Hernias by MHR Corp

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  • (A) Inguinal ligament inserting onto pubic tubercle,(B) anterior superior iliac spine (ASIS), (C) symphysis pubis, (D) deep inguinal ring,(E) superficial inguinal ring, (F) external oblique aponeurosis, (G) indirect inguinal hernia,(H) femoral hernia, (I) femoral nerve (outside femoral sheath), (J) femoral artery, and(K) femoral vein.
  • 1) Epigastric2) Diastasis (not a true hernia)3) Supra-umbilical hernia4) Umbilical hernia5) Incisional hernia6) Scar (previous inguinal hernia op)7) Recurrent inguinal hernia8) Spigelian hernia (very rare)9) Femoral hernia10) Inguinal hernia11) Pubic bone12) Inguinal ligament - groin skin crease
  • Hernias by MHR Corp

    1. 1. HERNIAS MOHD HANAFI RAMLEE
    2. 2. WE START WITH Q&A SESSION FIRST?
    3. 3. ARE YOU REMEMBER????
    4. 4. INGUINAL • Anteriorly • Skin, superficial fascia and external oblique aponeurosis; internal oblique covers its lateral 1/3. • Posteriorly: • The conjoint tendon (representing the fused common aponeurotic insertion of internal oblique and transverse abdominis muscle into the pubic crest), forms the posterior wall of the canal medially ; the transversalis fascia lies laterally. • Above: • Lowest fibers of internal oblique and transverse abdominis. • Below: • Lies the inguinal ligament FEMORAL CANAL • Superioranteriorly [rigid openig] • inguinal ligament • Inferoposteriorly • pubic ramus and the pectineus muscle • Medially • Gimbernat’s ligament(pubic part of inguinal ligament) and pubic bone • Laterally • femoral vein HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
    5. 5. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? INGUINAL CANAL
    6. 6. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? INGUINAL CANAL
    7. 7. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? FEMORAL CANAL
    8. 8. FEMORAL CANALINGUINAL CANAL
    9. 9. Inguinal ligament • Attached to pubic tubercle and anterior superior iliac spine. Mid-inguinal point • half way between ASIS and pubis - landmark for femoral artery in groin. (see lower limb pulses and cardiovascular examination). Midpoint of inguinal ligament • Half way between ASIS and pubic tubercle - landmark for deep inguinal ring and indirect inguinal hernia. Medial to this for direct inguinal hernia. TERMS: INGUINALOGY?
    10. 10. MID-PT INGUINAL LIGMID-INGUINAL POINT
    11. 11. INGUINAL • Sex: males more than females. • Age: all ages. • Peak time of presentation: 1st few months of life, late teens and early twenties, 40 – 60. • Occupation: heavy work (lifting) FEMORAL • Age: uncommon in children, majority found in 60-80 y/o women • Sex: more common in women HOW DO YOU DIFFERENTIATE IT EPIDEMOLOGICALLY? [age & sex]
    12. 12. INGUINAL • Local symptoms: discomfort, pain, swelling in the groin. • Systemic symptoms (if hernia is obstructing the lumen of loop of bowel): colicky abdominal pain, vomiting, abdominal distension, absolute constipation. FEMORAL • local: lump in groin, pain and discomfort • Systemic (if obstructed): colic, distension, vomiting and constipation HOW DO YOU DIFFERENTIATE IT BY HISTORY?
    13. 13. INGUINAL •SITE: just above the pubic crest and the pubic tubercle and is widest medial to the pubic tubercle •SIZE:1-2cm in diameter/extend down to the knee joint •SHAPE: pear-shaped or hour- glass appearance •SKIN:normal as the surrounding skin. But if strangulated, the skin ,may be a little reddened •SURFACE:usually smooth •SURROUNDING: Normal •TEMPERATURE: normal but if strangulated or infected, it become hot •TENDERNESS: discomfort. If strangulated, it can be very tender •COMPOSITION: gut (soft, resonant, fluctuant, bowel sounds), omentum (firm, dull, non-fluctuant) •COUGH IMPULSE: positive •REDUCIBILITY: positive FEMORAL CANAL •SITE: below and lateral to the pubic tubercle •SIZE: small •SHAPE: flattened •SKIN: normal as the surrounding skin. But if strangulated, the skin ,may be a little reddened •SURFACE: smooth •SURROUNDING: Normal •TEMPERATURE: normal but if strangulated or infected, it become hot •TENDERNESS: discomfort. If strangulated, it can be very tender •COMPOSITION: depend on content •COUGH IMPULSE: many femoral hernia do not have a positive cough impulse •REDUCIBILITY: reduced incompletely PHYSICAL EXAMINATION? 6S 2T C F 2C R
    14. 14. Incarcerated • irreducible hernia where the irreducibility is due to adhesions within the sac in the absence of obstruction or strangulation. • OR hypotheses - because of faeces within the large bowel. • SIMPLY: a hernia as being irreducible but not obstructed or strangulated. Obstructed • The bowel within the hernia is obstructed. The patient may have the four cardinal signs of obstruction (pain, vomiting, distention and constipation). Strangulated • occluded blood supply by pressure at the neck of the hernia. • Viability of bowell will impaired [except if contain omentum only] • 1st veins are occluded P  2nd arterial occlusion  gangrene developing. TERMS: INGUINALOGY?
