1. Inguinal hernias account for 90% of external abdominal hernias and occur when abdominal contents protrude through the groin area due to weaknesses in the abdominal wall. 2. There are two main types of inguinal hernias - indirect and direct. Indirect hernias occur lateral to the inferior epigastric artery while direct hernias occur through the posterior wall of the inguinal canal in the inguinal triangle. 3. Surgical repair is usually recommended for inguinal hernias to reinforce the abdominal wall, though a truss can be used temporarily in some cases. Common surgical techniques include ligation of the hernia sac and reinforcement of

1. ABDOMINAL WALL HERNIAS

2. 1.GENERAL CONSIDERATIONS

3. DEFINITION: A sprout and protrusion of tissue or viscus through a weakness or abnormal opening in an enclosing layer an external abdominal wall hernia is an abnormal protrusion of intra-abdominal tissue or viscus, whole or part, through an opening or defect of abdominal wall or pelvic wall

6. Inguinal hernias 90% of external abdominal hernias occur in the groin include indirect inguinal hernias and direct inguinal hernais

7. All Kinds of Hernias:

10. ETIOLOGY: Weakness of abdominal wall increased intraabdominal pressure, such as chronic cough, chronic constipation, straining on micturition due to prostatism A balloon with a protrusion

11. Clinical classification Reducible hernia : Contained viscus can be returned from the hernia to its normal domain spontaneously or with manual pressure when the patient is recumbent Irreducible hernia : Contained viscus cannot be returned from the hernia to its normal domain, usually it is due to the adhesions between the contents of hernia sac and the wall of hernia sac

12. Hernia:

13. Sliding hernia: A portion of the wall of the hernia sac is composed of an organ such as the cecum on the right side and the sigmoid colon on the left side. Occasionally, bladder is involved. The development of a sliding hernia is related to the variable degree of posterior fixation of the large bowel or other sliding organs.

14. Incarcerated hernia : If the neck of hernia is very narrow, protruded part of intraabdominal viscus in the hernia sac may be trapped by the narrow neck, and the lumen of a segment of bowel within the hernia sac, if it exists, may become obstructed. In which there is no interference with blood supply.

15. Strangulated hernia: If, in addition to incarceration, there is a compromise of the blood supply of the contained organ Gangrene of the hernia contents and the hernia sac usually occur after long time of incarceration

16. Special types of hernias Richter’s hernia: only part of circumference of the bowel becomes incarcerated or strangulated at the narrow neck of hernia. Littre’s hernia: when the incarcerated or strangulated part is a diverticulum of the small intestine, usually Meckel’s diverticulum.

17. Pathological anatomy: The external abdominal hernia consists of hernia ring, hernia sac, hernia content, and hernia covering.

18. Different parts of a hernia:

19. INGUINAL HERNIAS

20. Anatomical layers of inguinal region Skin and subcutaneous fat External oblique abdominal muscle Internal oblique abdominal muscle and transverse abdominal muscle Transvers abdominal fascia Fat out of peritoneum Peritoneum

23. Internal oblique abdominal muscle and transverse abdominal muscle: The lower arcing free edges of these two muscles fuse together to form the conjointed tendon . But this condition occurs only in 5% of persons. Thus, falx inguinalis , which forms the superior wall of the inguinal canal, refer to the lower arcing free edge of transverse abdominal muscle rather than two muscles.

24. Transvers abdominal fascia: Internal inguinal ring is a partial interruption in the transverse fascia, which is located at the halfway of the inguinal ligament and up 2 cm to it.

25. The anatomy of the groin:

29. Inguinal canal: Inguinal canal passes through the lower anterior abdominal wall from the external inguinal ring to the internal inguinal ring , which is about 4-5 cm long in the adults. In the male, the testis and the spermatic cord pass through the inguinal canal from the abdomen to the scrotum. In the female, the round ligament of the uterus passes it to the major labia.

32. The four walls of the inguinal canal Are formed by the muscular, aponeurotic, and fascial layers of the abdominal wall. The anterior wall is formed by the external oblique aponeurosis and the fibers of the internal oblique muscle.

33. The superior wall (roof of the inguinal canal) is formed by the falx inguinalis , which is the arcing free edge of the transverse abdominal muscle( or the conjointed tendon which is the arcing free edge of the fusing of the internal oblique abdominal muscle and the transverse abdominal muscle).

34. The inferior wall (floor of the inguinal canal) is formed by the inguinal ligament and the lacunas ligament . The posterior wall is formed by the transverse fascia .

35. Inguinal canal, showing arrangement of (1)external oblique muscle, (2)internal oblique muscle, (3)transversus muscle, (4)fascia transversalis.

