Hernia final year MBBS lecture surgery s

Definition
Definition
A hernia is a protrusion of
a viscus or part of a viscus
through an abnormal
opening in the walls of its
containing cavity .

COMPOSITION OF HERNIA

1. The sac
2. The covering of the sac
3. The content of the sac

The sac :
It is a diverticulum of peritoneum and is
made up of three parts :
 The mouth
 The neck and
The body of the sac.

 The covering:
 Coverings are derived from the layers of
abdominal wall through which the sac
pass
 Contents: can be
◦ Omentum = omentocle
◦ Intestine = enterocele

 Portion of circumference of intestine =
Richter’s hernia
 Portion of the bladder or Ovary(with or
without oviduct)
 Meckel’s diverteculum =Littre’s hernia

ETIOLOGY
ETIOLOGY
 Hernias occur at sites of weakness in the
wall  This weakness may be :
 Normal (physiological) weakness, related
to the anatomical causes.
 Congenital abnormality.
 Acquired
 Traumatic
 Diseases

PREDISPOSING FACTORS

All hernias occur at the site of
WEAKNESS OF THE ABDOMINAL
WALL which are acted on by
repeated INCREASE in abdominal
pressure

Repeated INCREASE in
Repeated INCREASE in
abdominal pressure is usually
abdominal pressure is usually
due to
due to
 Chronic cough
 Straining
 Bladder neck or urethral obstruction
 Pregnancy
 Vomiting
 Severe muscular effort
 Ascitic fluid

VARIETIES
VARIETIES
 Reducible
Reducible contents of the sac reduced
spontaneously or can be pushed back
manually. A reducible hernia imparts an
expansile impulse on coughing
Irreducible
Irreducible contents cannot be
returned to the peritoneal cavity either
because there are:
 adhesions between the sac and contents,
 because of the narrow neck of the sac.

IRREDUCIBLE HERNIAS
IRREDUCIBLE HERNIAS
Incarcerated
Incarcerated: there are adhesions
between the sac and the contents, but
there is no obstruction or interference
with blood supply. the hernia simply will
not reduce

IRREDUCIBLE HERNIAS
IRREDUCIBLE HERNIAS
 Obstructed
Obstructed: a hollow viscus is trapped
within the sac and obstruction occurs.
The blood supply remains intact. This is a
common cause of small bowel
obstruction.

IRREDUCIBLE HERNIAS
IRREDUCIBLE HERNIAS
 Strangulated
Strangulated: the arterial blood supply
to the contents of the sac is
compromised, in such a hernia unless
surgical relief is undertaken the contents
of the sac will become gangrenous.

CLASSIFICATION
CLASSIFICATION
A. External hernia
B. Internal hernia

CLASSIFICATION
CLASSIFICATION
External hernia
External hernia (Common)
Inguinal
Femoral
Umbilical
Epigastric
Incisional

CLASSIFICATION
CLASSIFICATION
 External hernia (Rare)
 Spigelian
 Gluteal
 Obturator
 Lumbar
◦ Superior
◦ Inferior

INGUINAL HERNIAS
INGUINAL HERNIAS

INGUINAL CANAL
INGUINAL CANAL
ANATOMY
ANATOMY

INGUINAL CANAL CONTENTS
Male:
Spermatic cord structures
vas deferens
testicular artery
testicular veins (pampiniform plexus)
genital branch of genitofemoral nerve
artery of the vas deference
Lymphatics
autonomic nerves
processus vaginalis
Ilio inguinal nerve
Female:  Round ligament of the uterus,  genital branch of
genitofemoral nerve,  lymphatics,  sympathetic plexus.

Female
Round ligament of the uterus
genital branch of genitofemoral nerve
Lymphatics
sympathetic plexus.

Indirect Inguinal Hernia
Indirect Inguinal Hernia
Hernia through the inguinal canal
Hernia through the inguinal canal

Direct Inguinal Hernia
The sac passes through a weakness or defect of the
transversalis fascia in the posterior wall of the inguinal
canal

Inguinal hernia
Inguinal hernia
 History:
1.Age ( young vs. old)
2.Occupation ( nature ?? )
3.Local symptoms: Swelling, discomfort and
pain
4.Systemic symptoms: if there is
obstruction or strangulation
5.Precipitating factors

Inguinal hernia
Inguinal hernia
 Examination:
1.Inspection for site, size, shape and color.
2.Palpation for surface, temp, tenderness,
composition and reducibility.
3.Expansible cough impulse.
4.General exam: for common causes of
increase intra abdominal pressure

Indirect Versus Direct inguinal
Indirect Versus Direct inguinal
hernias
hernias
 Indirect is the most common form of
hernia and its usually congenital due to
patent processus viginalis
 Direct usually acquired occur in old men
with weak abdominal muscles.