    15. 15. DIRECT INGUINAL HERNIA • Hernia pushes its way directly forward through posterior wall of inguinal canal. • Does not go down into the scrotum INDIRECT INGUINAL HERNIA • Pass through internal ring, along the canal in front of spermatic cord, within layers of spermatic fascia and cremasteric fascia, • If large enough, descend into the scrotumHOW DO YOU DIFFERENTIATE IT ANATOMYCALLY?
    16. 16. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? DIRECT INGUINAL HERNIA
    17. 17. HOW DO YOU DIFFERENTIATE IT ANATOMICALLY? INDIRECT INGUINAL HERNA
    18. 18. DIRECT INGUINAL HERNIA • Reduces upwards and then straight backwards. • Not controlled, after reduction, by pressure over the internal inguinal ring. • The defect may be felt in the abdominal wall above the pubic tubercle. • After reduction the bulge reappears exactly where it was before. • Uncommon in children and young adults. • Always acquired • Large orifice • appears immediately on standing, disappearing at once when lies down. INDIRECT INGUINAL HERNIA • Reduces upwards, then laterally and backwards • Controlled, after reduction, by pressure over the internal inguinal ring • The defect is not palpable as it is behind the fibers of the external oblique muscle • After reduction the bulge reappears in the middle of the inguinal region and then flows medially before turning down to the neck of the scrotum. • Narrow opening of internal ring: • hernia does not reach its full size until the patient has been up for some time. • tendency to strangulate WHAT OTHER FEATURES COULD DIFFERENTIATE BETWEEN
    19. 19. LEFT INGUINAL HERNIA WHAT IS THIS HERNIA?
    20. 20. STRANGULATED HERNIA Patient presented with acute, painful, non-reducible inguinal hernia. It's worth mentioning that in spite of rapid diagnosis and prompt surgical exploration, gangrenous bowel was identified. This highlights the potential seriousness of this condition WHAT IS THIS HERNIA?
    21. 21. FEMORAL HERNIA Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia. WHAT IS THIS HERNIA?
    22. 22. UMBILICAL HERNIA They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously. Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute. WHAT IS THIS HERNIA?
    23. 23. INCISIONAL HERNIA An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue. WHAT IS THIS HERNIA?
    24. 24. EPIGASTRIC HERNIA An epigastric hernia is a type of hernia which may develop in the epigastrium. Epigastric hernias are most common in infants but may occur in humans of any age. They typically result from a minor defect of the linea alba between the rectus abdominis muscles. This allows tissue from inside the abdomen to herniate anteriorly. On infants, this may manifest as an apparent 'bubble' under the skin of the belly between the umbilicus and xiphisternum. WHAT IS THIS HERNIA?
    25. 25. LITTRE HERNIA a hernia involving a Meckel's diverticulum. WHAT IS THIS HERNIA?
    26. 26. SPORT HERNIA It is a syndrome characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal. Football and ice hockey players are affected most frequently, and both recreational and professional athletes may be affected. A hernia cannot be found on physical examination or medical imaging, and is not revealed during surgery. The term hernia thus is a misnomer,[3] but has persisted, as surgical reconstructions similar to those performed for inguinal hernias are often effective for "sports hernias" as well. WHAT IS THIS HERNIA?
    27. 27. PERINEAL HERNIA a hernia involving the perineum (pelvic floor). The hernia may contain fluid, fat, any part of the intestine, the rectum, or the bladder. It is known to occur in humans, dogs, and other mammals, and often appears as a sudden swelling to one side (sometimes both sides) of the anus. WHAT IS THIS HERNIA? WHAT IS THIS HERNIA?
    28. 28. LECTURE: HERNIA abnormal weakness or hole in an anatomical structure which allows something inside to protrude through.
