Hernia

HERNIA
DR BASHIR YUNUS
Surgery resident
AKTH
4/23/2015bbinyunus2002@gmail.
com
1

DEFINATION
The abnormal
Protrusion of a
viscous or part
of it from the
wall of the
cavity in which
it is enclosed
through an
abnormal or
weak opening.
4/23/2015bbinyunus2002@gmail.c
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AETIOLOGY
1. Congenital – preformed sac- processus
vaginalis
2. Defect in or weakness of, the wall of the
abdominal cavity which predispose to it.
Ageing
Infection with resulting weak scar
Multiple pregnancies
Obesity
Injury to nerve e.g gridiron incision
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AETIOLOGY
3. Increase in intra-abdominal pressure
• Causes of straining
Chronic cough
Chronic urinary obstruction
Chronic constipation
• Ascites
4. Familial collagen disorder- prune belly
syndrome
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PATHOLOGY
Comprises of :
Covering
Sac
Content
The sac is a diverticulum of the
peritoneum with mouth, neck,
body and fundus.
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PATHOLOGY
• Hernias without neck and large mouth;
incisional hernia and direct hernia
• Hernias without sac – epigastric hernia-
protrusion extra peritoneal fat.
• The body of sac is thin in children and indirect
sacs but thick in long standing and direct
hernias.
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Contents of hernia sac
• Omentum – omentocele- difficult to reduce the
later part, initial part may reduce easily.
• Intestine – enterocele
• Two loops of intestine in a manner of W -Maydl’s
hernia
• Appendix – may become adherent and rarely acute
appendicitis occur.
• Meckel’s diverticulum – litter’s hernia
• urinary bladder-cystocele or as sliding hernia
when it forms part of the wall.
• Adnexia
• Fluid – from congested bowel or omentum
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complications
1. Irreducibility
adhesion
oedema
sliding hernia
impacted faeces
narrow neck
2. Obstruction
3. incarceration
4. Strangulation
5. Rupture of sac – trauma, pressure necrosis of
overlying skin
6. Fistula formation – Richter's hernia
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Complications
6. Reduction –en- mass
7. Hemorrhage
8. Hydrocele of sac
9. Extension of intra abdominal inflammation
10.Extension of intra abdominal tumour.
11. Torsion of omentum
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INGUINAL HERNIA
• ANATOMY
• TYPES
• CLINICAL FEATURES
• DIFFENTIAL DIAGNOSIS
• TREATMENT
• POST-OP. COMPLICATION
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INGUINAL REGION
4/23/2015
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bbinyunus2002@gmail.c
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INGUINAL CANAL
• A canal 4cm long located in the lower part of the
anterior abdominal wall above the groin,
directed downwards, medially and forward.
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INGUINAL CANAL
 Embryology – formed from the
herniation of the gubernaculum testis and
the processus vaginalis which makes it
possible for the testis and spermatic cord to
pass from the abdomen to the scrotum in
males and the round ligament to the libia
majus in female.
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INGUINAL CANAL
• EXTENT
 Deep inguinal ring(U-shaped opening on the
transversalis fascia 1.25cm above and
perpendicular to the mid inguinal point) to
the superficial inguinal ring (opening on the
external oblique aponeurosis).
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INGUINAL CANAL
• BOUNDRIES
Anterior wall is formed by the aponeurosis of the
external oblique, and reinforced by the internal oblique
muscle laterally.
Posterior wall is formed by the transversalis fascia(re-
enforced superficially aponeurotic fibers of transversus
abdominis) and conjoint tendon medial half.
Roof is formed by the internal oblique, transversus
abdominis and transversalis fascia
Floor is formed by the inguinal ligament (a ‘rolled up’
portion of the external oblique aponeurosis) and thickened
medially by the lacunar ligament.
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BOUNDRIES
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BOUNDRIES
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INGUINAL CANAL
• CONTENT
▫ Spermatic cord (men)
▫ Round ligament (women)
▫ Ilioinguinal nerve
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INGUINAL CANAL
Spermatic cord
The classic and memorable description of the contents of
spermatic cord in the male are:
• 3 arteries: cremasteric, differential and testicular art.
• 3 nerves: genital branch of the genitofemoral nerve
(L1/2), autonomic and visceral afferent fibres,
ilioinguinal nerve (N.B. outside spermatic cord but
travels next to it)
• 3 fascial layers: external spermatic, cremasteric,
and internal spermatic fascia.
