An inguinal hernia occurs when abdominal contents protrude through the abdominal wall in the groin region. There are two types - direct and indirect. Direct hernias develop through the posterior wall of the inguinal canal, while indirect hernias develop through the internal ring. Treatment involves surgical repair to remove the hernia sac and reinforce the abdominal wall defect to prevent recurrence. Other types of hernias include femoral, umbilical, epigastric, and incisional hernias which develop through weaknesses in the abdominal wall.

1. HERNIAS
Presented by:
Sameh Shehata

2. References
NaJah m. N. RaSIKh

3. Definition
 A hernia is the
protrusion of an
organ through its
containing wall.

4. Composition of a hernia
1. The sac
2. The covering of
the sac
3. The content of the
sac

5. Composition of a hernia
1. 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.

6. Composition of a hernia
2. The covering:
 Coverings are derived from the layers of abdominal
wall through which the sac pass
3. Contents:
 can be
 Omentum = omentocle
 Intestine = enterocele
 Portion of circumference of intestine = Richter’s
hernia
 Portion of the bladder
 Ovary(with or without oviduct)
 Meckel’s diverteculum =Littre’s hernia

7. 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

8. Varieties
A hernia at any site may be:
1. Reducible
This is the one which the contents of the sac reduced
spontaneously or can be pushed back manually. A
reducible hernia imparts an expansile impulse on
coughing.
2. Irreducible
This one whose contents cannot be returned to the
peritoneal cavity either because there are:
 adhesions between the sac and contents, or
 because of the narrow neck of the sac.

9. Varieties
 Irreducible hernia can be :
1. 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
2. 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.
3. 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.

11. Classification
A. External hernia
B. Internal hernia

12. Classification continue…
A. External hernia
Common hernia
 inguinal
 Femoral
 Umbilical
 incisional

13. Classification continue…
A. External hernia
Rare hernia
 Spigelian
 Gluteal
 Obturator
 lumbar

14. Some other hernias
 Spigelian hernia:
 This is a hernia through the linea semilunaris at the lateral
border of the rectus sheath.
 Littre's hernia:
 A hernia that contains a Meckel's diverticulum in the sac.
 Obturator hernia:
 This hernia occurs through the obturator foramen. It is
commoner in elderly females.
 Lumbar herniae:
 These occur in the lumbar region (below the 12th rib & above
the iliac crest).

15. Classification continue…
B. Internal hernia
Diaphragmatic hernia
 Esophogial hernia
 Paraesophogial
hernia

16. Signs and Symptoms
- A lump disappears, reappears, and enlarges on
straining and discomfort.
 Physical Signs:
 Reduced.
 + ve cough impulse.
 Investigation:
Hernia is diagnosed clinically. Investigations are
rarely indicated or valuable.

17. Management
 Treatment:
hernias should be operatively repaired both to relieve
symptoms and to eliminate the complications.
 Surgical techniques:
• Herniotomy: removal of sac and closure of its
neck.
• Herniorrhaphy: involves some sort of
reconstruction to:
• Restore the anatomy if this is disturbed.
• Increase the strength of the abdomenal wall.
• Construct a barrier to recurrence.

18. Inguinal hernia
 Epidemiology:
 Male : Female
• by 9 to 1 ratio
 young adults mostly
have indirect inguinal
hernia.
 As age of patient
increases, the incidence
of direct hernias
increases .

19. Inguinal hernia
 Risk factors:
( increases intra-abdominal pressure )
 Chronic cough.
 Constipation.
 Pregnancy.
 Straining at micturation.
 Severe muscular effort (lifting heavy
objects).
 Ascites - fluid may increase the size of an
existing sac.

20. Myopectineal Orifice of Fruchaud

21. Inguinal hernia
Inguinal Canal Anatomy
 Anterior wall:
 aponeurosis of external oblique
(along entire length),
 internal oblique on lateral one
third
 Posterior:
 fascia transversalis
 conjoint tendonon in medial
one third
 Roof:
 arching fibers of internal
oblique ,and
 transversus abdominis
 Floor (inferior):
 inguinal ligament, and
 lacunar ligamen at the medial
end

22. Inguinal hernia
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.

23. Inguinal hernia
Signs & symptoms:
 Bulge that enlarges when stand or strain, but often
asymptomatic.
 In general direct hernias produce fewer symptoms
than indirect hernias and are less likely to
complicate.
 On examination:
 Palpable defect or swelling may be present .
 Indirect Hernia usually bulge at Internal InguinalInternal Inguinal
Ring.Ring.
 Direct Hernia usually bulge at External InguinalExternal Inguinal
Ring.Ring.