    29. 29. Groin Hernias  96% Inguinal – 9:1 M:F  4% Femoral – 4:1 F:M  Lifetime risk approximately 25% in males and <5% in females  700,000 repairs each year
    30. 30. Incidence  Approximately 700,000 hernia repairs are performed as an outpatient procedure each year  Approximately 75% of all hernias occur in the inguinal region  Approximately 50% of hernias are indirect inguinal hernias  A vast majority occur in males  Hernias more commonly occur on the right side
    31. 31. Abdominal Wall Layers Skin External oblique Internal oblique Transversus abdominus Transversalis fascia (major strength layer) Peritoneum
    32. 32. GROIN HERNIA Anterior superior iliac spine Pubic tubercle Femoral Inguinal
    33. 33. ABDOMINAL WALL HERNIAS ABOVE THE GROIN Linea alba Linea semilunaris Arcuate line Spigelian hernia Epigastric hernia Umbilical hernia Incisional hernia
    34. 34. A hernia consist of 3 parts:  Sac; consist of a diverticulum of peritoneum.  Contents; Omentum, small or large intestine, urinary bladder, Omentum, ovaries malignant nodules or ascetic fluid.  Coverings; derived from the layers of abdominal wall. www.icareunit.com
    35. 35. Complications Of Hernias  Irreducible the hernia contents cannot be manipulated back into the abdominal cavity  Incarcerated the contents of the sac are literally inpresiond in the sac of Hernia  Obstruction  the loop of the bowel become non functioning with normal blood supply  Strangulated cut off the blood supply to the content sac (tender) www.icareunit.com
    36. 36. Types of Abdominal Hernia www.icareunit.com
    37. 37. Aetiology  Hernia occurs at sites of weakness in the abdominal wall. (may be congenital weakness)  Occur at site of penetration of structures through abdominal wall (e.g. femoral canal)  Occur through the layers of abdominal wall which was weakened following a surgical incision (incisional hernia)
    38. 38. Aetiology  Presence of preformed sac ◦ Patent processus vaginalis; prime cause of indirect hernia in infants and children  Repeated elevations in intra-abdominal pressure ◦ COPD ◦ BPH ◦ Constipation / IO ◦ Strains ◦ Pregnancy ◦ Ascites ◦ Peritoneal Dialysis ◦ Ventriculo-peritoneal shunt
    39. 39. Aetiology - Continue  ↑ intra-abdominal P ◦  Weak areas (Transversalis fascia/Internal inguinal ring)  Direct Hernia  Weakening of the body muscles and the tissue ◦ Lack of physical exercise, adipocity, multiple pregnancies ◦ Abnormality of collagen
    40. 40. RISK FACTORS  Congenital ◦ Persistence of processus vaginalis testis ◦ Prematurity ◦ Low birth weight ◦ Prolonged mechanical ventilation in neonates  Acquired ◦ Occupation (heavy lifting) ◦ Ascites ◦ Pregnancy ◦ Smoking ◦ Weak abdominal muscles ◦ Underlying diseases which cause abdominal straining,eg constipation, chronic cough, urinary obstruction ◦ Surgical incision ◦ Damage to nerves causes paralysis of abdominal muscles
    41. 41. classification Congenital / acquired Anatomical site Nature HOW TO CLASSIFY?
    42. 42. CLASSIFICATION - ORIGIN  Congenital ◦ Indirect inguinal hernia ◦ Umbilical hernia  Acquired ◦ Direct inguinal hernia ◦ Femoral hernia ◦ Incisional hernia ◦ Paraumbilical hernia ◦ Epigastric hernia
    43. 43. CLASSIFICATION (Anatomical sites)  Inguinal ( Direct and Indirect)  Femoral  Umbilical (Exomphalos, Congenital umbilical Hernia)  Para-umbilical  Epigastric  Others (Obturator, Gluteal, Sciatic, Lumbar)
    44. 44. CLASSIFICATIONS - NATURE
    45. 45. CLASSIFICATIONS - NATURE  Reducible ◦ can be replaced completely into peritoneal cavity. ◦ Disappear on lying down ◦ painless ◦ Cough impulse  Irreducible ◦ cannot be return to the abdomen ◦ no expansile cough impulse ◦ not painful ◦ due to adhesion between the sac and its contents or overcrowding within the sac  Strangulated ◦ blood supply to the organ is impaired causing gangrene ◦ sudden, severe pain and central abdominal colicky pain ◦ irreducible, no expansile cough impulse
    46. 46. INGUINAL HERNIA Protrusion of abdominal contents through the inguinal region – Most Common in Hernia – mostly indirect
    47. 47. ANATOMY OF INGUINAL CANAL  The inguinal canal is an oblique passage in the lower anterior abdominal wall, directed downwards and medially from internal to external inguinal ring  In male, transmits the spermatic cord, ilioinguinal nerve, and the genital branch of genitofemoral nerve.  In female, transmit the round ligament of the uterus and ilioinguinal nerve
    48. 48.  Internal/deep inguinal ring ◦ Oval opening in the fascia transversalis ◦ 0.5 inc above the inguinal ligament midway between ASIS and symphysis pubis ◦ Related to it medially is inferior epigastric vessels  External/superficial inguinal ring ◦ Triangular defect in the aponeurosis of the external oblique muscle ◦ Situated above and medial to pubic tubercle
    49. 49. BOUNDARIES OF INGUINAL CANAL  Anteriorly- external oblique aponeurosis (B)  Posteriorly- fascia transversalis (C)  Superiorly- conjoined muscles (fibres of internal oblique and transversalis fascia )  Inferiorly- inguinal ligament and lacunar ligament
    50. 50. Q:if there is a canal, why don’t hernias occur more frequently?
