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Hernia
- 1. HERNIA
- 2. • “Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it”
- 3. • Common Hernias – – – – – INGUINAL UMBILICAL FEMORAL EPIGASTRIC INCISIONAL • Rare Hernias – – – – – SPIGELIAN LUMBAR GLUTEAL SCIATIC OBTURATOR
- 4. Factors: Weakness of abdominal musculature • Congenital – Persistence of processus vaginalis – Patent canal of Tuck – Incomplete obliteration of umbilicus • Acquired – Fat – Pregnancy – Incision – Infection – Connective tissue – smoking, aging, CTD, systemic illness
- 5. Increased abdominal pressure • Chronic constipation • Chronic cough • Bladder outlet obstruction – stricture, prostrate • Straining – weight lifting • Intra-abdominal malignancy • Vomiting • Repeated pregnancy
- 6. • Sac • Covering • Contents – Omentocoele – Enterocoele – Cystocoele – Ovary
- 7. • Richter’s • Littre’s • Maydl’s
- 9. Reducible Hernia • Characteristic signs – Reducibility – Cough impulse
- 10. Irreducible Hernia • Due to – Adhesions – Narrowing of neck – Incarceration – Massive hernia inside scrotum
- 11. Obstructed Hernia • Irreducibility + Intestinal obstruction • Features – No cough impulse – Irreducible – Painless – Non tender – Features of intestinal obstruction
- 12. Strangulated Hernia • Blood supply of its contents impaired • Intestinal obstruction ± • Pathology – Intestinal obstruction – Dilation of hernial contents – Impairment of venous return – Stasis --------- Arterial impairment
- 13. • Appearance – Congested and bright red – Ecchymosis – Extravasation of blood into lumen/ sac – loss of tone – Translocation of gut bacteria – peritonitis/ sepsis – Gangrene
- 14. • Symptoms – Pain, vomiting – Ceases with onset of gangrene, ileus • Signs – Ill looking – Tense, tender – Irreducible, no cough impulse – Acute intestinal obstruction – Peritonitis
- 15. Strangulated Omentocele • No features of intestinal obstruction • Gangrene onset delayed
- 16. Strangulated Richter’s Hernia • • • • Features mimic gastroenteritis Obstruction > 50 % of circumference Colic, diarrhoes Constipation - ileus
- 17. Maydl’s Hernia • Retrograde strangulation • On opening sac – contents appear normal • Generalized peritonitis may set in early
- 18. Inflamed Hernia • Outside – Abrasion, ill fitting truss • Inside – Diverticulitis, appendicitis • Signs of inflammation + • Not associated with intestinal obstruction
- 19. INGUINAL HERNIA
- 20. Anatomy
- 21. Inguinal canal • • • • Triangular slit 3.75 cm long Above the inner half of inguinal ligament Deep to superficial inguinal ring Developed due to the descent of testis in embryonic life
- 22. Deep Inguinal Ring • • • • Opening in the fascia transversalis 1.25 cm above mid inguinal point Medially – inferior epigastric artery Spermatic cord in males; round ligament in females
- 23. Superficial Inguinal Ring • Aponeurosis of external oblique – crurae • Above and lateral to pubic crest • Spermatic cord/ round ligament and illioinguinal nerves
- 24. • Anteriorly – skin, fascia, EO aponeurosis, lateral third – IO aponeurosis • Posteriorly – transversalis fascia, medial ½ conjoint tendon • Above – transversus abdominins and internal oblique fibres • Below – inguinal ligamnet
- 25. Contents • Illioinguinal nerves • Spermatic cord – Vas defrens – Testicular artery, art to vas defrens, cremasteric – Pampiniform plexus of veins – Lymph vessels – Testicular plexus of sympathetic nerves, genital branch of genitofemoral
- 26. Hassenbach’s Triangle • • • • • • Site of direct hernia Medially – lateral border rectus abdominis Laterally – inferior epigastric vessel Inferiorly – inguinal ligament Floor – fascia transversalis Umbilical fold – obliterated umbilical artery
