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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 Hernias by MHR Corp Presentation Transcript

  • HERNIAS
    MOHD HANAFI RAMLEE
  • We start with q&a session first?
  • Are you remember????
    DEEP INGUINAL RING
    EXT OBL APONEUROSIS
    ASIS
    INGUINAL LIGAMENT INSERTING ONTO PUBIC TUBERCLE
    SUPERFICIAL INGUINAL RING
    FEMORAL NERVE
    FEMORAL ARTERY
    INDIRECT ING HERNIA
    FEMORAL VEIN
    FEMORAL HERNIA
    SYMPHYSIS PUBIS
  • HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
  • HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
    INGUINAL CANAL
  • HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
    INGUINAL CANAL
  • HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
    FEMORAL CANAL
  • FEMORAL CANAL
    INGUINAL CANAL
  • TERMS: INGUINALOGY?
  • MID-PT INGUINAL LIG
    MID-INGUINAL POINT
  • HOW DO YOU DIFFERENTIATE IT EPIDEMOLOGICALLY? [age & sex]
  • SIMILAR
    PRESENTATION
    HOW DO YOU DIFFERENTIATE IT BY HISTORY?
  • PHYSICAL EXAMINATION? 6S 2T C F
    2C R
  • TERMS: INGUINALOGY?
  • HOW DO YOU DIFFERENTIATE IT ANATOMYCALLY?
  • HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
    DIRECT INGUINAL HERNIA
  • HOW DO YOU DIFFERENTIATE IT ANATOMICALLY?
    INDIRECT INGUINAL HERNA
  • WHAT OTHER FEATURES COULD DIFFERENTIATE BETWEEN THOSE 2?
  • LEFT INGUINAL HERNIA
    What is this hernia?
  • STRANGULATED HERNIA
    Patient presented with acute, painful, non-reducible inguinal hernia. It's worthmentioning 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?
  • FEMORAL HERNIA
    What is this 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?
    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.
  • INCISIONAL HERNIA
    What is this 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?
    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?
    LITTRE HERNIA
    a hernia involving a Meckel's diverticulum.
  • SPORT HERNIA
    What is this 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.
  • PERINEAL HERNIA
    What is this 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?
  • LECTURE:HERNIA
    abnormal weakness or hole in an anatomical structure which allows something inside to protrude through.
  • 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
  • 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
  • Abdominal Wall Layers
    Skin
    External oblique
    Internal oblique
    Transversus abdominus
    Transversalis fascia (major strength layer)
    Peritoneum
  • Groin Hernia
    Anterior superior iliac spine
    Right inguinal
    ligament
    Inguinal
    Femoral
    Pubic tubercle
  • Abdominal Wall Hernias Above the Groin
    Linea alba
    Linea semilunaris
    Epigastric hernia
    Umbilical hernia
    Incisional hernia
    Arcuate
    line
    Spigelian hernia
  • 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
  • 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
  • Types of Abdominal Hernia
    www.icareunit.com
  • 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)
  • Aetiology
    Presence of preformed sac
    Patent processusvaginalis; 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
  • 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
  • RISK FACTORS
    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
    Congenital
    Persistence of processusvaginalis testis
    Prematurity
    Low birth weight
    Prolonged mechanical ventilation in neonates
  • HOW TO CLASSIFY?
  • CLASSIFICATION - ORIGIN
    Congenital
    Indirect inguinal hernia
    Umbilical hernia
    Acquired
    Direct inguinal hernia
    Femoral hernia
    Incisional hernia
    Paraumbilical hernia
    Epigastric hernia
  • CLASSIFICATION (Anatomical sites)
    Inguinal ( Direct and Indirect)
    Femoral
    Umbilical (Exomphalos, Congenital umbilical Hernia)
    Para-umbilical
    Epigastric
    Others (Obturator, Gluteal, Sciatic, Lumbar)
  • CLASSIFICATIONS - NATURE
  • 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
  • INGUINAL HERNIA
    Protrusion of abdominal contents through the inguinal region – Most Common in Hernia – mostly indirect
  • 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
  • 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
  • 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
  • Q:if there is a canal, why don’t hernias occur more frequently?
  • 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 pressureexceedsthe ability of these mechanisms to maintain the position of abdominal viscera.
