Title: Hernias No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than Hernia in all its varieties.
1HerniasNo disease of the human body, belonging
to the province of the surgeon, requires in its
treatment a better combination of accurate
anatomical knowledge with surgical skill than
Hernia in all its varieties.
Sir Astley Paston Cooper
(1804)
2Introduction
- It is an abnormal protrusion of an organ or
tissue through a defect in its surrounding walls.
- These sites most commonly include the inguinal,
femoral, and umbilical areas, the linea alba, the
lower portion of the semilunar line, and sites of
prior incisions.
3Abdominal Wall Hernias
- Groin
- Inguinal
- Indirect
- Direct
- Combined
- Femoral
- Anterior
- Umbilical
- Ventral
- Epigastric
- lateral
- hypogastric
- Spigelian
- Pelvic
- Obturator
- Sciatic
- Perineal
- Posterior
- Lumbar
4Incidence
- Approximately 75 of all hernias occur in the
inguinal region. Two thirds of these are
indirect, and the remainder are direct inguinal
hernias. - Men are 25 times more likely to have a groin
hernia than women. - There is a female dominance in femoral and
umbilical hernias of approximately 10 to 1 and 2
to 1, respectively. - Strangulation, the most common serious
complication of a hernia.
5Etiology
- Defect in the abdominal wall may be congenital
(e.g. inguinal canal, femoral canal) or acquired
(e.g. an incision). - Raised intra-abdominal pressure further weakens
the defect allowing some of the intra-abdominal
contents (e.g. omentum, small bowel loop) to
migrate through the opening. - A chronic cough, straining on micturition
or straining on defecation lifting a heavy
weight are all increase the intra abdominal
pressure - Smoking result of an acquired collagen deficiency
- Stretching of the abdominal musculature because
of an increase in contents, as in and intra
abdominal mass like malignancy. Obesity, can be
another factor. - Fat acts to separate muscle bundles and layers,
weakens aponeuroses and favours the appearance of
paraumbilical, direct inguinal and hiatus
hernias. - congenital preformed sac
6Composition of a hernia
- As a rule, a hernia consists of three parts the
sac, the coverings of the sac and the contents of
the sac. - The sac
- The sac is a diverticulum of peritoneum,
consisting of mouth, neck, body and fundus. The
neck is usually well defined but in some direct
inguinal hernias and in many incisional hernias
there is no actual neck. The diameter of the neck
is important because strangulation of bowel is a
likely complication when the neck is narrow, as
in femoral and paraumbilical hernias. - The covering
- Coverings are derived from the layers of the
abdominal wall through which the sac passes. - Contents
- These can be
- omentum omentocele (synonymepiplocele)
- intestine enterocele more commonly small
bowel but may be large intestine or appendix - a portion of the circumference of the intestine
Richters hernia - a portion of the bladder (or a diverticulum)
may constitute part of or be the sole content of
a direct inguinal, a sliding inguinal or a
femoral hernia - ovary with or without the corresponding
fallopian tube - a Meckels diverticulum a Littres hernia
- fluid, as part of ascites or as a residuum
thereof.
7Pathology
- An external hernia protrudes through all layers
of the abdominal wall, whereas an internal hernia
is a protrusion of intestine through a defect
within the body cavity. An interparietal hernia
occurs when the hernia sac is contained within a
musculoaponeurotic layer of the abdominal wall
eg Spigelian hernia . - Special forms
- Sliding A sliding hernia occurs when a
retroperitoneal organ comprises a portion of the
wall of the hernia sac. The most common viscus
involved is the colon or urinary bladder. - Most sliding hernias are a variant of
indirect inguinal hernias, although femoral and
direct sliding hernias can occur. - The primary danger associated with a
sliding hernia is the failure to recognize the
visceral component of the hernia sac and injury
to the bowel or bladder. - Maydls (Strangulated loop above defect)
8 9Spigilian hernia
10Complications
- Entrapment of the contents in the sac leads to
incarceration (unable to reduce contents) ,
intestinal obstruction and possibly strangulation
(blood supply to incarcerated contents is
compromised). - Other complications include inflammation,
hydrocele of hernial sac and rupture of hernial
sac.