36. (1)the external oblique abdominal muscle (2)the internal oblique abdominal (3)the transverse abdominal muscle (4)testicular veins (5)the efferent duct of the testes (6)the iliac vessels (7)the inferior epigastic artery and vein (8)the aponeurosis of the transverse abdominal muscle and the transversalis fascia (9)the public tubercle

37. Spermatic cord: When the testicle descents into the scrotum, it passes through the abdominal wall in the inguinal region. The spermatic cord passes obliquely downward through the inguinal canal from the internal inguinal ring, then it emerges through the external inguinal ring to pass into the scrotum.

38. Nerves of inguinal region: Include: iliohypogastric nerve, ilioinguinal nerve, and genitofemoral nerve. During operation: we should not damage these nerves.

39. Inguinal triangle: The inguinal triangle lies in the inferomedial inguinal region, which is an area of potential weakness and thus often the site of a direct inguinal hernia.

40. The medial border of it is the linea semilunaris (the lateral edge of the rictus sheath) The inferolateral border is the inguinal ligament The lateral border is the inferior epigastric artery

41. Pathological mechanism: The mechanism of indirect and direct inguinal hernia is different.

42. Indirect inguinal hernia: The processus vaginalis may close before birth. If that don’t happen, a persistent processus vaginalis may predispose to congenital indirect hernia during the early years of life. A weakened area of abdominal wall associated with an enlargement of the internal ring may cause an acquired indirect inguinal hernia .

43. As a result, an indirect inguinal hernia leaves the abdominal cavity at the internal ring and passes with the structures of the spermatic cord either a variable distance down the inguinal canal or all the way into the scrotum through the superficial inguinal ring directed by the spermatic cord.

44. Therefore, the neck of hernia must be located lateral to the inferior epigastric artery to enter the inguinal canal, and the sac of hernia must lie within the fibers of the cremaster muscle.

47. Direct inguinal hernia: Direct inguinal hernias are always acquired. A direct hernia protrudes through the posterior wall of the inguinal canal in the inguinal triangle , and pushes the peritoneum and transversalis fascia.

48. Normally, the posterior wall of inguinal canal in the area of the inguinal triangle is reinforced by aponeurotic fibers from the transverser abdominis and the falx inguinalis . However, this kind of reinforcement may be incomplete because the supporting extent of falx inguinalis varies among different persons. Thus, the inguinal triangle is a potential site of weakness to some people.

49. Conclusions of indirect and direct hernia: 1)The direct hernia projects through the inguinal triangle instead of the internal inguinal ring (2)Therefore, the neck of hernia passes medial to the inferior epigastric artery

50. (3)and the sac of hernia lies adjacent to(not within) the spermatic cord. So, this type of hernia is not through the external inguinal ring and is seldom enter the scrotum (4) Sliding hernia is more common in the indirect hernia than in the direct hernia..

51. (5)The risk of strangulation in indirect is more than in direct, because the indirect hernia passes through the internal inguinal ring and have a narrow neck, and the direct hernia usually protrudes through the inguinal triangle without a narrow neck.

53. Clinical manifestations: Symptoms: The most important symptom is a lump or swelling in the inguinal region which may be discovered by a routine physical examination or by the patient himself. Occasionally, the patient may have the feeling of the discomfort or slight pain.

54. Signs: The typical clinical feature is a swelling or a lump in the inguinal region, which may be reducible or irreducible with the patient supine and relaxed. When the patient is requested to strain or cough, the hernia may become apparent because of raising intraabdominal pressure.

55. Differences of two kinds of hernia Usually an indirect inguinal hernia appears as an elliptic swelling coming down the inguinal canal and frequently entering the scrotum. A direct inguinal hernia appears as a symmetric swelling at external ring. Both of them should be located superior to the inguinal ligament.

56. The physical signs of an hernia vary with the contents of the sac. For example, if a bowel enters the hernia sac, crepitaion will be noted on palpation because of the presence of gas and fluid within the lumen.

57. Methods of examination: When examining, patient should be standing in a relaxed position. The finger should be introduced through the external ring into the inguinal canal. The presence of a dilated external inguinal canal would be found.

58. When the examing finger has been advanced well into the inguinal canal and the patient is requested to cough or strain, the indirect hernia should strike the fingertip and the direct hernia should strike the ball of the finger .

59. A thumb placed over the internal inguinal ring should keep an indirect hernia reduced when the patient strains while permitting a direct hernia to appear; again, it is not always possible to locate the internal ring accurately enough to make this technique foolproof.

60. Incarcerated or strangulated hernia : They can often be seen in emergency conditions, which are common in the indirect inguinal hernia, but seldom in the direct hernia.

61. The small intestine is the organ most frequently affected, and small bowel obstruction may happen. The patient suffers the sudden onset of abdominal pain, vomiting, and distension. In that case, we should doubt the acute incarceration or strangulation of the bowel.

