for Medical students

1. ABDOMINAL HERNIA
LT COL SM SHAHADAT HOSSAIN
MCPS,FCPS( Surgery),FCPS(Thoracic Surgery)
Adv Trg on Thoracoscopy,CNUH,South Korea
CMH ,Bogra

2. DEFINITION
 Hernia means—’To bud’ or ‘to protrude’, ‘off shoot’
(Greek) ‘rupture’ (Latin).
 A hernia is the bulging of part of the contents of the
abdominal cavity through a weakness in the abdominal
wall.

3. SITES
a. Inguinal hernia is the most common hernia (73%)
b. Femoral is 7%
c. Umbilical is 8.5%
d. Others are 1.5.

4. ABDOMINAL HERNIA

5. ABDOMINAL HERNIA

6. ABDOMINAL HERNIA

7. CAUSES OF HERNIA
1. Basic design weakness
2. Weakness due to structures entering and leaving the
abdomen
3. Developmental failures
4. Genetic weakness of collagen
5. Sharp and blunt trauma
6. Weakness due to ageing and pregnancy
7. Primary neurological and muscle diseases
8. Excessive intra-abdominal pressure

8. Basic design weakness
1. Lumbar triangles
2. Posterior wall of the inguinal canal

9. Weakness due to structures entering and leaving
the abdomen
a. Inguinal canal →inguinal hernia the testicular artery,
veins and vas pass though this canal (the round
ligament in females).
b. Oesophagus → hiatus hernia.
c. Femoral vessels →femoral hernia.
d. Obturator nerve → obturator hernia.
e. Sciatic nerve → sciatic hernia.

10. PATHOPHYSIOLOGY OF HERNIA FORMATION
1. Constipation
2. Prostatic symptoms
3. Excessive coughing
4. Obesity
5. Pregnancy
6. Collagen deficiency

11. COMPOSITION OF A HERNIA
1. The sac
2. The covering of the sac
3. The content of the sac

12. SAC
It is a diverticulum of peritoneum and is made up of three
parts :
1. Mouth
2. Neck
3. Body

13. COVERING
Coverings are derived from the layers of abdominal wall
through which the sac pass

14. CONTENTS OF SAC
a. Omentum—Omentocele
b. Intestine—Enterocele
c. Richter’s hernia: A portion of circumference of bowel.
d. Urinary bladder— cystocele.
e. Ovary, often with fallopian tube.
f. Meckel’s diverticulum— Littre’s hernia.
g. Appendix— Amyand’s hernia.
h. Fluid.

15. CLASSIFICATION OF HERNIA
Clinical classification
1. Reducible Hernia:
 Hernia gets reduced on its own or by the patient or by the
surgeon.
 Intestine reduces with gurgling and it is difficult to reduce
the first portion.
 Omentum is doughy, and it is difficult to reduce the last
portion.

16. CLINICAL CLASSIFICATION
2. Irreducible Hernia:
 Here contents cannot be returned to the abdomen due to
narrow neck, adhesions, overcrowding.
 Irreducibility predisposes to strangulation.

17. CLINICAL CLASSIFICATION
3. Obstructed Hernia:
 It is an irreducible hernia with obstruction, but blood
supply to the bowel is not interfered.
 It eventually leads to strangulation.

18. CLINICAL CLASSIFICATION
4.Strangulated Hernia:
 It is an irreducible hernia with obstruction to blood flow.
 It is tense, tender, absence of expansile cough impulse.

19. CLINICAL CLASSIFICATION
5. Incarcerated hernia:
 There are adhesions between the sac and the contents.
 But there is no obstruction or interference of blood supply

20. CLASSIFICATION ACCORDING TO ORIGIN
A. Congenital
It occurs in a preformed sac/defect.
B.Acquired

21. CLASSIFICATION ACCORDING TO SITES
1. Inguinal hernia—occurring in inguinal canal.
2. Femoral hernia—occurring in femoral canal.
3. Obturator hernia.
4. Diaphragmatic hernia.
5. Lumbar hernia.
6. Spigelian hernia.
7. Umbilical hernia.
8. Epigastric hernia.

22. CLINICAL HISTORY
 Patients usually present a painless lump.
 Sharp, intermittent pains pinching of tissue.
 Severe pain risk of strangulation.
 History of cardiac and respiratory problems.
 History of prostatic symptoms.

23. EXAMINATION
Patient should be examined both standing and lying
down position

24. EXAMINATION
1. Cough impulse
2. Tenderness
3. Overlying skin colour changes
4. Multiple defects/contralateral side
5. Signs of previous repair
6. Reducibility
7. Scrotal content for groin hernia
8. Associated pathology

25. INVESTIGATIONS
1. Plain radiograph
2. Ultrasound scan
3. CT scan – incisional hernia
4. MRI – good in sportsman’s groin with pain
5. Contrast radiology – especially for inguinal hernia
6. Laparoscopy – useful to identify occult inguinal hernia

26. INVESTIGATIONS

27. TREATMENT PRINCIPLES
a. Not all hernias require surgical repair.
b. Small hernias can be more dangerous than large.
c. Pain, tenderness and skin colour changes imply high
risk of strangulation.
d. Femoral hernia should always be repaired.

28. BASIC PRINCIPLES OF HERNIA SURGERY
1. Reduction of the hernia content into the abdominal
cavity with removal of any non-viable tissue and bowel
repair if necessary.
2. Excision and closure of a peritoneal sac if present or
replacing it deep to the muscles.
3. Re-approximation of the walls of the neck of the hernia
if possible.
4. Permanent reinforcement of the abdominal wall defect
with sutures or mesh.

29. MESH IN HERNIA REPAIR
1. To bridge a defect: the mesh is simply fixed over the
defect as a tension-free patch.
2. To plug a defect: a plug of mesh is pushed into the
defect.
3. To augment a repair: the defect is closed with sutures
and the mesh added for reinforcement.

30. PROLENE MESH

31. MESH CHARACTERISTICS
1. Woven, knitted or sheet.
2. Synthetic or biological – mainly synthetic.
3. Light, medium or heavyweight – lightweight becoming more
popular.
4. Large pore, small pore – large pore causes less fibrosis and pain.
5. Intraperitoneal use or not – non-adhesive mesh on one side.
6. Non-absorbable or absorbable – mainly non-absorbable.