most Appendicitis
likely to present with perforated disease (51%–100%), while Ovarian Torsion Conservative
school-age children have lower rates of perforation.62,63,64 While management with
most age groups demonstrate the same symptoms previously detorsion and
described in adults, neonates can also present with abdominal oophoropexy
distension and lethargy or irritability. The Pediatric Appendici- Crohn’s terminal ileitis Appendectomy if base
tis Score has components similar to the Alvarado Score and is uninflamed
scored of 10 points, with maximum weight (2 points each) for Meckel’s diverticulitis Segmental small bowel
right lower quadrant tenderness and pain with cough, percussion resection and primary
or hopping. A score of 7 or greater indicates that the patient has anastomosis
a high chance of having appendicitis (78%–96% percent).65
Appendiceal Mass Laparoscopic
In the pediatric population, special considerations must be
appendectomy/
made to exclude relevant differential diagnoses such as intus-
ileocecectomy without
susception (currant jelly stools, abdominal mass), gastroenteritis
capsular disruption or
(often no luekocytosis), malrotation (pain out of proportion),
spillage and retrieval in
pregnancy (ectopic), mesenteric adenitis, torsion of the omen-
a bag
tum, and ovarian or testicular torsion.
1338 With regard to the management of children with appen-
dicitis, early appendicitis is treated preferably with a laparo-
scopic appendectomy, which has better outcomes than open
appendectomies in children.66,67 For patients with complicated
appendicitis, urgent appendectomy is advocated in the setting
of no abscess or mass. Laparoscopic appendectomy appears to
retain its benefits in this setting as well.68,69 In the setting of a
perforation, antibiotics are continued after surgery for at least
3 days, and preferably 5 days (APSA guidelines).70,71 Manage-
ment of perforated appendicitis with abscess is similar to adults,
although no adverse effects of an early laparoscopic appendec-
tomy have been seen even in this setting.39,72,73,74
PART II
Nonoperative management of appendicitis has also been
studied in children.75-77 It may be safe for children with early
presentation (less than 48 hours), limited inflammation (WBC
less than 18,000/cu.ml), appendicoliths, and no evidence of rup-
ture on imaging.78 Patients are usually administered IV antibi-
SPECIFIC CONSIDERATIONS
otics until inflammation reduces and then transitioned to oral
antibiotics.79 This is usually effective in reducing inflammation
(88%–92%), but has a recurrence rate of 22% at 1 year and
increased resource utilization.80
Appendicitis in Older Adults
Older adult patients can have diminished inflammation and thus
present with perforation or abscess more frequently.81,82
7 Such patients are at a higher risk for complications because
of their premorbid conditions, and it is more prudent to obtain
definitive diagnostic imaging prior to taking patients to the
operating room. Laparoscopic appendectomy is safe and might
allow patients to reduce pain and their hospital stay.83
Appendicitis in Pregnancy
Appendicitis occurs in 1 in 800 to 1 in 1000 pregnancies,
mostly in the first and second trimesters. Its incidence is rare
in the antepartum state, and it can occur in the postpartum state
in geriatric pregnancies (maternal age greater than 35 years).84
While the majority of the clinical features are similar, patients
can also present with heartburn, bowel irregularity, flatulence,
or a change in bowel habits. The point of maximum tender-
ness is usually displaced on physical exam. Ultrasonography is
the preferred imaging modality, although nonvisualization can
occur. Sensitivity can vary from 67% to 100%, and specificity
varies from 93% to 96%.39 An alternative imaging modality is
MRI, with a sensitivity of 94% and specificity of 97%.85 While
CT can be performed in pregnancy, the risk of fetal irradiation
leads many practitioners to avoid it unless other modalities are
inconclusive.86 When discussing options with the patient and the
patient’s family, it is important to note that the risk of fetal loss
is up to 36% if appendiceal perforation occurs.87 Therefore, there
remains a lower threshold to operate on such patients, with an
