2. HERNIAS
DEFINITION: A hernia is an abnormal protrusion of a viscus or part
of a viscus through a defect or a weakness either in the containing
wall of that viscus or within the cavity in which the viscus normally
is situated. Hernias are either external or internal.
3. External hernias
External hernias are common and present as an abnormal
lump which can be detected by clinical examination of the
abdomen or groin.
Internal hernias
Internal hernias are rare, and occur when the intestine (the
‘viscus’) passes beneath a constricting band or through a
peritoneal window (the ‘defect’) within the abdominal
cavity or in the diaphragm. They present as:
Acute intestinal obstruction, with or without intestinal
ischaemia, perforation and peritonitis, or Chronic recurrent
abdominal pain and vomiting due to incomplete and
intermittent intestinal obstruction.
4. Sites of internal herniation
Sites of internal herniation include:
• (i) the paraduodenal and paracaecal fossae
• (ii) the lesser sac through the epiploic foramen (foramen of
Winslow) or a defect in the transverse mesocolon
• (iii) beneath congenital bands or adhesions
• (iv) through defects in the small bowel mesentery
• (v) between the lateral abdominal walls and intestinal
stomas
• (vi) through defects in the diaphragm
5. Components of a hernia
Hernias are composed of a sac, the parts of which are
described as the neck, body and fundus and the hernial
contents. The sac consists of peritoneum which
protrudes through the abdominal wall defect or ‘hernial
orifice’, and envelopes the hernial contents. The neck of
the sac is situated at the defect. Hernias with a narrow or
rigid neck are more likely to obstruct and strangulate .
The body is the widest part of the hernial sac, and the
fundus is the apex or furthest extremity. Viscera most
likely to enter a hernial sac are those normally situated in
the region of the defect and
those which are mobile, namely the omentum, small
intestine and colon.
6.
7. TYPES OF HERNIA
Inguinal hernia:
Inguinal hernia is the
commonest hernia, and is
approximately 10 times
more common in males
than females. Two types
of inguinal hernia(IH) are
indirect inguinal (IIH) and
direct inguinal (DIH), but
they can occur together.
10. Importance of the integrity of the inguinal
canal
The inguinal canal passes through the abdominal
wall between the deep (internal) and superficial
(external) inguinal rings. It carries the spermatic
cord to the scrotum in the male, or the round
ligament of the uterus to the labium majora in the
female, together with the ilioinguinal nerve. The
canal is a site of weakness and therefore potential
herniation.
11. Indirect inguinal hernia
Indirect inguinal hernia
passes through the
internal ring and
traverses the inguinal
canal.
It may extend into the
scrotum (complete
hernia)
12. Indirect inguinal hernia……
It occurs as a result of congenitally patent processus vaginalis.
First clinical evidence may appear at
- Childhood
- Middle or old age
When incompletely obliterated
- Indirect inguinal hernia
- Communicating hydrocele
- Spermatic cord hydrocele
- Hydrocele of testis
Most common type of hernia in both men and women
5 to 10 times more common in men than women
More common on the right
- 60% right
- 30% left
- 10% bilateral
13. A pediatric inguinal hernia is almost always indirect
Potential indirect hernias
- Undescended testis
- Testis in the inguinal canal
- Testicular or spermatic cord hydrocele
It occurs in the floor of the inguinal canal because of an
acquired weakness in fascia traversalis.
The incidence therefore increases with age, and it is often
bilateral.
The abdominal structures protrude through the
Hesselbach’s triangle into the posterior wall of the inguinal
14. Direct Hernia
The hernia rarely descends into the
scrotum.
The neck of the direct hernia is wide, so it
is less often associated with strangulation.
Direct hernias are seen almost exclusively
in male patients
16. Femoral hernia
A femoral hernia occurs when the transversalis fascia
which normally covers the femoral ring is disrupted, so
that a peritoneal sac and hernial contents pass
through
the femoral ring into the femoral canal. The femoral
canal is the most medial compartment of the femoral
sheath, medial to the femoral vein. Femoral hernias are
2–3 times more common in females than males, and
occur in the older age group, often after a period of
weight loss. Femoral hernias are never congenital, and
are twice as common in parous as in non-parous
females.