62. Differential diagnosis: 1. Indirect, direct, femoral hernia: They have different characters. 2. Hydrocele of the spermatic cord. 3. An undescended testis: The testis cannot be felt in the scrotum. 4. Lymphadenopathy or abscesses of the groin.

63. Hydrocele of the scrotum:

64. Principles of treatment: All inguinal hernias should be managed by operative treatment in the adult patient except that the strong contraindications exist. Emergency operation should be done when the complications of incarceration, obstruction, and strangulation in the indirect hernia happen

65. Although direct hernia seldom occurs incarceration, operation is also needed because it is difficult to distinguish indirect hernia from direct hernia. The congenital inguinal hernia may spontaneously cure, operation can be delayed until the child is more than one year old.

66. Non-operative management: The doctor can use some external support device or truss to maintain hernia reduction. The patient can take off it at night and put on it in the morning before he arises. However, this method are recommended to be appllied only in the patients with strong contraindications of surgical operation because it isn’t a effective method.

67. When an acutely incarcerated hernia occurs, manual reduction may be used. The patient is placed in hips elevated position. After applying an appropriate dose of analgesics and sedation, gentle sustained pressure over the mass may effect reduction in 30 minutes. If that effort fails or strangulation may occur, a emergency operation should be done.

68. Operative treatment: Any problems which could increase intraabdominal pressure, such as chronic cough , constipation , prostatic hyperplasia , should be solved before operation to prevent a recurrent hernia.

69. Operative treatment:

70. After hernia repair, patient may need bed rest for 2-3 days and return to everyday home activities within one week. But patient should be advised against heavy lifting and other vigorous effort for 4-8 weeks. The anesthetic may be general, spinal, or local.

71. Operative techniques: A. Simple high ligation of the sac: anatomically isolate hernia sac, ligate at the neck of hernia sac, and removal of the sac. If simple high ligation of the sac is combined with a tightening of the intemal ring, it is called the Marcy repair .

72. B.Repair of hernia: There are three steps. (a)The management of the hernia sac and its contents, that includes high ligation of the sac and excision of sac. (b)The repair of the transverse fascial defect.

73. Closing or decreasing the size of internal ring by the suture is required in the most indirect hernia. In the direct hernia, it is usually a broadbased bulge, reinforced of weakened area in inguinal triangle by the fascial repair is required.

74. (c)The repair and reinforcement of the inguinal canal wall. The first two essential steps are the same in any repair of hernia for the most patient with inguinal hernia The main difference is how to repair and reinforce the wall of the inguinal canal.

75. There are five types of repair of hernia. Bassini repair: the most widely used method, approximates and suture the lower edge of internal oblique muscle and the conjointed tendon to the inguinal ligament beneath the spermatic cord, and leaves the spermatic cord between the internal oblique muscle and the external oblique aponeurosis.

76. Bassini repair:

77. Halsted repair: places the external oblique aponeurosis beneath the cord and suture it to the inguinal ligament, and leaves the spermatic cord under the skin and subcutaneous tissue, but otherwise resembles the Bassini repair.

78. Halsted repair:

79. McVay repair: brings the lower edge of internal oblique musle and the conjointed tendon farther posteriorly and inferiorly to Cooper’s ligament, and suture them. McVay repair is more appropriate for direct hernia, big indirect hernia, and recurrent hernia, but always requires a relaxing incision to relieve tension and has technical difficulties.

80. McVay repair:

81. Shouldice repair: before Bassini repair, cut transvers abdominal fascia and suture it overlaply. This method can decrease recurrent hernia effectively.

82. Shouldice repair:

83. Ferguson repair: approximates and suture the lower edge of internal oblique muscle and the conjointed tendon to the inguinal ligament above the spermatic cord, and leaves the spermatic cord beneath the repaired anterior wall of inguinal cannal(beneath the internal oblique muscle and the external oblique aponeurosis).

84. Ferguson repair:

85. Bassini, Halsted, Mcvay, Shouldice herniorrhaphy reinforce the posterior wall of the inguinal canal, while Ferguson herniorrhaphy reinforce the anterior wall of the inguinal canal.

86. C.Hernioplasty: Sometime, especially when a large defect is present, the repair will require the use of adjacent tissues or prosthetic materias to decrease tension and prevent recurrent hernias. They include autogenous fascial grafts(anterior layer of the rectus sheath) or some kind of mash

88. Management of incarcerated or strangulated hernias: The most incarcerated hernias need emergency operation. During the operation, it is vital to inspect whether strangulation has occurred or not before reduction.

89. If operation has been done early enough and no strangulation occur, you can replace the content and carry out a routine repair. If gangrene has already developed, all gangrenous tissue must be resected and you can not do a repair.

90. Management of sliding hernia: Management of the sac is complicated when a sliding hernia is present. The failure to recognize a sliding hernia may lead to injury involved organs or their blood supply. During operation, the hernia sac is identified and opened anteriorly away from the involved organ which makes up its posterior wall.