24. Inguinal hernia
There are two types
of inguinal hernia:
 Direct inguinal
hernia
 Indirect inguinal
hernia

25. 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.
1. Content:
1. Direct: Retroperitoneal fat. less commonly, peritoneal sac
containing bowel .
2. Indirect: Sac of peritoneum coming through internal ring,
through which omentum or bowel can enter.
2. Etiology:
• Direct: weakness of the posterior floor of the inguinal
canal (acquired).
• Indirect: patent processus vaginalis (Congenital) .

26. Differences between direct
and indirect hernias
 Boundaries of Hasselbach's
triangle:
 Medially: lateral border of
rectus abdominis.
 Laterally: inferior epigastric
vessels.
 Inferiorly: inguinal ligament.

27. Hesselbach’s Triangle

28. Inguinal hernia
 Both types (direct
and indirect inguinal
hernia) may occur at
the same time and
straddle the inferior
epigastric artery.
 This is called:
Pantaloon hernia

29. Inguinal hernia
Male inguinal hernia Female inguinal hernia

30. Indirect Inguinal hernia
Abdominal contents protrude through internal inguinal
ring

31. 31

32. Direct Inguinal Hernia

33. Inguinal hernia
 Complications:
 Irreducibility, but without signs of
obstruction or strangulation
 Small Bowel Obstruction, Usually
urgent surgical repair
 Strangulation, Surgical emergency
50% indirect, 3-10% direct.

34. Inguinal hernia
Management:
 Inguinal hernias should always be
repaired ( herniotomy, herniorrhaphy )
unless there are specific
contraindications.
 Types of operations:
1. a permanent sutures, as in Shouldice
repair (layered suture).
2. a permanent mesh -greater frequency to
decrease tension.

35. Inguinal hernia management
 Treatment of
aggravating factors
(chronic cough,
prostatic obstruction,
etc).
 Use of truss
(appliance to prevent
hernia from protruding)
when a patient refuses
operative repair or
when there are
absolute
contraindications to
operation

36. 36

37. Father of Modern Inguinal Hernia
Repair
EDUARDO BASSINI

38. 38
Herniotomy
Patent processus vaginalis ligated at
origin at internal ring (high ligation(
Nyhus type I
Children

39. 39
Bassini repair
Transversus abdominis aponeurosis +
transversalis fascia  inguinal ligament
with nonabsorbable interrupted sutures

40. 40
Shouldice repair
4rows of suture

41. 41
McVay repair
Inguinal and femoral hernias,
Transversus abdominis aponeurosis +
transversalis fascia  Cooper’s ligament
+ iliopubic tract

42. 42
Hernioplasty
High ligation, inverted sac + reinforce
defect with synthetic material
Tension-free
Lichtenstein
Recurrent rate 0.1%

43. Techniques
Suturing the mesh to the inguinal
ligament is not important.
Fixing the mesh to the rectus sheath
1-1.5cm medial and superior to the
pubic tubercle is very important.
Should have a surplus of mesh over
inguinal ligament, the medial suture
ensures surplus mesh inferiorly

44. Techniques
Coined by Liechtenstein in 1989
Central feature is polypropylene mesh
over unrepaired floor.
Gilbert repair uses a cone shaped
plug placed thru deep ring.
Slit placed in mesh for cord structures

45. Tension-Free Repair
Same initial approach as anterior
repair
Instead of sewing fascial layers
together to repair defect, a prosthetic
mesh onlay used
Simple to learn, easy to perform,
suited for local anesthesia, excellent
results with recurrence less than 4%.

48. Laparoscopic Procedures
Increasingly popular, controversial
Early in the development, hernias
were repaired by placing very large
mesh over entire inguinal region on
top of the peritoneum. Was
abandoned because of contact with
bowel.
Today, most performed TEP or TAPP

50. Laparoscopic Mesh Repair
Note:
Viewed from inside the
pelvis toward the direct
and indirect sites. A
broad portion of mesh is
stapled to span both
hernia defects. Staples
are not used in
proximity to
neurovascular
structures.

