Hernia and its physiotherapy management

1. Hernias
By-
Dr. K.K.Patel (M.PT)

2. Hernia is the protrusion of a part or whole of viscus
through an abnormal opening in the wall of the cavity
which contains it.

3. •Common external hernia are
1.Inguinal – about 73%
2.Femoral – about 17%
3.Umbilical – about 8.5%
4.Incisional – its incidence is not included
Other 1.5 % cases are rare hernia e.g.
1.Epigastric
2.Lumbar
3.Spigelian
4.Obturator
5.Gluteal

4. Etiology
A) Any condition which increase intra-abdominal
pressure
e.g. - Power full muscular effort or strain by lifting
heavy weight
- Whooping cough, chronic cough
- Obesity,
- Repeated pregnancy
- Vomiting, constipation

5. B- weakness of the abdominal muscle
- Congenital weakness
- Acquired weakness

6. Pathology
Hernia consists of three part..
The sac
The contents of sac
The covering of sac

7. The sac- It is a pouch of peritoneum which comes out
through the abdominal musculature.
The sac can be divided in three part
- The mouth
- The neck
- The body
- The fundus

8. The contents of sac – Abdominal viscus
(depended upon site)
Fluid – peritoneal exudates
The covering of sac- Depends upon the layers of
abdominal through which the sac passes

9. Classification
I. Reducible hernia
II. Irreducible hernia
III. Obstructed hernia
IV.Strangulated hernia

10. Reducible hernia – Hernia reduces itself as the patient
lies down or can be reduced by the patient or by
surgeon
One of the 2 most characteristic features of hernia is its
Reducibility and second feature is Impulses on
coughing.
Irreducible hernia - Here the content cannot be
returned to abdomen because of the adhesion formed
between sac and content

11. Obstructed hernia
It is irreducible hernia containing intestine which
obstructed from without or from within but doesn't
interfere blood supply to distal
Strangulated hernia
It is irreducible and obstructed hernia ant there is arrest
of blood supply to the contents

12. An external abdominal hernia is protrusion of
abdominal viscus through a weak spot in the
abdominal wall
Common external hernia are
•Inguinal hernia
•Femoral hernia
•Umbilical hernia
•Incisional hernia

13. Inguinal hernia
It is the protrusion of part of the contents of the
abdomen through the inguinal region of the abdominal
wall.
It is reducible
Expansible impulse on cough

15. There are two types of inguinal hernia
1. Indirect inguinal hernia
2. Direct inguinal hernia

16. 1. Indirect hernia
In indirect hernia the content of abdomen enter the deep
inguinal canal and traverse the whole canal to come
out through the superficial inguinal ring, it is lateral to
the inferior epigastric vessels

18. Much common than the direct hernia,
Can occur at any age but more common in children
and young adult
It is more commonly seen on right side. only 1/3 of
cases are involved bilateral
Impulses on coughing
When it is complete it is pyriform shape and when it is
incomplete it is oval shape
The hernia has to be reduced by the patient or the
doctor and it dose not reduced by itself

19. There are three types of indirect hernia
i. BUBONOCELE – hernia is limited to the inguinal
canal
ii.FUNICULAR – the contents of hernia can be felt
separately from the testis and the testis lie below the
hernia
iii.COMPLETE OR SCROTAL HERNIA – the hernia
descends down to the bottom of the scrotum lying in
front and side of the testis

20. Direct inguinal hernia
Direct inguinal hernias occur medial to the inferior
epigastric vessels through the posterior wall of the
inguinal canal
Female are not affected
More than ½ the case are bilateral. it is usually caused by
poor abdominal muscle.
It is always incomplete and spherical shape
This hernia is appears as forward bulges

21. It is automatically reduces when the patient lies down
If the impulses is felt on the middle finger it is a direct
hernia

22.  Invagination test –
When the little finger enters the ring if it goes upward, backwards, and out
wards it is an indirect hernia
If the impulses is felt on the tip of the finger it is an indirect hernia
When the little finger goes directly backwards, it is direct hernia
If the impulses is felt on the pulp of the finger it is an direct hernia

