This document discusses hernias, including the anatomy, causes, types, clinical presentation, diagnosis, and management. It defines a hernia as an abnormal protrusion of an organ through weakened tissue. There are many types of hernias classified by location, including inguinal, femoral, umbilical, incisional, and epigastric hernias. Clinical examination involves assessing for reducibility, cough impulse, tenderness. Management involves watchful waiting for asymptomatic hernias, while surgical repair with or without mesh is recommended for symptomatic hernias to prevent complications like strangulation.

1. HERNIAS
GREGORY GACHUKIA
MBCHB YEAR SIX
SUPERVISOR: DR. OGOMBE

2. • Differential diagnosis’ for groin swellings:
Inguinal hernia
Femoral Hernia
Undescended testes
Inguinal Lymphadenitis
Lipoma of the spermatic cord
Saphena varix

3. OVERVIEW
• A hernia is an abnormal protrusion of an organ or part of an organ from one
anatomic space to another.
• Composition of hernia:
• Defect in the wall/tissue
• The sac (mouth, neck, body)
• The content of the sac

5. ANATOMY

6. ANATOMICAL CAUSES OF HERNIAS
• Basic design weakness i.e. lumbar triangles, posterior wall of the inguinal canal
• Weakness due to structures entering and leaving the abdomen
• Developmental failures
• Genetic weakness of collagen e.g. Ehlers-Danlos syndrome, Marfan syndrome
• Sharp and blunt trauma
• Weakness due to ageing and pregnancy
• Primary neurological and muscle diseases e.g. traumatic nerve palsy, DMD/BMD,
CMD

7. PATHOPHYSIOLOGY OF HERNIA FORMATION
• A normal abdominal wall has sufficient strength to resist high abdominal pressure and
prevent herniation of content.
• Herniation has been attributed to conditions that result in increased intraabdominal
pressure however not a major factor e.g. constipation, weight-lifting, pregnancy, prostatic
symptoms, COPD, ascites
• Hernia an inherited collagen disease?
• More common in pregnancy due to relaxin-induced ligamentous laxity.
• Also in the elderly due to senescent degeneration of muscles and fibrous tissue.
• Effect of smoking - decreases rate of collagen formation due to the effect of nicotine.
which weakens the abdominal wall and impairs wound healing
• Being obese or overweight increases the strain and pressure on the abdominal muscles and
makes them weaker and more prone to developing hernias

8. CLASSIFICATION
1. By anatomical location
2. By degree of complication
3. Nyhus Classification

9. BY ANATOMICAL LOCATION
• Anterior abdominal wall hernias
• Epigastric hernias
• Umbilical hernias
• Paraumbilical hernias
• Incisional hernias
• Spigelian hernias
• Parastomal hernias
• Posterior abdominal wall hernias
• Lumbar hernias
• Groin hernias
• Inguinal hernias
• Femoral hernias
• Obturator hernias

10. ANTERIOR ABDOMINAL WALL HERNIAS

11. BY DEGREE OF COMPLICATION
• Occult hernia
• Reducible hernia
• Irreducible or incarcerated hernia
• Strangulated hernia

12. NYHUS CLASSIFICATION OF HERNIAS
Type Description
Type 1 Indirect inguinal hernia; normal internal inguinal ring; no posterior floor defect
Type II Indirect inguinal hernia; enlarged internal inguinal ring; does not extend to
scrotum
Type IIIA Direct inguinal hernia
Type IIIB Indirect inguinal hernia; posterior inguinal wall defect
Type IIIC Femoral hernia
Type IV Recurrent hernias

13. CLASSIFICATION CTD
• The European Hernia society suggested a simplified classification system:
Primary or recurrent (P or R)
Lateral,medial or femoral (L,M,F)
Defect size in finger breadth assumed to be 1.5cm

14. CLINICAL HISTORY AND DIAGNOSIS
• Self diagnosis is common
• Presents as a subcutaneous lump on the abdominal wall
• Often painless; severe pain suggests strangulation
• Reducibility?
• Bowel obstruction?
• Primary or recurrent hernia?
• Associated pathologies?
• Smoking?

15. EXAMINATION FOR HERNIA
• Examine the patient initially when lying down then while standing
• Overlying skin colour changes; bruising and overlying cellulitis suggests strangulation
• Surgical scars
• Reducibility
• Tenderness
• Cough impulse; may be negative in strangulated hernias and positive in saphena varix
• Size, rigidity and number of defects

16. INVESTIGATIONS
• Ultrasound
• CT scan

17. MANAGEMENT PRINCIPLES
• Not all hernias require repair; increasing size and irreducibility are indications
• Complicated and femoral hernias require repair
• All repairs follow the same basic principles:
• Reduction of the hernia content with necessary debridement and repair
• Excision and closure of the sac
• Reapproximation of the walls of the neck if possible
• Permanent reinforcement of the defect with sutures or mesh (net vs sheet; synthetic vs
biological; light vs medium vs heavyweight; large pore vs small pore; intraperitoneal vs
extrap; non-absorbable vs absorbable)

18. INGUINAL HERNIA
• Indirect inguinal hernia
• Also known as congenital, oblique or lateral hernia.
• M>F
• As the testis descends a tube of peritoneum is pulled with the testis and wraps around
it ultimately to form the tunica vaginalis.
• Bowel is able to pass inside the peritoneal tube down towards the scrotum and may be
referred to as scrotal hernia which is usually large.
• Most common type of inguinal hernia.