Indirect Versus Direct inguinal hernias
Indirect Inguinal Hernia Direct Inguinal Hernia
Pass through inguinal canal. Bulge from the posterior wall of the inguinal
canal
Can descend into the scrotum. Cannot descent into the scrotum.
Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.
Reduced: upward, then laterally and
backward.
Reduced: upward, then straight backward.
Controlled: after reduction by pressure over
the internal (deep) inguinal ring.
Not controlled: after reduction by pressure
over the internal (deep) inguinal ring.
The defect is not palpable (it is behind the
fibers of the external oblique muscle).
The defect may be felt in the abdominal wall
above the pubic tubercle.
After reduction: the bulge appears in the
middle of inguinal region and then flows
medially before turning down to the scrotum.
After reduction: the bulge reappears exactly
where it was before.
Common in children and young adults. Common in old age.

Note that examination using finger and
thumb across the neck of the scrotum will
help to distinguish a swelling of inguinal
origin and one that is entirely intrascrotal

Femoral Hernia
Femoral Hernia
Hernia medial to femoral vessels under
Hernia medial to femoral vessels under
inguinal ligament
inguinal ligament

Femoral Canal
Femoral Canal
The major feature of the femoral canal is the femoral sheath. This
sheath is a condensation of the deep fascia (fascia lata) of the thigh
and contains, from lateral to medial, the femoral artery, femoral
vein, and femoral canal. The femoral canal is a space medial to the
vein that allows for venous expansion and contains a lymph node
(node of Cloquet). Other features of the femoral triangle include
the femoral nerve, which lies lateral to the sheath,

Wall of The Femoral canal
anterior is the inguinal ligament
posterior is the iliopsoas, pectineal, and long adductor
muscles (floor).
Medial is lacunar ligament
Lateral is femoral vessel

Femoral hernia
Femoral hernia
Small femoral hernia may be unnoticed by
the patient or disregarded for years
perhaps until the day it strangulates.
Adherence of the greater omentum
sometimes causes a dragging pain. Rarely
a large sac is present .

Femoral hernia
Femoral hernia
History
 Age ; uncommon in children , most common
in old age female .
 Sex; women > men (but still commonest
hernia in women the inguinal hernia )
 The patient came with local symptoms
 1- discomfort and pain
 2- swelling in the groin
 General ; femoral hernia is more likely to be
strangulated than the inguinal hernia
 Multiplicity ; often bilateral

Femoral hernia versus inguinal
Femoral hernia versus inguinal
hernia
hernia
Inguinal hernia Femoral hernia
1
-
more common in male 1
-
more common in females
2
-
pass through the inguinal canal 2
-
pass through the femoral canal
3
-
neck of the sac is above and medial
the pubic tubercle
3
-
neck of the sac is below and lateral
the pubic tubercle
4
-
less common to be strangulated 4
-
more common to be strangulated
5
-
can be treated without surgery 5
-
must be treated surgically
6
-
the sac mainly contain ; bowel 6
-
the sac mainly contains ; omentum

Umbilical Hernia
Umbilical Hernia
Hernia through the umbilical ring
Hernia through the umbilical ring

Umbilical hernia
Umbilical hernia
 Signs and symptoms
 Age ; doesn’t appear until the umbilical
cord has separated and healed .
 No specific symptoms
 Have wide neck and reduce easily , rarely
give intestinal obstruction.
 Nature history ; 90 % disappear
spontaneously during the first year.

 Examination
 Inspection
 Site ; in the center of the umbilicus
 Size and shape ; size can vary from vary small to
very large . Shape is usually hemispherical.
 Palpation
 Composition ; contain bowel , which makes it
resonant to percussion . They reduce
spontaneously when the child lies down .
 Reducibility ; easy
 Cough impulse; invariably present .

