Engidaw Ambelu

1. LECTURE ON HERNIA FOR ANSTHESIA
2nd YEAR
BY Dr GETANEH.W (SURGICAL GP)
28/02/2018
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2. OBJECTIVES
• To know the common hernias
• To have overview of the clinical presentation
of hernia
• To have strong suspicion for worst
complication of hernia
• To know general principle of mang;t
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3. OUTLINE OF PRESENTATION
• Definition of hernia
• Epidemiology of hernia
• Common hernia &their clinical feature
• Complication
• General Rx principle
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4. Hernia
• Latin for rupture
• an abnormal protrusion of an organ or tissue
through a defect in its surrounding walls
• Occur at sites where Aponeurosis and fascia
are not covered by striated muscle
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5. Epidemiology
• 700,000 hernia repairs year
• Inguinal hernias -75% of all hernias
– 2/3 Indirect, remainder are direct
• Incisional hernias – 15 to 20%
• Umbilical and epigastria – 10%
• Femoral – 5%
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6. Epidemiology
• Prevalence of hernias increases with age
• Most serious complication – strangulation
– 1 to 3% of groin hernias
• Femoral – highest rate of complications 40%
– recommended all be repaired at time of discovery
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7. a Hernia composed of;
1.Sac: a folding of peritoneum
consisting of a mouth, neck, body
and fundus.
2.Coverings: derived from layers
of the abdominal wall.
3.Contents: which could be
anything from the omentum,
intestines, ovary or urinary
bladder.
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8. Abdominal Wall Anatomy
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9. 9

10. Anatomy
• Inguinal ligament –
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.

11. Inguinal Canal
• Between deep and
superficial inguinal rings
• Boundaries
– Superifical – external oblique
aponeurosis
– Superior – internal and
transversus
– Inferior – shelving edge of
inguinal ligament and lacunar
ligament
– Posterior (floor) –
transversalis fascia and
aponeurosis of transversus
abdominis muscle
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12. Common hernia
• Inguinal
• Umblical
• Femoral
• Incisional
• epigastric
Rare hernia
spegilian
obtruter
lumbar
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14. AETIOLOGY /CAUSES
A)increased intra-abdominal pressure
-BOO
-Heavy lifting
-Constipation
-Asites
-intraabdominal malignancy
-COPD
-straining
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15. Continue…
B)Weakness of abdominal musculature
-congenital-patent process vaginalis
-acquired;
-muscle weakness ff pregnancy
- abdominal surgery
-obesity
-defective collagen synthesis
(smoking,hereditary)
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16. In children,
• Specifically in infants, the parents"
observation of a swelling or protusion
may be the only positive feature.
• In the infancy may beTransilluminable
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17. Signs and Symptoms
• The signs and symptoms of a hernia can range from
noticing a painless lump to the painful, tender,
swollen protrusion of tissue that you are unable to
push back into the abdomen—possibly a strangulated
hernia.
• Asymptomatic reducible hernia
• New lump n the groin or other abdominal wall area
• May ache but is not tender when touched.
• Sometimes pain precedes the discovery of the lump.
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18. Cont.
• Lump increases in size when standing or when abdominal pressure
is increased (such as coughing)
• May be reduced (pushed back into the abdomen) unless very large
• Irreducible hernia
• Usually painful enlargement of a previous hernia that cannot be
returned into the abdominal cavity on its own or when you push it
• Some may be long term without pain
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19. Cont.
• Can lead to strangulation
• Signs and symptoms of bowel obstruction may occur, such as
nausea and vomiting
• Strangulated hernia
• Irreducible hernia where the entrapped intestine has its blood
supply cut off
• Pain always present followed quickly by tenderness and
sometimes symptoms of bowel obstruction (nausea and vomiting)
• You may appear ill with or without fever
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20. Cont.
• Surgical emergency
• All strangulated hernias are irreducible (but all irreducible hernias
are not strangulated)
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21. Inguinal Hernia
• Classified as congenital vs. acquired
• commonly thought that repeated increases in intra-
abdominal pressure contribute to hernia formation
• collagen formation and structure deteriorates with
age, and thus hernia formation is more common in
the older individual.
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22. Inguinal hernia
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Male inguinal hernia Female inguinal hernia

23. Diagnosis
• Physical Exam
• 74.5% sensitive and
96.3% specific
• examine the patient in
the standing and supine
positions
• difficult to distinguish
direct and indirect on
exam on alone
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24. Most important
1. Can you get above it?
2. Reducibility test
3. Expansile Cough Impulse;
4. Invagination test
5. Three finger test
Zieman’s technique
6. Ring occlusion test
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25. Also Asses
• Intra or extra abdominal
• Tension
• Composition
• Percussion and auscultation;
Bowel Sounds
• Always examine both groins
• Tranillumination
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26. 1-Cough Impulse
•Pt. coughs to highlight hernia.
•May not ;if the neck is blocked by
adhesions
•Visible & Palpable cough impulse.
•Reappear on straining,
standing or coughing
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27. 2-Reducibility test
• Ask pt. to reduce hernia himselves
• usually done in lying position.
• The thigh of the affected side should be flexed, adducted
and internally rotated.
• Finger guard of the inguinal canal by thumb and index finger
and then the scrotum is gently squeezed.
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28. Relation to Pubic Tubercle
INGUINAL HERNIA; The
neck above and
medial to the pubic
tubercle
FEMORAL HERNIA; The
neck below and lateral
to pubic tubercle
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29. 3-Get above the swelling test
• Done in standing position
• At the root of the scrotum place the
thumb in front and the index behind
•Try to reach above the swelling.
• Inguinal hernia; cannot get above
• Pure scrotal swelling; will get above
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30. 4-Invagination test
•The scrotum on each side is inverted
with the examining index finger
•Entering the inguinal canal along
the course of the cord structures.
•The size of the external ring.
•The finger push up to the
superf inguinal ring.
•The pulp should feel the ring.
•Pat is asked to cough,
•A palpable impulse will confirm the hernia;
felt on the pulp then direct
felt on the tip then indirect hernia. 30