    51. 51. The answers are:  1.The canal is oblique  2. The external oblique contraction forces the anterior wall to approximate  3.Contraction of the internal oblique and transverse abdominal muscles causes the roof to descend.  In other words ,hernias can only occur when the rises in intra abdominal pressure exceeds the ability of these mechanisms to maintain the position of abdominal viscera.
    52. 52. Groin Hernia Surgical Classification (Nyhus)  I: Indirect hernia w/normal internal ring  2: Indirect hernia w/enlarged internal ring  3a: Direct inguinal hernia  3b: Indirect hernia with weak floor  3c: Femoral hernia  4: All recurrent hernias
    53. 53. Inguinal Hernia www.icareunit.com
    54. 54. INGUINAL HERNIA  Can be divided into: 1. Direct 2. Indirect 3. Pantaloon -include both direct and indirect components -protrusions medial and lateral to inferior epigastric vessels -common in elderly men -twice as common in males than in females
    55. 55. Indirect Inguinal Hernia  Is a congenital lesion  Occurs when bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processus vaginalis  If the processus vaginalis does not remain patent an indirect hernia cannot develop  Most common type of hernia
    56. 56. Indirect Hernia Route Note: The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.
    57. 57. INGUINAL TRIANGLE / HASSELBACH TRIANGLE The inguinal triangle contains a depression referred to as the medial inguinal fossa, through which direct inguinal hernias protrude through the abdominal wall. It is defined by the following structures: * Rectus abdominis muscle (medially) * Inferior epigastric vessels (superior and laterally). * Inguinal ligament, sometimes referred to as Poupart's ligament (inferiorly) This can be remembered by the mnemonic RIP (as direct inguinal hernias rip directly through the abdominal wall).
    58. 58. Indirect Inguinal Hernia Track  Lateral to inferior epigastric vessels  Through deep inguinal ring and canal  Through external inguinal ring ◦ Often into scrotum  Hernial sac formed by processus vaginalis  Hernia is w/in the coverings of the spermatic cord http://www.aafp.org/afp/990101ap/143.html
    59. 59. Indirect Inguinal Hernia  Epidemiology ◦ Most common groin hernias in men and women ◦ 20x more common in males ◦ Most are congenital due to defective obliteration of the processus vaginalis and lack of closure of internal inguinal ring  Sx ◦ Bulge medial to pubic tubercle and into the scrotum ◦ Heaviness or dull discomfort more pronounced with lifting or straining ◦ Pain with straining or standing ◦ Severe pain and/or peritoneal signs with strangulation, fevers, N/V  PE ◦ Reducible versus non-reducible ◦ Can be mildly tender to exquisitely tender (strangulated)
    60. 60. Direct Inguinal Hernia  Proceeds directly through the posterior inguinal wall  Direct hernias protrude medial to the inferior epigastric vessels and are not associated with the processus vaginalis  They are generally believed to be acquired lesions  Usually occur in older males as a result of pressure and tension on the muscles and fascia
    61. 61. Direct Hernia Route Note: The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.
    62. 62. Hernia Track  Bulges through Hesselbach’s Triangle in hernial sac formed by transversalis fascia  Traverses the medial portion of the inguinal canal  Emerges around conjoint tendon to reach the superficial inguinal ring  Gains an outer covering of external spermatic fascia http://www.hernia.net.au/hernia_inguinal.html
    63. 63. Direct Inguinal Hernia  Common in older males, rare in women  Occur as a result of weakness in the floor of the abdominal wall medial to the inferior epigastric arteries ◦ Inborn Defect ◦ Smoking ◦ Chronic steroid use ◦ Collagen disorders ◦ Some studies have shown a correlation with heavy lifting  Sx ◦ Similar to Indirect hernias without extension of the hernia into the scrotum  PE ◦ Symptoms similar to indirect inguinal hernias ◦ Often more easily reducible than indirect hernias
    64. 64. Origin Pass through deep inguinal ring, lateral to inferior epigastric vessels Pass through posterior wall of inguinal canal, medial to inferior epigastric vessels Location More common on the right side Usually bilateral Age group More common in children and young adult Common in old man with weak abdominal muscle Congenital/ acquired May be congenital [processus vaginalis] Always acquired Extends to scrotum / labium majus Often Rarely Strangulate Commonly (narrow neck of the hernia, confined by the border of internal ring) Rarely INDIRECT DIRECT
    65. 65. INDIRECT DIRECT Reducibility Reduce upwards, then laterally and backwards Reduces upwards and straight backwards How the bulge reappears after reduction Reappears in the middle of inguinal region and then flows medially before turning down to the neck of scrotum The bulge reappears exactly where it was before Controlled by pressure over internal inguinal ring Yes No Palpable defect Defect not palpable as it is behind fibers of external oblique muscle Defect maybe felt in abdominal wall above pubic tubercle Recurrence Uncommon Common
    66. 66. Differences pathway of protrusion coming down the inguinal canal, may enter the scrotum pass through Hesselbach’s triangle, rarely enter the scrotum contours of sac elliptic, pear-shaped semispheric, wide base compress the internal ring after reduced controlled not controlled Relationship of sac neck with inferior epigastric artery Sac neck is lateral to it Sac neck is medial to it Incarcerated incidence high low
