How to remove it

1. HERNIA

2. CONTENTS
 ANATOMY OF THE ABDOMINAL WALL
 DEFINITION OF HERNIA
 TYPES OF HERNIAS
 CAUSES OF HERNIAS
 PATHOPHYSIOLOGY OF HERNIA
 NATURAL HISTORY OF HERNIAS
 CLINICAL PRESENTATION
 CLINICAL DIAGNOSIS
 CLINICAL MANAGEMENT OF HERNIAS

3. ANATOMY OF THE ABDOMINAL
WALL

4. Inguinal canal
 The inguinal region of the body, also known as the
groin, is located on the lower portion of the anterior
abdominal wall, with the thigh inferiorly, the pubic
tubercle medially, and the anterior superior iliac spine
(ASIS) superolaterally.
 The inguinal canal is a conduit where structures pass,
which has significance from an embryological and
pathological standpoint.

5. Inguinal canal cont..
 The inguinal canal has 2 openings: the deep (internal)
inguinal ring and the superficial (external) inguinal ring.
The boundaries of the canal are as follows:
 Posterior wall - Transversalis fascia laterally; conjoint
tendon medially
 Anterior wall - Internal oblique muscle laterally and
aponeurosis of external oblique muscle
 Roof - internal oblique and transversus abdominis
muscles
 Floor - Inguinal ligament and lacunar ligament
(medially)

7. Spermatic cord
 The contents of the inguinal canal in males consist of the
spermatic cord (with the genital branch of the
genitofemoral nerve) and the ilioinguinal nerve. For
females, the contents include the round ligament, genital
branch of the genitofemoral nerve, and the ilioinguinal
nerve.
 The spermatic cord is covered with 3 layers, as follows:
 The innermost layer consisting of the internal spermatic
fascia, which is derived from the transversalis fascia
 The cremasteric fascia, which is derived from the internal
oblique muscle
 The outermost layer consisting of the external spermatic
fascia, which is derived from the deep fascia of the
external oblique

8. Spermatic cord cont…
 The spermatic cord is formed by various nerves and
vessels that connect to the testis. The classic
description of the components of the spermatic cord is
of 3 arteries, as follows:
 Artery to the ductus deferens (or vas deferens),
testicular artery, cremasteric artery
 Veins- Pampiniform plexus, ductus deferens (vas
deferens), lymphatics
 Genital branch of the genitofemoral nerve (L1/L2)

10. HERNIAS
 A hernia is the protrusion of a viscus or part of a viscus
through an abnormal opening in its coverings
 A hernia is a protrusion of a viscus or part of a viscus
through an abnormal opening in the walls of its
containing cavity.

11. CAUSES OF HERNIAS
A. Congenital
 Indirect inguinal hernias are mostly congenital in that the sac is a
patent processus vaginalis.
B. Acquired
 Acquired hernia may be caused by the followings:
 Muscular weakness due to old age, debility, obesity and occupation
e.g. direct inguinal hernia.
 Iatrogenic factors — weakness of the operative scar (incisional
hernia), or division of the nerve (e.g. post-appendicectomy) may
cause hernia formation.
 Raised intra-abdominal pressure due to obstructive uropathy,
constipation or bronchial asthma may aggravate hernia formation.

12. CAUSES OF HERNIAS
 It is usually more obvious when standing, straining, or lifting heavy
objects. A hernia may, however, be the cause of discomfort and
pain depending upon its size and contents.
 Abdominal straining (heavy lifting, constipation, urinary retention)
 Persistent cough
 Smoking
 Poor nutrition
 Ascites (accumulation of abdominal fluid)
 Undescended testes
 Obesity
 Peritoneal dialysis
 Physical exertion

13. TYPES OF HERNIAS
Common
 Umbilical/para-umbilical.
 Inguinal (direct and indirect).
 Femoral.
 Incisional.
Uncommon
 Epigastric.
 Gluteal, lumbar, obturator

15. Parts of a Hernia
 A hernia consists of the followings:
 (i) Peritoneal sac — which has a mouth, neck
(narrowest part), body and fundus.
 (ii) Content — may be:
a) Intestine (enterocele)/Omentum
(omentocele)/Meckel‘s diverticulum (Littre‘s hernia)
b) A portion of the bladder/Ovary with or without
fallopian tube/Fluid (ascites).
 (iii)Coverings — provided by layers of the abdominal
wall.

16. pathophysiology
 The defect in the abdominal wall may be congenital
(e.g.umbilical hernia, femoral canal) or acquired (e.g.
an incision) and is lined with peritoneum (the sac).
 Raised intra-abdominal pressure further weakens the
defect allowing some of the intra-abdominal contents
(e.g. omentum, small bowel loop) to migrate through
the opening.
 Entrapment of the contents in the sac leads to
incarceration (unable to reduce contents) and possibly
strangulation (blood supply to incarcerated contents is
compromised)

18. Natural history of hernias
 Hernias are termed reducible if their contents can be
pushed back into the abdominal cavity. They are
termed incarcerated if they cannot be pushed back .
 An incarcerated hernia may entrap bowel and cause
bowel obstruction, or it may become strangulated if the
contents of the hernia sac become ischemic.

