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HERNIAHERNIA
Dr.Iyyappan
ObjectivesObjectives
• Definition
• Anatomy
• Precipitating factors
• Types
• Clinical features
• Preoperative assessment
• Management and repair
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.
Common External HerniasCommon External Hernias
• ABDOMINAL WALL & GROIN
• Midline
• Umbilical
• Para- umbilical
• Epigastric
• Inguinal
• Direct/ Indirect/ Combined
• Femoral
• Incisional
• 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
• 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
DevelopmentDevelopment
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
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
Anatomy of a HerniaAnatomy of a Hernia
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 .
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
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
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
Predisposing:Predisposing:
• Chronic cough
• Straining
• Bladder neck or urethral obstruction
• Pregnancy
• Vomiting
• Severe muscular effort
• Ascitic fluid
Inguinal HerniaInguinal Hernia
• Examination
• Standing / Lying Supine
• Cough impulse
• Reducibility
• Contents
• Bowel sounds
• Scrotal contents
Inguinal Hernia - ExaminationInguinal Hernia - Examination
• Surface markings
• Anterior superior iliac spine
• Pubic tubercle
• Midpoint of inguinal ligament
asis
pubic tubercle
midpoint of inguinal liagament
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.
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
Varieties of HerniasVarieties of Hernias
• Maydls
• W loop of intestine
• Richters
• Partial inclusion of intestinal wall
• Sliding hernia
• Bladder
• Sigmoid colon/ appendix
MaydlsMaydls’’ HerniaHernia
RichtersRichters’’ HerniaHernia
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
Inguinal Floor ReconstructionInguinal Floor Reconstruction
Inguinal
Floor
Reconstruction
Primary tissue repair
Open tension free
repair
Laproscopic&
preperitoneal repairs
Open Hernia RepairOpen Hernia Repair
• Day-care surgery
• Anaesthesia
• General
• Local
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.
Bassini repairBassini repair
Bassini repairBassini repair
Open tension free repairOpen tension free repair
1. Lichtenstein repair
2. Mesh plug technique
Laparoscopic RepairLaparoscopic Repair
Laparoscopic RepairLaparoscopic Repair
Triangle of DoomTriangle of Doom
Triangle of PainTriangle of Pain
Hernia ComplicationsHernia Complications
• Incarceration
• Strangulation
• Intestinal obstruction
Retrograde incarcerationRetrograde incarceration
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
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
Femoral CanalFemoral Canal
• Anterior is the inguinal ligament
• Posterior - iliopsoas, pectineal, and long adductor
muscles (floor).
• Medial - lacunar ligament
• Lateral - femoral vessel
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
Femoral HerniaFemoral Hernia
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
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)
Femoral Hernia RepairFemoral Hernia Repair
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
ThankThank
YouYou

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Hernias

  • 2. ObjectivesObjectives • Definition • Anatomy • Precipitating factors • Types • Clinical features • Preoperative assessment • Management and repair
  • 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
  • 7.
  • 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
  • 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
  • 18.
  • 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
  • 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.
  • 32. Open tension free repairOpen tension free repair 1. Lichtenstein repair 2. Mesh plug technique
  • 33.
  • 34.
  • 35.
  • 40. Hernia ComplicationsHernia Complications • Incarceration • Strangulation • Intestinal obstruction
  • 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
  • 47.
  • 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)
  • 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