Ventral Hernia

1. ABDOMINAL WALL
HERNIAS
Dr Phillip Leo Chalya
M.D.(Dar);M.MED.Surg(Mak)
General Surgeon
Department of Surgery
Bugando Medical Centre

2. Plan of Discussion
 Definition
 Surgical anatomy of hernia
 Aetiology
 Classification
 Management of individual hernias
 Inguinal
 Femoral
 Umbilical
 Epigastric
 Incisional/ventral

3. 1. Definition
 Protrusion of a viscus or part of it through a
defect in the abdominal wall

4. 2. Surgical anatomy
 All hernias consists of 3 parts:-
 The sac
 This is the diverticulum of peritonium consisting of a mouth,
neck and the fundus
 Coverings
 Derived from the layers of the abdominal wall through which
the sac passes
 Contents
 Omentum (omentocoele)
 Intestine (enterocoele)
 Part of the urinary bladder ( cystocoele)
 Ovaries
 Meckel’s diverticulum (Littre’s hernia)
 Part of the circumferance of the intestine (Richter’s hernia)
 Fluids

5. 3.Aetiology
 Congenital
 weakness of the abdominal wall
 Acquired
  intra-abdominal pressure
 Chronic cough
 Straining
 Obstructive uropathy
 Chronic constipation
 Lifting heavy objects
 Acquired deficiency of collagens weakness of abd wall
 Demage to the ilioingiunal nerve

6. 4. Classification
 Aetiological classification
 Congenital hernias
 Acquired hernias
 Anatomical classification
 According to the site of the hernia
 Inguinal hernia
 Femoral hernia
 Umbilical hernia
 Paraumbilical hernia
 Epigastric hernia
 Incisional hernia
 etc

7. Classification (cont)
 According to the contents of the hernia
 Enterocoele (intestines)
 Omentocoele (omentum)
 Cystocoele (urinary bladder)
 Littre’s hernia (Meckel’s diverticulum)
 Richter’s hernia (part of the circumference of the bowel)
 Clinical classification
 Reducible hernia
 Contents can be easily returned into the abdominal cavity
leaving the hernial sac in its position

8. Classification (cont)
 Irreducible hernia
 Contents cannot be returned to the abdomen
 It is due to :-
 Adhesions of its contents to each other
 Adhesions of its contents with the sac
 Adhesions of one part of the sac to the other part
 Sliding hernia
 Very large scrotal hernia
 Obstructed hernia
 Irreducible hernia + intestinal obstruction
 No interference with blood supply to the intestine

9. Classification (cont)
 Strangulated hernia
 Irreducible hernia + interference with blood
supply± intestinal obstruction
 Inflamed hernia
 Rare type
 Occurs when the contents of the hernia become
inflamed and present with constitutional symptoms
associated with inflammation e.g. overlying skin
become red, oedematous, tenderness.
 Differs frm strang hernia not tense and not ac I.O.

10. 5. Individual hernias
 Inguinal hernia
 Femoral hernia
 Umbilical hernia
 Paraumbilical hernia
 Epigastric hernia
 Incisional hernia

11. A. Inguinal hernia
 Surgical anatomy
 Superficial inguinal ring (SIR)
 Triangular opening in the aponeurosis of the external
oblique muscle
 Lies 1.25cm above and lateral to the pubic tubercle
 Deep inguinal ring (DIR)
 U-shaped condensation of the transversalis fascia
 Lies 1.25cm above the mid-inguinal point
 Inguinal canal
 Position: extends downwards and medially from the
DIR to the SIR
 It is 3.75 cm long

12. Inguinal hernia (cont)
 Boundaries:
 Anteriorly: External oblique aponeurosis
 Posteriorly: Fascia transversalis+conjoint tendon+inferior
epigastric vessels
 Superiorly: conjoint muscles (internal oblique+transversalis )
 Inferiorly: inguinal ligament
 Contents
 3 coverings:
 Internal spermatic fascia
 Cremasteric fascia
 External spermatic fascia
 3 nerves:
 Ilio-inguinal nerve
 Ilio-hypogastric nerve
 Genital branch of the genitofemoral nerve