- 27. Mechanisms for preventing hernia • • • • • Obliquity of inguinal canal Shutter mechanism of fibres of IO, TA Sphincter action of TA, IO at deep inguinal ring Ball valve action of cremasteric Fibres of internal oblique over deep inguinal ring • Conjoint tendon
- 29. INDIRECT INGUINAL HERNIA • • • • More common Young individuals More common on the right side On basis of extent – Bubonocele – Funicular hernia – Complete hernia
- 30. • Coverings – Peritoneum – Extraperitoneal fat – Internal spermatic fascia – Cremasteric fascia – External spermatic fascia – Superficial fascia – skin
- 31. DIRECT INGUINAL HERNIA • • • • Directly through the hasselbach’s triangle Acquired (ex- Oglive hernia) More common in elderly, malgaigne bulgings Rarely gets strangulated
- 32. • Symptoms – Pain/ discomfort – Lump – Systemic symptoms – obstruction, strangulation – Predisposing factors – constipation, chronic bronchitis, urinary obstruction – Past history
- 33. • Signs – REDUCIBILITY – COUGH IMPULSE – Position – d/f femoral hernia – Get above the swelling – Invagination test – Ring occlusion test
- 34. Rare Varieties • Interstitial hernia – Between muscle layers of abdominal wall – Commonly associated with undescended testis – Preperitoneal – Intraperitoneal – Extraperitoneal
- 35. Rare Varieties • Sliding hernia – Older men – Extraperitoneal bowel with sac of peritoneum – Caecum, pelvic colon, bladder – Strangulation of intestine within and outside the peritoneum • Richter’s • Maydl’s • Littre’s
- 36. TREATMENT • Conservative management • Surgical management
- 37. Conservative management : No Treatment • Indications – Severe ill health – Short life expectency – Refuse operation
- 38. Conservative management : Truss • Indications – Refuse operation – Old patients with severe co morbidities – Children ( c/I – undescended testis) • Contraindications – – – – – Irreducible hernia Undescended testis Chronic bronchitits, strenous labour Associated with large hydrocele Not intelligent enough to position properly
- 39. • Dangers – Pressure atropht of muscles of inguinal region – Ostruction or strangulation – Used with partially reduced hernia – may cause trauma – Improper cleanliness – unhealthy skin – Adhesions between sac and canal – Chance of strangulation remains
- 40. Operative treatment • Herniotomy – Neck of sac transfixed, ligated and excised – Infants and children; young men with good musculature • Herniorrhaphy – Herniotomy + repair of postrior wall – Indirect hernias – Adults with good muscle tone
- 41. Hernioplasty • Herniotomy + reinforcement of posterior wall • Autologous – Fascia lata – External oblique aponeurosis – Anterior rectus sheath flap – Skin flap – dermoplasty/ skin ribbon • Heterogenous – Prolene – Stainless steel
- 42. • Indications – Indirect hernia – poor muscle tone – Direct hernia – Recurranthernia – Predisposing factors – chronic cough,etc
- 43. Treatment of Strangulated Hernia • Emergency surgery • Resuscitation • Reduction of hernia – Foot end elevation – Ice pack – NG, IV fluids – Analgesia, antibiotic
- 44. • Assess viability – Green/ black color – Flaccid , lustureless appearance – No peristalssis – Blood stained, foul smelling fluid in sac • Bowel viable - HERNIORRHAPHY
- 45. • Bowel nonviable – Linear patch of gangrene – invagination – Loop of bowel – resection and anastomosis if gen condition permits – Bowel large intestine – exteriorisation
- 46. RECURRENT INGUINAL HERNIA • Types of hernia – Sliding – Large/ long standing – Large direct hernia • Types of patients – chronic cough • Inadequate preoperative preparation
- 47. RECURRENT INGUINAL HERNIA • Operative faults – – – – – Failure to ligate sac Tension in repair Use of absorbable sutures Bleeding – infection Fault in selection of operation • Postoperative care – Wound infection – Lifting heaavy weights – Persistence of predisposing factors • Appearance of new hernia