17. Femoral Hernia cont.
The hernia content passes beneath the
inguinal ligament tranverses the femoral canal
seen as mass at the level of foramen ovale
Incarceration and Strangulation are frequent
(30-40%).
More common in women (1/3 of all groin
hernias) than in men (2% of all groin hernias).
However, Inguinal hernia is more frequent
both in men and in women than femoral hernia.
femoral hernias are related to physical
exertion and to pregnancy.
18.
19.
20. Umbilical Hernia
Umbilical hernias occur at the umbilicus.
10 times more often in women than in men.
The defect is common in children but is
usually (95%) obliterated spontaneously.
In adult, umbilical hernias are often
associated with increased intra-abdominal
pressure (ascites, pregnancy, obesity, large
intra-abdominal tumour).
21.
22. Epigastria Hernia
It develops through a defect in the linea alba
above the umbilicus.
About 20% of epigastric hernias are multiple
23. Incisional Hernia
Results from poor wound healing in a previous
surgical incision.
90% are seen during the first 3 years.
Common etiologic factors:
- poor surgical techniques
- wound infection
- wound hematoma
- advanced age
- malnutrition
- increased postoperative abdominal pressure
(ileus, ascites, pulmonary complication)
26. Richter’s hernia
Only part of the
circumference of the bowel
(usually the anti mesenteric
border) is trapped within the
hernial sac. The herniated
part may become ischaemic.
Because the lumen of the
bowel is not occluded,
intestinal obstruction does
not occur, and there are few
symptoms until the ischaemic
part perforates.
27. Littre’s hernia: A Meckel’s diverticulum lies within
the hernial sac.Littre’s hernia occurs most commonly in a
femoral or´inguinal hernia
Maydl’s hernia
The hernial sac contains two loops of intestine. The loop
of intestine within the abdominal cavity may become
obstructed or strangulated, and this may not be
recognised unless the hernial contents are inspected and
returned to the abdominal cavity (‘reduced’) completely
30. Etiology
Congenital: Associated with a developmental
disorder, such as:
persistent processus vaginalis (infantile inguinal
hernia) or failure of complete obliteration of umbilical
opening (infantile umbilical hernia).
Acquired: Weakness of the abdominal wall due to:
- ageing or previous surgery.
- increase intra-abdominal pressure, such as heavy
lifting, chronic cough, straining on urination or
defecation, abdominal distension, ascites, pregnancy.
31. Predisposing factors
A hernia occurs because of:
(a) weakness or defect in the abdominal wall
(b) positive intra-abdominal pressure (IAP) (which is often
raised) forces the viscus into the defect.
Causes of sudden or sustained increases in intra-
abdominal pressure include
• Coughing
• Vomiting
• Straining during urination or defecation
• Pregnancy and childbirth
• Occupational heavy lifting or straining, and strenuous activity
• muscular exercise
• Obesity
• Ascites
• Continuous ambulatory peritoneal dialysis (CAPD)
• Gross organomegaly
32. Complications
Most hernias are uncomplicated at presentation. The three
important complications of hernias are in order of
progression, irreducibility, obstruction and strangulation.
Irreducibility
A hernia is ‘irreducible’ when the sac cannot be emptied
completely of contents. Irreducibility is caused by:
i. adhesions between the sac and its contents
ii. fibrosis leading to narrowing at the neck of the sac, or
a sudden increase in IAP that causes transient stretching of
the neck and forceful movement into the sac of contents,
which cannot subsequently return to their original location.
Generally, irreducible hernias should be operated on soon
after presentation. Although irreducibility is not an
indication for urgent operation, it is the step before
obstruction supervenes. In addition irreducible hernias are
usually painful.
