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HERNIA
• “Protrusion of a part or whole of viscus
through an abnormal opening in the wall of
the cavity that contains it”
• Common Hernias
–
–
–
–
–

INGUINAL
UMBILICAL
FEMORAL
EPIGASTRIC
INCISIONAL

• Rare Hernias
–
–
–
–
–

SPIGELIAN
LUMBAR
G...
Factors: Weakness of abdominal
musculature
• Congenital
– Persistence of
processus vaginalis
– Patent canal of Tuck
– Inco...
Increased abdominal pressure
• Chronic constipation
• Chronic cough
• Bladder outlet obstruction – stricture,
prostrate
• ...
• Sac
• Covering
• Contents
– Omentocoele
– Enterocoele
– Cystocoele
– Ovary
• Richter’s
• Littre’s
• Maydl’s
Classification
•
•
•
•

Reducible
Irreducible
Obstructed/ Incarcerated
Strangulated
Reducible Hernia
• Characteristic signs
– Reducibility
– Cough impulse
Irreducible Hernia
• Due to
– Adhesions
– Narrowing of neck
– Incarceration
– Massive hernia inside scrotum
Obstructed Hernia
• Irreducibility + Intestinal obstruction
• Features
– No cough impulse
– Irreducible
– Painless
– Non t...
Strangulated Hernia
• Blood supply of its contents impaired
• Intestinal obstruction ±
• Pathology
– Intestinal obstructio...
• Appearance
– Congested and bright red
– Ecchymosis
– Extravasation of blood into lumen/ sac
– loss of tone
– Translocati...
• Symptoms
– Pain, vomiting
– Ceases with onset of gangrene, ileus

• Signs
– Ill looking
– Tense, tender
– Irreducible, n...
Strangulated Omentocele
• No features of intestinal obstruction
• Gangrene onset delayed
Strangulated Richter’s Hernia
•
•
•
•

Features mimic gastroenteritis
Obstruction > 50 % of circumference
Colic, diarrhoes...
Maydl’s Hernia
• Retrograde strangulation
• On opening sac – contents appear normal
• Generalized peritonitis may set in e...
Inflamed Hernia
• Outside
– Abrasion, ill fitting truss

• Inside
– Diverticulitis, appendicitis

• Signs of inflammation ...
INGUINAL HERNIA
Anatomy
Inguinal canal
•
•
•
•

Triangular slit 3.75 cm long
Above the inner half of inguinal ligament
Deep to superficial inguina...
Deep Inguinal Ring
•
•
•
•

Opening in the fascia transversalis
1.25 cm above mid inguinal point
Medially – inferior epiga...
Superficial Inguinal Ring
• Aponeurosis of external oblique – crurae
• Above and lateral to pubic crest
• Spermatic cord/ ...
• Anteriorly – skin, fascia, EO
aponeurosis, lateral third – IO aponeurosis
• Posteriorly – transversalis fascia, medial ½...
Contents
• Illioinguinal nerves
• Spermatic cord
– Vas defrens
– Testicular artery, art to vas defrens, cremasteric
– Pamp...
Hassenbach’s Triangle
•
•
•
•
•
•

Site of direct hernia
Medially – lateral border rectus abdominis
Laterally – inferior e...
Mechanisms for preventing hernia
•
•
•
•
•

Obliquity of inguinal canal
Shutter mechanism of fibres of IO, TA
Sphincter ac...
INDIRECT INGUINAL HERNIA
•
•
•
•

More common
Young individuals
More common on the right side
On basis of extent
– Bubonoc...
• Coverings
– Peritoneum
– Extraperitoneal fat
– Internal spermatic fascia
– Cremasteric fascia
– External spermatic fasci...
DIRECT INGUINAL HERNIA
•
•
•
•