acceptable negative exploration rate of as high as 30%. Lapa-
roscopic appendectomies can be safely performed in pregnant
patients, although studies suggest a variable but reproducible
higher rate of fetal loss (around 7% vs. 3%) than open tech-
niques. Lower intra-abdominal pressures (10–12 mmHg) during
insufflation have been suggested to reduce early labor. Nonoper-
ative management has also been proposed for pregnant patients,
but treatment failure rates have been reported as high as 25%.
Chronic or Recurrent Appendicitis
Patients with recurrent right lower quadrant abdominal pain not
associated with a febrile illness with imaging findings sugges-
tive of an appendicolith or dilated appendix are classified as
having chronic appendicitis.88 Patients often report resolution
of symptoms with an appendectomy. In the absence of imaging
abnormalities, prophylactic appendectomy is not encouraged.45
OUTCOMES AND POSTOPERATIVE COURSE
Appendectomy is a relatively safe procedure with an extremely
low mortality rate (less than 1%). The commonest adverse
events include soft tissue infections, either superficial or
8 deep (including abscesses). Patients with uncomplicated
appendicitis do not require further antibiotics after an appendec-
tomy, while patients with perforated appendicitis are treated
with 3 to 7 days of antibiotics (4 days from the STOP-IT trial).89
Patients with wound infections can be managed with simple
wound opening and packing, and delayed primary closure has
not been shown to be beneficial.90 In laparoscopic cases, these
are usually the periumbilical ports.91 Patients with deep space
abscesses are managed with percutaneous drainage and antibiot-
ics. Fistulas (appendicocutaneous or appendicovesicular) are
managed conservatively as the first step. Bowel obstructions
and infertility are infrequent but reported.
Stump Appendicitis
An uncommon complication after surgery is the development
of appendicitis in an incompletely excised appendiceal stump
(greater than 0.5 cm stump length). Optimal management
requires reexcision of the appendiceal base, but diagnosis can be
difficult and requires careful assessment of the patient’s history,
physical exam, and imaging studies.92 Use of the “appendiceal
critical view” (appendix placed at 10 o’clock, taenia coli/libera
at 3 o’clock, and terminal ileum at 6 o’clock) and identification
of where the taeniae coli merge and disappear is paramount to
identifying and ligating the base of the appendix during the ini-
tial operation (Fig. 30-3). In patients who have had prior appen-
dectomy, a low index of suspicion is important to prevent delay
in diagnosis and complications. Prior appendectomy should not
be an absolute criterion in ruling out acute appendicitis.
Appendiceal Neoplasms
The incidence of appendiceal neoplasms is estimated at around
1% of all appendectomy specimens, although the true incidence
of appendiceal neoplasms is not known.93 Neoplasms that occur
in the appendix are predominantly gastroenteropancreatic neu-
roendocrine tumors (or GEP-NETs, previously called carci-
noids), mucinous neoplasms, or adenocarcinomas.94-96 Almost
one-third of the neoplasms of the appendix present with acute
appendicitis, while the others are often incidentally detected or
are detected after regional spread of disease.97
Gastroenteropancreatic Neuroendocrine
Tumors (GEP-NETs or Carcinoid)
Appendiceal carcinoid tumors are submucosal rubbery masses
that are detected incidentally on the appendix.98 Carcinoid
tumors of the appendix are relatively indolent but can develop
nodal or hepatic metastases.99 Infrequently, these can be associ-
ated with a carcinoid syndrome if there are hepatic metastases
(2.9%).100 Upon incidental findings of a suspected carcinoid, the
surgeon must evaluate the nodal basin along the ileocolic ped-
icle and also examine the liver for any signs of metastases. For
lesions that are less than 1 cm (95% of all lesions), a negative
margin appendectomy is adequate. For tumors 2 cm or larger, a
right hemicolectomy is recommended. For lesions 1 to 2 cm in
size, there is no consensus on a completion colectomy. A right
colectomy is often performed for mesenteric invasion, enlarged