33. Obstruction
A hernia becomes obstructed when the neck is
sufficiently narrow to occlude the lumen of the
intestine contained within the sac. Obstructed hernias
are nearly always irreducible and, if not treated, may
become strangulated. Often, there is a history of a
sudden increase in IAP that has pushed intestine or
other contents into the sac. The patient presents with
symptoms and signs of intestinal obstruction
(abdominal colic, vomiting, constipation, abdominal
distension) together with a tender irreducible hernia.
Failure to examine the hernial orifices in a patient with
intestinal obstruction may lead to the wrong operative
approach being undertaken. It may be difficult to
distinguish obstruction from strangulation on clinical
grounds, and therefore obstructed hernias should be
treated as a matter of urgency.
34. Strangulation
Strangulation means that the blood supply of the
contents has ceased due to compression at the hernial
orifice. Initially, lymphatic and venous channels are
obstructed, leading to oedema and venous congestion
but with continued arterial inflow. When the tissue
pressure equals arterial pressure, arterial flow ceases
and tissue necrosis ensues. Strangulation is a serious
complication and, if the intestine is involved, leads to
peritonitis which can be fatal. A strangulated hernia is
both irreducible and obstructed, and is very tense and
usually exquisitely tender. Erythema of the overlying skin
is a late sign. Strangulated hernias must be operated on
urgently. A strangulated Richter’s hernia is not preceded
by intestinal obstruction and there maybe few local signs.
35. Diagnosis
History:
Some patients may describe a sudden pain and bulging while
lifting, coughing or straining (physical activities).
The mass may be continuously or intermittently present
In general, direct hernias produce fewer symptoms than indirect
inguinal hernias less likely to become incarcerated or
strangulated.
Physical Examination:
A mass may be
- visible
- tender
- reducible
- bowel sounds may be audible.
36. Tests
Positive cough test
Internal and external ring test
Three finger test / Z-Man test
Radiography:
Plain films
Ultrasound scan
CT scan
MRI
37. Treatment
Ideally, all hernias should be treated surgically.
Because of the risk of incarceration, strangulation and
obstruction are greater than the risk of elective operation.
The principles of repair:
Preparation of hernial sac
Opening the sac (herniotomy)
Return of hernia contents into the peritoneal cavity
Excision or reduction (invagination) of the hernial sac
Repair or the hernial defect
- Tissues approximation
(Bassini, Halsted)
- Prosthetic reinforcement
. Open
. Laparoscopic
38.
39. HERNIAS IN CHILDHOOD
The two most common types of hernias in children are:
An umbilical hernia which usually appears a few weeks
after birth. It usually occurs after the umbilical cord has
fallen off. In general, it goes away before two years of age
without treatment. It also occurs when a part of the
intestine sticks through the abdominal wall through the
navel.
An inguinal hernia occurs when part of the intestine pushes
through the abdominal wall in or around the groin. Inguinal
hernias occur in up to five out of 100 babies.
40.
41. Causes of hernia
UMBILICAL HERNIA
The navel has very little muscle beneath the skin. It is a
weak area. When a baby cries or pushes out their belly, the
pressure sometimes pushes part of an organ or tissue
through the navel.
INGUINAL HERNIA
Baby boys are more likely to have this type of hernia. The
inguinal canal is the passage through which the testes
descend into the scrotum. Normally, this canal closes
shortly after birth. If it does not close completely, it leaves a
hole through which a loop of the intestine can pass into the
groin or scrotum. This creates a bulge under the skin.
42. Signs and symptoms
Umbilical
a soft swelling around the navel
the swelling may appear later in the day
the swelling gets bigger if your child coughs, cries,
sneezes or stiffens their abdominal muscles
Inguinal hernia
a soft swelling above the groin or in the scrotum
the swelling may appear later in the day
the swelling gets bigger if your child cries, coughs,
sneezes or stiffens their abdominal muscles
43. Complications
If a loop of intestine or another organ or tissue becomes
trapped in its hole, its blood supply can become blocked. This
is called a strangulated hernia. When this occurs, the area
becomes discoloured and painful. Your child may vomit. If this
happens, take your child to the doctor immediately, or go to
the nearest Emergency Department right away.