Acquired umbilical hernia
Acquired umbilical hernia
 Hernia through the umbilical scar , so it is a
true umbilical hernia.
 Not common and is usually secondary to
increase intra abdominal pressure.
 The most common causes
 1- pregnancy
 2- ascitis
 3- ovarian cyst
 4- fibrodis
 5- bowel distention

Para umbilical Hernia
Para umbilical Hernia
A protrusion through the linea alba just
A protrusion through the linea alba just
above or sometimes just below the
above or sometimes just below the
umbilicus
umbilicus

PARAUMBLICAL HERNIA
PARAUMBLICAL HERNIA
 It occurs just above or just below the
umbilicus, and is more common in obese
females.
 Predisposing factors
◦ multiple pregnancies and
◦ obesity.

PARAUMBLICAL HERNIA
PARAUMBLICAL HERNIA
 The neck of the sac is usually narrow and
therefore there is a high risk of
strangulation.
 The most common content is
◦ omentum then
◦ transverse colon and
◦ small intestine

Epigastric Hernia
Epigastric Hernia
Protrusion of extraperitoneal fat through
Protrusion of extraperitoneal fat through
the linea alba anywhere between the
the linea alba anywhere between the
xiphoid process and the umbilicus
xiphoid process and the umbilicus

EPIGASTRIC HERNIA
EPIGASTRIC HERNIA
 This is usually a small protrusion through
the linea Alba in the upper part of the
abdomen
 It consists of :
◦ extraperitoneal fat only, but
◦ may contain omentum or small bowel.

EPIGASTRIC HERNIA
EPIGASTRIC HERNIA
 It may be extremely painful, probably
because of trapping and ischaemia of
extraperitoneal fat

Incisional Hernia
Incisional Hernia
Hernia through an incisional site
Hernia through an incisional site

INCISIONAL HERNIA
INCISIONAL HERNIA
 Etiology :
 Age: Wound healing is poor in the older patient.
 Obesity.
 Postoperative wound infection.
 Postoperative wound haematoma.
 Raised intra-abdominal pressure postoperatively, e.g.
coughing, straining, constipation, ileus.
 Steroid therapy.
 Type of incision: Midline vertical wounds have a higher
incidence than transverse incisions.
 Poor suturing technique: Rarely does a suture break

INCISIONAL HERNIA
INCISIONAL HERNIA
Sign & symptoms :
A swelling protrudes through the wound.
It may occur up to 5 years postoperatively.
Many are large and involve the whole incision
and consequently the neck of the sac is wide and
the risk of strangulation rare.
If the defect is small there is a greater risk of
strangulation .

Lumber Hernia
Lumber Hernia
Through the inferior lumber triangle of
Through the inferior lumber triangle of
Petit
Petit

Spigelian hernia
This is a hernia through the linea
semilunaris at the lateral border of the
rectus sheath

Obturator hernia
This hernia occurs through the obturator
foramen. It is commoner in elderly females.

OBTURATOR HERNIA
OBTURATOR HERNIA
◦ This extremely rare abdominal hernia
happens mostly in women.
◦ This hernia protrudes from the pelvic cavity
through an opening in your pelvic bone
(obturator foramen).
◦ This will not show any bulge but can act like a
bowel obstruction and cause nausea and
vomiting.

INTERNAL HERNIAS
INTERNAL HERNIAS
Diaphragmatic hernia
Traumatic:
rare and followed by
injuries to chest and
abdomen. The Lt
diaphragm is affected
more than Rt and is
accompanied by
herniation of stomach
and spleen.

DIAPHRAGMATIC HERNIAS
DIAPHRAGMATIC HERNIAS
Hiatus:
1.Sliding.
2.Para-esophegial

DIAGNOSIS
DIAGNOSIS
Mainly clinical
History
Clinical Examination
◦ Cough impulse
◦ Invagination test
◦ Ring occlusion test
◦ Zeiman’s technique
Investigations
◦ USG
◦ CT Scan
◦ MRI

INVAGINATION TEST
INVAGINATION TEST

RING OCCLUSION TEST
RING OCCLUSION TEST

ZIEMAN’S TEST
ZIEMAN’S TEST
 INDEX
◦ Indirect inguinal
 MIDDLE
◦ Direct inguinal
 RING
◦ Femoral

SYSTEMIC EXAMINATION
SYSTEMIC EXAMINATION
 Abdominal
 Chest
 Urinary
 Digital rectal examination