Directly through the hasselbach’s triangle
Acquired (ex- Oglive hernia)
More common in eld...
• Symptoms
– Pain/ discomfort
– Lump
– Systemic symptoms – obstruction, strangulation
– Predisposing factors – constipatio...
• Signs
– REDUCIBILITY
– COUGH IMPULSE
– Position – d/f femoral hernia
– Get above the swelling
– Invagination test
– Ring...
Rare Varieties
• Interstitial hernia
– Between muscle layers of abdominal wall
– Commonly associated with undescended test...
Rare Varieties
• Sliding hernia
– Older men
– Extraperitoneal bowel with sac of peritoneum
– Caecum, pelvic colon, bladder...
TREATMENT
• Conservative management
• Surgical management
Conservative management :
No Treatment
• Indications
– Severe ill health
– Short life expectency
– Refuse operation
Conservative management : Truss
• Indications
– Refuse operation
– Old patients with severe co morbidities
– Children ( c/...
• Dangers
– Pressure atropht of muscles of inguinal region
– Ostruction or strangulation
– Used with partially reduced her...
Operative treatment
• Herniotomy
– Neck of sac transfixed, ligated and excised
– Infants and children; young men with good...
Hernioplasty
• Herniotomy + reinforcement of posterior wall
• Autologous
– Fascia lata
– External oblique aponeurosis
– An...
• Indications
– Indirect hernia – poor muscle tone
– Direct hernia
– Recurranthernia
– Predisposing factors – chronic coug...
Treatment of Strangulated Hernia
• Emergency surgery
• Resuscitation
• Reduction of hernia
– Foot end elevation
– Ice pack...
• Assess viability
– Green/ black color
– Flaccid , lustureless appearance
– No peristalssis
– Blood stained, foul smellin...
• Bowel nonviable
– Linear patch of gangrene – invagination
– Loop of bowel – resection and anastomosis if gen
condition p...
RECURRENT INGUINAL HERNIA
• Types of hernia
– Sliding
– Large/ long standing
– Large direct hernia

• Types of patients – ...
RECURRENT INGUINAL HERNIA
• Operative faults
–
–
–
–
–

Failure to ligate sac
Tension in repair
Use of absorbable sutures
...
FEMORAL HERNIA
• Femoral ring – femoral canal – saphenous
opening
• More common in
– Females
– Old age

• Most liable to strangulate
Anatomy
Coverings of the sac of femoral hernia
•
•
•
•
•
•
•

Skin
Superficial fascia
Cribriform fascia
Anterior layer of femoral ...
Rare types of femoral hernia
• Prevascular
hernia(Velpeu’s) – ass with
posterior dislocation
(Narath’s hernia)
• Retrovasc...
• Symptoms
– Swelling
– Pain
– Systemic symptoms

•
•
•
•

Zeimenns technique
Invagination technique
Ring occlusion test
P...
Treatment
• No conservative management
• Surgery – herniorrhaphy
– High operation(McEvedy’s)
– Lottheissen’s

– Lockwood
UMBILICAL HERNIA
• Three major types
– Exomphalos
– Umbilical hernia in infants and children
– Paraumbilical hernia in adu...
Exomphalos
• Minor
– Small sac
– Summit attached to the umbilical cord
– Treatment
• twisting of umbilical cord and strapp...
Exomphalos
• Major
• Umbilical cord attached to inferior
aspect of swelling
• Contains intestines, liver
• Surgical emerge...
Umbilical hernia in children and infants
•
•
•
•

Weak umbilical scar following neonatal sepsis
Usually asymptomatic
90% c...
Paraumbilical hernia of adults
• Supraumbilical or infraumbilical
• Adhesions - seldom reducible
• Predisposing factors –
...
EPIGASTRIC HERNIA
(Fatty Hernia of Linea Alba)
•
•
•
•

Through fibres of linea alba
Blood vessels pierce linea alba
Initi...
INCISIONAL HERNIA
(Ventral Hernia)
• Defect with patient
–
–
–
–

Obesity
Chronic cough perioperative period
Undue abdomin...
• Postoperative
– Infection
– Postop cough, distention
– Postop peritonitis
– Early removal of sutures
– Postop steroid th...
Types of incisional hernia
• Type 1
– Upper abdomen/ midline lower abdomen
– Wide gap in musculature
– Low risk of strangu...
Treatment
• Prevention of incisional hernia
– Weight reduction
– Correct nutritional defects
– Treat chronic cough
– Caref...
• Conservative management
– Reducible type 1