11Classification
- Hernia may be
- Reducible hernias
- The hernia either reduces itself when the patient
lies down or can be reduced by the patient or the
surgeon. - The intestine usually gurgles on reduction and
the first portion is more difficult to reduce
than the last. - Omentum, in contrast, is described as doughy and
the last portion is more difficult to reduce than
the first. - A reducible hernia imparts an expansile impulse
on coughing. - Irreducible hernia
- In this case the contents cannot be returned to
the abdomen but there is no evidence of other
complications. It is usually due to adhesions
between the sac and its contents or overcrowding
within the sac. Note that any degree of
irreducibility predisposes to strangulation. - Obstructed hernia
- This is an irreducible hernia containing
intestine that is obstructed from without or
within, but there is no interference to the blood
supply to the bowel. The symptoms (colicky
abdominal pain and tenderness over the hernia
site) are less severe and the onset more gradual
than in strangulated hernias, but more often than
not the obstruction culminates in strangulation.
- Usually there is no clear distinction clinically
between obstruction and strangulation and the
safe course is to assume that strangulation is
imminent and treat accordingly. - Incarcerated hernia
- The term incarceration is often used loosely as
an alternative to obstruction or strangulation
but is correctly employed only when it is
considered that the lumen of that portion of the
colon occupying a hernial sac is blocked with
faeces. - Strangulated hernia
- A hernia becomes strangulated when the blood
supply of its contents is seriously impaired,
rendering the contents ischaemic. Gangrene may
occur as early as 56 hours after the onset of
the first symptoms.
12 Strangulated herniaPathology
- The intestine is obstructed and its blood supply
impaired. Initially, only the venous return is
impeded the wall of the intestine becomes
congested and bright red with the transudation of
serous fluid into the sac. As congestion
increases the wall of the intestine becomes
purple in colour. The intestinal pressure
increases, distending the intestinal loop and
impairing venous return further. As venous stasis
increases, the arterial supply becomes more and
more impaired. Blood is extravasated under the
serosa and is effused into the lumen. The fluid
in the sac becomes blood-stained and the shining
serosa dull because of a fibrinous, sticky
exudate. At this stage the walls of the intestine
have lost their tone and become friable.
Bacterial transudation occurs secondary to the
lowered intestinal viability and the sac fluid
becomes infected. Gangrene appears at the rings
of constrictionwhich become deeply indented and
grey in colour. The gangrene then develops in the
anti-mesenteric border, the colour varying from
black to green depending on the decomposition of
blood in the subserosa. The mesentery involved by
the strangulation also becomes gangrenous. If the
strangulation is unrelieved, perforation of the
wall of the intestine occurs, either at the
convexity of the loop or at the seat of
constriction. Peritonitis spreads from the sac to
the peritoneal cavity.
13 Strangulated herniaClinical
features
- Pain, at first situated over the hernia, is
followed by generalised abdominal pain, colicky
in character and often located mainly at the
umbilicus. Nausea and subsequently vomiting
ensue. - The patient may complain of an increase in hernia
size. - On examination the hernia is tense, extremely
tender and irreducible, and there is no expansile
cough impulse.
14Clinical features hernia
- Painless bulge which increase with straining and
disappear on laying down patients may complain
of a full or dragging sensation . Hernias are
usually not painful unless complicated or huge . - Predisposing factors and complications should be
included during history taking . - Bulge elicited with the Valsalva maneuver,
coughing or straining helps demonstrate small
hernias. - On examination you could find a mass in a sit of
hernial orifice which is reducable , and gives
impuls on cough. - Femoral hernias are below and lateral to the
pubic tubercle,50 present as a surgical
emergency due to obstructed contents. - Inguinal hernias start off above and medial to
the pubic tubercle but may descend broadly when
larger. - (a) Indirect inguinal hernias can be controlled
by digital pressure over the internal inguinal
ring, and are common in younger. - (b) Direct inguinal hernias are poorly controlled
by digital pressure and are commoner in older men
. -
- Finally, a fingertip is placed into the
inguinal canal by invaginating the scrotum to
detect a small hernia. A bulge moving lateral to
medial in the inguinal canal suggests an indirect
hernia. If a bulge progresses from deep to
superficial through the inguinal floor, a direct
hernia is suspected.