13. Inguinal hernia (cont)
 3 arteries:
 Testicular artery
 Artery of the vas
 Cremasteric artery
 3 others
 Vas deferens
 Lymphatic vessels
 Veins- Pampiniform plexus of veins

14. The anatomy of the inguinal region

15. Inguinal hernia (cont)
 Classification
 Aetiological classification
 Congenital inguinal hernia:
 Due to persistence of processus vaginalis
 Developed from a pre-formed sac
 Reaches the scrotum very quickly
 Acquired inguinal hernia:
 Occurring later in life as a result of underlying weakness of the
abdominal muscles

16. Inguinal hernia (cont)
 Anatomical classification
3 types of classification
 According to the extent of the hernia
 Bubonocele type: hernia does not come out the SIR
 Funicular type: comes out through the SIR but does not reach
the bottom of the scrotum
 Complete type: reaches the bottom of the scrotum
 According to the contents
 Enterocoele
 Omentocoele
 Cystocoele
 Littre’s hernia
 Richter’s hernia etc

17. Inguinal hernia (cont)
 According to its site of exit
 Indirect:
 Comes through DIR lateral to the inferior epigastric artery
 Direct:
 Comes out through the Hesselbach’s triangle bounded:-
 Medially: lateral border of rectus abdominis
 Laterally: inferior epigastric artery
 Inferiorly: inguinal ligament
 The neck of the sac lies medial to the inferior epigastric artery

18. Inguinal hernia (cont)
 Clinical classification
 Reducible inguinal hernia
 Irreducible inguinal hernia
 Obstructed inguinal hernia
 Strangulated inguinal hernia
 Inflamed inguinal hernia- hernia containing inflamed
organs e.g. appendix, salpinx, meckel’s diverticulum

19. Inguinal hernia (cont)
 Diagnosis
—Mainly by history and clinical examination
 History
 Age
 indirect inguinal hernia is common young individual while direct
inguinal hernia is common in the older
 Complaints
 Pain
 pain may occur long before the lump is noticed and usually
ceases when it is fully formed
 When hernia become painful and tensestrangulation

20. Inguinal hernia (cont)
 Groin lump: note:-
 How did it start?
 Where did it 1st appear?
 What was the size + extent
when it was first seen?
 Congenital type: reaches the
bottom of the scrotum at its firs
appearance
 Acquired type: small to start and
gradually descend to reach the
bottom of the scrotum
 Does it disappear
automatically on lying down?

21. Inguinal hernia (cont)
 Features of intestinal obstruction
 Colicy abdominal pain
 Absolute constipation
 Vomiting
 Abdominal distension
 Other complaints
 Chronic cough
 Features of obstructive uropathy e.g. poor urinary stream
 Previous H/o hernial repair or appendicectomy
 H/o strenuous work is responsible for development
of hernia

22. Inguinal hernia (cont)
 Local examination
 Inspection
 Swelling: note:-
 Size and shape:
 Indirect: pyriform with a stalk at the SIR, usually extend into
scrotum
 Direct : spherical and show little tendency to descend into the
scrotum
 Position and extent:
 If the swelling reaches the scrotum congenital type
 If not  fonicular and acquired type
 Visible peristalsis

23. Inguinal hernia (cont)
 Skin over the swelling
 Impulse on coughing
 Position of the swelling
 Palpation: note:-
 Position and extent:
 2 landmarks:pubic tubercle+inguinal ligament
 IH lies above inguinal ligament and medial to PT
 FH lies below and lateral to the pubic tubercle
 To get above the swelling
 To differentiate scrotal swelling frm inguinoscrotal
swelling

24. Inguinal hernia (cont)
 Reducibility
 Impulse on coughing
 Invagination test
 Ring occlusion test
 Relationship of the swelling to the testis and
spermatic cord

25. Inguinal hernia (cont)
 Treatment
 Surgical – hernial repair (herniorrhaphy)
 Types of herniorrhaphy
 Basini’s repair
 Shouldice repair
 Lichtenstein repair