23. Ring occlusion test
The hernia must be reduced first
A thumb is pressed on the deep inguinal ring then asked to cough
A direct hernia will show bulge medial to the finger but an indirect hernia
will not find assess, so no bulge

24. Treatment –
Herniotomy- In this operation the neck of the sac is transfixed and ligated
and then the hernial sac is excised
It is indicated –
 In infants and children in whom there is preformed sac
 In case of young adults with very good inguinal musculature

25. Hernioraphy –
It is consist of herniotomy + repair of posterior wall of the inguinal canal
by opposing the conjoined tendon to the inguinal ligament
Hernioplasty –
Herniotomy + reinforced repair of the posterior wall of the inguinal canal
by filling the gap between the conjoined tendon and ligament by
Autogenous or heterogenous material

26. Femoral hernia
Abdominal contents pass through the femoral ring, transverse the femoral
canal and comes out through the saphenous opening.
it is 3rd most common hernia after the inguinal and incisional hernia.
Common in female elderly and most liable to get strangulated

28. You may see a bulge in the upper thigh next to the groin.
Most femoral hernias cause no symptoms. There may be some groin
discomfort that is worse when you stand, lift heavy objects, or strain.
Sometimes, the first symptoms are abdominal pain, nausea, and vomiting.
This may mean that the intestine is blocked, which is an emergency.

29. Umbilical hernia
This is due to failure of all part of mid gut return to the colon during early
fetal life. So the abdominal organ remain protruded.
Umbilical hernia in infants and children –
This is hernia through a weak umbilical scar,
The hernia is usually symptomless and increase in size during crying

31. If small, symptomless then conservative treatment.
Operation is only justified when the hernia fails to disappear after 18
months – Herniorapphy
Para- umbilical hernia of adult –
In the adults the hernia does not protrude through the umbilical. But it is
protrusion through the linea alba just above the umbilicus or occasionally
below the umbilicus
That is why its called para umbilical hernia

32. Women are by far the major victims,
Obese patient are mainly involved.
Treatment – operation is the treatment of choice
MAYO’ S OPERATION

33. Incisional hernia
An incisional hernia is one which occurs through an acquired scar in the
abdominal wall caused by a previous surgical operation or an accidental
trauma.

34. Etiology
1. Defect with patient
- Obese individual
- Chronic cough
- Abdominal distension in the early POD
- Malnutrision

35. 2- Fault during operation
- Injury to the motor nerve supplying the area.
- Improper closer of wound
- Tube drainage through the laparotomy wound
- Haemostasis was not perfect
- Certain incision are more liable to causes incisional hernia

36. 3-Postoperative causes
- Infection
- Postoperative cough and distension
- Postoperative peritonitis due to more chance
of wound infection.
- To early removal of sutures

37. Hernia may occur through the small portion of scar at lower end
Diffuse bulging of whole length of incision
Gradually size become increased and irreducible
Mostly asymptomatic and broad neck don’t need any treatment
Treatment
Conservative treatment – abdominal belt
Operative management

38. Physiotherapy management –
For the undergoing surgery for an inguinal hernia pulmonary
complications may be a risk when there is a chronic chest condition
Pre and post operative breathing exercise and chest physiotherapy are
important
DVT is possible complication after herniorraphy and so exercise for legs
should be given before and after surgery

39. These patients likely to have weak abdominal muscles which should be
strengthen after surgery
A progressive scheme of exercise starting with static in middle to inner
range and following with free active exercise should be implemented,
care should be taken not to go beyond the ability of the patient and
exercise in outer range of the abdomen should be avoided
Patients should be instructed in correct lifting techniques.

40. Patient undergoing surgery for a femoral hernia should have similar
physiotherapy
The risk of pulmonary complications is smaller but there may be a greater
risk of developing a DVT
Correct lifting techniques should be taught so that the intra abdominal
pressure is not abnormally high during lifting

41. Patients undergoing for the umbilical and
insicional hernia surgery physiotherapy is as
for abdominal surgery
 To prevent pulmonary and circulatory
complication.
 Strengthen abdominal muscle
 Teach postural correction
 Scar management
 Advice on back care
 Advice on progression of activities to
function