15Clinical features
- Incisional hernias bulge through previous scar ,
and are accentuated by tensing the recti. Large
incisional hernias may contain much of the small
bowel and may by irreducible/ dificult in repair
due to the loss of the right of abode in the
abdomen of the contents. - True umbilical hernias are present from birth and
are symmetrical defects in the umbilicus due to
failure to close. Or can be seen in ascetics - Para-umbilical hernias develop due to an
acquired defect in the periumbilical fascia below
or above the umbilicus. - The evaluation of other abdominal wall hernias
also requires diligent physical examination. As
with the inguinal region, the anterior abdominal
wall should be evaluated - Assess the hernia for predisposing factors
,severity of symptoms, risk of complications
(type, size of neck), ease of repair (size,
location), likelihood of success (size, loss of
right of abode). - Assess the patient for fitness for surgery,
impact of hernia on lifestyle (job, hobbies).
16inguinal hernia
- Types of inguinal hernia
- Inguinal hernias are classified as either direct
or indirect. The sac of an indirect inguinal
hernia passes from the internal inguinal ring
obliquely toward the external inguinal ring and
ultimately into the scrotum. In contrast, the
sac of a direct inguinal hernia protrudes outward
and forward and is medial to the internal
inguinal ring and inferior epigastric vessels.
Combined inguinal hernia are bouth direct and
indirect
17Anatomy of the inguinal canal
- The inguinal canal is approximately 4 cm in
length and is located 2 to 4 cm cephalad to the
inguinal ligament. In infants, the superficial
and deep inguinal rings are almost - superimposed and the obliquity of the canal is
slight - The canal extends between the internal (deep)
inguinal and the external (superficial) inguinal
rings. - The superficial inguinal ring is a triangular
aperture in the aponeurosis of the external
oblique muscle and lies 1.25 cm above the pubic
tubercle. - The deep inguinal ring is a U-shaped condensation
of the transversalis fascia and it lies 1.25 cm
above the inguinal (Pouparts) ligament, midway
between the symphysis pubis and the anterior
superior iliac spine. - The anterior boundary comprises mainly the
external oblique aponeurosis with the conjoined
muscle laterally. - The posterior boundary is formed by the fascia
transversalis and the conjoined tendon (internal
oblique and transversus abdominus medially). - The inferior epigastric vessels lie posteriorly
and medially to the deep inguinal ring. - The superior boundary is formed by the conjoined
muscles (internal oblique and transversus) - and the inferior boundary is the inguinal
ligament.
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19Content of the inguinal canal
- The inguinal canal contains the spermatic cord or
the round ligament of the uterus. - The spermatic cord is composed of cremasteric
muscle fibers, external and internal spermatic
fascia the testicular artery and accompanying
veins, the genital branch of the genitofemoral
nerve, the vas deferens, the cremasteric vessels,
the lymphatics, and the processus vaginalis. - The iliohypogastric and ilioinguinal nerves and
the genital branch of the genitofemoral nerve are
the important nerves in the groin area - The iliohypogastric and ilioinguinal nerves
provide sensation to the skin of the groin, the
base of the penis, and the ipsilateral upper
medial thigh. - The genital nerve innervates the cremaster muscle
and the skin on the lateral side of the scrotum
and labia
20The Hesselbach triangle
- The inferior epigastric vessels serve as its
superolateral border, the rectus sheath as medial
border, and the inguinal ligament as the inferior
border. Direct hernias occur within the
Hesselbach triangle, whereas indirect inguinal
hernias arise lateral to the triangle
21Direct and indirect inguinal hernia
22Femoral Canal
- The boundaries of the femoral ring are
- anteriorly by the inguinal ligament
- posteriorly by Astley Coopers (iliopectineal)
ligament, the pubic bone and the fascia over the
pectineus muscle - medially by the concave knife-like edge of
Gimbernats (lacunar) ligament, which is also
prolonged along the iliopectineal line, as Astley
Coopers ligament - laterally by a thin septum separating it from
the femoral vein. - A femoral hernia occurs through this space and is
medial to the femoral vessels
23Inguinal hernia
24Differential diagnosis of inguinal hernia
- In the male
- vaginal hydrocele
- encysted hydrocele of the cord
- spermatocele
- femoral hernia
- incompletely descended testis in the inguinal
canal an - inguinal hernia is often associated with this
condition - lipoma of the cord this is often a difficult
but unimportant diagnosis and it is usually not
settled until the parts are displayedby
operation. - In females
- hydrocele of the canal of Nuck this is the
most common differential - diagnostic problem
- femoral hernia.
