2. Objectives
• Anatomy of abdominal wall and their hernias
• Ventral hernias types and their presentation ,clinical features , risk
factors, differential diagnosis
• Anatomy of groin and their hernias
• Groin hernias types and their presentation ,clinical features , risk
factors, differential diagnosis
• Clinical presentation of hernias
• Baseline Management
3. What is hernia ?
a protrusion, bulge, or projection of an organ or part of an organ
through the body wall that normally contains it
CLASSIFICATION
They classified based on location and etiology
5. • Ventral hernia – Ventral hernias occur anteriorly and include primary
ventral hernias (epigastric, umbilical, Spigelian), parastomal hernias,
and most incisional hernias (ventral incisional hernias).
• Groin hernia – The groin is the region at the lower margin of the
abdomen where the thigh meets the hip. Groin hernias are
subclassified into inguinal and femoral hernias
• Pelvic hernia – Pelvic hernias protrude through one of the pelvic
foramina (sciatic and obturator hernia) or the pelvic floor (perineal
hernias).
• Flank hernia – Flank hernias protrude through weakened areas of
back musculature and include the superior and inferior lumbar
triangle hernias
6.
7.
8. Abdominal wall hernias can also be classified by etiology:
• Congenital hernia : congenital abdominal wall defects ,the most
common are omphalocele and gastroschisis.
• Acquired hernia: primary hernias and incisional hernias
9. ANATOMY
The abdominal wall is comprised of a complex fusion of overlapping
layers of muscles and connective tissues that contain and protect the
intra-abdominal organs while facilitating movement and breathing
Layers of abdominal wall:
1-SKIN AND SUBCUTANEOUS TISSUE
2-MUSCLES(rectus abdominis, ext. and int. oblique ,transversus
abdominis, pyramidalis)
3-FASCIA(rectus sheath , transversalis fascia ,linea alba)
10.
11.
12. Blood supply of abdominal wall
Deep arteries
Epigastric arteries (inferior and superior)
Deep circumflex iliac arteries
Musculophrenic arteries
Superficial arteries
consists of branches of the femoral artery, including the superficial
epigastric (or superficial inferior epigastric), superficial external
pudendal, and superficial circumflex arteries.
17. Epigastric hernia
• Pathogenesis: congenitally
weakened linea alba
,forceful diaphragmatic
contraction
,perforation of the linea alba
by vascular lacunae
• Risk factors: extensive training
or coughing, obesity
smoking, chronic steroid use
diabetes , old age
and male gender
18. • Asymptomatic, but most patients present because of a small, slightly
uncomfortable lump between the umbilicus and the xiphoid. The
defects are often no more than 1 cm in diameter .Up to 20 percent of
epigastric hernias are multiple. Bowel incarceration or strangulation is
rare.
• Repair of an epigastric hernia is reserved for symptomatic patients For
open repair, a small midline or transverse incision is made overlying
the hernia. The hernia contents are either reduced or resected, and
the defect is closed with interrupted sutures or mesh.
19. Umbilical hernia
• Found in 23 to 50 percent of
individuals screened by
physical exam or ultrasound
• More commonly in females
than in males with a 3:1 ratio.
In men, umbilical hernias most
often present incarcerated,
whereas females, particularly
those close to their ideal body
weight, are more likely to have
an easily reducible mass
20. • Umbilical hernia can usually be
diagnosed with palpation of a
soft mass either at, slightly
above, slightly below, or to one
side or another of the
umbilicus. Larger umbilical
hernias may be associated with
skin erythema, ulceration, or
ischemia.
• Recurrence rates range from 0
to 3 percent after a mesh repair
to up to 14 percent after a
sutured repair
21. Incisional hernia
• 10 to 15 percent of patients
with a prior abdominal incision
• Midline incisions have the
highest incidences of incisional
hernias (3 to 20 percent)
• Risk factors: old age, obesity,
smoking, malnutrition,
immunosuppressive therapy,
and connective tissue
disorders, also infection,
tension, technique.