31. 31

32. 5-Three finger test / Zieman’s technique
Index finger; deep inguinal ring (indirect hernia)
Middle finger; superficial ing. Ring (direct hernia)
Ring finger; saphenous opening (femoral hernia)
The patient is asked to cough.
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33. 6-Ring occlusion test
•Reduce the hernia
•Occlusion of the deep ring by thumb.
•Then holding the thumb in position ask
The pt to stand
then cough
•If no bulging;
indirect
•If bulging;
direct .
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34. describe the hernia
1. Site (inguinal)
2. Right/Left
3. Reducible/Irreducible
4. Complete/Incomplete
5. Direct/Indirect
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35. Diagnosis
• Radiologic Investigations
• Herniography
• Suspected hernia, but clinical dx unclear
• Procedure done under flouroscopy following injection of
contrast medium
• Frontal and oblique radiographs are taken with and without
increased intra-abdominal pressure
• Ultrasonography
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36. Direct Inguinal Hernia
• Medial to the inferior
epigastric artery and
vein, and within
Hesselbach's triangle
• acquired weakness in
the inguinal floor
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37. Indirect Inguinal hernia
• Abdominal contents protrude through internal
inguinal ring
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38. Indirect Inguinal Hernia
• Accepted hypothesis:
incomplete or defective
obliteration of the
processus vaginalis
during the fetal period
• remnant layer of
peritoneum forms a sac
at the internal ring
• more frequently on the
right
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39. Direct summary
•Bilateral
•Acqiured
•Processus vaginalis; Absent
•Rarely strangulate;
medial to
epigastric vessels;
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40. indirect summary
•Relation to epigastric vessels; Lataral
•Processus vaginalis; Present
•congenital
•Unilateral (usually).
•always descends
the scrotum
•prone to obstruction
and strangulation
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41. Inguinal
• Superficial inguinal ring—1.25 cm
above and lateral to the pubic
tubercle
• Deep inguinal ring—1.25 cm above
and medial to the mid point of
inguinal ligament
• Length of the inguinal canal—3.25cm
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42. Ingiunal canal Contents
Ilioinguinal nerve.
Spermatic cord, which contains:
3 arteries:
• Testicular a.
• Ductus deferens a.
• Cremasteric a.
3 nerves:
• Cremasteric n.
• Genital branch of the genitofemoral n.
• Autonomics
3 other things:
• Ductus deferens
• Pampiniform plexus
• Lymphatics 42

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Femoral Hernia (cont..)
Femoral hernias are more common in women,
present as a groin lump.
the cause of unexplained small bowel obstruction.
an absent Cough impulse
globular lump than the pear shaped lump of the inguinal
hernia.
• Differential Diagnoses:
Inguinal Hernia.
Femoral Artery Aneurism.
Femoral Lymphadenopathy.
Psoas Abscess.

44. Femoral
• More common in females
• Up to 40% present as
emergencies with hernia
incarceration or
strangulation
• Passes medial to the femoral
vessels and nerve in the
femoral canal through the
empty space
• Inguinal ligament forms the
superior border
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45. 45
Umbilical Hernia:
•In infants & children.
•Boys more than girls.
•Tend to resolve without any treatment by
around the age of 5 years.
•Obstruction and strangulation is rare.

46. Umbilical
Incidence
• Reported ~10%
• several times greater in Black children
• more common in premature children all races
• Most close spontaneously by age 2 or 3
• Acquired rather than congenital in adults
• Female to male ratio 3:1
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47. Epigastric
• midline junction of the
aponeuroses (linea alba)
between the xiphoid process
and umbilicus
• Paraumbilical hernia -
epigastric hernia that
borders the umbilicus
• Estimated frequency 3-5%
• More common in Males 3:1
• 20% may be multiple
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48. Epigastric
• Clinical
• Often asymptomatic, incidental finding
• If symptomatic, vague abdominal pain above the umbilicus
exacerbated by standing or coughing; relieved in supine position
• Severe pain secondary to incarceration/strangulation of
preperitoneal fat (often no peritoneal sac) or omentum
• Exam: palpate small, soft, reducible mass superior to the umbilicus
• RARE to have strangulated bowel
• Tx
• Excise fat and sac, close primarily
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49. Ventral wall (Incisional)
• Highest incidence in midline and
transverse incisions
• Up to20% after laparotomy
• 1/3 present in 5-10 years
postoperatively
• Risk factors
• obesity, DM, ascites, steroids,
smoking malnutrition, wound
infection
• Technical aspects of wound closure
• Type of incision
• Excessive tension (prone to fascial
disruption)
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50. Types Cont.
• Incisional hernia
• Abdominal surgery causes a flaw in the abdominal wall
that must heal on its own.
• This flaw can create an area of weakness where a hernia
may develop.
• This occurs after 2-10% of all abdominal surgeries,
although some people are more at risk.
• After surgical repair, these hernias have a high rate of
returning (20-45%).
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51. complication
• Strangulation
• Incarceratoin
• Inflammation
• Obstruction
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52. General principle of mang’t
• Watchiful waiting
• Surgery
Herniotomy
Herniorrhaphy
Hernioplasty
Laparascopic repair
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