25Treatment of inguinal hernia
- Most surgeons recommend operation on discovery of
an inguinal hernia because the natural history of
a groin hernia is that of progressive enlargement
and weakening, with the potential for
incarceration and strangulation. - In adults, local, epidural or spinal, as well as
general anaesthesia, can be used - Principles of surgery
- Herniotomy The basic operation is inguinal
herniotomy, which entails dissecting out and
opening the hernial sac, reducing any contents
and then transfixing the neck of the sac and
removing the remainder. It is employed either by
itself or as the first step in a repair procedure
(herniorrhaphy). - Herniorrhaphy consists of (1) excisionof the
hernial sac plus (2) repair of the stretched
internal - inguinal ring and the transversalis
fascia and (3) further reinforcement of the
posterior wall of the inguinal canal. (2) and
(3) must be achieved without tension resulting in
the wound and various techniques exist to achieve
this, e.g. Shouldice operation. - Hernioplasty repair the defect with prosthetic
mish - The Lichtenstein tension-free hernia repair.
- This procedure is performed by careful
dissection of the inguinal canal. - High ligation of an indirect hernia sac is
performed - An 8 11-cm sheet of Marlex mesh is fashioned to
fit the inguinal canal. - And a new internal ring is made by mesh.
- It can be done by Laparoscopy .
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27Nyhus Classification of Groin Hernia
- Type I Indirect inguinal herniainternal
inguinal ring normal(e.g., pediatric hernia) - Type II Indirect inguinal herniainternal
inguinal ring dilated but posterior inguinal wall
intact inferior deep epigastric vessels not
displaced - Type III Posterior wall defect
- A. Direct inguinal hernia
- B. Indirect inguinal
herniainternal inguinal ring dilated,
medially encroaching on or destroying the
transversalis fascia of Hesselbachs triangle
(e.g., massive scrotal, sliding, or pantaloon
hernia) - C. Femoral hernia
- Type IV Recurrent hernia
- A. Direct
- B. Indirect
- C. Femoral
- D. Combined
28femoral hernia
- It is more common in female
- Usually presented by strangulated hernia
Presented by SS of intestinal obstruction
together with painful swelling in the femoral
triangle ( below and lateral to pubic tubercle )
may go up if large - DD An inguinal hernia. The neck of the sac
lies above and medial to the medial end of the
inguinal ligament at its attachment to the pubic
tubercle. The neck of the sac of a femoral hernia
lies below and lateral to this - A saphena varix. The swelling
disappears completely when the patient lies flat
whereas a femoral hernia sac is usually still
palpable. In both, there is an impulse on
coughing. A saphena varix will, however, impart a
fluid thrill to the examining fingers when the
patient coughs or when the saphenous vein below
the varix is tapped with the fingers of the other
hand. - An enlarged femoral lymph node. There
may be other enlarged lymph nodes to aid the
diagnosis. If Cloquets lymph node alone is
affected it may be impossible to distinguish from
a femoral hernia sac unless there are other
clues, such as an infected wound or abrasion on
the corresponding limb or on the perineum. - Lipoma.
- A femoral aneurysm.
