The document provides a comprehensive overview of abdominal hernias, defining them as the protrusion of abdominal contents through the abdominal wall and categorizing types such as inguinal, femoral, and umbilical hernias. It discusses anatomical structures, clinical manifestations, indications for surgery, and various repair techniques, in addition to complications and differential diagnoses associated with hernias. Specific types of hernias and their characteristics are also detailed, along with considerations for surgical management and complications.

1. ABDOMINAL
HERNIAE
A. WEISS M.D
D.E.S ,Chirurgie Générale,Viscérale et Laparoscopique
A.F.S/A.F.S.A/DU - France
References:
Richard S.SNELL/ Clinical Anatomy/By SNELL/7e.Vol2
Seymour I. SCHWARTZ/ Principles of Surgery Companion Handbook/McGraw-Hill/1998
F. C BRUNICARDI and others/Schwartz’s Principles of Surgery/McGraw-Hill/8e/2004.

2. DEFINITION:
 A hernia is the protrusion of part of the
abdominal contents beyond the normal
confines of the abdominal wall .
 It consists of three parts: the sac, the contents
of the sac, and the coverings of the sac.
 The hernial sac is a pouch ( diverticulum) of peritoneum and
has a neck and a body.
 The hernial contents may consist of any structure found
within the abdominal cavity .
 The hernial covering are formed from the layers of the
abdominal wall throw which hernial sac passes.

3. It consists of three
parts: the sac, the
contents of the sac,
and the coverings
of the sac.
A hernia is the protrusion of part of the abdominal
contents beyond the normal confines of the
abdominal wall .

4. TYPE OF ABDONINAL HERNIAE
 Inguinal (indirect or direct).
 Femoral.
 Umbilical (congenital or
acquired).
 Epigastric (linea alba) .
 Separation of the recti
abdominis.
 Incisional hernia.
 Hernia of the linea
semilunaris (Spigelian
hernia).
 Lumbar hernia ( Petit’s
triangle hernia).
 Internal hernia.

5. STRUCTURE OF THE ANTERIOR
ABDOMINAL WALL :
 Skin .
 Superficial Fascia :
◦ Superficial fatty layer (fascia of Camper ).
◦ Deep membranous layer ( Scarpa’s Fascia ).
 Deep fascia .
 Muscles of the Anterior Abdominal Wall :
◦ External Oblique .
◦ Internal Oblique .
◦ Transversus .
◦ Rectus Abdominis .
◦ Pyramidalis ( if present ).
 Fascia Transversalis .
 Extra Peritonial fat .
 Parietal Peritoneum .

6. ANATOMY OF THE INGUINAL CANAL
 The inguinal canal is an oblique passage through the lower part of
the anterior abdominal wall and present an both sexes.
 The canal is about 4 cm long in the adults and extends from the
deep inguinal ring , a hole in the fascia transversalis , downward
and medially to the superficial inguinal ring , a hole in the
aponeurosis of the external oblique muscle .
 It lies parallel to and immediately above the inguinal ligament .
◦ In the newborn child, the deep ring lies almost directly posterior
to the superficial ring so that the canal is considerably shorter at
this age .
 The DEEP INGUINAL RING : an oval opening in the fascia
transversalis lies about 1.3 cm above the inguinal ligament midway
between the anterior iliac spine and the symphysis pubis and
related to it medially are the inferior epigastric vessels .
 The SUPERFICIAL RING is a triangular-shaped defect in the
aponeurosis of the external oblique muscle and lies immediately
above and medial to the pubis tubercle .

7. ANATOMY OF THE INGUINAL CANAL
 Walls of the INGUINAL CANAL :
◦ Anterior wall : the aponeurosis of the External
Oblique muscle .
◦ Posterior wall : the Fascia Transversalis .
◦ Inferior wall or Floor of the canal : the inguinal
ligement ( rolled –under inferior edge of the
aponeurosis of the External Oblique muscle ) .
◦ Superior wall or the roof of the canal :The
conjoint tendon ( arching lowest fibers of the
Internal oblique and Transversus abdominis
muscles ) .

8. ANATOMY OF THE INGUINAL CANAL
 Contents of the INGUINAL CANAL :
◦ Spermatic cord :
 Vas deferens .
 Testicular artery .
 Testicular veins (pampinform plexus ).
 Testicular lymph vessels .
 Autonomic nerves .
 Processus vaginalis ( remains of ) .
 Cremasteric artery .
 Artery of the vas deferens .
 Genital branch of the genitofemoral nerve .
◦ Other structures :
 Ilio-hypogastric nerve .
 Ilioi-nguinal nerve .

