H E R N I A S AND INCISIONAL HERNIAS

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H E R N I A SANDINCISIONAL HERNIAS
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• Definition
• Hernia develops whenever the lining or contents
  of one finite anatomic space protrudes abnormally
  either into a surrounding tissue plane or into
  some adjacent body cavity

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• The defective hiatus in supporting structures is
  generally referred to as a ring or neck, while an
  outpocketing from the parent cavity is called the
  sac
• Allthough a sac need not be present, all hernias
  by definition are associated with a weekness,
  defect, or dilated hiatus in the confining wall
  of a primary compartment

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• Classification
• Anatomical
• Inguinal hernia (75 of hernias)
• Femoral hernia (6)
• Epigastric and ombilical hernia (5)
• Rarer abdominal wall hernias
• ( obturator, spigelian, lombar, sciatic,
  perineal)
• Clinical
• Reduicible - coercible
• - uncoercible
• Irreduicible incarcerated (no vasculary injury)
• - strangulated (with
  vasculary injury)

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Anatomy of the inguinal region
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Some definitions regarding hernia contents

• Reducible the contents can return to the
  abdominal cavity
• Ireducible incarcerated (viable contents)
• - strangulated (ischemic or
  necrotic
  contents)
• Sliding part of the wall of the sac may be
  colon on the left, caecum on the right, or
  bladder on either side
• Richters hernia a hernia that has strangulated
  a part of the intestinal wall, without
  compromising the lumen (stangulation not
  excluded)

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• Maydls hernia hernia containing two adjacent
  loops of small intestin, with strangulation
  of the segment between the loops
• Littres hernia a hernia containing a Meckel
  diverticulum

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Inguinal hernia

• Definition
• a protrusion of part of the contents of the
  abdomen through the inguinal region of the
  abdominal wall
• 75 of all hernias
• More common in male than in female

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Anatomy of the inguinal canal

• This canal has the following boundaries
• Anterior aponeurosis of the external oblique
• Posterior conjoint tendon combined tendon of
  internal oblique and transversus abdominis.
• Roof - arching fibres of internal oblique and
  transversus abdominis
• Floor inguinal ligament
• Medially is the pubic symphysis.
• Laterally is the anterior superior iliac spine.
• Contens of the inguinal canal
• - spermatic cord in men
• - round ligament in women

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The inguinal region (posterior view)
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Anatomical classification of inguinal hernia

• A. Indirect hernia passes through the intern
  ring
• Direct hernia passes through the
  Hasselbach triangle, a weak point of the
  posterior wall of the inguinal canal
• - little significance for treatment
• B. Inguinal hernia
• Inguino-scrotal hernia

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Types of inguinal hernia

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Precipitating factors

• Increased intraabdominal pressure
• - physical activity (ocupational history)
• - straining defecation or urination ( rectal or
  
• colon cancer, prostatic enlargement,
• constipation)
• - obesity
• - pregnancy
• - ascites
• - valsavagenic (coughing)
• Presence of an abnormal congenital anatomic route
  (patent processus vaginalis)

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Clinical features - symptomes

• Local symptoms
• - Pain or discomfort (there are painless
• 
  hernias too)
• - A lump in the inguinal region.
• ! Pain irreducibility of a previously
• reducible hernia strangulation
• gt emergency operation is indicated.

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Clinical features - symptomes

• Systemic symptoms are signs of complicated
• 
  hernias
• - Colicky abdominal pain
• - vomiting
• - abdominal distension
• - absolute constipation

A small defect is more dangerous because a tight
defect is more likely to strangulate
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Clinical features - signs

• Inspection
• - a lump in the inguinal region having
  expansile cough impulse
• Palpation
• - examination of the patient in standing and
  lying
• - palpation of the inguinal supperficial ring
  through the scrotum
• - reducible / unreducible
• - direct / indirect hernia
• Percussion and auscultation
• - a hernia that contains gut may be resonant,
  and bowel sounds may be audible over it

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Differential diagnosis

• 1. Femoral hernia - below and lateral to pubic
  tubercle
• 2. Lymph node - no cough impulsion
• - usually below
  inguinal ligament
• 3. Varicocele dilated veins in spermatic cord
  visible with patient
  standing
• 4. Cyst of canal Nuck able to get above lump
• 
  (females only)
• 5. Hydrocele not reducible (males only)
• 6. Undescebded testis- absence of the testis in
  scrotum
• - may be
  associated with patent
  processus vaginalis