- 48. FEMORAL HERNIA
- 49. • Femoral ring – femoral canal – saphenous opening • More common in – Females – Old age • Most liable to strangulate
- 50. Anatomy
- 51. Coverings of the sac of femoral hernia • • • • • • • Skin Superficial fascia Cribriform fascia Anterior layer of femoral sheath Fatty contents of femoral canal Femoral septum Peritoneum
- 52. Rare types of femoral hernia • Prevascular hernia(Velpeu’s) – ass with posterior dislocation (Narath’s hernia) • Retrovascular hernia Serafini • Pectineal hernia – Cloquet’s • External femoral hernia – Hesselbach’s • Lacunar hernia – Lingier’s
- 53. • Symptoms – Swelling – Pain – Systemic symptoms • • • • Zeimenns technique Invagination technique Ring occlusion test Position of swelling
- 54. Treatment • No conservative management • Surgery – herniorrhaphy – High operation(McEvedy’s) – Lottheissen’s – Lockwood
- 55. UMBILICAL HERNIA • Three major types – Exomphalos – Umbilical hernia in infants and children – Paraumbilical hernia in adults
- 56. Exomphalos • Minor – Small sac – Summit attached to the umbilical cord – Treatment • twisting of umbilical cord and strapping
- 57. Exomphalos • Major • Umbilical cord attached to inferior aspect of swelling • Contains intestines, liver • Surgical emergency • Immediate decompression and reduction
- 58. Umbilical hernia in children and infants • • • • Weak umbilical scar following neonatal sepsis Usually asymptomatic 90% cured within 12 – 18 months > 18 months – surgery
- 59. Paraumbilical hernia of adults • Supraumbilical or infraumbilical • Adhesions - seldom reducible • Predisposing factors – – Women – Obesity – Repeated pregnancy • Treatment – Mayo’s operation
- 60. EPIGASTRIC HERNIA (Fatty Hernia of Linea Alba) • • • • Through fibres of linea alba Blood vessels pierce linea alba Initially extraperitoneal fat only M.c. – young muscular men with strenous activity • Usually irreducible, no cough impulse • If symptomatic - surgery
- 61. INCISIONAL HERNIA (Ventral Hernia) • Defect with patient – – – – Obesity Chronic cough perioperative period Undue abdominal distention Malnutrition • Operative – – – – – Injury to nerves Careless wound closure Hemorrhage – infection Tube drainage through laparotomy wound Midline infraumbilical
- 62. • Postoperative – Infection – Postop cough, distention – Postop peritonitis – Early removal of sutures – Postop steroid therapy
- 63. Types of incisional hernia • Type 1 – Upper abdomen/ midline lower abdomen – Wide gap in musculature – Low risk of strangulation • Type 2 – Lateral part of abdomen – Small defect – Strangulation risk high
- 64. Treatment • Prevention of incisional hernia – Weight reduction – Correct nutritional defects – Treat chronic cough – Careful closure of abdomen – Prevent post op wound infection
- 65. • Conservative management – Reducible type 1 • SURGICAL MANAGEMENT
- 66. LUMBAR HERNIA • Superior lumbar hernia • Inferior lumbar hernia
- 67. Incisional lumbar hernia • Renal surgery with post op infection • Paralysis of lumbar muscles(phantom hernia) • Treatment – Primary hernia – herniorrhaphy – Incisional hernia
- 68. OBTURATOR HERNIA • Rare; old women • Through obturator foramen • Thigh flexed, abducted and externally rotated • Referred pain to knee joint • Strangulation - surgery
- 69. SPIGELEAN HERNIA • Interparietal hernia • At level of arcuate line, lateral to rectus • Treatment - surgery
- 70. • Gluteal hernia • Sciatic hernia
- 71. CONCLUSION • Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it • Inguinal hernia most frequent • Usual mode of treatment is surgical
- 72. THANK YOU
Editor's Notes
- Sac – mouth, neck, body fundus
- Pectineal hernia – Cloquet’s hernia – behind femoral vessels between pectineusmuscle;External femoral hernia – Hesselbach’s hernia- lateral to femoral artery