9. THE MYOPECTINEAL ORIFICE OF
FRUCHAUD :
 Fruchaud's contribution to inguinal
herniology was to examine the common
anatomic etiology of direct, indirect,
and femoral hernias, rather than to look
at each individually .
 The term myopectineal orifice, an area
bound superiorly by the internal
oblique and transversus abdominis
muscles, medially by the rectus muscle
and sheath, laterally by the iliopsoas
muscle, and inferiorly by Cooper's
ligament (pecten pubis).
 Critical anatomic landmarks such as the
inguinal ligament, spermatic cord, and
the femoral vessels are contained within
this area. This funnel-shaped orifice is
lined in its entirety by the transversalis
fascia. Fruchaud's concept is that the
fundamental cause of all groin hernia is
failure of the transversalis fascia to
retain the peritoneum.

10. CLINICAL MANIFISTATIONS
 The natural history of hernias is a slow enlargement to the point of
irreducibility and disfigurement, with the risk of strangulation.
 The discomforts produced by hernias are always worse at the end of the
day and are relieved at night when the patient reclines and the hernia
reduces.
 Groin pain without a demonstrable hernia usually does not indicate the
onset of a hernia.
 Most hernias develop insidiously, but some are precipitated by a single
forceful muscular event.
 Typically, a hernial sac with its contents enlarges and transmits a palpable
impulse when the patient strains or coughs.
 Usually, the patient must stand during the examination because it is
impossible to palpate a reduced groin hernia when the patient is supine.
 Hydroceles transilluminate, but hernias do not.
 Hernias undetectable by physical examination can be demonstrated by
using ultrasound or computed tomography (CT).
 Strangulation produces intense pain in the hernia, followed quickly by
tenderness, intestinal obstruction, and signs or symptoms of sepsis.

11. INDICATIONS FOR SURGERY
 All hernias should be repaired unless local or
systemic conditions of the patient preclude a
safe outcome.
 The possible exception is a hernia with a
wide neck and shallow sac that is anticipated
to enlarge slowly.
 Trusses are helpful in the management of
small hernias when operation is
contraindicated.
 Trusses are contraindicated for patients with
femoral hernias.

12. HERNIAS OF THE GROIN
( Inguinal and femoral )
 ETIOLOGY:
Intraperitoneal hypertension
 Presumed Causes of Groin
Herniation :
◦ Coughing .
◦ Chronic obstructive pulmonary
disease.
◦ Obesity .
◦ Straining ( Constipation ,Prostatism).
◦ Pregnancy.
◦ Family history of a hernia
◦ Ascites
◦ Defective collagen synthesis
◦ Previous right lower quadrant
incision
◦ Congenital connective tissue
disorders
◦ Cigarette smoking
◦ Heavy lifting
◦ Physical exertion (?)

13. HERNIAS OF THE GROIN
DIFFERENTIAL DIAGNOSIS
 Lymphoma.
 Retroperitoneal sarcoma.
 Metastasis.
 Testicular tumor.
 Varicocele.
 Epididymitis.
 Testicular torsion.
 Hydrocele.
 Ectopic testicle.
 Undescended testicle.
 Femoral artery aneurysm or
pseudoaneurysm.
 Lymph node.
 Sebaceous cyst.
 Hidradenitis.
 Cyst of the canal of Nuck (female).
 Saphenous varix.
 Psoas abscess.
 Hematoma.

14. HERNIAS OF THE GROIN
1- Indirect inguinal hernia :
The indirect inguinal hernia can be
summarized as follow :
I. It is the remains of the processus
vaginalis and therefore is
congenital in origin.
II. It is more common than a direct
inguinal hernia.
III. It is mutch more common in males
than females.
IV. It is more common on the right
side.
V. The hernial sac enters the inguinal
canal through the deep inguinal
ring and lateral to the interior
epigastric vessels,the neck of the
sac is narrow.
VI. The hernial sac may extend down
into the scrotum or labium majus.

15. HERNIAS OF THE GROIN
2 - Direct inguinal hernia :
The direct inguinal hernia can
be summarized as follow :
I. It is common in old men with
week abdominal muscles and is
rare in women.
II. The hernial sac bluges forwrad
throwgh the posterior wall of the
inguinal canal medial to the
inferior epigastric vessels.
III. The neck of the hernial sac is wide.

16. HERNIAS OF THE GROIN
PARTICULAR CASE
Sliding Inguinal Hernia:
It is defined as any hernia in which part of the sac is the wall of a viscus.
It is rarely found in patients less than 30 years of age, but increases to 20% after the age of 70.
On the right, the cecum, ascending colon, or appendix are most commonly involved, and on the
left, the sigmoid colon is involved. The uterus, fallopian tube, ovary, ureter, and bladder
can be involved on either side.
The sliding component is usually found on the posterolateral side of the internal ring.
it is not necessary to resect hernia sacs, and that simple reduction into the preperitoneal space is
sufficient.
This eliminates the primary danger associated with sliding hernias, which is injury to the viscus
during high ligation and sac excision.

17. HERNIAS OF THE GROIN
3 - Femoral hernia :
The femoral hernia can be
summarized as follow :
I. A protrusion of abdominal parietal
peritoneum down throwgh the
femoral canal to from the hernial sac.
II. It is more common in women than in
men .
III. The neck of the hernial sac lies below
and lateral to the pubic tubercle.
IV. The neck of the hernial sac lies at the
femoral ring and at that point is
related interiorly to the inguinal
ligament, posterioly to the pectineal
ligament, laterally to the femoral
vien,and medially to the sharp free
edge of the lacunar ligament.

