Definition of hernia• A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity• It is commonly used to describe a weakness in the abdominal wall
General features common to all hernias1. Aetiology• Weakness of abdominal wall• Any condition that raises intra-abdominal pressure,such as ■ Coughing ■ Straining (Constipation ,Prostatism) ■ Obesity ■ Intra-abdominal malignancy Pregnancy
…cont… Family history a hernia Ascites Upright positionCongenital connective tissue disorders Defective collagen synthesis Previous right lower quadrant incisionArterial aneurysmsCigarette smokingHeavy lifting
….cont…. Composition of a hernia• the sac,• the coverings of the sac and• the contents of the sac.
Classification• Based on site: Epigasteric Para umbilical umbilical Lumbar spigelian Groin area
Inguinal hernia Surgical anatomy1. The superficial inguinal ring: -a triangular aperture in the aponeurosis of the external oblique muscle-lies 1.25 cm above the pubic tubercle2. deep inguinal ring: - U-shaped condensation of the transversalis fascia
…cont..• it lies 1.25 cm above the inguinal ligament -midway b/n p.symphisis and ASIS• NB :the competency of the deep inguinal ring depends on the integrity of this fascia
…CONT..3. inguinal canal• It lies from the deep to the superficial inguinal ring• is about 3.75 cm long• directed downwards and medially from the deep to the superficial inguinal ring• anterior boundary-EOA• The posterior boundary-TF• Superior wall(roof)-conjoint tendon• Inferior wall(floor)-inguinal ligament
…CONT…CONTENTES OF INGUINAL CANAL - spermatic cord(male) - ilioinguinal nerve - Genitofemoral nerve - round ligament of uterus(female)
TYPES OF INGUINAL HERNIA• A.INDIRECT IH• B.DIRECT IH
Indirect(oblique) IH• It travels down the canal on the outer (lateral and anterior) side of the spermatic cord.• Its neck is lateral to the inferior epigastric vessels• most common form of hernia(young)• In adult males, 65% of inguinal hernias are indirect and 55% are Rt sided.
…cont..• In the first decade of life, it is more common on the right side in the male b/c:- failure of closure of processusvaginalis- later descend of Rt testis
Types of indirect inguinal hernia• 1 Bubonocele. The hernia is limited to the inguinal canal.• 2 Funicular. The processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testis, which lies below the hernia.• 3 Complete ( scrotal) The testis appears to lie within the lower part of the hernia.
Direct inguinal hernia• It comes out directly forwards through the posterior wall of the inguinal canal- emerges medial to inferior epigastric vessles.- In adult males,it acounts 35% of inguinal hernias• Women practically never develop a direct inguinal hernia.
…Cont…• A direct inguinal hernia is always acquired.• The sac passes through a weakness of the transversalis fascia in theposterior wall of the inguinal canal.• Often the patient has poor lower abdominal musculature.
…cont…• It do not often attain a large size or descend into the scrotum.• As the neck of the sac is wide, direct inguinal hernias do not often strangulate. .They are most common in older men.
…cont… Predisposing factors are .smoking• occupations that involve straining and heavy lifting.• Damage to the ilioinguinal nerve (previous appendicectomy)
Characteristic Direct Indirect Weakness of anterior abdominal Patency of processus Predisposing factors wall in inguinal triangle vaginalis in younger persons, the great majority of which are males Frequency Less common More commonExit Peritoneum plus transversalis fascia Peritoneum of persistentp p.vaginalis Via superficial ring inside cord, Traverses inguinal canal withinCourse commonly passing into scrotum/labium processus vaginalis majusExit from anterior Via superficial ring, lateral to Passes through or aroundabdominal wall cord; rarely enters scrotum inguinal canal,
Clinical Evaluation: History• Demographics – Age – Gender• Presentation of bulge – When, where, how – Activities that make it better or worse – Discomfort vs. pain – Signs/symptoms of bowel obstruction
…cont…• Surgery: previous repairs/operations• Review of factors related to increased intra- abdominal pressure – Chronic cough – Constipation – Straining to urinate
Differential diagnosis. In males• vaginal hydrocele• encysted hydrocele of the cord;• spermatocele;• femoral hernia;• incompletely descended testis in theinguinal canal• lipoma of the cord
differential diagnosis cont… In the female• hydrocele of the canal of Nuck(small invagination of parietal peritonium) – this is the most common differential diagnostic problem;• femoral hernia.
Investigations• Radiologic investigation is sometimes warranted to correctly diagnose the cause of pain or a mass in the groin.• One radiologic diagnostic tool is heriography. Its major drawback is its invasiveness.• Ultrasound is useful but is highly operator dependent.• Cross-sectional imaging techniques are being employed with increasing frequency. Both MRI and CT may reveal other causes of groin pain
Management Nonoperative Treatment- The term "watchful waiting" is used to describe this nonoperative treatment recommendation -It is only applicable in asymptomatic or minimally symptomatic hernias -Patients are counseled about the signs and symptoms of complications from their hernia
…contd…• A truss is a mechanical appliance consisting of a belt with a pad that is applied to the groin after spontaneous or manual reduction of a hernia• The purpose is twofold: - to maintain reduction - to prevent enlargement.