• SURGICAL MANAGEMENT
LUMBAR HERNIA
• Superior lumbar
hernia
• Inferior lumbar
hernia
Incisional lumbar hernia
• Renal surgery with post op infection
• Paralysis of lumbar muscles(phantom hernia)
• Treatment
...
OBTURATOR HERNIA
• Rare; old women
• Through obturator
foramen
• Thigh flexed, abducted and
externally rotated
• Referred ...
SPIGELEAN HERNIA
• Interparietal hernia
• At level of arcuate line,
lateral to rectus
• Treatment - surgery
• Gluteal hernia
• Sciatic hernia
CONCLUSION
• Protrusion of a part or whole of viscus through
an abnormal opening in the wall of the cavity
that contains i...
THANK YOU
Hernia
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Hernia

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Hernia

  1. 1. HERNIA
  2. 2. • “Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it”
  3. 3. • Common Hernias – – – – – INGUINAL UMBILICAL FEMORAL EPIGASTRIC INCISIONAL • Rare Hernias – – – – – SPIGELIAN LUMBAR GLUTEAL SCIATIC OBTURATOR
  4. 4. Factors: Weakness of abdominal musculature • Congenital – Persistence of processus vaginalis – Patent canal of Tuck – Incomplete obliteration of umbilicus • Acquired – Fat – Pregnancy – Incision – Infection – Connective tissue – smoking, aging, CTD, systemic illness
  5. 5. Increased abdominal pressure • Chronic constipation • Chronic cough • Bladder outlet obstruction – stricture, prostrate • Straining – weight lifting • Intra-abdominal malignancy • Vomiting • Repeated pregnancy
  6. 6. • Sac • Covering • Contents – Omentocoele – Enterocoele – Cystocoele – Ovary
  7. 7. • Richter’s • Littre’s • Maydl’s
  8. 8. Classification • • • • Reducible Irreducible Obstructed/ Incarcerated Strangulated
  9. 9. Reducible Hernia • Characteristic signs – Reducibility – Cough impulse
  10. 10. Irreducible Hernia • Due to – Adhesions – Narrowing of neck – Incarceration – Massive hernia inside scrotum
  11. 11. Obstructed Hernia • Irreducibility + Intestinal obstruction • Features – No cough impulse – Irreducible – Painless – Non tender – Features of intestinal obstruction
  12. 12. Strangulated Hernia • Blood supply of its contents impaired • Intestinal obstruction ± • Pathology – Intestinal obstruction – Dilation of hernial contents – Impairment of venous return – Stasis --------- Arterial impairment
  13. 13. • Appearance – Congested and bright red – Ecchymosis – Extravasation of blood into lumen/ sac – loss of tone – Translocation of gut bacteria – peritonitis/ sepsis – Gangrene
  14. 14. • Symptoms – Pain, vomiting – Ceases with onset of gangrene, ileus • Signs – Ill looking – Tense, tender – Irreducible, no cough impulse – Acute intestinal obstruction – Peritonitis
  15. 15. Strangulated Omentocele • No features of intestinal obstruction • Gangrene onset delayed
  16. 16. Strangulated Richter’s Hernia • • • • Features mimic gastroenteritis Obstruction > 50 % of circumference Colic, diarrhoes Constipation - ileus
  17. 17. Maydl’s Hernia • Retrograde strangulation • On opening sac – contents appear normal • Generalized peritonitis may set in early
  18. 18. Inflamed Hernia • Outside – Abrasion, ill fitting truss • Inside – Diverticulitis, appendicitis • Signs of inflammation + • Not associated with intestinal obstruction
  19. 19. INGUINAL HERNIA
  20. 20. Anatomy
  21. 21. Inguinal canal • • • • Triangular slit 3.75 cm long Above the inner half of inguinal ligament Deep to superficial inguinal ring Developed due to the descent of testis in embryonic life
  22. 22. Deep Inguinal Ring • • • • Opening in the fascia transversalis 1.25 cm above mid inguinal point Medially – inferior epigastric artery Spermatic cord in males; round ligament in females
  23. 23. Superficial Inguinal Ring • Aponeurosis of external oblique – crurae • Above and lateral to pubic crest • Spermatic cord/ round ligament and illioinguinal nerves
  24. 24. • Anteriorly – skin, fascia, EO aponeurosis, lateral third – IO aponeurosis • Posteriorly – transversalis fascia, medial ½ conjoint tendon • Above – transversus abdominins and internal oblique fibres • Below – inguinal ligamnet
