Hernia refers to the bulging of abdominal contents through a weakness in the abdominal wall, with types including external and internal hernias. Diagnosis typically involves physical examination, imaging techniques, and careful observation of symptoms, while management principles focus on reducing the hernia, excising non-viable tissue, and reinforcing the abdominal wall using sutures or mesh. Treatment may vary based on the hernia type and associated complications, with incarcerated hernias requiring more urgent attention.

1. HERNIA

2. HERNIA
Hernia of the abdominal wall or
external hernia is the bulging of part
of the contents of the abdominal
cavity through a weakness in the
abdominal wall.

3.  Internal hernia is such disease, visceral
organs hit the peritoneum pouch. It formed
in the place of natural peritoneum fold or
recess and generally kept in the
abdominal cavity.

4. Anatomy of a Hernia

10. Anatomical causes of abdominal w
herniation

12. The Walls Of The Inguinal Canal
ANTERIOR WALL
 laterally - muscles fibers of the external oblique
 medially - aponeurosis of the external oblique
 most medially there is not wall but instead there is a deficiency called the
superficial inguinal ring.
SUPERIOR -- arching fibers of the internal oblique and sometimes transverse
abdominis. These fibers start anterior and lateral, pass over the spermatic
cord and the medially forms part of the posterior wall of the canal.
POSTERIOR -- lateral the posterior wall is deficient at the deep inguinal ring.
Medially the posterior wall is made up of the fused aponeuroses of the
internal oblique and transverse abdominis, called the conjoined tendon X.
INFERIOR (or floor) -- inguinal ligament. Medially, some of the fibers of the
inguinal ligament curve under the spermatic cord and fasten into the
pectineal line of the pubis, this is the lacunar ligament which forms part of
the floor of the inguinal canal.

13. PATHOMORPHOLOGY
 Each abdominal hernia consists of hernia
gate, hernia sac and hernia contents.
Hernia sac forms by outpouching of
parietal peritoneum and can contain small
intestine and omentum. Sometimes it
containes other organs: large intestine,
urinary bladder, ovary, and appendix.
 The main parts of the hernia pouch are
neck, body and fundus.

14. CLASSIFICATION
 1) Depends on anatomical localization: inguinal
(indirect and direct), midline hernia, epigastric
hernia, femoral hernia, lumbar hernia, sciatic
hernia, incisional hernia, umbilical hernia .
 2) depends on etiology: congenital and acquired
 3) Depends on clinical presentations: complete
and incomplete, reducible and nonreducible,
traumatic and postoperative, complicated and
noncomplicated.

16. Examination for hernia
 Examined on lying down initially and then
standing.
 Asked to cough
 Divarification is best seen by asking a supine
patient to simply lift his head off the pillow.
 The overlying skin is usually of normal colour.
 If bruising is present this may suggest venous
engorgement of the content.
 If there is overlying cellulitis then hernia content
is strangulating.
 In most cases a cough impulse is felt

19. DIAGNOSIS PROGRAM
 physical examination.
 Digital investigation
 Sonography of the hernia pouch.
 Common blood analysis.
 Common urine analysis.

20.  Diagnosis
being made on clinical examination
 No specific investigation is required
 Chest radiograph:- hiatus hernia and diaphragmatic hernia
 Ultrasound scan:- may be helpful in cases of irreducible hernia,
where the differential diagnosis includes a mass or fluid collection,
or when the nature of the hernia content is in doubt.
 Computed tomography (CT):-

complex incisional hernia,

determining the number and size of muscle defects,

identifying the content,

giving some indication of presence of adhesions and

excluding other intra-abdominal pathology such as ascites,
occult malignancy and portal hypertension.

21. Management principles

22. Choice of treatment method
 Basic principles:
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. Reapproximation of the walls of the neck of the
hernia if possible
4. Permanent reinforcement of the abdominal wall
defect with sutures or mesh.


23. Treatment of the femoral hernia
 The term ‘mesh’ refers to prosthetic material,
either a net or a flat sheet, which is used to
strengthen a hernia repair.
 Mesh can be used:

to bridge a defect: the mesh is simply fixed
over the defect as a tension-free patch;

to plug a defect: a plug of mesh is pushed into
the defect;

to augment a repair: the defect is closed with
sutures and the mesh added for
reinforcement.

27.  A well-placed mesh should have good overlap around all
margins of the defect, at least 2 cm but up to 5 cm if
possible.
 Suturing a mesh edge to edge into the defect (inlay),
with no overlap, is not recommended.
 Mesh plug repairs have gained some popularity in small
defects especially where overlap is hard to achieve.
 Plug operations are fast but plugs can form a dense
‘meshoma’ of plug and collagen.
 Other complications include migration, erosion into
adjacent organs, fistula formation and chronic pain.

28. Bassini repair

29. Girard repair

32. Laparoscopic treatment

33. Laparoscopic treatment

34. Treatment of umbilical hernia
 The Lexer operation is most widespread. It
performed by imposition of sutures on an
umbilical ring

35. Treatment of umbilical hernia
 After the Meyo
method defect
of anterior
abdominal wall
in the umbilical
ring is sutured
by U-shaped
stitches in
transversal
direction

36. Treatment of umbilical hernia
 Sapezhko
proposed to
form
duplication of
the abdominal
white line by
stitches in
longitudinal
direction.

37. INCARCERATED HERNIA
 Incarcerated hernia is sudden pressing of
hernia contents in a hernia orifice.
Incarceration is the most frequent and
most dangerous complication of hernia
diseases.

39. Etiology and pathogenesis
 At the elastic incarceration, after increasing
intraabdominal pressure, one or a few organs
relocated from an abdominal cavity to the hernia
sack, where it is compressed with following
ischemia and necrosis in the area of hernia gate.

40.  At the fecal incarceration in the intestinal
loop which is in a hernia sack, plenty of
excrement passed quickly. Proximal part
of loop is overfilled, and distal is
compressed in a hernia gate.

41. Classification of the incarcerated
hernia
 complete
 Incomplete
 partial (the Richter’s hernia)
 retrograde
 without the destructive changes of hernia
contents
 with the phlegmon of hernia sack

42. Retrograde incarceration

43. Retrograde incarceration

44. Diagnosis program
 examination.
 Physical examination.
 Blood analysis and urine analysis.
 Digital investigation of the rectum.
 Survey X-Ray of abdominal cavity
organs.

45. Treatment
 Approximately 70% of incarcerated hernia
can be reduced manually.
 in the case of failure, surgery should be
immediately performed for incarcerated
hernia.