Treatment• Operation is the treatment of choice• The basic operation is inguinal herniotomy w/c entails dissecting out and opening the hernial sac - reducing any contents -transfixing the neck of thesac -removing the remainder
• Herniotomy and repair (herniorrhaphy) consists of: (1) excision of the hernial sac (2) repair of the stretched internal inguinal ring and the transversalis fascia (3) further reinforcement of the posterior wall of the inguinal canal
Groin Hernia Repair Complications• Recurrence• Chronic groin pain: up to 30%• Numbness over base of scrotum• Neuropathic Iliohypogastric neuralgia Ilioinguinal neuralgia Genitofemoral neuralgia Lateral cutaneous neuralgia
…cont…• Wound – Hematoma: 1.0% – Infection: 1.3% – Seroma (a pocket of clear serous fluid that sometimes develops in the body after surgery)• Infertility – Injury to vas deferens – Ischemic orchitis is uncommon• Urinary retention
Femoral Hernia- Is a protrusion of abdominal viscera (often a loop ofsmall intestine) through the femoral ring into the femoralcanal)- The femoral ring is the usual originating site of afemoral hernia- The femoral canal is the way that the femoral artery,vein, and nerve leave the abdominal cavity to enter thethigh.- contents of the femoral canal are fat, lymphatic vessels and lymph nodes of Cloquet- This hernia causes a bulge below the inguinal crease inroughly the middle of the thigh.
…contd…• is the third most common type of primary hernia• It accounts for about 20% of hernias in women and 5% in men• it cannot be controlled by a truss• most liable to become strangulated b/c of : -narrowness of the neck of the sac -rigidity of the femoral ring.
…contd… The femoral ring is bounded:• anteriorly by the inguinal ligament;• posteriorly by iliopectineal ligament, the pubic bone and the fascia over the pectineus muscle;• medially by lacunar ligament,• laterally by a thin septum separating it from the femoral vein
…cont… Pathology• A hernia passing down the femoral canal descends vertically as far as the saphenous opening• A fully distended femoral hernia assumes the shape of a retort and its bulbous extremity may be above the inguinal ligament.• they are usually irreducible and apt to strangulate.
…cont… Sex incidence-f:m ratio is 2:1-female patients are frequently elderly-The condition is more prevalent in women who have borne children than in nulliparae -male patients are usually between 30 and 45 years of age.
….cont… Clinical features . is rare before puberty.• b/n 20 and 40 years of age the prevalence rises and this continues to old age.• The Rt side is affected twice as often as the left and in 20% of cases the condition is bilateral.• Symptoms less pronounced than those of an inguinal hernia
…cont…• indeed, a small femoral hernia may be unnoticed by the patient or disregarded for years, perhaps until the day it strangulates.• Adherence of the greater omentum sometimes causes a dragging pain.• Rarely, a large sac is present
…cont… Differential diagnosis- inguinal hernia- saphena varix(a dilation of the saphenous vein at its junction with the femoral vein in the groin)- enlarged femoral lymph node- Lipoma- femoral aneurysm- psoas abscess- distended psoas bursa
…cont… Treatment• The constant risk of strangulation is sufficient reason to recommend operation,• It should be carried out soon after the diagnosis has been made
Definition:- A hydrocele is an abnormal collection ofserous ﬂuid in a part of the processusvaginalis, usually the tunica.
AetiologyA hydrocele can be produced in four different ways:- • by excessive production of ﬂuid within the sac, e.g.secondary hydrocele; • by defective absorption of ﬂuid; this appears to be theexplanation for most primary hydroceles although thereason the ﬂuid is not absorbed is obscure; • by interference with lymphatic drainage of scrotalstructures; • by connection with the peritoneal cavity via a patentprocessus vaginalis (congenital).
Classification of hydrocele• Congenital• Acquired
Congenital hydrocele :Vaginal hydrocele : occurs when hydrocelesac is patent only in the scrotumTrue Congenital hydrocele:-processusvaginalis is patent & connects to theperitoneal cavity. In children <3yrsInfantile hydrocele:- the tunica and processusvaginalis are distended to the superficialinguinal ring. There is no conection. Occurs inall agesHydrocele of the cord:- swelling near thespermatic cord. D/D hernia, lipoma of thecord
Acquired hydrocele -Primary(Ideopathic)• Develop slowly• Large• Hard and tense• No defined cause• Over 40s
-Secondary• Develops rapidly• Small• Lax• Secondary to inflammation,trauma or tumor of testes• Younger age group(20-40)
Symptoms:Scrotal swellingPain & discomfort if its secondaryFrequent &painful micturation if secondary toepididymo-orchitisMalaise & weight loss if secondary to tumor withdistant metastasesDon’t affect fertility
Tesicular torsion• This is twisting of the testis with interference to the arterial blood supply. • the actual torsion is usually of the spermatic cord• Possible mechanism; it is associated with: 1. Imperfectly descended testis 2. High investment of tunica vaginalis with a horizontal lie of testis 3. Epididymis& testis are separated by a mesorchium, & twisting occurs at the mesorchium.• The incidence is highest between 10 & 20 years.
• Classification Intravaginal torsion . . Cord twists with in the tunica vaginalis .Occurs in adolescents and adultsExtravaginal torsion Cord twists outside of the tunica vaginalis Occurs in neonates/prenatal
Pathogenesis• twist of the cord -venous and arterial occlusion -anaerobic respiration with hypercabia, hypoxia, and acidosis -Ischemic pain -oedema and haemorrhage set in -Irreversible ischemic injury by 4 hrs -Degrees of twisting determines the salvagability of the testis
Clinical features• Intravaginal -pubertal males - most occurs during sleep -may follow exercise, straining, lifting or masturbation -testicular pain .sudden onset -nausea and vomiting -pain referred to to the ipsilateral lower abdominal quadrant -usually no urinary symptoms or fever
. Examination -abnormal testicular lie -swelling -absent cremasteric reflex -pain increased on elevating the testis
Investigation -ultrasound -radionuclide imagingTreatment scrotal exploration -explore and fix both testis. -remove necrotic testis.
References• Bailey and love short practice of surgery 25th edition• Manipal• emedicine.medscape.com