Treatment
Umbilical hernia:
Most children do not need surgery for an umbilical hernia.
Surgery may be required if it is very large or not going away. If
surgery is needed, it is a minor operation. During surgery, the
intestine is put back in place. The abdominal wall muscles are
stitched up. The surgery is usually done after the age of three
years. It is rare for an umbilical hernia to become strangulated
44. Inguinal hernia
All children with inguinal hernia need surgery, because the
hernia may become strangulated. Usually, the operation
will be booked ahead of time. However, if the hernia is
painful, your child may need emergency surgery.
During surgery, the small intestine, or other organ or tissue,
is pushed back into place. The surgeon repairs the hole or
space that is causing the hernia. The surgeon may check
the other side of the groin for another hernia or weakness.
In general, your child can return home the day of the
surgery. They can be active in a few days.
Give antibiotics and analgesics
45. TESTICULAR TORSION
This is twisting of the testis with interference to the
arterial blood supply. The actual torsion is usually of
the spermatic cord. Each testicle is attached to the
spermatic cord and scrotum. Testicular torsion happens
if the testicle rotates on the cord that runs upwards
from the testicle into the abdomen. The rotation twists
the spermatic cord and reduces blood flow. If the
testicle rotates several times, blood flow can be
entirely blocked, causing damage more quickly. It
occurs in a congenitally abnormal situation. It is
associated with imperfectly descended testis, or high
investment of the tunica vaginalis with a horizontal lie
of the testis; or when the epididymis and testis are
separated by a mesorchium, in which case the twist
occurs at the mesorchium.
46.
47.
48. ETIOLOGY/CAUSE
Testicular torsion can happen at any time, while
standing, sleeping, exercising or sitting and with no
apparent trigger in those who are susceptible.
Sometime it is prompted by an injury or because of
rapid growth during puberty.
Testicular torsion often occurs several hours after
vigorous activity, after a minor injury to the testicles
or
due to cold temperature.
Testicular torsion is most common between ages
12 and 18, but it can occur at any age, even before
birth.
49. Symptoms and signs
Sudden onset of severe pain in the scrotum
and groin and radiating to the lower abdomen
associated with nausea and vomiting.
May follow strain, lifting, exercise or
masturbation.
The testis will be swollen and painful, it will be
drawn up to the groin. Difficult to differentiate
from epididymo-orchitis.
In the latter, there is usually a fever, leukocytosis
and the testis is not drawn up to the groin.
Young boys who have testicular torsion typically
wake up due to scrotal pain in the middle of the
night or early in the morning.
50. Risk factors
Age: Testicular torsion is most common
between ages 12 and 18.
Previous testicular torsion: If you've had
testicular pain that went away without
treatment (intermittent torsion and
detorsion), it's likely to occur again. The more
frequent the bouts of pain, the higher the risk
of testicular damage.
Family history of testicular torsion: The
condition can run in families.
51. Complications
Testicular torsion can cause the following
complications:
Damage to or death of the testicle: When
testicular torsion is not treated for several
hours, blocked blood flow can cause permanent
damage to the testicle. If the testicle is badly
damaged, it has to be surgically removed.
Inability to father children: In some cases,
damage or loss of a testicle affects a man's
ability to father children
53. Prevention
Illustration of penis before and during
testicular torsion.
Having testicles that can rotate in the scrotum
is a trait inherited by some males. If you have
this trait, the only way to prevent testicular
torsion is surgery to attach both testicles to
the inside of the scrotum.
54. Treatment
Bed rest. Scrotal support. Surgical exploration may
be required to evacuate the haematocele and
repair a split in the tunica albuginea. If swelling and
irregularity of the testis persists after allowing
adequate time for recovery, suspect a testicular
tumour and institute appropriate investigations.