• 3 other structures: pampiniform plexus, vas
deferens (ductus deferens), testicular lymphatics
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Hesselbach’s Triangle(inguinal triangle)
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INGUINAL CANAL
• Hesselbach’s Triangle
The triangular part of the posterior wall of the inguinal
canal.
• Boundaries
▫ Inferior: Medial half of inguinal ligament
▫ Medial: Linea semilunaris(lateral border of rectus
abdominis)
▫ Lateral : Inferior epigastric artery
• Surgical importance
▫ Not reinforced by conjoint tendon
▫ Potentially weak area
▫ Direct Inguinal hernias protrude through it
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NATURAL MECH. PREVENTING HERNIA
• Obliquity of the canal
• Internal oblique muscle opposite the deep ring
• Shutter action of the arched fibers of internal
oblique and transversus abdominis
• Plugging action of the spermatic cord due to
contraction of the cremasteric muscle
• Sliding valve action of the U-shape internal ring
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INGUINAL HERNIA
Inguinal hernias occur in the inguinal canal.
Commonest hernia in both sexes. It occurs in 16% of
males. It accounts for 95% of hernias in male and
40-50% of hernias in females.
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INGUINAL HERNIA
• TYPES
▫ Indirect
▫ Direct
An indirect inguinal hernia enters the inguinal
canal through the internal inguinal ring and
passes obliquely downwards and medially into the
canal. Direct passes into the canal via
Hesselbach’s triangle and so cannot normally
pass through the external ring.
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DIFFERENCES BETWEEN DIRECT AND
INDIRECT HERNIAS
1. Origin and coarse:
 Direct: Develops in the area of Hasselbach's triangle. The origin is
medially to the inferior epigastric vessels.
 Indirect: Develops at the internal ring. The origin is lateral to the
inferior epigastric artery.
2. Content:
 Direct: Retroperitoneal fat. less commonly, peritoneal sac containing
bowel .
 Indirect: Sac of peritoneum coming through internal ring, through which
omentum or bowel can enter.
3. Etiology:
 Direct: weakness of the posterior floor of the inguinal canal (acquired).
 Indirect: patent processus vaginalis (Congenital) .
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INDIRECT INGUINAL HERNIA
• Usually congenital due to persistence in
processus.
• May be acquired. May occur at any age in adult
life.
▫ TYPES
 Vaginal or complete
 Incomplete - funicular
- bubonocele
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Vaginal hernia
▫ Also known as complete or scrotal hernia
▫ Processus vaginalis is patent through out
▫ Sac is continuous with the tunica vaginalis
▫ Hernia descends to the bottom of the scrotum
▫ Testis is not felt separately before reduction of
hernia.
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Funicular hernia
• Processus vaginalis is closed at the lower end
hence sac is separate from the tunica vaginalis
• Testis is felt separately from the content of the
sac.
• Most indirect hernia belong to this category and
commonly seen in adults.
• Usually acquired but may be congenital
• Appears as inguino-scrotal as in vaginal.
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Bubonocele
▫ Processus is closed at the external ring
▫ Hernia is limited in the inguinal canal hence
appear as inguinal swelling.
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COVERINGS OF INDIRECT ING.HERNIA
• Skin
• Superficial fascia; when hernia comes out of
external ring. Dartos muscle when in scrotum
• External oblique aponeurosis or external
spermatic fascia when of external ring
• Cremasteric muscle
• Internal spermatic fascia
• Processus vaginalis or peritoneum.
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DIRECT INGUINAL HERNIA
• As mentioned above
• Lies outside the cord
• Mostly acquired
• Found predominantly in elderly males
• Seldom comes out through the external ring
• Appears immediately on standing and returns
on lying down.
• Rarely strangulates
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COVERINGS OF DIRECT HERNIA
• Skin
• Superficial fascia
• External oblique aponeurosis
• Conjoint tendon when the sac passes medial to
the lateral umbilical ligament
• Fascia transversalis
• Peritoneum- sac
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CLINICAL FEATURES
• Symptoms
▫ May be asymptomatic
▫ Swelling in the groin
▫ Pain- due to stretching of the deep ring by the
protruding viscous.
NB: severe pain in swelling associated with
abdominal pain indicates strangulation.
