for under graduates

1. HERNIAHERNIA
Dr.Iyyappan

2. ObjectivesObjectives
• Definition
• Anatomy
• Precipitating factors
• Types
• Clinical features
• Preoperative assessment
• Management and repair

3. DefinitionDefinition
A hernia is a protrusion of a viscus or
part of a viscus through an abnormal
opening in the walls of its
containing cavity.

4. Common External HerniasCommon External Hernias
• ABDOMINAL WALL & GROIN
• Midline
• Umbilical
• Para- umbilical
• Epigastric
• Inguinal
• Direct/ Indirect/ Combined
• Femoral
• Incisional

5. • Indirect Inguinal Hernia
 Hernia through the inguinal canal
• Direct Inguinal Hernia
 Weakness or defect of the transversalis fascia
• Femoral Hernia
 Hernia medial to femoral vessels under inguinal ligament
• Umbilical Hernia
 Hernia through the umbilical ring

6. • Paraumbilical Hernia
◦ A protrusion through the linea alba just above or sometimes just
below the umbilicus
• Epigastric Hernia
o Protrusion of extraperitoneal fat through the linea alba anywhere
between the xiphoid process and the umbilicus
• Incisional Hernia
o Hernia through an incisional site
• Lumber Hernia
o occur through the inferior lumber triangle of Petit

8. DevelopmentDevelopment

9. AnatomyAnatomy
• The inguinal canal :-
• 4 cm long and is directed obliquely
• Canal lies parallel and 2-4 cm superior to the medial half of the inguinal ligament.
• Ligament extends from the anterior superior iliac spine to the pubic tubercle.
• The inguinal canal has openings at either end : –
• The deep ring - approximately 1.25 cm superior to the middle of the inguinal ligament
• The superficial ring – hesselbach’s triangle

10. Inguinal AnatomyInguinal Anatomy
• Floor
• Transversalis fascia
• Medially the conjoint tendon
• Roof
• External oblique aponeurosis
• Laterally the conjoint tendon
• Skin and superficial fascia
• Above
• Conjoint tendon
• Below
• The inguinal ligament

11. Anatomy of a HerniaAnatomy of a Hernia

12. ContentsContents
1. Spermatic cord ( round ligament of the uterus in female )
The contents of the spermatic cord are
a. the ductus (vas) deferens and its artery .
b. the testicular artery and venous (pampiniform) plexus.
c. the genital branch of the genitofemoral nerve.
d. lymphatic vessels and sympathetic nerve fibers.
e. fat and connective tissue surrounding the cord and its coverings in various
amounts
2. Ilioinguinal nerve .
3. Ilioinguinal lymph node .

13. Inguinal HerniaInguinal Hernia
• Commonest external hernia
• Male preponderance
• Infant / adult
• Direct / indirect / combined
• Weakness / increased pressure
• Cause pain / discomfort
• Carry risk of complications
• Treated surgically

14. Common PresentationsCommon Presentations
• A lump
• Comes and goes
• Appears on straining /coughing
• A pain
• Dragging pain/ Pain on exertion
• Incidental finding on examination/ imaging
• Presenting as a complication
• Incarceration/ Intestinal obstruction

15. Inguinal herniaInguinal hernia
History:
1.Age ( young vs. old)
2.Occupation ( nature ?? )
3.Local symptoms: Swelling, discomfort and pain
4.Systemic symptoms: if there is obstruction or strangulation
5.Precipitating factors

16. Predisposing:Predisposing:
• Chronic cough
• Straining
• Bladder neck or urethral obstruction
• Pregnancy
• Vomiting
• Severe muscular effort
• Ascitic fluid

17. Inguinal HerniaInguinal Hernia
• Examination
• Standing / Lying Supine
• Cough impulse
• Reducibility
• Contents
• Bowel sounds
• Scrotal contents

19. Inguinal Hernia - ExaminationInguinal Hernia - Examination
• Surface markings
• Anterior superior iliac spine
• Pubic tubercle
• Midpoint of inguinal ligament

20. asis
pubic tubercle
midpoint of inguinal liagament

21. Indirect Inguinal Hernia Direct Inguinal Hernia
Pass through inguinal canal. Bulge from the posterior wall of the inguinal
canal
Can descend into the scrotum. Cannot descent into the scrotum.
Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.
Reduced: upward, then laterally and
backward.
Reduced: upward, then straight backward.
Controlled: after reduction by pressure
over the internal (deep) inguinal ring.
Not controlled: after reduction by pressure
over the internal (deep) inguinal ring.
The defect is not palpable (it is behind the
fibers of the external oblique muscle).
The defect may be felt in the abdominal wall
above the pubic tubercle.
After reduction: the bulge appears in the
middle of inguinal region and then flows
medially before turning down to the
scrotum.
After reduction: the bulge reappears exactly
where it was before.
Common in children and young adults. Common in old age.