26. B. Femoral hernia
 Definition
 Protrusion of abdominal contents through femoral
canal
 Femoral hernias are less common than inguinal
hernias
 FH are four times more common in women
 They are found more often in elderly and
multiparous individuals

27. 2.Surgical anatomy
 Femoral hernias emerge through the groin from the
femoral canal
 The FC has rigid boundaries consisting of medially
the lacunar ligament, anteriorly the inguinal
ligament, posteriorly the pectineal ligament, and
laterally the femoral vein
 The femoral canal normally contains lymph nodes
and loose connective tissue, which forms the
characteristic 'onion skin' over the fundus of the
hernia sac.

28. Surgical anatomy (cont)

29. 3.Presentation and diagnosis
 A femoral hernia may be an incidental finding
or it may present as a symptomatic groin
swelling
 A relatively large proportion (30–80 per cent)
present with strangulation and/or obstruction
due to the narrow neck of the hernial sac and
the sharp edge of the lacunar ligament

30. 4. Differential diagnosis
 Lymph nodes
 Lipoma
 Inguinal hernia
 Aneurysm of the femoral artery
 Saphena varix
 Varicocele (occasionally seen in preg-nancy).

31. 5. Treatment
 Surgery is mandatory once the diagnosis of
femoral hernia has been confirmed
 If the diagnosis of femoral hernia is in doubt,
surgical exploration should be performed

32. C. Umbilical hernia
 Introduction
 There are three distinct types of hernia that occur
around the umbilicus:-
(i) Congenital (omphalocele or exomphalos)
(ii) Infantile umbilical hernia
(iii) Adult paraumbilical hernia

33. Umbilical hernia
A. Congenital umbilical hernia
 Incidence
 Occurs in 1 in 5000 births and is associated with other serious
congenital abnormalities in 60 per cent of cases
 Anatomy
 During intrauterine development the amniotic sac contains the
embryologic midgut
 At 10 weeks of gestation the gut normally returns to the abdominal
cavity
 When this doesn't occur, the umbilical canal fails to close and at
birth a broad funnel-shaped defect is present at the umbilicus
 Viscera covered only by peritoneum protrude through this
abdominal wall defect

34. Umbilical hernia
 Diagnosis
 The diagnosis is immediately evident at the time of birth,
with an obvious protrusion of abdominal viscera through
the umbilicus
 It’s located in the midline and the herniated viscera are
covered by peritoneum
 this congenital abdominal wall defect distinguishes from
gastroschisis, where the abdominal wall defect is off
midline, and the herniated viscera are uncovered by
either peritoneum or skin

35. Umbilical hernia
 Treatment
 Urgent surgical repair should be performed before
rupture of the sac occurs or infection supervenes
B. Infantile umbilical hernia
 Common in males > female M:F=2:1
 The incidence is high in pts with:-
 LBW
 Down syndrome
 Ascites

36. Umbilical hernia
 Anatomy
 At birth, following division of the umbilical cord, the
stump heals by granulation and scarring to fuse
with the umbilical ring of the abdominal wall
 Failure of fusion at the abdominal wall allows a
peritoneal sac to protrude, usually at the superior
margin of the ring
 The infantile hernia, as opposed to the congenital
type, is always covered with skin, and reaches its
maximal size 1 month after birth

37. Umbilical hernia
 Diagnosis
 This hernia is usually symptomless and presents
as an easily reducible lump which becomes more
prominent during crying and coughing
 Strangulation of this hernia is extremely rare, and
congenital umbilical hernias rarely enlarge over
time
 The hernia contents usually remain unchanged in
size until just before final closure

38. Umbilical hernia
 Treatment
 This hernia will spontaneously disappear in 93% of
children by the age of 2 years
 Operative treatment in the newborn baby is
deferred to allow time for spontaneous closure
 Surgical repair is indicated
 for any symptoms associated with the umbilical hernia
 if the hernia persists beyond 2 years of age
 Hernias greater than 2 cm in size