19. Natural history of hernia
Reducible
Irreducible
Incarcerated
Strangulated
Ischemia
Perforation

20. Clinical manifestations
 Patient presents with a lump over the site of the hernia.
 Femoral hernias are below and lateral to the pubic
tubercle, they usually flatten the groin crease and are
10 times more common in women than men. Femoral
hernias are irreducible.
 Inguinal hernias start off above and medial to the pubic
tubercle but may descend broadly when larger, they
usually accentuate the groin crease. Most are benign
and have a low risk of complications.

21.  (a) Indirect inguinal hernias can be controlled by
digital pressure over the internal inguinal ring, may be
narrow necked and are common in younger men (3% per
annum present with complications).
 (b) Direct inguinal hernias are poorly controlled by
digital pressure, are often broad necked and are
commoner in oldermen (0.3% per annum strangulate).

22.  Incisional hernias bulge, are usually broad necked,
poorly controlled by pressure and are accentuated by
tensing the recti abdominis muscle.
 Large, chronic incisional hernias may contain much of
the small bowel and may by irreducible/unrepairable
due to the ‘loss of the right of abode in the abdomen’ of
the contents.
 True umbilical hernias are present from birth and are
symmetrical defects in the umbilicus due to failure to
close.
 Para-umbilical hernias develop due to an acquired
defect in the periumbilical fascia.

23. Diagnosis
 Examination in the Standing Position
A. Inspection
 Observe
 site: Inguinal/inguinoscrotal: Uni/bilateral:
 Size & shape of the swelling
 Skin over the swelling: Note peristaltic movement and
operative scar, if any.
 Impulse on coughing: Ask the patient to cough. The test is
positive if there is:
1. Increase in size of pre-existing swelling.
2. Appearance of a momentary bulge.

24.  B. Palpation
 (i) Elicit tenderness.
 (ii) Confirm the site:
1. Inguinal — determine its relation to pubic tubercle.
Inguinal hernias are above and lateral to pubic
tubercle. Differentiates it from femoral hernia.
2. Inguinoscrotal — you cannot get above the swelling
(differentiating it from only scrotal swelling).
 (iii)Size and shape.

25.  (iv) Surface — may be smooth (enterocele) or rough
(omentocele).
 (v) Consistency —may be soft (enterocele) or
firm/doughy (omentocele).
 (vi) Expansile impulses on coughing— hold the swelling
between index finger and thumb, and ask the patient to
cough. The fingers will get separated if the test is
positive. Causes of expansile impulse on cough
1. Raised intra-abdominal tension forces more contents
into the sac

26.  Gaseous distension if the content is intestinal.
 Vascular congestion.
 Reducibility—the patient now lies down with the thigh
of the affected side flexed and medially rotated in
order to relax oblique muscles of the abdomen.
 Method: Apply steady pressure over the fundus of the
sac with one hand while the other hand will be guiding
the contents through the superficial inguinal.

27.  Note the followings:
 Direction of reduction: Upwards, backwards and
laterally (indirect hernia) Directly backwards (direct
inguinal hernia)
 Any gargling sound (enterocele).
 First part is difficult to reduce but the last part slips in
easily (enterocele).
 In omentocele, last part is difficult to reduce

28. C. Percussion
 Resonant to percussion in enterocele and dull in
omentocele.
D. Auscultation
 Bowel sounds heard in enterocele and not heard in
omentocele.

29. Management
 Conservative Treatment—Truss: A truss can keep the
hernia reduced without curing it. This is specially
indicated for patients, who are unfit for surgery or who
want to tide over a period of inconvenience for
operation.
 Indications: Extreme old age/Cardiopulmonary
conditions/Patient refuses surgery.
 Dangers: It may precipitate strangulation/it induces
adhesions.

30.  Surgery is the best option for treatment of inguinal
hernias or any hernia.
 Inguinal hernia in a child: Herniotomy, i.e. excision of
the hernial sac.

31. Management cont..
 Inguinal hernia repair in adult:
 a. Herniorrhaphy- excision of the hernial sac with repair of
the posterior wall of inguinal canal, by approximating the
conjoint inguinal ligament, using interrupted sutures of
absorbable suture material like prolene called classical
Bassini type of repair.
 This type of herniorrhaphy (fascia transversalis is also
plicated) is considered better procedure as it strengthens
the thinned, attenuated fascia transversalis.
 Repair or narrowing of the deep ring (Lyttle‘s repair) is a
part of strengthening of the posterior wall and is the most
important step of repair.
 Inguinal hernia in an old man with a weak abdomen or a big
gap in the posterior wall of the inguinal canal.

32. Management cont..
 Hernioplasty: Excision of the hernia sac with repair of the
posterior wall of the inguinal canal fascialata or prolene mesh.
Hernioplasty offers best protection if posterior wall is thin and
muscles are weak. It can be done by using autogenous and
heterogeneous (preferred) materials.
 Autogenous materials includes fascia lata (Galli), skin (Rehn), strips
of external oblique and triangular piece of anterior rectus sheath.
 Heterogeneous materials include Marlex and proline meshes.
 The rio-tension mesh repair reduces postoperative pain.
 In direct inguinal hernia: The hernia sac after isolation is not
excised but inverted into the abdomen and transversalis fascia
repaired, herniorrhaphy or hernioplasty is done.