22. Note that examination using finger and thumb across the neck of the scrotum will
help to distinguish a swelling of inguinal origin and one that is entirely intrascrotal

23. Varieties of HerniasVarieties of Hernias
• Maydls
• W loop of intestine
• Richters
• Partial inclusion of intestinal wall
• Sliding hernia
• Bladder
• Sigmoid colon/ appendix

24. MaydlsMaydls’’ HerniaHernia

25. RichtersRichters’’ HerniaHernia

26. Hernia ManagementHernia Management
• Investigations
• None required for routine uncomplicated case
• Plain X-ray for suspected bowel obstruction
• Ultrasound in case of diagnostic uncertainty
• Routine pre-op investigations

27. Inguinal Floor ReconstructionInguinal Floor Reconstruction
Inguinal
Floor
Reconstruction
Primary tissue repair
Open tension free
repair
Laproscopic&
preperitoneal repairs

28. Open Hernia RepairOpen Hernia Repair
• Day-care surgery
• Anaesthesia
• General
• Local

29. Primary tissue repairPrimary tissue repair
1. Bassini repair: inferior arch of transversalis fascia or conjoint tendon
is approximated to shelving portion of inguinal ligament.
2. McVay: Transversalis Fascia is sutured to cooper ligament.
3. Shouldice: Transversalis Fascia is incised and reapproximated.

30. Bassini repairBassini repair

31. Bassini repairBassini repair

32. Open tension free repairOpen tension free repair
1. Lichtenstein repair
2. Mesh plug technique

36. Laparoscopic RepairLaparoscopic Repair

37. Laparoscopic RepairLaparoscopic Repair

38. Triangle of DoomTriangle of Doom

39. Triangle of PainTriangle of Pain

40. Hernia ComplicationsHernia Complications
• Incarceration
• Strangulation
• Intestinal obstruction

41. Retrograde incarcerationRetrograde incarceration

42. Femoral hernia versus inguinal herniaFemoral hernia versus inguinal hernia
Inguinal hernia Femoral hernia
1-more common in male 1-more common in females
2-pass through the inguinal canal 2-pass through the femoral canal
3-neck of the sac is above and medial
the pubic tubercle
3-neck of the sac is below and lateral
the pubic tubercle
4-less common to be strangulated 4-more common to be strangulated
5-can be treated without surgery 5-must be treated surgically
6-the two diagnostic signs of hernia+ 6-the two diagnostic signs of hernia-
7-the sac mainly contain ; bowel 7-the sac mainly contains ; omentum

43. Femoral hernia Femoral hernia
• Age - uncommon in children , most common in
old age female
• Sex - women > men (but still commonest hernia
in women the inguinal hernia )
• Often bilateral
• Femoral hernia is more likely to be strangulated
than the inguinal hernia

44. Femoral CanalFemoral Canal
• Anterior is the inguinal ligament
• Posterior - iliopsoas, pectineal, and long adductor
muscles (floor).
• Medial - lacunar ligament
• Lateral - femoral vessel

45. Femoral HerniaFemoral Hernia
• Herniation through femoral canal
• Appears below and lateral to pubic tubercle
• Relatively uncommon
• Commoner in females
• Contains omentum or small intestine
• High risk of strangulation
• Repaired surgically

46. Femoral HerniaFemoral Hernia

48. Femoral hernia repairFemoral hernia repair
• Femoral hernias should be repaired very soon after the diagnosis has
been made because of the high risk of strangulation.
• There is no place for a truss for a femoral hernia.
• Different approaches :
Open VS Laparoscopic

49. Open surgeryOpen surgery
Three approaches have been described
for open surgery :
1. Infra-inguinal approach (Lookwood)
2. Supra-inguinal approach ( McEvedy)
3. Trans-inguinal approach ( Lotheissen)

50. Femoral Hernia RepairFemoral Hernia Repair

51. SummarySummary
• Inguinal hernia is the commonest external hernia
• Indirect hernias have a higher risk of strangulation
• Hernias are treated by surgery, to relieve symptoms and
prevent complications
• Femoral hernias have a high risk of strangulation

52. ThankThank
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