22. • Incisional hernias typically develop
in the early postoperative period
• Presentation: bulge in the
abdominal wall at the site of a
prior incision with varying degrees
of discomfort and/or be a
cosmetic concern only, aggravated
by coughing or straining with a
protrusion of the abdominal wall
at the site of a previous incision.
• Diagnostic imaging : CT and
ultrasound
23. Spigelian hernia
• Occurs through a defect in the Spigelian
aponeurosis, which is the aponeurosis of
the transverse abdominal muscle bounded
by the linea semilunaris laterally and the
lateral edge of the rectus muscle medially.
• Preperitoneal fat emerges through the
defect, bringing an extension of the
peritoneum with it through the Spigelian
fascia.
• Surgical repair is generally recommended
once a Spigelian hernia is diagnosed.
24. • The patient most often
presents with a swelling
in the mid to lower
abdomen, just lateral to
the rectus muscle. The
patient may also
complain of a sharp pain
or tenderness at this site.
Suspected Spigelian
hernias .
• Diagnosis: (CT) or
ultrasound
25. The optimal method of ventral hernia repair
would
• Prevent hernia recurrence
• Have a low rate of surgical site infection
• Provide dynamic muscle support
• Provide a repair with physiologic tension
• Prevent eventration or abdominal wall bulging
• Incorporate the abdominal wall
26.
27.
28. Recurrence rate of ventral hernias
• Recurrence rate of primary ventral hernia repair is 5 to 10 percent at
two years.
• The recurrence rate of ventral incisional hernias can be as high as 25
to 43 percent at three years.
32. Inguinal canal
• The inguinal canal is a slit-like space in
between the muscles of the anterior
abdominal wall, above the medial half
of the inguinal ligament.
• The deep inguinal ring is a defect in the
transversalis fascia about 1cm above
the midpoint of the inguinal ligament.
• The superficial inguinal ring, which is
above and medial to the pubic tubercle,
is a defect in the external oblique
aponeurosis.
34. Contents of inguinal canal
• Vas deferens
• 3 arteries ( testicular artery , artery
to vas deferens from inferior
vesical , cremasteric artery)
• 3 nerves ( genital branch of
genitofemoral , ilioinguinal and
sympathetic)
• lymphatics drain to para-aortic
• Pampiniform venous plexus
• Processus vaginalis
35. Hasselbalch triangle
• The inguinal triangle is located
within the inferomedial aspect of
the abdominal wall. It has the
following boundaries:
• Medial – lateral border of the
rectus abdominis muscle.
• Lateral – inferior epigastric
vessels.
• Inferior – inguinal ligament.
37. Differential diagnosis of lump in groin
• Inguinal hernia
• Femoral hernia
• Enlarged LN
• Saphena varix
• Ectopic testis
• Femoral aneurysms
• Hydrocele of the cord or canal of nuck
• Lipoma
• Psoas bursa or abscess
38. Groin hernias
• Groin hernias are classified anatomically as inguinal (indirect or
direct) or femoral
• Approximately 96 percent of groin hernias are inguinal and 4 percent
are femoral
• Indirect inguinal hernia is the most common groin hernia in both
sexes
• Direct inguinal hernia accounts for 30 to 40 percent of groin hernias
in men .but approximately 14 to 21 percent of groin hernias in
women
39. • Femoral hernias account for <10 percent of all groin hernias and only
2 to 4 percent of all groin hernia repairs . Femoral hernias represent
20 to 31 percent of repairs in women compared with only 1 percent
in men. Femoral hernias occur later in life than inguinal hernias. Over
the age of 70, femoral hernias represent 52 percent of repairs in
women and 7 percent of repairs in men.