19. TYPES OF INDIRECT INGUINAL HERNIA
• Bubonocele: the hernia sac stops within
the inguinal canal after entering the
deep inguinal ring
• Funicular: the hernia sac after emerging
out of superficial inguinal ring stops
just above the testis
• Complete scrotal: processus vaginalis is
patent throughout being continuos
with tunica vaginalis of the testis

21. DIRECT INGUINAL HERNIA
• Also known as the acquired or medial hernia.
• It is a result of stretching and weakening of the abdominal wall just medial to the
inferior epigastric vessels in the Hassel Bach's triangle (area of weakness) whereby the
abdominal wall here only consists of transversalis fascia.
• Almost always occurs in the middle-aged and elderly because their abdominal walls
weaken as they age.
• It is usually broadly based hence unlikely to strangulate
• A medially placed bladder can be pulled into the direct hernia

23. SPECIAL TESTS FOR HERNIAS

26. TEST
• Leg raising test-manifested by malgaigne’s bulging

29. INGUINAL HERNIAS-SPECIAL TYPES
• Dual Hernia
• Sliding Hernia
• Ritcher’s Hernia
• Maydl’s Hernia
• Littre’s Hernia
• Amyand’s hernia

30. DIFFERENTIAL DIAGNOSIS
• Lymph node groin mass or an abdomnal mass
• Hydrocele
• Femoral hernia
• Spigelian hernia
• Saphena varix
• Varicocele

31. MANAGEMENT
1. Watchful waiting in asymptomatic hernias
2. Herniotomy with some form of muscle strengthening (herniorrhaphy).
3. Open suture repair:
1. Bassini type
2. Shouldice Modification
3. Maloney's modification
4. Desarda modification

32. CONT’D
4. Open flat mesh repair:
1. Lichtenstein – commonly used and has lowered hernia recurrence rate and
accelerated post operative recovery. most common operation in resource rich
countries.
2. Prolene Hernia system
5. Open preperitoneal repair – Stoppa’s
6. Laparoscopic repair
1. TEP/TAPP- usually indicated in recurrent and bilateral hernias.

34. COMPLICATIONS OF SURGERY
• Bleeding- due to accidental damage to inferior epigastric or iliac vessels
• Urinary retention
• Femoral nerve blockade causing patient to be unable to move. usually resolves in 12hrs.
• Medium seroma- may resolve spontaneously or require aspiration and can be
misdiagnosed as an early recurrence
• SSI
• Chronic pain
• Hernia recurrence
• Testicular atrophy

35. FEMORAL HERNIA
• Occurs through the femoral canal
• Less common than the inguinal hernia.
• More common in females than in males-
Due to the difference in shape of their
pelvis: in females the shape increases the
size of the femoral canal thus increase risk
of hernia
• more common in low weight elderly women
• Easily missed on examination.
• 50% of cases present as an emergency with
very high risk of strangulation.

37. Diagnosis:
 Appears below and lateral to the pubic tubercle and lies in the upper leg rather than in the
lower abdomen.
 Often rapidly becomes irreducible and loses any cough impulse due to the tightness of the
neck
Differential diagnosis:
1. Inflamed lymph node
2. Direct inguinal hernia.
3. Saphena varix.
4. Femoral artery aneurysm.
5. Psoas abscess.
6. Rupture of adductor longus with haematoma.

38. Investigations:
• If there’s uncertainty, request for ultrasound or CT scan should be requested.
• All patients with unexplained small bowel obstruction should undergo careful
examination for a femoral hernia.
• It is now common to perform CT scanning in cases of bowel obstruction primarily
to exclude malignancy, but it can identify an obstructing femoral hernia missed
by clinicians.

39. Management:
 There is no alternative to surgery for a femoral hernia, treat them with urgency.
 There are three approaches and appropriate cases can be managed laparoscopically.
1. Low approach (Lockwood)- suitable when there is no risk of bowel resection
2. Inguinal approach (Lotheissen)
3. High approach (McEvedy)- ideal in emergency situations where risk of strangulation is
high
4. AK henry’s approach
5. Laparascopic approach- TEP and TAPP: ideal for elective cases

41. UMBILICAL HERNIA
• The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually
within a week of birth.
• This process may be delayed, leading to the development of herniation in the neonatal period. The
umbilical ring may also stretch and reopen in adult life.
Umbilical hernia in children:
• Common (1 in every 10 live births), with a higher incidence in premature babies.
• M=F; black infants X8 more than in white.
• Obstruction and/or strangulation are extremely uncommon below the age of three years.
• Conservative treatment is indicated under the age of 2 years when the hernia is asymptomatic.
• 95% resolve spontaneously.
• If the hernia persists beyond the age of 2 years, it is unlikely to resolve and surgical repair is indicated:
herniorrhaphy.