91. The entire anterior portion of the sac is removed. Posteriorly as much sac as possible is removed without injuring the sliding organ. Then the involved organ is reduced into its original position and the defect in peritoneum is closed. Finally, a routine repair can be carried out.

92. FEMORAL HERNIA

93. A femoral hernia protrudes through the femoral ring beneath the inguinal ligament, which is common in women. Because it has a narrow neck, it is easy to incarceration and strangulation.

94. Anatomy: The lateral border of the femoral ring is the femoral vein The anterior border is the inguinal ligament The medial border is the lacunar ligament The posterior border is the perineal ligament(Cooper's ligament) The femoral ring extend inferiorly to form the femoral canal.

95. Pathological mechanism: Mainly due to the defect in the transverse fascia in the direct triangle. A peritoneal sac passes under the inguinal ligament(the femoral ring) into the femoral canal. The inguinal ligament is a tight band and beneath it the femoral vessels enter the thigh.

96. Medial to the femoral vein is a small empty space through which a femoral hernia may project with a very narrow neck. The contents of the hernia easily occur incarceration and strangulation.

98. Clinical manifestations: Symptoms: Normally asymptomatic until incarceration or strangulation occurs. Even with obstruction or strangulation, the patient may feel discomfort more in the abdomen than in the femoral area. Signs: A small bulge in the upper medial thigh just below the level of the inguinal ligament.

99. Differential diagnosis: Inguinal hernia: A saphenous varix: without comfortable Lipoma: Abscess:

101. Treatment: Because of the high incidence of incarceration and strangulation, all femoral hernias should be managed by operative treatment. If incarceration of femoral hernia has occurred, manuall reduction is forbidden and emergency operation is indicated.

102. The principles of operation: complete excision of the hernia sac, repair and reinforcement of the defect in the transversalis fascia, closure of the femoral canal. McVay is the common repairing method.

103. OTHER TYPES OF ABDOMINAL WALL HERNIAS

104. Incisional hernia Develop in an old operative incision. The incisional wound infection is the most important factor. Age, obesity, other diseases, poor surgical technique are other causes. The principle of management is early operative repair.

105. Umbilical hernia: Umbilicus is a weakened area in the abdominal wall due to the exist of the umbilical cord of embryo. Congenital umbilical hernia is common in infants. But most of these infants spontaneous close the fascial defect within the first two years of life.

106. The principle of treatment: using some external support device when child is less than six months; and the operative repair should be delayed until two years old. Umbilical hernia in adults can be seen in women with multiple pregnancies, obesity, or patients with severe ascites.

107. Epigastric hernia: Also called the hernia linea alba , usually occur above the level of the umbilicus. An area of congenital weakness in the linea alba with increased intraabdominal pressure is the cause of this type of hernia. More common in men than in women. A small epigastric hernia without significant clinical symptoms does not need surgical repair.

108. CONCLUSION 1. Definition: Hernia means a sprout and protrusion of tissue or viscus through a weakness or abnormal opening in an enclosing layer.

109. 2. Causes of hernia: (1)Weakness of abdominal wall. (2)increased intraabdominal pressure.

110. 3. Clinical classification: (1)Reducible hernia. (2)Irreducible hernia. (3)Sliding hernia. (4)Incarcerated and strangulated hernia.

111. 4. The external abdominal hernia consists of hernia ring, hernia sac, hernia content, and hernia covering.

112. 5. The structure of the inguinal canal: The inguinal canal passes through the lower anterior abdominal wall from the external inguinal ring to the internal inguinal ring. In the male, the spermatic cord passes through the inguinal canal . In the female, the round ligament of the uterus passes through it.

113. The anterior wall is formed by the external oblique aponeurosis and the fibers of the internal oblique muscle. The superior wall is formed by the falx inguinalis, which is the arcing free edge of the transverse abdominal muscle(or the conjointed tendon which is the arcing free edge of the fusing of the internal oblique abdominal muscle and the transverse abdominal muscle).

114. The inferior wall is formed by the inguinal ligament and the lacunas ligament. The posterior wall is formed by the transverse fascia.

115. 6. The structure of the inguinal triangle: The medial border of it is the linea semilunaris(the lateral edge of the rictus sheath) The inferolateral border is the inguinal ligament The lateral border is the inferior epigastric artery.

116. 7. The differences between the indirect and the direct inguinal hernia:

117. 8. The methods of repairing the inguinal canal wall. Bassini repair Halsted repair McVay repair Shouldice repair Fergusion repair

118. 9. The structure of the femoral ring: The lateral border of the femoral ring is the femoral vein The anterior border is the inguinal ligament The medial border is the lacunar ligament The posterior border is the perineal ligament(Cooper's ligament)