Surgery

1. Lesson IV
Topic: HERNIAS AND HYDROCELES.
By:
DR. MORO E. B
M.D, M.Chir, MSC-HSM
FASECSA
Senior Consultant Surgeon/
Associate Professor of Surgery

2. 1.0. Definition
A protrusion of whole or part of a viscus
from its normal position through an opening
in the wall of its containing cavity.
1.1. Varieties
 Hernias may occur externally (inguinal,
epigastric, femoral or umbilical) or
Internally (hiatus hernia)
 All hernias occur at the sites of weakness or
potential weakness at the wall of the cavity where
they are normally placed.
 Such cavities are usually where blood vessels and
other structures enter or leave the cavity.

3. 1.2. Classification
Common:
 Inguinal
 Femoral
 Umbilical/Para-umbilical
 Epigastric
 Incisional
Uncommon (Rare)
 Obturator
 Spigelian
 Lumber
 Gluteal
 Sciatic
 Perineal

4. 2.0. Predisposing Factors
There are two categories of predisposing
factors; Congenital defects and Acquired
defects.
2.1. Congenital Defects
 Persistence of the processus vaginals
( indirect inguinal hernias)
 Incomplete obliteration of the umbilicus
(umbilical hernia)
 Patent canal of Nuck (indirect inguinal hernia in
females
 Persistent communication between abdominal
thoracic cavities.

5. 2.2. Acquired Defects
 Surgical incisions (incisional hernia)
 Muscle weakness due to obesity, fatty infiltration,
pregnancy, wasting disease, aging process, nerve division
and polio-myelities.
2.3. Precipitating Factors
Rapid increase in abdominal pressure due to:
 Chronic cough
 Straining at bowel opening
 Bladder neck or urethral obstruction
 Parturition
 Vomiting
 Severe muscular effort
 Ascitis

6. 3.0. Surgical Pathology
A hernia consists of the sac, body and
covering of the sac, and contents of the
sac.
3.1. The Sac
Peritoneal sac divided into:
 Mouth
 Neck
 Body
 Fundus

7. 3.2. The Body
 This is thin in young hernias and in infants but
thickened in matures hernias. The covering are derived
from the layers (fascia) of the abdominal wall through
which it passes.
3.3. The Contents
 Fluids (peritoneal exudate)
 Omentum (omentocele)
 Intestine (enterocele)
 A portion of the circumference of intestine
(Richter’s hernia)
 Portion or diverticulum of the bladder
 Ovary with or without the fallopian tube in females
 Meckel’s diverticulum (Littre.s hernia)
 Two loops of bowel (Maydl’s hernia or pandelon)

8. 3.4. Types of Hernias by Contents
 Reducible: contents can be completely emptied
from the sac
 Irreducible: contents cannot be completely
emptied due to existence of adhesions between the
contents and the sac.
 Obstructed: content bowel is obstructed and
oedematous without obstruction to arterial supply.
 Strangulated: content bowel is obstructed with
obstruction to mesenteric blood supply which may
result in gangrene and perforation.
 Incarcerated: When content is irreducible large
gut with retention of faeces.

9.  4.0. Clinical Features
 Benign swelling with or without tenderness
 Swelling may or may not be manually reduced
 The protrusion of the swelling may be increased
with coughing
 Swelling is soft in consistence
4.1. Diagnosis
 This is clinical
 No specific investigations but general
investigations can be done.