Unsuspected pre-existing testicular tumours may
be unmasked following trauma.
55. Pyloric Stenosis
Pyloric stenosis also called gastric outlet obstruction is an
uncommon condition in infants that affects babies
between birth and 6 months of age by blocking food
from entering the small intestine causing forceful
vomiting that can lead to dehydration.
It is the second most common problem requiring
surgery in newborns.
Normally, a muscular valve (pylorus) which is the lower
portion of the stomach that connects to the small
intestine holds food in the stomach until it is ready for
the next stage in the digestive process. In pyloric
stenosis, the pylorus muscles thicken and become
abnormally large, narrowing the opening of the pylorus
and eventually preventing or blocking food from moving
from the stomach to the intestine.
56.
57. Causes
The causes of pyloric stenosis are unknown,
but genetic and environmental factors might
play a role. Pyloric stenosis usually isn't
present at birth and probably develops
afterward.
58. Signs and symptoms
Signs of pyloric stenosis usually appear within three to five weeks after birth.
Pyloric stenosis is rare in babies older than 3 months.
Signs include:
Vomiting after feeding: The baby may vomit forcefully, ejecting breast
milk or formula up to several feet away (projectile vomiting). Vomiting might be
mild at first and gradually become more severe as the pylorus opening narrows.
The vomit may sometimes contain blood.
Persistent hunger: Babies who have pyloric stenosis often want to eat
soon after vomiting.
Stomach contractions: You may notice wave-like contractions (peristalsis)
that ripple across your baby's upper abdomen soon after feeding but before
vomiting. This is caused by stomach muscles trying to force food through the
narrowed pylorus.
Dehydration:Your baby might cry without tears or become lethargic. You
might find yourself changing fewer wet diapers or diapers that aren't as wet as you
expect.
Changes in bowel movements: Since pyloric stenosis prevents
food from reaching the intestines, babies with this condition might be constipated.
Weight problems: Pyloric stenosis can keep a baby from gaining weight,
and sometimes can cause weight loss.
59. Complications
Pyloric stenosis can lead to:
Failure to grow and develop.
Dehydration: Frequent vomiting can cause
dehydration and a mineral (electrolyte) imbalance.
Electrolytes help regulate many vital functions.
Stomach irritation: Repeated vomiting can irritate
your baby's stomach and may cause mild bleeding.
Jaundice: Rarely, a substance secreted by the liver
(bilirubin) can build up, causing a yellowish
discoloration of the skin and eyes.
60. Risk factors
Risk factors for pyloric stenosis include:
Sex: Pyloric stenosis is seen more often in boys — especially
firstborn children — than in girls.
Race: Pyloric stenosis is more common in whites of northern
European ancestry, less common in African-Americans and rare
in Asians.
Premature birth: Pyloric stenosis is more common in
babies born prematurely than in full-term babies.
Family history: Studies found higher rates of this
disorder among certain families. Pyloric stenosis develops in
about 20 percent of male descendants and 10 percent of female
descendants of mothers who had the condition.
Smoking during pregnancy: This behavior can
nearly double the risk of pyloric stenosis.
61. Rick factors cont.
Early antibiotic use: Babies given certain
antibiotics in the first weeks of life — erythromycin to treat
whooping cough, for example — have an increased risk of
pyloric stenosis. In addition, babies born to mothers who
took certain antibiotics in late pregnancy may have an
increased risk of pyloric stenosis.
Bottle-feeding: Some studies suggest that bottle-
feeding rather than breast-feeding can increase the risk of
pyloric stenosis. Most of the people who participated in
these studies used formula rather than breast milk, so it
isn't clear whether the increased risk is related to formula
or the mechanism of bottle-feeding.
62. Treatment
Pyloric stenosis can be fixed with surgery.
Surgery: Pyloromyotomy and Laparoscopic
surgery.
Supportive care: Electrolyte repletion and IV
fluids.
Specialists: Paediatric surgeon, Paediatrician,
and Gastroenterologist.