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Evolutive complications

• Incarceration
• Strangulation gt infarction and necrosis of
• the contents gt perforation of the bowel
• Rare complications
• - local pressure effects on structures in
  proximity of the sac
• - rupture of the hernia

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Treatmet of inguinal hernia

• Hernia reduction (taxis)
• - should be tried in acute incarcerated hernia
• - should be done with gentle efforts
• - may need analgesia and sedation
• - if unsuccesfully after a few minutes of
  continous
  
  
• pressure gt emmergency operation (otherwise
  risk
• of injury of the sac contents)
• Using of a truss if surgery is considered
  inappropriate

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Hernia repair

• Basic principles
• 1. Eliminate or control factors that have
  favored
• the evolution of the hernia
• 2. Totally remove the sac or at least interrupt
  the communication between abdomen and hernia
  pouch
• 3. Correct any associated fascial defect by
  - narrowing a normally situated hiatus
  - transferring supporting structures to
  overcome any fascial weakness
• - implanting autogenous fascia or synthetic
  substitute

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Hernia repair technique

• There have been described several techniques
• Most used Halsted, Bassini, Shouldice, McVay,
• Ferguson
• Approach transperitoneal (seldom used)
• - inguinal
• Classification of techniques
• - anatomical
• - prefunicular
• - retrofunicular

Repair of the abdominal
wall
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Steps of the repair of the inguinal hernia

1. Inguinal incision
2. Incision of the aponeurosis of the externus
   muscle gt open the inguinal canal
3. Dissection of the spermatic cord and isolation of
   the hernia sac
4. Opening the sac, verifying and repositioning its
   contents
5. Ligation and excision of the sac
6. Reconstruction of the abdominal wall

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McVay procedure (retrofunicular)
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Shouldice procedure (anatomical)
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Laparoscopic repair of inguinal hernia

• Is considered appropriate only in indirect
  hernias with no muscular defect in the abdominal
  wall
• Laparoscopic herniorrhaphy by insertion of
  synthetic mesh to eliminate the muscular defect
  associated with an inguinal hernia is now the
  procedure most widely used

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Femoral hernia

• Definition a protrusion of peritoneum through
  the femoral canal
• It may contain - abdominal contents
• - extraperitoneal fat
• Are twice as common on the right side as on the
  left
• Are four times more common in women than in men
• Incidence increases with advancing age

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Anatomy of the femoral canal

• Borders
• - anteriorly - the inguinal ligament
  - posteriorly - the pectineal (Cooper's)
  ligament - medially - the unyielding lacunar
  ligament, and - laterally by the iliopsoas
  muscle
• Contents (from lateral to medial)
• - the femoral and the genitofemoral nerve
• - the femoral artery
• - the femoral vein
• The sac progresses usually towards the foramen
  ovale

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Anatomy of the femoral canal
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Development of femoral hernia
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Clinical features

• If reducible it may present as an asymptomatic
  lump or as localized intermittent discomfort
• If it becomes irreducible, the lump and localized
  discomfort become constant features
• Mild pyrexia localized discomfort gt
  strangulated omentum within the hernial sac
• Obstruction gt strangulated small bowel is likely

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• Richter's hernias are common in femoral hernias
  gt strangulation of the antemesenteric intestinal
  wall without obstruction
• Occasionally present with visible distension of
  the long saphenous vein gt the hernia has
  extended through the fossa ovalis and is
  compressing the sapheno-femoral junction
• Because of the tight femoral ring strangulation
  is more frequent than in inguinal hernias

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Femoral hernias - treatment

• Femoral hernias should not be treated
  conservatively (impossible to control the
  hernial neck with a truss and the incidence of
  strangulation is high)
• Principles of femoral hernia repair
• - excision or reduction of the hernial sac
• - and narrowing of the stretched femoral
  opening

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Approaches to femoral hernia repair

• The low approach
• - is suitable only for the uncomplicated small
  elective hernia in a thin patient
• - the incision is placed directly over the
  hernia, parallel to the inguinal ligament
• - the stretched femoral opening is narrowed by
  placing one or two non-absorbable sutures
  medial to the femoral ring, apposing the
  inguinal and pectineal ligaments

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Low approach sac dissection
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Low approach apposition of the inguinal and
pectineal ligament
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Approaches to femoral hernia repair

• The inguinal approach
• - is useful when a concomitant inguinal hernia
  needs to be repaired and obligatory when a
  femoral hernia is misdiagnosed as an inguinal
  hernia
• - The same incision as for an inguinal hernia
• - The femoral canal is approached through
  transversalis fascia on the back wall of the
  inguinal canal
• - Closure of the tissue layers is then
  completed as for an inguinal hernia.