44. Umbilical hernia in adults:
• Common in overweight men or multiparous women.
• Progressively increase in size and may get very large indeed.
• Round defect with rigid fibrous margins typically slightly to one side of the umbilical depression,
creating a crescent shaped appearance to the umbilicus.
• Large hernias may contain small or large bowel but even when very large the neck of the sac is
usually narrow compared to the contents hence are prone to obstruction and strangulation.
• Most patients complain of pain due to tissue tension or symptoms of intermittent bowel
obstruction.
• Surgery advised which includes:
1. Open umbilical hernia repair/Mayo’s operation
2. Laparoscopic umbilical hernia repair

45. EPIGASTRIC HERNIA
• These arise through the midline raphe (linea
alba) anywhere between the xiphoid process
and the umbilicus, usually midway.
• They are usually less than 1 cm in maximum
diameter and commonly contain only
extraperitoneal fat which gradually enlarges,
spreading in the subcutaneous plane to
resemble the shape of a mushroom.
• Common cause of recurrence is failure to
identify a second defect at time of original
repair.

47. Diagnosis:
• The patients are often fit, healthy males between 25 and 40 years of age. These
hernias can be very painful even when the swelling is the size of a pea due to
partial strangulation.
• It may be locally tender with pain that mimics a peptic ulcer.
• It is unlikely to be reducible because of the narrow neck and resemble a lipoma.
• A cough impulse may or may not be felt.
• Surgery should only be offered if the hernia is sufficiently symptomatic
(laparoscopic repair)

48. INCISIONAL HERNIA
• These arise through a defect in the musculofascial
layers of the abdominal wall in the region of a
postoperative scar.
• Thus they may appear anywhere on the abdominal
surface.
• 10–50 per cent of laparotomy incisions and 1–5 per
cent of laparoscopic port-site incisions.
• Type 1 and II
• Factors predisposing their development are:
a). Patient factors (obesity, general poor healing due to
malnutrition, immunosuppression or steroid therapy,
chronic cough, cancer).
b). Wound factors (poor quality tissues, wound
infection).
c). Surgical factors (inappropriate suture material,
incorrect suture placement.)

49. Diagnosis:
• Commonly appear as a localized swelling involving a small portion of the scar but may present as a diffuse
bulging of the whole length of the incision.
• Vascular damage to skin may lead to dermatitis.
• Obstruction is common but strangulation is rare.
• Wide variation in size.
Management
• Asymptomatic incisional hernias may not require treatment at all.
• The wearing of an abdominal binder or belt may prevent the hernia from increasing in size.
• Surgery is often straightforward and both open and laparoscopic options are available.

51. SURGICAL REPAIR MODALITIES FOR INCISIONAL
HERNIAS

53. SPIGELIAN HERNIA
• Uncommon (probably underdiagnosed)
• M=F; most common in the elderly.
• They arise through a defect in the Spigelian fascia which is
the aponeurosis of the transversus abdominis muscle.
• Occurs at the level of the arcuate line through the
Spigelian fascia
• The hernia sac lies either deep to the internal oblique or
between external and internal oblique muscles
• In young patients they usually contain extraperitoneal fat
only but in older patients there is often a peritoneal sac
and they can become very large indeed.
• May also be congenital showing incomplete
differentiation of mesenchymal layers within abdominal
wall.

54. Diagnosis:
• Young patients usually present with intermittent pain, due to
pinching of the fat (similar to an epigastric hernia).
• There’s a soft reducible mass lateral to the rectus muscle and below
the umbilicus
• Positive cough impulse
• Older patients generally present with a reducible swelling at the
edge of the rectus sheath and may have symptoms of intermittent
obstruction.
• Diagnosis should be suspected because of the location of the
symptoms and is confirmed by CT.
Management:
• Surgery is recommended as the narrow and fibrous neck
predisposes to strangulation. Surgery can be open or laparoscopic
(TAPP or intraperitoneal onlay of mesh (IPOM).
• Spigelian fascia is repaired by suture or mesh laid deep to external
oblique aponeurosis.

55. SPERGELIAN HERNIA REPAIR

56. LUMBAR HERNIA
• It can be: primary or secondary; superior or inferior
• Secondary is due to previous renal surgery and
accidental injury to subcostal nerve; more common
• Most primary lumbar hernias occur through the
inferior lumbar triangle or Petit bounded below by
the crest of the ilium, laterally by the external
oblique muscle and medially by the latissimus dorsi.
• Less commonly, the sac comes through the superior
lumbar triangle, which is bounded by the 12th rib
above, medially by the sacrospinalis and laterally by
the posterior border of the internal oblique muscle.

58. REFERENCES
• Williams, N., O'Connell, P., & McCaskie, A. (2018). Bailey and Love's short practice of surgery (27th
ed.). CRC.
• Abdominal hernias - Knowledge @ AMBOSS. Amboss.com. (2023). Retrieved 15th January 2023,