51. Laparoscopic Procedures
The argued advantage of these
procedures was less pain and
disability, faster return to work.
Great for bilateral hernia, with no
increase in morbidity.
For recurrent hernia
Disadvantages are cost, time.

52. Recurrence
Type of repair Recurrence
McVay 9%
Shouldice 7-11%
Liechtenstein 0-4%
Laparoscopic 0-1%

53. Femoral hernia
 The defect is in the
transversalis fascia
overlying the femoral ring at
the entry to the femoral
canal.
 The hernia passes through
the femoral canal and
presents in the groin, below
and lateral to the pubic
tubercle.
 It is more common in
females and carries a higher
risk of strangulation.
 Femoral canal-ant.by
inguinal ligament,post by
fascia over pectineus
muscle,lat. by femoral vein n
medial by lacunar ligament

54. Femoral hernia
Signs & symptoms:
 A lump occurs below and lateral to the
pubic tubercle. It may be reducible.
 It may not be noticed until it becomes
tender and painful.
 This type of hernia should be carefully
sought in the obese patient who
presents with signs of intestinal
obstruction without an obvious cause.
 DD’s-saphena varix,enlarged inguinal
LN,femoral artery aneurysm,rare
femoral abscess.

55. Femoral hernia

56. Femoral hernia
Surgical repair:
 An incision is made directly over the
swelling.
 The sac is opened and the contents
reduced and the sac removed.
 Femoral canal obliterated with 3
interrupted non absorbable suture.
 Treatment of strangulation or
obstruction, if present.
 There is no place for a truss in the
treatment of femoral hernia.

57. Anatomy
Inguinal ligament
(Poupart’s) – inferior edge
of external oblique
Lacunar ligament –
triangular extension of the
inguinal ligament before
its insertion upon the pubic
tubercle
conjoined tendon (5-10%)-
Internal oblique fuses with
transversus abdominis
aponeurosis
Cooper’s Ligament -
formed by the periosteum
and fascia along the
superior ramus of the
pubis.

58. Umbilical hernia
 This occurs in children
because of incomplete
closure of the umbilical
orifice.
 The majority close
spontaneously during
the first year of life.
 Surgical repair should
only be carried out if
the hernia has not
disappeared by the
age of 3 and the
fascial defect is greater
than 1.5cm in
diameter.

59. Para-Umbilical hernia
 It occurs just above or
just below the
umbilicus, and is more
common in obese
females.
 Predisposing factors
 multiple pregnancies
and
 obesity.

60. Para-Umbilical 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.
 Treatment: is by
 Contents of sac freed from it’s wall,excision of
the sac, and fascial defect repaired by
 Upper flap overlapping the lower,a two layer
overlapping repair thereby doubling the
strength of repair (Mayo repair)
 >4 cm,recurrent-polypropylene mesh

62. 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.

63. Epigastric hernia
 It may be extremely painful,
probably because of trapping and
ischaemia of extraperitoneal fat.
 Treatment
 is by enlaging the defect,excising the
fat, simple suture of the defect with
non-absorbable sutures .
>4 cm propylene mesh placed
retromuscular plane

64. Incisional hernia
 This occurs
through a defect
in the scar of a
previous
abdominal
incision.

65. 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

66. 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 .
 Treatment-palliative-abd.belt
 - preoperative measures-reduce weight,treat
cough,improve nutritional status.stop smoking.
 -surgery:excision of sac,identification n apposition,
 -large hernia-poly propylene mesh,

67. Richter’s hernia
 Part of the wall of
the intestine
becomes trapped
in the defect.
 This is usually the
antimesenteric
border of the small
bowel.
 The lumen is
intact
( no obstruction )

68. 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.
 Hiatus:
1. Sliding.
2. Para-esophegial.

69. Diaphragmatic hernia
 Sliding:
 in which the
gastroesophogeal
junction itself
slides through the
defect into the
chest.

70. Diaphragmatic hernia
 Para-esophageal
 in which the junction
remains fixed while
another portion of the
stomach moves up
through the defect.
 This can be
dangerous as they
may allow the
stomach to rotate and
obstruct.

71. Hiatus hernia