    67. 67. History,symptoms…  Any age, but peak in few months of life,late teens,early 20ties,between40-60yrs old  Occupation : heavy lifting  Local symptoms: discomfort,pain,dragging, aching sensation in groin  chronic constipation,straining(Intra-abdominal malignancy eg.carcinoma of left colon)  Persistent coughing (chronic bronchitis)  Difficulty in micturition
    68. 68. Diagnosis  Physical exam ◦ The patient should be standing and facing the examiner ◦ Visual inspection may reveal a loss of symmetry in the inguinal area or bulge ◦ Having the patient perform valsalva’s maneuver or cough may accentuate the bulge ◦ A fingertip is then placed in the inguinal canal; Valsalva maneuver is repeated ◦ Differentiation between indirect and direct hernias at the time of examination is not essential
    69. 69. PHYSICAL EXAMINATION  Ask the patient to stand up.  Look at the lump from in front.  Inspection  See the exact site and shape of the lump ◦ Inguinal hernia- appear above & medial to pubic tubercle and bulges above the groin crease ◦ Reveal whether the lump extends down into the scrotum ◦ Femoral hernia-bulge behind the skin crease of the groin  Feel from the front ◦ examine the scrotum and its contents ◦ if you cannot feel the upper edge of the lump, it is likely to be hernia
    70. 70.  Feel from the side. ◦ Stand on the side of patient, same side of hernia. Place one hand in the patient’s back to support him & your examining hand on the lump parallel to the inguinal ligament ◦ Position, temperature, tenderness, shape, size, surface, composition  Expansile cough impulse. ◦ Compress the lump firmly with your fingers, ask the pt to turn his head towards the opposite side, and then to cough ◦ If the swelling expands with coughing, it has an expansile cough impulse
    71. 71. Ask the pt to put his hands on the lump and lifts it upwards and backwards - Direct (2)- Reduces upwards and straight backwards ◦ Indirect (1)- Reduce upwards, then laterally and backwards The way the bulge appears after reduction will also help to confirm the site of origin ◦ Direct (2)- The bulge reappears exactly where it was before ◦ Indirect (1)-Reappears in the middle of inguinal region and then flows medially before turning down to the neck of scrotum Is the swelling reducible?
    72. 72.  Can the hernia be controlled by pressure? ◦ Press your finger over the internal inguinal ring (Midpoint of inguinal ligament- between pubic tubercle and anterior superior iliac spine) and ask the patient to cough ◦ Bulge present (cannot be controlled) – direct inguinal hernia ◦ Bulge not present( can be controlled) – indirect inguinal hernia
    73. 73. end  Percuss and auscultate the lump ◦ -If there is gut in the sac it may be resonant ◦ and there may be audible bowel sounds  Examine the other side of the inguinal region  Examine the abdomen ◦ Look for anything that may increase the intra- abdominal pressure, eg. Large bladder, enlarged prostate, ascites  General examination
    74. 74. Diagnosis  The patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal region  They may describe minor pain or vague discomfort associated with the bulge  Extreme pain usually represents incarceration with intestinal vascular compromise  Paresthesias may be present if inguinal nerves are compressed
    75. 75. Inguinal Hernia Treatment  Medical Management ◦ Watchful Waiting Trial with 720 men >18 y/o and asymp/minimal sx; easily reducible  Open tension free repair versus Waitful Watching  23% and 31% of WW group had surgery at 2 and 4 years ◦ Truss use is not supported in the literature  Incarceration/Strangulation ◦ Only true indications for repair ◦ Emergent reduction ◦ Bowel can be saved in most patients if operation occurs within four to six hours
    76. 76. Tx Cont’d  Operative Repair ◦ Only definitive repair ◦ Recurrence in .5 to 15% depending on type of repair ◦ Open Repair versus Laparoscopic repair  Lap with less post op pain and faster return to work  Increase risk of complications with longer surgery, higher risk of nerve, vascular, bowel, and bladder injury ◦ Mesh versus suture repair  Mesh repair creates less tension but very few studies to compare the techniques  One meta-analysis of 26000 hernia repairs found mesh repairs with a lower reoperation rate ◦ Complications include recurrence, infection, seromas, pain and neuralgia
    77. 77. SURGICAL MANAGEMENT  Herniotomy (infants) ◦ patent processus vaginalis is ligated & the hernial sac excised at the age of ≈1 yr  Hernioplasty ◦ excision of the sac & repair of the weakened inguinal canal, commonly performed either by:  Shouldice repair  Lichtenstein repair
    78. 78.  Truss ◦ used to control certain types of hernia when surgery is either inappropriate/ unacceptable to patient ◦ Pressure truss-hernia is easily reducible & can be kept reduced & free of symptoms ◦ ‘Bag truss’ – support the very large hernia which cannot be reduced
    79. 79. Specific Surgical Procedures  Lichenstein (Tension Free) Repair  McVay (Cooper’s Ligament) Repair  Shouldice (Canadian) Repair  Laproscopic Hernia Repair  Bassini Repair
    80. 80. Bassini Repair ◦ Is frequently used for indirect inguinal hernias and small direct hernias ◦ The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament
    81. 81. Bassini Repair
    82. 82. McVay Repair  AKA: Cooper’s ligament Repair ◦ Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias ◦ The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally
    83. 83. McVay Repair Note: This repair reconstructs the inguinal canal without using a mesh prosthesis.