39. Umbilical hernia
C. Adult paraumbilical hernia
 Most adult umbilical hernias are acquired
 About 10 % of adult umbilical hernias are
congenital hernias carried into adulthood
 The superior rim of the umbilicus is the site of
attachment of the round ligament and the remnants
of the urachus and umbilical arteries, thus creating
a weak area in the abdominal fascia
 Additionally, the lowest tendonous insertion of the
rectus abdominis muscle into the linea alba is at the
level of the superior umbilical rim

40. Umbilical hernia
 Stretching of the abdominal wall due to
multiple pregnancies, ascites, or obesity
predisposes to the development of an umbilical
hernia
 The condition usually occurs after the age of 35
years and, due to its association with
pregnancy, is five times more common in
females

41. Umbilical hernia
 Diagnosis
 This hernia tends to enlarge progressively over time
and may be asymptomatic depending on size and
body habitus
 It may produce localized pain as the fascial defect
enlarges or herniated content stretches overlying
subcutaneous tissue and skin
 Gastrointestinal symptoms commonly occur owing
to traction between the hernia contents and the
stomach or transverse colon
 When the hernia sac contains bowel, colic due to
intermittent intestinal obstruction is possible

42. Umbilical hernia
 Treatment
 Once diagnosed, an umbilical hernia should be
repaired

43. D. Epigastric hernia
 These are hernias through linea alba in the
epigatric region
 An epigastric hernia is present in 5% of all
abdominal wall hernias
 This hernia may present at any age, but is most
common between 20 and 50 years of age
 It is three times more common in men than in
women

44. Epigastric hernia
 Anatomy
 Epigastric hernias are protrusions of preperitoneal
fat through a fascial defect in the decussating fibers
of the supraumbilical portion of the linea alba
 The defect usually occurs where the linea alba is
pierced by a blood vessel
 A peritoneal sac may accompany fat through the
defect, containing omentum or rarely bowel

45. Epigastric hernia
 Diagnosis
 The majority of epigastric hernias are asymptomatic
 Vague upper abdominal pain and nausea, associated with
epigastric tenderness may be present
 These symptoms tend to be more severe when the patient is
supine, owing to traction on the hernia contents
 A lump, which may be tender, is usually palpable in non-
obese subjects
 Gangrene of the contents of the hernia occasionally occurs,
producing severe epigastric tenderness and localized
muscular rigidity
 These features may mimic those of an intra-abdominal
catastrophe

46. Epigastric hernia
 Treatment
 Once diagnosed, these hernias should be repaired

47. E. Incisional hernia
 Definition
 Incisional hernia is defined as an abnormal
protrusion of a viscus through the
musculoaponeurotic layers of a surgical scar
 Incisional hernias lie under a well-healed skin
incision
 Incisional hernia is more common, occurring in
approximately 10% of patients

48. Incisional hernia
 Risk factors
 Preoperative factors
 advanced age
 male sex
 previous irradiation
 Jaundice
 uraemia
 Anaemia
 Diabetes
 Malnutrition
 malignant disease
 vitamin C depletion
 Obesity
 the administration of steroids or cytotoxic drugs.

49. Incisional hernia
 Operative factors
 type of incision
 the choice of suture material
 the method of wound closure
 Postoperative factors
 Increased intra-abdominal pressure due to:
 inadequate postoperative analgesia
 Vomiting
 the development of a postoperative chest infection
resulting in coughing
 gross distension from paralytic ileus

50. Incisional hernia
 Clinical presentation
 Incisional hernias can develop at any age
 Although clinical evidence of incisional hernia may
be delayed for more than 10 years after
laparotomy and less than half are apparent at 1
year
 The presentation of incisional hernia depends on
the site of the original wound, the size of the neck
of the hernia, the size of the hernia, and the
presence of complications
 Small defects in the scar may result in large
hernias, and this may predispose to strangulation

51. Incisional hernia following laparotomy
for peritonitis

52. Incisional hernia
 Treatment
 The majority of incisional hernias are asymptomatic,
and the majority of symptomatic hernias may be
managed conservatively
 Small incisional hernia Mayo’s repair
 Large incisional herniasrepaired by implanting a
mesh of non-absorbable material