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CLINICAL FEATURES
• EXAMINATION
▫ Visible cough impulse
▫ Reducibility: unless complicated
▫ Deep ring occlusion test: distinguishes direct from
indirect hernia.
▫ Extent: complete or incomplete
NB: pantaloon hernia- direct and indirect inguinal
hernia co-exist.
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DIFFERENTIAL DIAG. OF GROIN
SWELLING
• In males
▫ Femoral hernia
▫ Vaginal hydrocele
▫ Encysted hydrocele of the cord
▫ Malgaigne’s bulges
▫ Ectopic or undescended testis
▫ Cyst of the epididymis
▫ Inguinal lymphadenopathy
▫ Saphena varix
▫ Sebaceous cyst
▫ Lipoma
▫ Psoas abscess
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DIFFERENTIAL DIAG. OF GROIN
SWELLING
• In female
▫ Femoral hernia
▫ Cyst of canal of nuck
▫ lipoma
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DIFFERENTIALS OF INGUINOSCROTAL
SWELLING
• Infantile hydrocele
• Congenital hydrocele
• Encysted hydrocele of the cord
• Varicocele
• Lymph varix or lymphangiectasis of the cord
• funiculitis
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TREATMENT
• Non operative - conservative
• Operative
▫ Open
▫ Laparoscopic
• Post operative complications
• Causes of recurrence
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CONSERVATIVE
1. NO TREATMENT
▫ Severely ill with short life expectancy
2. TRUSS TREATMENT
▫ Prevent descent of content
MODE OF ACTION
 Press anterior wall against posterior wall of ing.
canal
 compresses the deep ring
 Causes adhesion of the sac with wall of canal
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CONSERVATIVE
INDICATIONS FOR TRUSS.
1. In infants: Except when associated with
undescended testis
2. In old patient: when surgery is contraindicated
3. Those who refuse operative treatment
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CONSERVATIVE
CONTRAINDICATIONS FOR TRUSS
1. Irreducible hernia
2. Patient with source of chronic strain
3. Hernia with huge hydrocele
4. Hernia with undescended testis
5. Patients with poor intelligence and perseverance
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CONSERVATIVE
PROBLEMS OF TRUSS
1. Improper use leads to obstrution and
strangulation
2. Improper cleaning leads to unhealthy skin
3. Prolong use leads to muscle atrophy
4. Adhesions
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CONSERVATIVE
TYPES OF TRUSS
1. RAT-TAILED
2. ADDER-HEADED
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CONSERVATIVE
METHOD OF USE
1. Should apply in lying down position after
reduction.
2. Use constantly except when patient is in bed. It
should be worn before getting off bed
3. The skin cover by pad and the perineum should
be kept clean by daily toilet.
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CONSERVATIVE
• TAXIS
It implies vigorous manipulation in an attempt to
reduce an acute obstructed hernia of short
duration only but without any feature of intestinal
obstruction or strangulation.
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CONSERVATION
• PROCEDURE
By an experience surgeon
Done after admission in a hospital
Patient lying supine and foot of bed raised by 9 inch
block
Adequate analgesia: pethidine then wait for 20-30min
then give buscopan
When well sedated, try to reduce the hernia
Observe patient for 24-48hr (for obstruction,
strangulation or recurrence)
During observation, patient is allowed plain water and
electrolyte orally only
Plan for an elective operation.
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CONSERVATIVE
• DANGERS OF TAXIS
Reduction-en-mass
Reduction of content into the loculus of the sac
Contusion or rupture of content
Extra peritoneal reduction (when sac ruptures)
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OPERATIVES
▫ Operative treatment is the treatment of choice as
there is risk of complications.
▫ In uncomplicated hernia, the source of strain
should be treated first.
▫ In infant of few days old, wait until baby is
3month old.
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OPERATIVES
• Operation is the treatment of choice
▫ INDIRECT INGUINAL HERNIA
▫ The 3 essential requirements;
 Herniotomy
 Lytle’s repair
 herniorrhaphy
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OPERATIVES
• HERNIOTOMY
▫ Separation of sac from cord srtuctures
▫ Reducing the content
▫ Transfixation and ligation of sac
▫ Excise the redundant sac
▫ NB; indirect sac is anteriolateral to the cord
▫ It is done for infant and children, adolescent and young
adult with good musculature.