    84. 84. Shouldice Repair AKA: Canadian Repair ◦ A primary repair of the hernia defect with 4 overlapping layers of tissue. ◦ Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.
    85. 85. Shouldice Repair
    86. 86. Lichtenstein Repair AKA: Tension-Free Repair One of the most commonly performed procedures A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord
    87. 87. Lichtenstein Repair Note: Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.
    88. 88. Laparoscopic Hernia Repair ◦ Early attempts resulted in exceptionally high reoccurrence rates ◦ Current techniques include  Transabdominal preperitoneal repair (TAPP)  Totally extraperitoneal approach (TEPA)
    89. 89. Laparoscopic Mesh Repair Note: Viewed from inside the pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.
    90. 90. Hernia Complications  Incarceration  14 to 31% of inguinal hernias, usually in infants < 1y/o  Swelling due to decreased venous and arterial flow  Outright pain, irritability and crying in children  Bowel obstruction (N/V/colicky abdominal pain/distention)  Tender, edematous, erythematous  Strangulation  Severe pain secondary to bowel ischemia  Bowel obstruction  Swelling, erythema, tenderness, peritoneal signs, fever, N/V  Study of 439 patients showed probability of strangulation was 2.8% at three months, 4.5% at two years for groin hernias
    91. 91. Femoral Hernia www.icareunit.com
    92. 92. Left Femoral Hernia www.icareunit.com
    93. 93. Femoral hernia  Protrusion of extraperitoneal fat,peritoneal sac and abdominal contents through femoral canal  Femoral hernias often appear within the femoral triangle, INFEROLATERAL to the pubic tubercle  Anatomically ,Femoral triangle is bounded by : ◦ Inguinal ligament superiorly and anteriorly ◦ Adductor longus medially ◦ Femoral vein laterally ◦ Pubic ramus and pectineus muscle posteriorly
    94. 94. Femoral Hernia  40% present with emergencies (incarceration/strangulation)  Most commonly in females, especially older women ◦ Less bulky musculature ◦ Weakness of pelvic floor muscles 2/2 childbirth ◦ Pelvic floor muscle atrophy 2/2 age ◦ Prior inguinal hernia repair is a RF http://herniaplasty.med.nyu.edu/strangulatedhernia.html
    95. 95. FEMORAL SHEATH  Is a downward protrusion into the thigh of the fascial envelope lining the abdominal walls  Continuous above with the fascia transversalis  Surrounds femoral vessels and lymphatics for 1 inch below the inguinal ligament  Divided into 3 compartments: -lateral: femoral artery -intermediate: femoral vein -medial: lymph vessels
    96. 96. ANATOMY OF FEMORAL CANAL  Medial compartment of femoral sheath  Upper opening known as femoral ring  Femoral septum closes the opening  Contents: fatty connective tissue, lymph vessels, 1 deep inguinal lymph node
    97. 97. Hernia Track  Hernia protrudes through medial aspect of femoral canal/sheath  Below the inguinal ligament medial to the femoral vein  Below and lateral to the pubic tubercle through the femoral ring  Becomes more pronounced when it passes through the saphenous opening http://www.aafp.org/afp/990101ap/143.html
    98. 98. FEMORAL HERNIA  Protrusion of the extraperitoneal fat, a peritoneal sac and sometimes abdominal contents through the femoral canal  More common in females due to wider female pelvis (but note that inguinal hernias are commoner than femoral in females)  Never due to congenital sac, usu acquired  Usu. In middle-aged and elderly  Neck is narrow and therefore usually irreducible and prone to strangulation
    99. 99. FEMORAL HERNIA  Presents as a globular swelling below and lateral to the pubic tubercle  Swelling is seen directly behind the skin crease of the groin  As the hernia enlarges, it passes through the saphenous opening in the deep fascia and then turns upwards so that it may project above the inguinal ligament
    100. 100. History  Age : not common until the age of 50  Sex: more common in women (because of their wider female pelvis)than in men (but never forget that even in women, the commonest hernia in groin is still inguinal hernia)  Symptoms:  Local: lump in the groin ,pain,discomfort  General : if it cause intestinal obstruction; abdominal.colic ,distension, vomiting,constipation  Femoral hernia is able to strangle a part of bowel,without occluding lumen and cause obstruction (Richter’s hernia)