  • 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
  • Inguinal Hernia
    www.icareunit.com
  • INGUINAL HERNIA
    Can be divided into:
    Direct
    Indirect
    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
  • Indirect Inguinal Hernia
    Is a congenital lesion
    Occurs when bowel, omentum or other abdominal organs protrudes through the abdominal ring within a patent processusvaginalis
    If the processusvaginalis does not remain patent an indirect hernia cannot develop
    Most common type of hernia
  • Indirect Hernia Route
    Note:
    The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.
  • 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'sligament (inferiorly)
    This can be remembered by the mnemonic RIP (as direct inguinal hernias rip directly through the abdominal wall).
  • 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 processusvaginalis
    Hernia is w/in the coverings of the spermatic cord
    http://www.aafp.org/afp/990101ap/143.html
  • 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 processusvaginalis 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)
  • 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 processusvaginalis
    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
  • Direct Hernia Route
    Note:
    The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.
  • 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
  • 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
  • INDIRECT
    DIRECT
  • Differences
  • 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
  • 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
  • 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
  • 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
    • 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?
  • 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
  • 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
  • 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
  • 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
  • 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
  • SURGICAL MANAGEMENT
    Herniotomy (infants)
    patent processusvaginalis 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
  • 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
  • Specific Surgical Procedures
    Lichenstein (Tension Free) Repair
    McVay (Cooper’s Ligament) Repair
    Shouldice (Canadian) Repair
    Laproscopic Hernia Repair
    Bassini Repair
  • 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
  • Bassini Repair
  • McVay Repair
    AKA: Cooper’s ligamentRepair
    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
  • McVay Repair
    Note:
    This repair reconstructs the inguinal canal without using a mesh prosthesis.
  • 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.
  • Shouldice Repair
  • 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
  • Lichtenstein Repair
    Note:
    Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.
  • Laparoscopic Hernia Repair
    Early attempts resulted in exceptionally high reoccurrence rates
    Current techniques include
    Transabdominal preperitoneal repair (TAPP)
    Totally extraperitoneal approach (TEPA)
  • Laparoscopic MeshRepair
    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.
  • 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
  • Femoral Hernia
    www.icareunit.com
  • Left Femoral Hernia
    www.icareunit.com
  • Femoral hernia
    Protrusion of extraperitonealfat,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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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)
  • 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
  • Normally the bulge appears to be directly behind the skin crease of the groin
  • 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
  • MANAGEMENT
    Repaired by excision of the sac
    closure of the femoral canal
  • 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
  • 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
  • CONGENITAL UMBILICAL HERNIAE
    Appear at the site where the umbilical vessels enter the abdomen during fetal life
  • Umbilical hernia
    Normal umbilicus
    Exomphalos (rare)
    failure of midgut to return to abdominal cavity in early fetal life.
    Bowel contained in sac, if rupture can cause fatal peritonitis.
  • 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%
  • 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.
  • 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.
  • 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
  • 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
  • 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.
  • 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
  • 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.
  • 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:
    Obesity.
    Flabbiness of the abdominal muscles.
    Multiparity.
    Clinical Features:
    Clolicky pain and/or irreducibilty due to omental adhesions.
  • 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.
  • Epigastric hernia
    Protrusion of extraperitoneal fat, sometimes small peritoneal sac between defect in the linea alba some where between xiphisternum and umbilicus.
    Firm.
    Irreducible.
  • 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
  • Diaphragmatic hernia1. 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.
  • 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.
  • Rolling/ Para-oesophageal (10%)
    Stomach rolls up anteriorly, producing partial volvulus.
    No disturbances of the cardio-oesophageal mechanism.
  • Unusual hernias
  • 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
  • Richter’s
    Hernia where only a portion of the bowel wall circumference incarcerates or strangulates
  • Littre’s
    Any groin hernia that involves a Meckel’s Diverticulum
    Usually incarcerated or strangulated
  • Armand’s
    Any hernia that contains the appendix
    Can cause symptoms of Appendicitis
  • Pantaloon Hernia
    Simultaneous Direct and Indirect Inguinal Hernias
    Two bulges straddle the inferior epigastric vessels
  • Treatment
    Most abdominal hernias can be surgically repaired.
    Uncomplicated hernias are principally repaired by herniorrhaphy.
    aHerniorrhaphy (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.
  • 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
  • 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-free repairs.
  • 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