18. HERNIAS OF THE GROIN
INGUINAL HERNIA REPAIRS
• Open anterior ,Nonprosthetic:
Marcy, Bassini, Moloney Darn, McVay Cooper's Ligament Repair,
Shouldice.
• Open anterior ,Prosthetic :
Lichtenstein Tension-Free Hernioplasty, Mesh Plug and Patch.

19. HERNIAS OF THE GROIN
INGUINAL HERNIA REPAIRS
 Open preperitoneal, Nonprosthetic.
 Open preperitoneal, Prosthetic:
Read-Rives, Wantz/Stoppa/Rives.
 Combination anterior and preperitoneal, Prosthetic.
 Laparoscopic inguinal herniorrhaphy.

20. HERNIAS OF THE GROIN
Complications of Groin Hernia Repairs
 Recurrence.
 Chronic Groin Pain.
 Hematoma.
 Seroma.
 Bladder Injury.
 Wound Infection.
 Osteitis Pubis
 Prosthetic Complications
 Ischemic orchitis.
 Testicular atrophy.
 Dysejaculation syndrome
(rare).
 Hydroceles.
 Testicular descent.
 Laparoscopic Complications.

21. UMBILICAL HERNIA
 Umbilical hernias develop at the
umbilical ring and may be present at
birth or develop gradually during the
life of the individual
 Umbilical hernias are present in
approximately 10% of all newborns
and are more common in premature
infants.
 Most congenital umbilical hernias
close spontaneously by age 5 years. If
closure does not occur by this time,
elective surgical repair is usually
advised.
 Adults with small, asymptomatic
umbilical hernias may be followed
clinically.
 Surgical treatment is offered if a
hernia is observed to enlarge, is
associated with symptoms, or if
incarceration occurs. In the latter
situation, emergent surgical
treatment consisting of primary
sutured repair is performed.

22. EPIGASTRIC ( LINEA ALBA ) HERNIA
 Epigastric hernias are located
in the midline between the
xiphoid process and the
umbilicus.
 They are generally small, may
be multiple, and at elective
repair, are usually found to
contain omentum or a portion
of the falciform ligament.
 It is common in middle-aged
manual workers.

23. SPIGELIAN HERNIA
( HERNIA OF THE LINEA SEMILUNARIS )
 Spigelian hernias can occur
anywhere along the length of
the Spigelian line or zone—an
aponeurotic band of variable
width at the lateral border of
the rectus abdominus.
 The most frequent location of
these rare hernias is at or
slightly above the level of the
arcuate line.
 These are not always clinically
evident as a bulge, and may
come to medical attention
because of pain or
incarceration.
SPIGELIAN HERNIA

24. SEPARATION OF THE RECTI ABDOMINIS
• Separation of the recti abdominis occurs in elderly multiparous women with
weak abdominal muscles .
• The aponeuroses forming the rectus sheath become excessively stretched.
• When the patient coughs or strains, the recti separate widely , and a large
hernia sac ,containing abdominal viscera, bulges forward between the
margins of the recti.
• This can be corrected by wearing a suitable abdominal belt .
• Surgical correction of a severe rectus diastasis by plication of the anterior
rectus sheath may be undertaken for cosmetic indications, or if it is associated
with disability of abdominal wall muscular function.

25. INCISIONAL HERNIA
 Incisional hernias result from a
healing failure of a prior abdominal
wall surgical closure.
 careful investigation shows that
they occur in at least 10 to 15% of all
laparotomy incisions.
 Incisional hernias may be
asymptomatic or present with pain,
incarceration, or strangulation.
 Risk factors for the development of
a ventral incisional hernia include :
◦ Postoperative wound infection.
◦ Malnutrition.
◦ Obesity.
◦ Immunosuppression,.
◦ Chronically increased intra-
abdominal pressure.

26. INTERNAL HERNIA
 Occasionally, a loop of intestine
enters a peritoneal recess ( e.g., the
lesser sac or the duodenal recess)
and becomes strangulated at the
edge of the recess.
 Clinically: intestinal obstruction.
 Diagnosis: by C.T Scan.

27. LUMBAR HERNIA
•The lumbar hernia occurs through the lumbar triangle and is rare.
•The lumbar triangle ( Petit’s triangle) is a weak area in the posterior part of the abdominal
wall.
•It is bounded anteriorly by the posterior margin of the external oblique muscle,
posteriorly by the anterior border of the latissimus dorsi muscle, and inferiorly by the iliac
crest.
•The floor of the triangle is formed by the internal oblique muscle and the transversus
abdominis muscles.
•The neck of the hernia is usually large, and the incidence of strangulation low.

28. THANK YOU
Abdul.Kader WEISS 2009