    101. 101. Examination:  Examination includes description of  1.Position:(A femoral hernia appear at INFEROLATERAL to the pubic tubercle, whereas inguinal hernias appear SUPEROMEDIAL to the pubic tubercle.)  2.size, shape,  3.Skin colour  4.tempreture  5.Tender/Non-tender  6.Composition, consistency  7.Cough Impulse  8. Reducibility
    102. 102. Normally the bulge appears to be directly behind the skin crease of the groin
    103. 103. PATHOLOGY OF FEMORAL HERNIA Pathology- If the femoral hernia becomes large, it tends to be deflected upwards and may seem to arise above the inguinal ligament
    104. 104. Femoral hernia Female: male = 2:1 Bulges behind the skin crease of the groin Many do not have expansile cough impulse Not reduce easily Inguinal hernia Bulges above groin crease Expansile cough impulse Can be reduced
    105. 105. MANAGEMENT Repaired by excision of the sac closure of the femoral canal
    106. 106. Treatment  All femoral hernias should undergo operation, because of it’s constant risk of strangulation and be repaired by excision of the sac and closure of femoral canal
    107. 107. Umbilical Hernia  Congenital ◦ Opening in linea alba when umbilical scar fails to heal at birth ◦ More common in AA children ◦ Most close in first 12-18 months of life ◦ Repair rarely recommended prior to 3 y/o  Acquired ◦ 3:1 F:M – Men more likely have incarceration ◦ Associated with increased ◦ intra-abdominal pressure  Obesity  Ascites  Abdominal distention  Pregnancy http://medicine.ucsd.edu/clinicalimg/abdomen-incarcerated-umbo.html
    108. 108. Umbilical hernia congenital acquired paraumbilical
    109. 109. CONGENITAL UMBILICAL HERNIAE  Appear at the site where the umbilical vessels enter the abdomen during fetal life
    110. 110. Umbilical hernia  Exomphalos (rare)  failure of midgut to return to abdominal cavity in early fetal life.  Bowel contained in sac, if rupture can cause fatal peritonitis. Normal umbilicus
    111. 111. Incisional Hernia  Sx ◦ Bulge of abdominal wall deep to skin scar ◦ Cosmetic concern versus discomfort ◦ Worsened with coughing or straining ◦ Incarceration  <1cm, >7-8 cm unlikely to incarcerate  Tx ◦ Most should be repaired (unlike groin hernias) ◦ Suture versus mesh repair  Suture repair in one European study showed 60% recurrence with mesh recurrence at 30%
    112. 112. Congenital umbilical hernia  Failure of complete closure of the umbilical cicatrix.  Umbilicus everted. Acquired umbilical hernia • Raised intra-abdominal pressure (pregnancy, ascites, fibroids) • Umbilicus everted.
    113. 113. Paraumbilical hernia  Adult (acquired)  Just above or below umbilicus  Often in obese, multiparous, middle-aged woman.  Hernia protrude through defect beside umbilicus, turning it into crescent- shaped slit.  Neck narrow.
    114. 114. Congenital umbilical hernia  Usually hemispherical  Soft, compressible, easy to reduce  Common in black children  Management: ◦ surgical repair should not be carried out unless the hernia persists after the child is 2 years old ◦ strapping the hernia/ providing a truss to allay parental anxiety
    115. 115. ACQUIRED UMBILICAL HERNIAE  Hernia through umbilical scar, so it is a true umbilical hernia and has the umbilical skin tethered to it  History ◦ Finding the cause of the raised abdominal pressure eg. Pregnancy, ascites, ovarian cysts, fibroids, and bowel distension
    116. 116. Incisional Hernia Definition: An incisional hernia occurs when the area of weakness is the result of an incompletely healed surgical wound. These can be among the most frustrating and difficult hernias to treat. It can occur at any incision, but tend to occur more commonly along a straight line from the sternum breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence. Causes:  Any reasons leading to an icrease in intraabdominal pressure postoperatively such as: chronic cough, vomitting, infection, malnutrition diabetes, steroid treatment or a tension closure done during the previous operation. Clinical Features:  Swelling at the incisional site +/- pain.