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OPERATIVES
• LYTLE’S REPAIR
• Tightening of the internal inguinal ring around
the spermatic cord.
• Use prolene 2.o
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OPERATIVES
• HERNIORRHAPHY
▫ Heniotomy +reconstruction of the posterior wall of the
inguinal canal
I. Lichtenstein
II. Bassini repair
III. Shouldice repair
IV. Nylon darn
V. Mc Vay’s
VI. Gilbert’s plug
VII. Stoppas repair
VIII.Kuntz operation
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OPERATIVES
• Lichtenstein
▫ Mesh repair of posterior wall
• Bassini
▫ Suturing the cojoint tendon to the inguinal
ligament behind the cord with non absorbable
monofilament preferably nylon
• Shouldice
▫ Modification of Bassini
▫ Multilayered(4layers) Bassini’s repair
▫ 1st 2layers double breasting of transversalis fascia
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OPERATIVES
• Shouldice con’t.
▫ 3rd layer is suturing the cojoint tendon to the
inguinal ligament
▫ 4th layer involves suturing the anterior rectus
sheath and the cojoined tendon of the inner
surface of lower leaf of external oblique muscle
▫ Best anatomical repair, least recurrence
• McVay’s
▫ approximation of cojoint tendon with ligament of
cooper
▫ Prevent both femoral and inguinal hernia
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POST-OP COMPLICATIONS
• INTRA-OPERATIVE
▫ Injury to the external iliac or femoral vessels
▫ Injury the vas deferens
▫ Injury to the bladder and colon esp in sliding hernia
▫ Injury to the inferior epigastric vessel
▫ Injury to the content of the sac
▫ Injury to the testicular artery
• EARLY POST-OP
▫ Retention of urine
▫ Haematoma of cord and scrotum
▫ Wound infection
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• LATE POST-OP
▫ Recurrence
▫ Sinuses
▫ Neuralgic pain- ilioinguinal nerve – hyperasthesia
over the medial side of the inguinal canal
▫ Painful scar
▫ Atrophy of the testis due to injury to testicular artery
▫ Ostetis pubis
▫ Mesh extrusion with or without foreign body reaction
▫ Epidermoid cyst
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CAUSES OF RECURRENCE
• Inadequate pre-op preparation
▫ Persistent causes of straining
▫ Infection
Intra-operative
▫ Tension repair
▫ Low ligation of sac
▫ Inadequate lytle’s repair (in huge long standing
hernia)
Treatment of recurrence is via preperitoneal
repair(there is fibrosis of the previous site). Can be
open or laparoscopic(gold standard).
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Special hernias
• Sliding hernia(Hernia-en-glissade)
▫ The content forms part of the sac.
▫ Part of the posterior wall formed not only by the
peritoneum but also by part of retroperitoneal
structure. Eg urinary bladder, caecum, sigmoid colon.
▫ Features;
 Old age
 Long standing case
 Left sided more common
 Huge scrotal
 Appears slowly after reduction
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• Significance of sliding hernia;
▫ Easily strangulated
▫ Failure to recognize the visceral component of the
hernia sac during operation leading to injury .
Treatment
hernioplasty
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• Spigelian hernia
▫ Hernia through the spigelian fascia; a strip of
fascia that runs parallel to the outerborder of
rectus sheath from tip of the 9th costal cartilage to
pubic tubercle.
• Richter’s hernia
▫ Only portion of the circumference become
protruded into the hernia sac.
▫ Chance of strangulation without complete
obstruction of the lumen.
▫ Diarrhea is seen in cases of strangulation
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• Littre’s hernia
▫ Meckel’s diverticulum is seen in the sac
• Sacless hernia
▫ Epigastric hernia of the linea alba
• Dual hernia
▫ Also known pantaloon/saddle bag hernia
▫ Has two sacs direct and indirect hernia
▫ Deep ring occlusion test may be confusing
▫ One of the causes of recurrence, since the indirect
sac can be missed in repair of the direct.
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• Maydl’s hernia
▫ Also known as Hernia-en-W
▫ Two adjacent loops of bowel remain in the
sac(look like W), the connecting portion remains
inside the abdomen
▫ The connecting portion of the W is more
vulnerable to strangulation
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• Ogilvie hernia
▫ Congenital direct hernia; through a rigid circular
orifice in the conjoined tendon just lateral to
where it insert into the rectus sheath.
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Hernia

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