A B
Figure 30-3. A and B. Appendiceal critical view.
nodes, or positive or unclear margins. Measurement of serum
chromogranin A is recommended.
Goblet Cell Carcinomas
These lesions were mistakenly called goblet cell carcinoids,
implying a rather indolent biology, while goblet cell carcinomas
are adenocarcinoid with both adenocarcinoma and neuroendocrine
features.101,102 Such lesions carry a worse prognosis than carcinoids
but slightly better than adenocarcinomas. There is a high risk of
peritoneal recurrence in such cases. For incidentally detected
lesions, a systematic surveillance of the peritoneum must be per-
formed, and a peritoneal cancer index score must be documented
if disease is present.103 In the absence of metastatic disease, a right
hemicolectomy is generally appropriate, although some advocate
for a right colectomy only for tumors 2 cm or larger.104
Lymphomas
Appendiceal lymphomas are rare (1%–3% of lymphomas, usu-
ally non-Hodgkin’s) and difficult to diagnose preoperatively
(appendiceal diameter can be 2.5 cm or larger).105,106 Manage-
ment includes an appendectomy in most cases.
Adenocarcinoma
Primary adenocarcinoma of the appendix is a rare neoplasm with
three major histologic subtypes: mucinous adenocarcinoma,
colonic adenocarcinoma, and adenocarcinoid. The most common
mode of presentation for appendiceal carcinoma is acute
9 appendicitis. Patients also may present with ascites or a
palpable mass, or the neoplasm may be discovered during an
operative procedure for an unrelated cause. The recommended
treatment for all patients with adenocarcinoma of the appendix is
a formal right hemicolectomy. Appendiceal adenocarcinomas
have a propensity for early perforation, although they are not
clearly associated with a worsened prognosis. Overall 5-year sur-
vival is 55% and varies with stage and grade. Patients with
appendiceal adenocarcinoma are at significant risk for both syn-
chronous and metachronous neoplasms, approximately half of
which will originate from the gastrointestinal tract.
Appendiceal Mucoceles and Mucinous
Neoplasms of the Appendix
The term appendiceal mucocele broadly describes a mucus-filled
appendix that could be secondary to neoplastic or nonneoplastic
1339
CHAPTER 30 THE APPENDIX
pathologies (mucosal hyperplasia, simple or retention cysts,
mucinous cystadenomas, mucinous cystadenocarcinoma). The
most common form of presentation is incidental; however, pre-
sentation with appendicitis occurs in a third of cases.107,108 On
cross-sectional imaging, a low attenuation, round, well encapsu-
lated cystic mass in the right or quadrant is often encountered,
and features such as wall irregularity and soft tissue thickening
are suggestive of a neoplastic process. It is important to carefully
assess for the presence of ascites, peritoneal disease, and scal-
loping of the liver surface on imaging upon initial evaluation.
A reliable diagnosis cannot be established using imaging alone,
and it is recommended that surgical excision without capsular
disruption is undertaken.109 The importance of careful handling
of a mucocele and the avoidance of rupture cannot be overem-
phasized because the intraperitoneal spread of neoplastic cells at
subsequent development of pseudomyxoma peritonei are nearly
certain in cases of adenocarcinoma.110,111 When suspecting a
mucinous neoplasm of the appendix, it is imperative to systemat-
ically examine the peritoneum and document a peritoneal cancer
index score if mucin is present. Biopsies to examine the content
of epithelial cell, neoplastic cells, and mucin can be helpful.
In cases where a homogeneous cyst without nodularity or
signs of dissemination is encountered, laparoscopic excision is
acceptable, provided that a stapler is fired across the base of
the cecum to avoid a positive margin. The specimen should be
placed in a plastic bag and carefully removed through a small
incision. In the absence of mesenteric or peritoneal involvement,
an appendectomy with concurrent appendiceal lymphadenec-
tomy is sufficient, as the chances of lymph node involvement
are quite low. If peritoneal spread is evident upon exploration, it
is important to obtain biopsies and document the peritoneal dis-
ease burden. An appendectomy is acceptable if the patient has
acute appendicitis, but suboptimal debulking is discouraged. In
addition, colorectal, ovarian, and endometrial cancers can coex-
ist in the setting of appendiceal mucoceles, and careful examina-
tion of intra-abdominal structures is important.
When there is discordance between the primary lesion
histology and the peritoneum, the peritoneal histology is usu-
ally given priority. For instance, if patients had a neoplasm in
the appendix but adenocarcinoma in the peritoneum, the patient
would be considered as having adenocarcinoma (AJCC M1b)
disease. The recent AJCC 8th edition and the PSOGI 2016
1340 Table 30-4
AJCC 8th edition and the PSOGI 2016 classification consensus of mucinous neoplasia of the appendix
LESION PERITONEAL DISEASE AT DIAGNOSIS PROGNOSIS TREATMENT
Low-grade appendiceal Confined to the appendix Excellent-curative Negative margin
mucinous neoplasm appendectomy, rarely need
(LAMN) ileocecectomy
LAMN Peri-appendiceal Acellular mucin Excellent-low risk of Negative margin
dissecting through the wall (t4a) or recurrence appendectomy, resection of
adjacent organs (t4b) acellular mucin
PART II