40. Risk factors:
• History of hernia or prior hernia repair (including childhood)
• Older age
• Male sex
• Caucasian race
• Chronic cough
• Chronic constipation
• Abdominal wall injury
• Smoking
• Family history of hernia
41. • A common symptom associated with hernia is a heaviness or dull
discomfort in the groin, which may or may not be associated with a
visible bulge. Groin hernias in women can also result in vague pelvic
discomfort. Moderate-to-severe pain with hernias is unusual and,
when present, should raise the possibility of incarceration or
strangulation.
• Women are more likely to present emergently due to a higher
incidence of femoral hernias, which are more likely to strangulate
• Two thirds of groin hernias are located on the right side
42. • Male patients – Many groin hernias in men are obvious on physical
examination.
• Female patients – Groin hernias in women often do not have a visible
bulge. the layers of the abdominal wall absorb the hernia impulse,
making the external ring difficult to locate. Ultrasound or diagnostic
laparoscopy may be needed to detect hernias in women.
• Although the data are limited, one study reported a sensitivity of 75
percent and specificity of 96 percent for a diagnosis of inguinal hernia
on physical exam by surgeons
43. • Indirect hernia – the abdominal
contents herniation occurs
through the deep ring into the
inguinal canal.
• Comes out through the superficial
ring.
• It may extend into the scrotum.
• Depending upon extent it may be
complete or incomplete.
44.
45. • Direct hernia – contents herniate
directly through the posterior wall of
the inguinal canal through the
Hesselbach’s triangle
It is a weakness in posterior wall of
the inguinal canal
• Femoral herniae are
relatively uncommon but are are an
important problem due to their high
rate of strangulation
• Femoral hernia occur when abdominal
viscera or omentum passes through
the femoral ring and into the potential
space of the femoral canal.
46.
47. Clinical presentations of hernia
• Reducible –contents can be returned into the abdominal cavity.
• Irreducible – contents cannot be returned into the abdominal
cavity.
• Obstructed – irreducibilty + intestinal obstruction, but the blood
supply is not impaired.
• Strangulated- irreducibilty + intestinal obstruction+ arrest of the
blood supply.
• Inflammed- rare condition. Occurs when contents eg.
Appendix,meckel’s diverticulum is inflamed
53. Recurrence rate of groin hernias
• Recurrence rates for primary hernia repair range from 0.5 to 15
percent depending upon the hernia site (direct, indirect, femoral),
type of repair (mesh, no mesh, open, laparoscopic), and clinical
circumstances (elective, emergent)
• Hernia recurrence is less common with repair of inguinal compared
with femoral hernia repair due to the higher rates of emergency
surgery and complications associated with femoral hernia
Rectus abdominis — The rectus abdominis consists of a pair of strap muscles that extend the length of the anterior abdominal wall and are separated by the linea alba . These muscles arise from the symphysis pubis and the pubic crest with insertion into the fifth, sixth, and seventh costal cartilages and the xiphoid process. The rectus sheath has variable contributions from the oblique and transversus muscles.
External oblique — The external oblique muscle is a broad, thin muscle that arises from the surfaces of the lower eight ribs, fanning out downward to insert medially into the xiphoid process, the linea alba, and the anterior portion of the iliac crest. Its aponeurotic sheet contributes to the anterior sheath of the rectus abdominis, then fuses at the linea alba in the midline with the contralateral counterpart). The remainder of the aponeurosis extends from the iliac spine to the pubic tubercle, where it becomes the inguinal ligament.
Internal oblique — The internal oblique muscle is a broad, thin muscle that lies deep to the external oblique, with its origins from the thoracolumbar fascia, the anterior two thirds of the iliac crest, and the lateral two thirds of the inguinal ligament .The muscle fibers travel upward and forward to insert into the lower borders of the lower three ribs and their costal cartilages, the xiphoid process, the linea alba, and the symphysis pubis. Above the arcuate line, its aponeurotic sheet contributes to both the anterior and posterior sheath of the rectus abdominis, then fuses at the linea alba in the midline with the contralateral counterpart . Below the arcuate line, the aponeurosis of the internal oblique muscle courses only anteriorly to the rectus abdominis muscle as part of the anterior rectus sheath.