    117. 117. Incisional Hernia  Due to failure of fascial tissues to heal and close  Promoted by inhibition of wound healing  10-15% of abdominal incisions  Highest incidence with midline incisions ◦ Incisional hernia more likely with vertical
    118. 118. Incisional hernia  Hernia protrudes through an acquired scar in the abdominal wall.  Neck wide.  Aetiology: poor suture, poor material, coughing, infection, haematoma, n. damageparalysis of abdominal m.
    119. 119. B. Paraumbilical Hernia: Affects adults. The defect is either supra or infraumbilical through the linea alba. The female to male ratio is 20:1. May contain omentum, small intestine or transverse colon. Etiology: 1.Obesity. 2.Flabbiness of the abdominal muscles. 3.Multiparity. Clinical Features: Clolicky pain and/or irreducibilty due to omental adhesions.
    120. 120. Epigastric Hernia  Due to a defectin the linea alba between the xiphoid process and the umbilicus  Starts as a protrusion of the extraperitoneal fat at the site where a small vessel pierces the lina alba and as it enlarges it drags a pouch of peritoneum after it. Clinical Features:  Swelling +/- pain similar to a peptic ulcer pain.
    121. 121. Epigastric hernia  Protrusion of extraperitoneal fat, sometimes small peritoneal sac between defect in the linea alba some where between xiphisternum and umbilicus.  Firm.  Irreducible.
    122. 122. Ventral hernia  A large hernial sac containing abd. visceral bulges forward between elongated gap of two rectus abdominis muscle.  In elderly, pregnancy, repeated midline abd. operation.  Majority cases – no Rx
    123. 123. Diaphragmatic hernia 1. Congenital diaphragmatic hernia Hernia protrudes through:  Foramen of Mogagni  Foramen of Bochdalek  Deficiency in the whole central tendon  A congenital large hiatal hernia 2. Traumatic diaphragmatic hernia • Aetiology: crush injury, penetrating injury. • Left more often affected than right. • Herniation of stomach and spleen into thoracic cavity.
    124. 124. 3. Acquired hiatal hernia Sliding (90%)  Stomach slides through hiatus.  Anterior is covered with peritoneal sac; posterior is extraperitoneal.  Space occupying.  Disturbances of cardio- oesophageal sphincter.
    125. 125. Rolling/ Para-oesophageal (10%)  Stomach rolls up anteriorly, producing partial volvulus.  No disturbances of the cardio- oesophageal mechanism.
    126. 126. Unusual hernias
    127. 127. Spigelian Hernias  Lateral ventral hernia ◦ Junction of vertical semilunar line and horizontal semicircular line (arcuate line)  90% located 0 - 6 cm above anterior superior iliac spine ◦ Sharp pain, swelling, easily reducible ◦ 20% present with incarceration ◦ median age = 50 years ◦ more common in males and on (R) ◦ Rare  PE ◦ Difficult to diagnose ◦ Below EAO ◦ U/S or CT can aid in diagnosis http://herniaplasty.med.nyu.edu/spigelianhernia.html
    128. 128. Richter’s  Hernia where only a portion of the bowel wall circumference incarcerates or strangulates
    129. 129. Littre’s  Any groin hernia that involves a Meckel’s Diverticulum  Usually incarcerated or strangulated
    130. 130. Armand’s  Any hernia that contains the appendix  Can cause symptoms of Appendicitis
    131. 131. Pantaloon Hernia  Simultaneous Direct and Indirect Inguinal Hernias  Two bulges straddle the inferior epigastric vessels
    132. 132. Treatment Most abdominal hernias can be surgically repaired. Uncomplicated hernias are principally repaired by herniorrhaphy. a Herniorrhaphy (Hernioplasty) is a surgical procedure for correcting hernia, which can be devided into four techniques: Groups 1 and 2: open "tension" repair:  in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed. [4]  Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today.
    133. 133. Treatment (cont..) Group 3: open "tension-free" repair:  Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region.  This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond aspirin or acetaminophen.  Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair
    134. 134. Treatment (cont..) Group 4: laparoscopic repair  "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it.  It is further sub-devided into: T.A.P.P repair (transabdominal preperitoneal) T.E.P repair (totally extraperitoneal)  It has no proven superiority to the open method other than a faster recovery time and a slightly lower post-operative pain score.  laparoscopic surgery, though, requires general anesthesia, more expensive and consumes more O.R. time than open repair and carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-
    135. 135. Take Home Points  Hernias can involve the small bowel, appendix, a Meckel’s diverticulum, ureter  Incarceration with frank pain or strangulation are operative emergencies and bowel can be saved if done within 4-6 hours  An attempt at reduction should be made with a hernia, but operative reduction is the only definitive treatment  Femoral hernias have a high rate of incarceration and should be repaired, but other inguinal hernias may be watched if asymptomatic  With abdominal incisions, try not to put excessive tension or damage the suture in any way as it can promote incisional hernias

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