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Hernia

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  • Bassini revolutionized the surgical repair of the groin hernia with his novel anatomical dissection and low recurrence rates – first operation in 1884
  • This structure is posterior to the iliopubic tract and forms the posterior border of the femoral canal

Transcript

  • 1. HERNIAS Presented by: Sameh Shehata
  • 2. References NaJah m. N. RaSIKh
  • 3. Definition  A hernia is the protrusion of an organ through its containing wall.
  • 4. Composition of a hernia 1. The sac 2. The covering of the sac 3. The content of the sac
  • 5. Composition of a hernia 1. The sac :  It is a diverticulum of peritoneum and is made up of three parts :  The mouth,  The neck and  The body of the sac.
  • 6. Composition of a hernia 2. The covering:  Coverings are derived from the layers of abdominal wall through which the sac pass 3. Contents:  can be  Omentum = omentocle  Intestine = enterocele  Portion of circumference of intestine = Richter’s hernia  Portion of the bladder  Ovary(with or without oviduct)  Meckel’s diverteculum =Littre’s hernia
  • 7. Etiology  Hernias occur at sites of weakness in the wall  This weakness may be :  Normal (physiological) weakness, related to the anatomical causes.  Congenital abnormality.  Acquired : • Traumatic • Diseases
  • 8. Varieties A hernia at any site may be: 1. Reducible This is the one which the contents of the sac reduced spontaneously or can be pushed back manually. A reducible hernia imparts an expansile impulse on coughing. 2. Irreducible This one whose contents cannot be returned to the peritoneal cavity either because there are:  adhesions between the sac and contents, or  because of the narrow neck of the sac.
  • 9. Varieties  Irreducible hernia can be : 1. Incarcerated: there are adhesions between the sac and the contents, but there is no obstruction or interference with blood supply. the hernia simply will not reduce 2. Obstructed: a hollow viscus is trapped within the sac and obstruction occurs. The blood supply remains intact. This is a common cause of small bowel obstruction. 3. Strangulated: the arterial blood supply to the contents of the sac is compromised, in such a hernia unless surgical relief is undertaken the contents of the sac will become gangrenous.
  • 10. Classification A. External hernia B. Internal hernia
  • 11. Classification continue… A. External hernia Common hernia  inguinal  Femoral  Umbilical  incisional
  • 12. Classification continue… A. External hernia Rare hernia  Spigelian  Gluteal  Obturator  lumbar
  • 13. Some other hernias  Spigelian hernia:  This is a hernia through the linea semilunaris at the lateral border of the rectus sheath.  Littre's hernia:  A hernia that contains a Meckel's diverticulum in the sac.  Obturator hernia:  This hernia occurs through the obturator foramen. It is commoner in elderly females.  Lumbar herniae:  These occur in the lumbar region (below the 12th rib & above the iliac crest).
  • 14. Classification continue… B. Internal hernia Diaphragmatic hernia  Esophogial hernia  Paraesophogial hernia
  • 15. Signs and Symptoms - A lump disappears, reappears, and enlarges on straining and discomfort.  Physical Signs:  Reduced.  + ve cough impulse.  Investigation: Hernia is diagnosed clinically. Investigations are rarely indicated or valuable.
  • 16. Management  Treatment: hernias should be operatively repaired both to relieve symptoms and to eliminate the complications.  Surgical techniques: • Herniotomy: removal of sac and closure of its neck. • Herniorrhaphy: involves some sort of reconstruction to: • Restore the anatomy if this is disturbed. • Increase the strength of the abdomenal wall. • Construct a barrier to recurrence.
  • 17. Inguinal hernia  Epidemiology:  Male : Female • by 9 to 1 ratio  young adults mostly have indirect inguinal hernia.  As age of patient increases, the incidence of direct hernias increases .
  • 18. Inguinal hernia  Risk factors: ( increases intra-abdominal pressure )  Chronic cough.  Constipation.  Pregnancy.  Straining at micturation.  Severe muscular effort (lifting heavy objects).  Ascites - fluid may increase the size of an existing sac.
  • 19. Myopectineal Orifice of Fruchaud
  • 20. Inguinal hernia Inguinal Canal Anatomy  Anterior wall:  aponeurosis of external oblique (along entire length),  internal oblique on lateral one third  Posterior:  fascia transversalis  conjoint tendonon in medial one third  Roof:  arching fibers of internal oblique ,and  transversus abdominis  Floor (inferior):  inguinal ligament, and  lacunar ligamen at the medial end
  • 21. Inguinal hernia Inguinal Canal Contents:  Male:  Spermatic cord structures: • vas deferens, • testicular artery • testicular veins (pampiniform plexus), • genital branch of genitofemoral nerve, • artery of the vas deference, • lymphatics, • autonomic nerves, • processus vaginalis. • Ilio inguinal nerve  Female:  Round ligament of the uterus,  genital branch of genitofemoral nerve,  lymphatics,  sympathetic plexus.