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Inguinal approach
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Inguinal approach
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EPIGASTRIC HERNIA

• Is a protrusion of preperitoneal fat through a
  gap in the decussating fibres of the
  supraumbilical portion of the linea alba. The
  defect usually occurs where the linea alba is
  pierced by a blood vessel
• A peritoneal sac may accompany fat through the
  defect and may contain omentum but only rarely
  bowel
• The majority asymptomatic
• Rarely - Vague upper abdominal pain and nausea
  associated with epigastric tenderness (more
  severe when the patient is lying)

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Umbilical hernia

• Classification
• 1. Congenital (omphalocel, exomphalos)
• - At birth the umbilicus is absent and a broad
  defect in the abdominal wall is present
  through which viscera protrude into the
  umbilical cord. Peritoneum, but not skin,
  covers the protruding viscera
• 2. Infantile
• -after birth because of the failure of fusion
  of the ombilical cord stump to the umbilical
  ring
• - always covered by skin

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• 3. Adult paraumbilical hernia
• - is an acquired hernia which occurs following
  disruption of the linea alba above, or much less
  commonly below, the umbilical cicatrix
• - Precipitating factors obesity
• multiple pregnancy
• ascites
• - Gastrointestinal symptoms due to traction
  between the hernial contents and the stomach and
  colon
• - Has a small neck
• gt Incarceration and strangulation are
  common gt Early operation is
  advisable

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Massive paraumbilical hernia
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Umbilical hernia steps of the repair

• Incision
• Dissection of the sack
• Opening of the sac and contents reduction
• Ligation and resection of the sac
• Closure of the defect in one or two layers
  (Mayo procedure)
• - in case of massive defect synthetic mesh
  can be used

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Incisional hernia

• Wounds may fail in one of two ways
• 1. Wound dehiscence partial or complete
  disruption of an abdominal wound closure
  with protrusion or evisceration of the
  abdominal contents
• - occurs prior to cutaneous healing
• 2.Incisional hernia abnormal protrusion of a
  viscus through the musculoaponeurotic layers
  of a surgical scar
• - lie under a well healed skin incision

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Incisional hernia - Ethiology

• Preoperative factors
• - obesity -
  age
• - uraemia -
  male sex
• - anaemia -
  previous
• - diabetes
  irradiation
• - malnutrition
• - malignant disease
• - vitamin C depletion
• - administration of steroids
• or cytotoxic drugs.

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Incisional hernia - Ethiology

• Operative factors
• - the type of incision (medial, pararectal,
  Kocher)
• - the choice of suture material
• - the method of wound closure
• Are less important in the development of
  incisional hernia

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Incisional hernia - Ethiology

• Postoperative factors
• - wound sepsis
• - increased intra-abdominal pressure due to
• - inadequate postoperative analgesia
• - vomiting
• - development of a postoperative chest
  infection
  resulting in coughing
• - gross distension from paralytic ileus

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Incisional hernia Clinical features

• The majority are asymptomatic
• Small defects in the scar may result in large
  hernias gt incarceration and strangulation
• Large hernias are unsightly and may give rise to
  abdominal discomfort
• Pressure necrosis and ulceration may occur in the
  skin overlying a large hernia.

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Incisional hernia following laparatomy for
peritonitis
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Management of incisional hernia

• Conservative - weight loss, elastic corset
• Surgical repair types
• 1.In the same way as a laparotomy wound is
  repaired, with a mass closure of No. 1 nylon.
• 2.The rectus sheath may be overlapped as in the
  Mayo double-breasted vest over pants repair
• 3.The defect may be repaired by the use of a
  darn of nylon or fascia lata.
• 4.Lower midline incisions may be amenable to
  closure by swinging muscle over to close the
  defect.
• 5.Large defects may be repaired by implanting a
  non- absorbable mesh of tantalum, Marlex,
  Mersilene, or polytetrafluoroethylene (PTFE)

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Direct closure with relaxing aponeurotic incision
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The Mayo double breasted repair
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Repair using a synthetic mesh