Classification Of Hernias

1. Hernias
Dr Massam

2. Objectives
At the end of this session, students are expected
to be able to:
• Define hernia
• Identify different risk factors of hernia
• Describe clinical features of hernia.
• Describe different classifications of hernia
• Briefly describe inguinal, femoral, umbilical,
epigastric, speligean and incisional hernias

3. Objectives
• Describe the differential diagnosis of groin
hernias
• Identify the investigations of hernia
• Describe the treatment of hernia.
• Describe post-operative complications of
herniorrhaphy.

4. Introduction
Definition:
• A condition in which part of an organ is
displaced and protrudes through the wall of
the cavity containing it (often involving the
intestine at a weak point in the abdominal
wall).
• The wall can be the abdominal wall, muscle
fascia, diaphragm or foramen magnum

5. Introduction cont..
• Abdominal hernias refers to protrusion of the
peritoneum or preperitoneal fat or peritoneal
organ(s) through an abnormal opening in the
abdominal wall
• It often presents as a “bulge” or painless
swelling (for several days to months)
• Peritoneal contents may be trapped in “sac”

6. Introduction cont..
• All hernias consists of 3 parts:-
–The sac
• This is the diverticulum of peritonium
consisting of a mouth, neck and the
fundus
–Coverings
• Derived from the layers of the abdominal
wall through which the sac passes

7. Introduction cont..
–Contents
• Omentum (omentocoele)
• Intestine (enterocoele)
• Part of the urinary bladder ( cystocoele)
• Ovaries
• Meckel’s diverticulum (Littre’s hernia)
• Part of the circumferance of the intestine
(Richter’s hernia)
• Fluids

8. Risk factors
• Varies with age
–Pediatric
• Tend to be a congenital remnant
–Adult
• Usually due to tissue weakness
• Burst strength < abdominal wall tension
• Varies with gender

9. Risk factors/Pathophysiology
• Mainly due to two(2) factors, these are:-
–Weakness of abdominal wall muscles and
–Increased abdominal pressure which forces
the content out through the normal
abdominal musculature

10. Risk factors/Pathophysiology
Weakness of abdominal musculature
• Due to congenital weakness
Examples includes:-
– persistence of processus vaginalis lead to
indirect inguinal hernia
–Incomplete obliteration of umbilicus may
lead to infantile umbilical hernia
–Patent canal of Nuck in female cause
indirect inguinal hernia

11. Risk factors/Pathophysiology
Weakness of abdominal musculature
• Due to acquired weakness
Examples includes:-
–Muscle weakness may follow repeated
pregnancy
–Surgical incision may lead to division of
nerve fibres and thus causes muscle
weakness causing incisional hernia
–Obesity

12. Risk factors/Pathophysiology
Due to increased intra-abdominal pressure
• Examples includes:-
– Whooping cough in children
– Chronic cough in bronchitis, PTB
– Bladder neck obstruction or urethral stricture
– Enlarged prostate causing dysuria
– Lifting heavy weight
– Vomiting
– constipation

13. Classification
According to the origin of the hernia
–Congenital hernias
–Acquired hernias

14. Classification cont..
According to the site of the hernia
–Inguinal hernia
–Femoral hernia
–Umbilical hernia
–Paraumbilical hernia
–Epigastric hernia
–Incisional hernia

16. Classification cont..
Clinical classification
–Reducible hernia
• Contents can be easily returned into the
abdominal cavity leaving the hernial sac
in its position
–Irreducible hernia
• Contents cannot be returned to the
abdomen

17. Classification cont..
Clinical classification…
–Obstructed hernia
• Irreducible hernia + intestinal obstruction
• No interference with blood supply to the
intestine
–Strangulated hernia
• Irreducible hernia + interference with
blood supply± intestinal obstruction

18. Classification cont..
According to the contents of the hernia
–Enterocoele (intestines)
–Omentocoele (omentum)
–Cystocoele (urinary bladder)
–Littre’s hernia (Meckel’s diverticulum)
–Richter’s hernia (part of the circumference
of the bowel)

19. Inguinal hernia
• The intestine push through a weak or tear into
the lower abdominal wall
• 75% of all abdominal wall hernias
• Occurs 25% more often in men than women
• 2 type :
–i.) Indirect inguinal hernia
–ii.) Direct inguinal hernia

20. Inguinal hernia cont..
Indirect inguinal hernia
• Muscle weakness at the inguinal ring causes
failure closure of the deep inguinal ring
• When increased intra-abdominal pressure and
dilatation of inguinal ring allow abdominal
contents to enter the channel
• The protrusion passes through the deep
inguinal ring and is located lateral to the
inferior epigastric artery