  • 22. Inguinal hernia Signs & symptoms:  Bulge that enlarges when stand or strain, but often asymptomatic.  In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate.  On examination:  Palpable defect or swelling may be present .  Indirect Hernia usually bulge at Internal InguinalInternal Inguinal Ring.Ring.  Direct Hernia usually bulge at External InguinalExternal Inguinal Ring.Ring.
  • 23. Inguinal hernia There are two types of inguinal hernia:  Direct inguinal hernia  Indirect inguinal hernia
  • 24. Differences between direct and indirect hernias 1. Origin and coarse: • Direct: Develops in the area of Hasselbach's triangle. The origin is medially to the inferior epigastric vessels. • Indirect: Develops at the internal ring. The origin is lateral to the inferior epigastric artery. 1. Content: 1. Direct: Retroperitoneal fat. less commonly, peritoneal sac containing bowel . 2. Indirect: Sac of peritoneum coming through internal ring, through which omentum or bowel can enter. 2. Etiology: • Direct: weakness of the posterior floor of the inguinal canal (acquired). • Indirect: patent processus vaginalis (Congenital) .
  • 25. Differences between direct and indirect hernias  Boundaries of Hasselbach's triangle:  Medially: lateral border of rectus abdominis.  Laterally: inferior epigastric vessels.  Inferiorly: inguinal ligament.
  • 26. Hesselbach’s Triangle
  • 27. Inguinal hernia  Both types (direct and indirect inguinal hernia) may occur at the same time and straddle the inferior epigastric artery.  This is called: Pantaloon hernia
  • 28. Inguinal hernia Male inguinal hernia Female inguinal hernia
  • 29. Indirect Inguinal hernia Abdominal contents protrude through internal inguinal ring
  • 30. 31
  • 31. Direct Inguinal Hernia
  • 32. Inguinal hernia  Complications:  Irreducibility, but without signs of obstruction or strangulation  Small Bowel Obstruction, Usually urgent surgical repair  Strangulation, Surgical emergency 50% indirect, 3-10% direct.
  • 33. Inguinal hernia Management:  Inguinal hernias should always be repaired ( herniotomy, herniorrhaphy ) unless there are specific contraindications.  Types of operations: 1. a permanent sutures, as in Shouldice repair (layered suture). 2. a permanent mesh -greater frequency to decrease tension.
  • 34. Inguinal hernia management  Treatment of aggravating factors (chronic cough, prostatic obstruction, etc).  Use of truss (appliance to prevent hernia from protruding) when a patient refuses operative repair or when there are absolute contraindications to operation
  • 35. 36
  • 36. Father of Modern Inguinal Hernia Repair EDUARDO BASSINI
  • 37. 38 Herniotomy Patent processus vaginalis ligated at origin at internal ring (high ligation( Nyhus type I Children
  • 38. 39 Bassini repair Transversus abdominis aponeurosis + transversalis fascia  inguinal ligament with nonabsorbable interrupted sutures
  • 39. 40 Shouldice repair 4rows of suture
  • 40. 41 McVay repair Inguinal and femoral hernias, Transversus abdominis aponeurosis + transversalis fascia  Cooper’s ligament + iliopubic tract
  • 41. 42 Hernioplasty High ligation, inverted sac + reinforce defect with synthetic material Tension-free Lichtenstein Recurrent rate 0.1%
  • 42. Techniques Suturing the mesh to the inguinal ligament is not important. Fixing the mesh to the rectus sheath 1-1.5cm medial and superior to the pubic tubercle is very important. Should have a surplus of mesh over inguinal ligament, the medial suture ensures surplus mesh inferiorly
  • 43. Techniques Coined by Liechtenstein in 1989 Central feature is polypropylene mesh over unrepaired floor. Gilbert repair uses a cone shaped plug placed thru deep ring. Slit placed in mesh for cord structures
  • 44. Tension-Free Repair Same initial approach as anterior repair Instead of sewing fascial layers together to repair defect, a prosthetic mesh onlay used Simple to learn, easy to perform, suited for local anesthesia, excellent results with recurrence less than 4%.
  • 45. Laparoscopic Procedures Increasingly popular, controversial Early in the development, hernias were repaired by placing very large mesh over entire inguinal region on top of the peritoneum. Was abandoned because of contact with bowel. Today, most performed TEP or TAPP
  • 46. 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.
  • 47. Laparoscopic Procedures The argued advantage of these procedures was less pain and disability, faster return to work. Great for bilateral hernia, with no increase in morbidity. For recurrent hernia Disadvantages are cost, time.