10. 4.3. Differential Diagnosis
 In males:
 vaginal hydrocele
 encysted hydrocele of the cord
 a spermatocele
 a femoral hernia
 an incompletely descended testis
 a lypoma of the cord
 In females
Hydrocele of the canal of Nuck
a femoral hernia

11. 5.0. Treatment
 Surgery is the treatment of choice and
consist of pre-operative care, operative and post
operative care.
5.1. Pre-operative Care
 Precipitating factors like obesity, constipation,
bladder neck obstruction, chronic cough and
smoking should be controlled before operation
5.2. Operative
The following maneuvers are usually carried out
singly or in combination:

12.  Herniotomy
Opening the sac, emptying (reducing) and
transfixing the neck.
 Herniorrhaphy
Repair of the stretched internal ring, the transversalis
fascia and reinforcement of the posterior inguinal wall.
 Hernioplasty
Strengthening of the defect with a patch of fascia or
with a prosthesis (mesh).
NB: In the last two herniotomy is done

13. 5.3. Post-operative Care.
i) General.
 Administration of :
Antibiotics
Analgesics
 Treatment of any pre-disposing factor Early
mobilization of the elderly.
ii) Specific.
 Wound dressing
 Prevention of complications and recurrence.
Complications of a hernial repair may be:
 Haematoma formation
 Oedema
 Torsion


14. Breakdown
Infection.
Development of a hydrocele
• Recurrence may be due to:
Tension in suturing (tissues break off due to tension).
Fibroblastic reaction to sutures (better in
non-absorbable filaments than in
absorbable).
Any pre-operative factors predisposing
to delayed healing.
Failure to use non-absorbable suture.
Failure to ligate the sac at the neck.
Failure to perform herniorrhaphy.

15.  Complication (cont.)
Inadequate repair of a weakened posterior wall of
the inguinal canal
Failure to avoid factors predisposing to wound
infection
Non closure of the medial end of the posterior
wall of the inguinal canal ( between conjoint
tendon, pubic periosteum and the inguinal
ligament).
END

16. 1.0 Def: Hydrocele is the collection of fluid within the
tunica vaginalis.
1.1 Categories of Hydroceles.
i)Primary hydroceles:
There is no underlying or associated disease of the testis
or the epididymos.
Types of Primary Hydroceles:
•Congenital
•Infantile
• Vaginal
•Encysted.

17. The congenital hydrocele communicates
with peritoneum while the other three are
obliterated.
ii) Secondary Hydroceles.
These are associated with disease, inflammation or
neoplasm of the testis or epididymos.
2.0 Surgical Anatomy.
• In Primary congenital hydrocele there is incomplete
obliteration of the processus vaginalis and the tunica
vaginalis is distended with peritoneal fluid. This is
connecting with peritoneum.

18. • In the infantile and encysted types there is partial
obliteration of the processus vaginalis. These are non-
connecting with peritoneum.
• In the vaginal type (commonest), the tunica
vaginalis is distended with varying amounts of straw-
coloured fluid.
Secondary Hydroceles.
In secondary hydroceles, fluid collection in the tunica
vaginalis may be:
• Rapid as in acute epididymorchitis or testicular
torsion.
• Slow as in chronic inflammations or testicular
tumors. The fluid is usually an exudate.

19. 3.0 Clinical Features.
The clinical presentation is that of a
uni-locular or uncommonly bi-locular scrotal swelling
with the following characteristics:
• Tense or laxed swelling.
• Transillunating.
• Emptying or non-emptying in lying position.
• Inability to separate testis from the
hydrocele.
• Flactuant in palpation.
• Usually non-tender.
• Normal surface temperature.

20. 4.0 Diagnosis.
The diagnosis of a hydrocele is clinical i.e. from
history, presentation and findings on examination.
4.1 Differential Diagnosis.
A hydrocele may be differentated from the following
conditions:
• Inguino-scrotal hernia.
• Testicular torsion.
• Epididymorchitis.
• Spermatocele.
• Cystic disease of the scrotum
• Incompletely descended testis.

21. 5.0 Investigations.
• General pre-operative investigations (HB,
Blood grouping and cross-match, Urinalysis)
• Specific ( Ultra-sound, fluid aspiration for
cytology and investigation for any
underlying disease in secondary hydrocele.
6.0 Treatment.
• Aspiration.
This has a very high rate of recurrence. It is
now abandoned.
• Hydrocelectomy is the treatment of choice.

22. END