21. Inguinal hernia cont..
Direct inguinal hernia
• It pass through a weak point in the fascia of
abdominal wall and at the medial to the
inferior epigastric artery

22. Inguinal hernia cont..

23. Inguinal hernia cont..
Indirect inguinal hernia Direct inguinal hernia

24. Femoral hernia
• Protrusion of abdominal contents through
femoral canal
• A plug of fats in the femoral canal enlarged
and pull the peritoneum and often the urinary
bladder into the sac
• More frequently in women because of the
wider of the female pelvis
• They are found more often in elderly and
multiparous individuals

25. Femoral hernia cont..

26. Umbilical hernia
• An umbilical hernia occurs when intestine,
fat, or fluid pushes through a weak spot in the
belly
• This causes a bulge near the belly button, or
navel
• Congenital they appear in infancy while
acquired occurs due to increased in intra-
abdominal pressure
• Common seen in obese or pregnant women

27. Umbilical hernia cont..

28. Epigastric hernia
• These are hernias through linea alba in the
epigatric region
• An epigastric hernia is present in 5% of all
abdominal wall hernias
• It is three times more common in men than in
women

29. Incisional hernia
• This is an abnormal protrusion of a viscus
through the musculo-aponeurotic layers of a
surgical scar
• Incisional hernias lie under a well-healed skin
incision

30. Incisional hernia

31. Spigelian Hernia
• Defect through transversus abdominus and
internal oblique muscles
–Occurs at junction of arcuate line and linea
semilunaris
–Covered by external oblique aponeurosis

32. Special Types of Inguinal Hernia
• Richter's hernia
–Partial enterocele
–presents with strangulation and obstruction
• Maydl's hernia
–With loop strangulation
–Strangulated bowel within abdominal cavity
• Littre's hernia
–Strangulated Meckel's diverticulum

33. Clinical features
• Hernia usually present with a
lump/bulge/swelling at an appropriate
anatomical site
• The hernia often increases in size on coughing
or straining
• It reduces in size or disappears when relaxed
or supine

34. Clinical features cont..
• If the hernia causes obstruction colicky
abdominal pain, distension and vomiting may
occur
• If strangulation occurs the lump will become
red and tender

35. Groin Hernias: Differential
Diagnosis
• Tendonitis
• Muscle tear
• Lymph node
• Lipoma
• Varicose vein
• Hydrocele
• Epididymitis
• Spermatocele

36. Investigations
• Diagnosis is usually based on clinical features
• Thorough history and Local examination of the
hernia is usually more important in diagnosing
the hernia

37. Investigations cont..
• Ultrasound may be useful incase when
physical examination is uncertain.
• Plain x is of very little value. May be useful
incase of obstructed or strangulated intestinal
obstructions.

38. Treatment
• The vast majority of hernias are repaired
electively, based on the assumption that the
risk of incarceration/strangulation is less than
the risk of repair.
• Patients presenting with prohibitive operative
risk, and those with debilitating cardiovascular,
pulmonary, or hepatic disease, are managed
with a truss

39. Treatment cont..
Conservative treatment
• TRUSS is indicated in a patient:-
–With severe general ill-health not suitable
for anaesthesia
–With chronic bronchitis not cured by
medicinal treatment
–With obstructive uropathy
–Who refuses surgery

40. Abdominal Truss in hernia

41. Treatment cont..
Surgical treatment
• Open hernial repair includes herniotomy and
herniorrhaphy
• Herniotomy involves removal of the sac and closure
of the neck
• Herniorrhaphy involves a form of reconstruction to:-
– Restore the disturbed anatomy
– Increase the strength of the abdominal wall
– Construct a barrier to recurrence

42. NOTE
• No herniorrhaphy (only Herniotomy) is done
in infancy and children since there is a NO
preformed hernia sac.
• Herniorrhaphy = Herniotomy + repair of the
posterior wall

43. Postoperative complications
• Hematoma formation
• Injury to adjacent structures
–Major vessel injury
–Bowel injury
–Bladder injury
• Wound infection
• Urinary retention
• Recurrence
• Hydrocoele
• Nerve transaction and Nerve entrapment

44. Key points
• Hernias represent fascial defects with
protrusion of a peritoneal sac or preperitoneal
fat
• Asymptomatic bulge is most common
• Hernia risk is related to visceral obstruction or
strangulation
• Tension-free repair with mesh produces lowest
recurrence rates

45. Review questions
1. What is hernia?
2. Mention risk factors of hernia?
3. Outline management of hernia?
45

46. References
• S.DAS,A Manual on clinical surgery 2011
• Bailey &Love’s short Practice of Surgery 26th
Edition
• SRB_s Manual of Surgery