  25. 25. Contents • Illioinguinal nerves • Spermatic cord – Vas defrens – Testicular artery, art to vas defrens, cremasteric – Pampiniform plexus of veins – Lymph vessels – Testicular plexus of sympathetic nerves, genital branch of genitofemoral
  26. 26. Hassenbach’s Triangle • • • • • • Site of direct hernia Medially – lateral border rectus abdominis Laterally – inferior epigastric vessel Inferiorly – inguinal ligament Floor – fascia transversalis Umbilical fold – obliterated umbilical artery
  27. 27. Mechanisms for preventing hernia • • • • • Obliquity of inguinal canal Shutter mechanism of fibres of IO, TA Sphincter action of TA, IO at deep inguinal ring Ball valve action of cremasteric Fibres of internal oblique over deep inguinal ring • Conjoint tendon
  28. 28. INDIRECT INGUINAL HERNIA • • • • More common Young individuals More common on the right side On basis of extent – Bubonocele – Funicular hernia – Complete hernia
  29. 29. • Coverings – Peritoneum – Extraperitoneal fat – Internal spermatic fascia – Cremasteric fascia – External spermatic fascia – Superficial fascia – skin
  30. 30. DIRECT INGUINAL HERNIA • • • • Directly through the hasselbach’s triangle Acquired (ex- Oglive hernia) More common in elderly, malgaigne bulgings Rarely gets strangulated
  31. 31. • Symptoms – Pain/ discomfort – Lump – Systemic symptoms – obstruction, strangulation – Predisposing factors – constipation, chronic bronchitis, urinary obstruction – Past history
  32. 32. • Signs – REDUCIBILITY – COUGH IMPULSE – Position – d/f femoral hernia – Get above the swelling – Invagination test – Ring occlusion test
  33. 33. Rare Varieties • Interstitial hernia – Between muscle layers of abdominal wall – Commonly associated with undescended testis – Preperitoneal – Intraperitoneal – Extraperitoneal
  34. 34. Rare Varieties • Sliding hernia – Older men – Extraperitoneal bowel with sac of peritoneum – Caecum, pelvic colon, bladder – Strangulation of intestine within and outside the peritoneum • Richter’s • Maydl’s • Littre’s
  35. 35. TREATMENT • Conservative management • Surgical management
  36. 36. Conservative management : No Treatment • Indications – Severe ill health – Short life expectency – Refuse operation
  37. 37. Conservative management : Truss • Indications – Refuse operation – Old patients with severe co morbidities – Children ( c/I – undescended testis) • Contraindications – – – – – Irreducible hernia Undescended testis Chronic bronchitits, strenous labour Associated with large hydrocele Not intelligent enough to position properly
  38. 38. • Dangers – Pressure atropht of muscles of inguinal region – Ostruction or strangulation – Used with partially reduced hernia – may cause trauma – Improper cleanliness – unhealthy skin – Adhesions between sac and canal – Chance of strangulation remains
  39. 39. Operative treatment • Herniotomy – Neck of sac transfixed, ligated and excised – Infants and children; young men with good musculature • Herniorrhaphy – Herniotomy + repair of postrior wall – Indirect hernias – Adults with good muscle tone
  40. 40. Hernioplasty • Herniotomy + reinforcement of posterior wall • Autologous – Fascia lata – External oblique aponeurosis – Anterior rectus sheath flap – Skin flap – dermoplasty/ skin ribbon • Heterogenous – Prolene – Stainless steel
  41. 41. • Indications – Indirect hernia – poor muscle tone – Direct hernia – Recurranthernia – Predisposing factors – chronic cough,etc
  42. 42. Treatment of Strangulated Hernia • Emergency surgery • Resuscitation • Reduction of hernia – Foot end elevation – Ice pack – NG, IV fluids – Analgesia, antibiotic
  43. 43. • Assess viability – Green/ black color – Flaccid , lustureless appearance – No peristalssis – Blood stained, foul smelling fluid in sac • Bowel viable - HERNIORRHAPHY
  44. 44. • Bowel nonviable – Linear patch of gangrene – invagination – Loop of bowel – resection and anastomosis if gen condition permits – Bowel large intestine – exteriorisation
  45. 45. RECURRENT INGUINAL HERNIA • Types of hernia – Sliding – Large/ long standing – Large direct hernia • Types of patients – chronic cough • Inadequate preoperative preparation