  • 48. Recurrence Type of repair Recurrence McVay 9% Shouldice 7-11% Liechtenstein 0-4% Laparoscopic 0-1%
  • 49. Femoral hernia  The defect is in the transversalis fascia overlying the femoral ring at the entry to the femoral canal.  The hernia passes through the femoral canal and presents in the groin, below and lateral to the pubic tubercle.  It is more common in females and carries a higher risk of strangulation.  Femoral canal-ant.by inguinal ligament,post by fascia over pectineus muscle,lat. by femoral vein n medial by lacunar ligament
  • 50. Femoral hernia Signs & symptoms:  A lump occurs below and lateral to the pubic tubercle. It may be reducible.  It may not be noticed until it becomes tender and painful.  This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstruction without an obvious cause.  DD’s-saphena varix,enlarged inguinal LN,femoral artery aneurysm,rare femoral abscess.
  • 51. Femoral hernia
  • 52. Femoral hernia Surgical repair:  An incision is made directly over the swelling.  The sac is opened and the contents reduced and the sac removed.  Femoral canal obliterated with 3 interrupted non absorbable suture.  Treatment of strangulation or obstruction, if present.  There is no place for a truss in the treatment of femoral hernia.
  • 53. Anatomy Inguinal ligament (Poupart’s) – inferior edge of external oblique Lacunar ligament – triangular extension of the inguinal ligament before its insertion upon the pubic tubercle conjoined tendon (5-10%)- Internal oblique fuses with transversus abdominis aponeurosis Cooper’s Ligament - formed by the periosteum and fascia along the superior ramus of the pubis.
  • 54. Umbilical hernia  This occurs in children because of incomplete closure of the umbilical orifice.  The majority close spontaneously during the first year of life.  Surgical repair should only be carried out if the hernia has not disappeared by the age of 3 and the fascial defect is greater than 1.5cm in diameter.
  • 55. Para-Umbilical hernia  It occurs just above or just below the umbilicus, and is more common in obese females.  Predisposing factors  multiple pregnancies and  obesity.
  • 56. Para-Umbilical hernia  The neck of the sac is usually narrow and therefore there is a high risk of strangulation.  The most common content is  omentum ,then  transverse colon and small intestine.  Treatment: is by  Contents of sac freed from it’s wall,excision of the sac, and fascial defect repaired by  Upper flap overlapping the lower,a two layer overlapping repair thereby doubling the strength of repair (Mayo repair)  >4 cm,recurrent-polypropylene mesh
  • 57. Epigastric hernia  This is usually a small protrusion through the linea Alba in the upper part of the abdomen.  It consists of :  extraperitoneal fat only, but  May contain omentum or small bowel.
  • 58. Epigastric hernia  It may be extremely painful, probably because of trapping and ischaemia of extraperitoneal fat.  Treatment  is by enlaging the defect,excising the fat, simple suture of the defect with non-absorbable sutures . >4 cm propylene mesh placed retromuscular plane
  • 59. Incisional hernia  This occurs through a defect in the scar of a previous abdominal incision.
  • 60. Incisional hernia  Etiology :  Age: Wound healing is poor in the older patient.  Obesity.  Postoperative wound infection.  Postoperative wound haematoma.  Raised intra-abdominal pressure postoperatively, e.g. coughing, straining, constipation, ileus.  Steroid therapy.  Type of incision: Midline vertical wounds have a higher incidence than transverse incisions.  Poor suturing technique: Rarely does a suture break
  • 61. Incisional hernia  Sign & symptoms :  A swelling protrudes through the wound.  It May occur up to 5 years postoperatively.  Many are large and involve the whole incision and consequently the neck of the sac is wide and the risk of strangulation rare.  If the defect is small there is a greater risk of strangulation .  Treatment-palliative-abd.belt  - preoperative measures-reduce weight,treat cough,improve nutritional status.stop smoking.  -surgery:excision of sac,identification n apposition,  -large hernia-poly propylene mesh,
  • 62. Richter’s hernia  Part of the wall of the intestine becomes trapped in the defect.  This is usually the antimesenteric border of the small bowel.  The lumen is intact ( no obstruction )
  • 63. Diaphragmatic hernia  Traumatic: rare and followed by injuries to chest and abdomen. The Lt diaphragm is affected more than Rt and is accompanied by herniation of stomach and spleen.  Hiatus: 1. Sliding. 2. Para-esophegial.
  • 64. Diaphragmatic hernia  Sliding:  in which the gastroesophogeal junction itself slides through the defect into the chest.
  • 65. Diaphragmatic hernia  Para-esophageal  in which the junction remains fixed while another portion of the stomach moves up through the defect.  This can be dangerous as they may allow the stomach to rotate and obstruct.
  • 66. Hiatus hernia