- A psoas abscess. There is often a
fluctuating swelling an iliac abscess which
communicates with the swelling in question. If
suspected, an examination of the spine and a
radiograph will confirm the diagnosis - A distended psoas bursa. The swelling
diminishes when the hip is flexed and
osteoarthritis of the hip is present. - Rupture of the adductor longus with
haematoma formation. Suspected on clinical
history - A femoral hernia can be repaired using the
standard Cooper ligament repair, a preperitoneal
approach, or a laparoscopic approach
29UMBILICAL HERNIA
- Exomphalos ( minor lt5cm major ) is a
congenital umbilical hernia in neonate due to
failiar of mid gut ton return to the abdomen .
The bowel is covered by amniotic membrane and
whartons jelly . It is treated by urgent
surgery - Umbilical hernias in infants ( infantile
umbilical hernia) are congenital and are quite
common. They close spontaneously in the vast
majority of cases by the age of 2 years. Those
that persist after the age of 5 years are
frequently repaired surgically, although
complications related to these hernias in
children are unusual. - Umbilical hernias in adults are largely acquired.
These hernias occur more frequently in women and
in patients with conditions that result in
increased intra-abdominal pressure, such as
pregnancy, obesity, ascites, or abdominal
distention. Strangulation and rupture of the
hernia can occur in chronic ascitic conditions.
Adults who have symptoms, a large hernia,
incarceration, thinning of the overlying skin, or
uncontrollable ascites should have hernia repair. - Paraumbilical hernia occur due to defect in
linia alba just above ( commoner) or below the
umbilicus . It is usually partially irreducible
because of the formation of omental adhesions
within the sacand the neck of the sac is often
remarkably narrow compared with the size of the
sac and the volume of its contents. Women are
affected five times more frequently than men. The
patient is usually overweight and between the
ages of 35 and 50. Repeated pregnancy are
important aetiological factors. Symptomatically,
a large umbilical hernia causes a dragging pain
because of its weight. Gastrointestinal symptoms
are common and are probably due to traction on
the stomach or transverse colon. Often there are
transient attacks of intestinal colic because of
partial intestinal obstruction. - In long-standing cases, intertrigo of the
adjacent surfaces of skin and trophic ulcers of
the fundus are troublesome complications. - Classically, repair was done using the
vest-over-pants repair proposed by Mayo. - Larger defects (greater than 3 to 4 cm)
should be closed using prosthetic mesh . - Also can be repaired by a laparoscopic
approach with intra-abdominal mesh placement
30UMBILICAL HERNIA
31EPIGASTRIC HERNIAS
- Epigastric hernias are two to three times more
common in men. These hernias are located between
the xiphoid process and umbilicus and are usually
within 5 to 6 cm above the umbilicus. - The defects are small and often produce pain out
of proportion to their size owing to
incarceration of preperitoneal fat. - They are multiple in up to 20 of patients.
Repair is often accomplished by simple closure of
the fascial defect .
32INCISIONAL AND VENTRAL HERNIAS
- Incisional hernias have been reported to occur in
up to 10 of laparotomies. - Incisional hernias occur as a result of excessive
tension and inadequate healing of a previous
incision, which is often associated with surgical
site infections. - Obesity, advanced age, malnutrition, ascites,
pregnancy, and conditions that increase
intraabdominal pressure are predisposing factors
for the development of an incisional hernia. - Chronic pulmonary disease and diabetes mellitus
have also been recognized as risk factors for the
development of incisional hernia. - Medications such as corticosteroids and
chemotherapeutic agents and can contribute to
poor wound healing and increase the risk of
developing an incisional hernia.
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34INCISIONAL AND VENTRAL HERNIAS
- These hernias enlarge over time, leading to pain,
bowel obstruction, incarceration, and
strangulation. - Large ventral hernias can result in loss of
abdominal domain, which occurs when the abdominal
contents no longer reside in the abdominal
cavity. - Return of displaced viscera to the abdominal
cavity during repair may lead to increased
abdominal pressure, abdominal compartment
syndrome, and acute respiratory failure. - Primary repair of incisional hernias can be done
when the defect is small (lt4 cm) and there is
viable surrounding tissue. Larger defects (gt4 cm
in diameter) have a high recurrence rate if
closed primarily and should be repaired with a
prosthesis. Recurrence rates vary between 10 and
50 and are generally lower with prosthetic mesh
repairs. Prosthetic material may be placed as an
on-lay patch to buttress a tissue repair,
interposed between the fascial defect, or
sandwiched ( in-lay) between tissue planes. - The use of laparoscopic ventral hernia repair has
been increasing, particularly for large defects.