LAMN Peri-appendiceal Epithelial cells Excellent-high risk of Negative margin

dissecting through the wall (t4a) or
adjacent organs (t4b)
LAMN Distant epithelial cells or acellular
SPECIFIC CONSIDERATIONS
recurrence appendectomy, peritoneal
surveillance with second
look laparoscopy vs. HIPEC
Excellent-high risk of Negative margin

mucin (M1a) recurrence appendectomy,

Low grade mucinous carcinoma omentectomy, HIPEC
peritonei
High-grade appendiceal Management is identical to a LAMN with risk stratification as shown above but slightly worse
mucinous neoplasm prognosis.
(HAMN-rare)
Mucinous adenocarcinoma Confined to the appendix Very Good Right hemicolectomy
Mucinous adenocarcinoma Peritoneal Dissemination Well Differentiated-Very Cytoreductive surgery and
High grade mucinous carcinoma good HIPEC, with systemic
peritonei with or without signet Moderately differentiated chemotherapy for high grade
ring cells –Good histologies
Poorly differentiated/signet
ring cell histology:
10 year survival of 10-20%
Adenocarcinoma (non- Management identical to the mucinous histologies, with more extensive use of systemic
mucinous, including chemotherapy
goblet cell histology)
Serrated Adenoma (rare) Confined to appendix Excellent-curative Appendectomy
Adenoma (rare) Confined to appendix Excellent-curative Appendectomy
Data from American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York,
2017 and Carr NJ, Cecil TD, Mohamed F, et al: A Consensus for Classification and Pathologic Reporting of Pseudomyxoma Peritonei and Associated
Appendiceal Neoplasia: The Results of the Peritoneal Surface Oncology Group International (PSOGI) Modified Delphi Process, Am J Surg Pathol.
2016 Jan;40(1):14-26.

classification consensus has resulted in a therapy-directed clas- made the morbidity and mortality similar to any major open GI
sification of mucinous neoplasms of the appendix, summarized procedure. This technique can also be performed laparoscopi-
in Table 30-4.112 cally when the disease is detected early and is low volume.

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drome can have varied prognosis ranging from curative to pal-
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chemotherapy (HIPEC) are considered the standard of care for
patients with PMP syndrome from appendiceal primaries.113-115
Early detection and management of limited peritoneal dis-
ease is favorable and preferred as opposed to extensive intra-
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parietal and visceral peritonectomies, and intraperitoneal
administration of heated (42oC [108oF]) chemotherapy (usually
mitomycin) in the abdomen. Previously considered a morbid
surgery, high volume centers and standardized practices have
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