DIFFERENTIAL DIAGNOSIS

Inguinal Swelling Inguinoscrotal Swelling Femoral Hernia
• 1. Enlarged lymph • 1. Encysted
nodes hydrocele of cord • 1. Inguinal hernia
• 2. Undescended • 2. Varicocele • 2. Saphenavarix
testis • 3. Lymphvarix • 3. Cloquet’s node
• 3. Lipoma • 4. Diffuse lipoma of • 4. Lipoma
• 4. Femoral hernia cord • 5. Femoral aneurysm
• 5. Saphena varix • 5. Inflammatory • 6. Psoas abscess
thickening of cord
• 6. Psoas abscess
• 7. Femoral aneurysm
TONY 2010 MBBS

Management
Management
and repair
and repair

Preoperative assessment
 proper history and examination
 identify high risk patients
 prepare the preoperative notes :
 consent..
 pre op Dx
 procedure planned
 Anasthesia anticipated (general , local,
spinal)

 Investigation data ( pre operative tests ) :
1. Lab :
* CBC : to check hemoglobin level  anemia and WBCs 
infections
* U&E : to check for any electrolyte imbalance
* LFTs : indicated in jaundiced patients and suspected hepatitis
or any clotting problems
* PT & PTT
* ABG
* grouping and cross matching
2. Imaging :
* Chest X ray : for all patients
3. ECG : for any patient who is more than 40 years of age

TREATMENT
TREATMENT
Treat the precipitating cause of hernia first:
Benign prostatic hyperplasia
Tuberculosis
COPD
Constipation
Stop smoking
Conservative Treatment
Only in old patients with direct hernia
Truss
Surgery

TREATMENT
TREATMENT
SURGERY
SURGERY
Herniotomy
Hernioplasty
Herniorraphy

TREATMENT
TREATMENT
Herniotomy
Herniotomy:
Dissecting out and opening of hernia
sac,reducing any contents ,transfixing
neck of sac & removing the remainder
NO NEED TO OPEN UP CANAL IN CHILDREN BECAUSE
SUPERFICIAL AND DEEP RING ARE SUPERIMPOSED ……
THERE FORE NO NEED OF REPAIR
HENCE DONE ALONE IN CHILDREN,ADOLESCENT

OPERATIVE TREATMENT
OPERATIVE TREATMENT
Hernioplasty
Hernioplasty
Strengthening of posterior wall
Original Bassini’s
Modified Bassini’s
Mac Vay’s
Shouldice

OPERATIVE TREATMENT
OPERATIVE TREATMENT
Herniorraphy
Herniorraphy
Prosthetic repair
Lichenstien
Gilbert’s
Prolene hernia repair
Laparoscopic mesh repair
Stopas repair

 Bassini repair: inferior arch of
transversalis fascia (TF) or conjoint
tendon is approximated to shelving
portion of inguinal ligament.

 McVay: TF is sutured to cooper
ligament.

 Shouldice: TF is incised and
reapproximated.

Prolene Darning repair
Prolene Darning repair

Open tension free repair
Open tension free repair
Lichtenstein repair &Patch and Plug
technique: Mesh is used to reconstruct
inguinal floor

Laproscopic &
Laproscopic &
preperitoneal repairs
preperitoneal repairs
 TAPP (transabdominal prepeitoneal procedure): peritoneal space
entered by conventional lap at umbilicus and peritoneum
overlaying inguinal floor is dissected away as flap.
 TEP (Total extraperitoneal repair): preperitoneal space is
developed with a balloon inserted between posterior rectus
sheath and peritoneum  balloon inflated to dissect the peritoneal
flaps awau from posterior abdomianl wall and the direct and
indirect spaces, other ports inserted into this preperitoneal space
without entering peritoneal cavity.
 After lap. Dissection and reduction of hernia sac , a large piece of
mesh is placed over inguinal floor

Femoral hernia repair
Femoral hernia repair
• Femoral hernias should be repaired very soon after the
diagnosis has been made because of the high risk of
strangulation.
• There is no place for a truss for a femoral hernia.
• Different approaches :
Open VS Laparoscopic

Open surgery
Open surgery
Three approaches have been described for
open surgery :
1. Infra-inguinal approach (Lookwood)
2. Supra-inguinal approach ( McEvedy)
3. Trans-inguinal approach ( Lotheissen)

Hernia final year MBBS lecture surgery s

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