  46. 46. RECURRENT INGUINAL HERNIA • Operative faults – – – – – Failure to ligate sac Tension in repair Use of absorbable sutures Bleeding – infection Fault in selection of operation • Postoperative care – Wound infection – Lifting heaavy weights – Persistence of predisposing factors • Appearance of new hernia
  47. 47. FEMORAL HERNIA
  48. 48. • Femoral ring – femoral canal – saphenous opening • More common in – Females – Old age • Most liable to strangulate
  49. 49. Anatomy
  50. 50. Coverings of the sac of femoral hernia • • • • • • • Skin Superficial fascia Cribriform fascia Anterior layer of femoral sheath Fatty contents of femoral canal Femoral septum Peritoneum
  51. 51. Rare types of femoral hernia • Prevascular hernia(Velpeu’s) – ass with posterior dislocation (Narath’s hernia) • Retrovascular hernia Serafini • Pectineal hernia – Cloquet’s • External femoral hernia – Hesselbach’s • Lacunar hernia – Lingier’s
  52. 52. • Symptoms – Swelling – Pain – Systemic symptoms • • • • Zeimenns technique Invagination technique Ring occlusion test Position of swelling
  53. 53. Treatment • No conservative management • Surgery – herniorrhaphy – High operation(McEvedy’s) – Lottheissen’s – Lockwood
  54. 54. UMBILICAL HERNIA • Three major types – Exomphalos – Umbilical hernia in infants and children – Paraumbilical hernia in adults
  55. 55. Exomphalos • Minor – Small sac – Summit attached to the umbilical cord – Treatment • twisting of umbilical cord and strapping
  56. 56. Exomphalos • Major • Umbilical cord attached to inferior aspect of swelling • Contains intestines, liver • Surgical emergency • Immediate decompression and reduction
  57. 57. Umbilical hernia in children and infants • • • • Weak umbilical scar following neonatal sepsis Usually asymptomatic 90% cured within 12 – 18 months > 18 months – surgery
  58. 58. Paraumbilical hernia of adults • Supraumbilical or infraumbilical • Adhesions - seldom reducible • Predisposing factors – – Women – Obesity – Repeated pregnancy • Treatment – Mayo’s operation
  59. 59. EPIGASTRIC HERNIA (Fatty Hernia of Linea Alba) • • • • Through fibres of linea alba Blood vessels pierce linea alba Initially extraperitoneal fat only M.c. – young muscular men with strenous activity • Usually irreducible, no cough impulse • If symptomatic - surgery
  60. 60. INCISIONAL HERNIA (Ventral Hernia) • Defect with patient – – – – Obesity Chronic cough perioperative period Undue abdominal distention Malnutrition • Operative – – – – – Injury to nerves Careless wound closure Hemorrhage – infection Tube drainage through laparotomy wound Midline infraumbilical
  61. 61. • Postoperative – Infection – Postop cough, distention – Postop peritonitis – Early removal of sutures – Postop steroid therapy
  62. 62. Types of incisional hernia • Type 1 – Upper abdomen/ midline lower abdomen – Wide gap in musculature – Low risk of strangulation • Type 2 – Lateral part of abdomen – Small defect – Strangulation risk high
  63. 63. Treatment • Prevention of incisional hernia – Weight reduction – Correct nutritional defects – Treat chronic cough – Careful closure of abdomen – Prevent post op wound infection
  64. 64. • Conservative management – Reducible type 1 • SURGICAL MANAGEMENT
  65. 65. LUMBAR HERNIA • Superior lumbar hernia • Inferior lumbar hernia
  66. 66. Incisional lumbar hernia • Renal surgery with post op infection • Paralysis of lumbar muscles(phantom hernia) • Treatment – Primary hernia – herniorrhaphy – Incisional hernia
  67. 67. OBTURATOR HERNIA • Rare; old women • Through obturator foramen • Thigh flexed, abducted and externally rotated • Referred pain to knee joint • Strangulation - surgery
  68. 68. SPIGELEAN HERNIA • Interparietal hernia • At level of arcuate line, lateral to rectus • Treatment - surgery
  69. 69. • Gluteal hernia • Sciatic hernia
  70. 70. CONCLUSION • Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it • Inguinal hernia most frequent • Usual mode of treatment is surgical
  71. 71. THANK YOU

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