35Management of Strangulated Hernias
- Causes
- Pathology
- Clinical picture
- Preoperative treatment of strangulated hernias
- Resuscitate with adequate fluids and
electrolyte - Empty stomach with nasogastric tube
- Give antibiotics to contain infection
- Catheterise to monitor haemodynamic state
- Repair of a suspected strangulated hernia is an
emergency. The hernia sac opened first and the
contents can be directly visualized and their
viability assessed. The constricting ring is
identified and can be incised to free the
entrapped viscus with minimal danger to the
surrounding organs, blood vessels, and nerves.
If it is necessary to resect strangulated
intestine, the peritoneum can be opened and
resection done without the need for a second
incision.
36Complication of hernia repair
- Wound infection Vs Prosthesis infection
- Hematoma
- Pulmonary embolism
- Ischemic orchitis
- Testicular atrophy
- Acute urinary retention.
- Chronic pain.
- Hernia recurrence. The recurrence rate after
surgery should be less than 2 - Nerve Injuries The nerves most commonly affected
during open hernia repair are the ilioinguinal,
genital branch of the genitofemoral, and
iliohypogastric .Transient neuralgias can occur
and are usually self-limited and resolve within a
few weeks after operation. Persistent neuralgias
usually result in pain and hyperesthesia in the
area of distribution. Symptoms are often
reproduced by palpation over the point of
entrapment. Transection of a sensory nerve
usually results in an area of numbness
corresponding to the distribution of the involved
nerve
37Burst abdomen
- Also known as abdominal wound dehiscence, wound
failure, wound disruption, evisceration, and
eventration. - Describes partial or complete postoperative
separation of an abdominal wound closure with
protrusion or evisceration of the abdominal
contents. - Wound dehiscence and incisional hernia are part
of the same wound failure process - Dehiscence of the wound occurs before cutaneous
healing, while incisional hernias lie under a
well-healed skin incision. - Accompanied by high morbidity and mortality.
38CLINICAL MANIFESTATION
- Dehiscence usually declares itself 7-14 days
post-operative . - May manifest following straining or removal of
the sutures. - Patient often notes a ripping sensation or a
feeling that something has given way. - Impending dehiscence of the abdominal wall is
often preceded by the appearance of a salmon-pink
serous discharge from the wound.
39RISK FACTORS FOR ABDOMINALWOUND DEHISCENCE
- These may conveniently be divided into
preoperative factors, operative factors, and
post-operative factors.
40Pre-Operative Factors
- Male Sex Among patients with wound dehiscence
men outnumber women by at least 2 to 1 - Age The incidence in the aged is higher
- lt45 y.o. dehiscence occurs in 1.3
- gt45 y.o. dehiscence occurs in 5.4
- Emergency Operation Has been shown to be a risk
factor for dehiscence in some studies. May be
related more to haemodynamic instability than too
the unscheduled procedure. - Diabetesdiabetes failed at a rate of 25,
usually secondary to wound sepsis. The
introduction of insulin improved these results. - Renal failure.
- Jaundice.
- Anaemia.
- Malnutritution Protein deficencies Vitamin C
- Corticosteriods
41Operative Factors
- Incision type
- Closure Mass versus Layered Closure
- Interrupted versus Continuous Sutures
- Suture Materials
- Size of Tissue Bite stitch interval and the
tissue bite are 1cm - Suture Length-to-Wound Length Ratio 41
42Post-Operative Factors
- Elevation of Intra-Abdominal Pressure This may be
due to coughing, vomitting , ileus, urinary
retention - Wound Infection
- Radiation TherapyBoth in the past and
perioperatively - Chimotherapy .
43TREATMENT
- For most patients immediate re-operation is
indicated - Pre-operative preparation include
- To cover the exposed bowel with sterile wet gauze
- broad spectrum antibiotics should be given.
- Morphia
- Intravenous fluid therapy
- Nell Per Oss