Transversus abdominis — The transversus abdominis muscle is a thin muscle sheet that lies deep to the internal oblique muscle. It arises from the deep surface of the lower six costal cartilages, lumbar fascia, iliac crest, and lateral third of the inguinal ligament and inserts into the xiphoid process, linea alba, and symphysis pubis . The fibers of this muscle sheet run horizontally and forward. Its aponeurotic sheet contributes to the posterior rectus sheath above the arcuate line and the anterior rectus sheath below the arcuate line .It then fuses at the linea alba in the midline with the contralateral counterpart.
Pyramidalis — The pyramidalis muscle is a flat, triangular muscle at the inferior margin of the anterior abdominal wall. It originates from the superior pubic ramus, between the symphysis pubis and the pubic tubercle, and runs superomedially inserting into the linea alba. Most of the existing literature regarding this muscle focuses on whether or not it actually exists
Rectus sheath — The rectus sheath is composed of the broad, sheet-like aponeuroses of the flank muscles that enclose the rectus abdominis (and pyramidalis muscle, if present). Lateral to the rectus abdominis, the aponeuroses can be separated, but they fuse as they reach the midline.
The external oblique muscle, the most superficial of the flank muscles, has a broad aponeurosis that passes anteriorly over the rectus abdominis. Beneath the external oblique, the internal oblique has a bilaminar aponeurosis that passes anterior and posterior to the rectus abdominis above the arcuate line, but only anterior to the rectus below the arcuate line. The innermost abdominal muscle is the transversus abdominis. Its aponeurosis is posterior to the rectus abdominis above the arcuate line and anterior to the rectus abdominis below the arcuate line where it fuses with the aponeurosis of the internal oblique.
Inferior to the arcuate line, the aponeuroses of all three muscles form the anterior sheath. The posterior sheath is absent, and the rectus lies directly on top of the transversalis fascia. The arcuate line is the site where the inferior epigastric vessels enter the rectus sheath, travel superiorly, and converge with the superior epigastric vessels. The arcuate line is absent in as many as 30 percent of individuals .
Transversalis fascia — The transversalis fascia is a weak fibrous layer covering the inner surface of the transversus abdominis muscles and is separated from the peritoneum by a layer of fat, commonly known as the preperitoneal fat layer. It is frequently incised off the bladder when the peritoneal cavity is opened. This layer of connective tissue forms a continuous lining for the abdominal and pelvic cavities and is continuous with the diaphragmatic fascia, the iliacus fascia, and the pelvic fascia.
Linea alba — The linea alba stretches from the xiphoid process to the pubic symphysis. It is defined as the fusion of the aponeuroses of the external oblique, internal oblique, and transversus abdominis muscles . It maintains the abdominal musculature at a certain proximity to each other. The linea tends to have its widest margin approximately 3 cm superior to the umbilicus and has varying distances depending upon the point of reference along the abdominal wall ..
Inferior epigastric arteries — The inferior epigastric artery is thought to be the dominant vascular supply to the anterior abdominal wall . It branches from the external iliac artery passing medially adjacent to the inguinal ligament. It ascends medial to the internal (deep) inguinal ring and superficial to the transversalis fascia. It then proceeds toward the umbilicus and crosses the lateral border of the rectus muscle at the arcuate line where it enters the posterior rectus sheath. Once the artery enters the sheath, it branches extensively. It ascends within the rectus sheath to communicate with the superior epigastric artery. The angle between the vessels and lateral border of the rectus forms the apex of the inguinal (Hesselbach's) triangle, the base of which is the inguinal ligament.
The musculocutaneous perforating vessels of the inferior epigastric artery reach and supply deeper tissue as well as the integument of the anterior abdominal wall. These perforators are particularly relevant in reconstructive surgery as an important supply for abdominal tissue flaps used. The number, location, and course of these perforators are highly variable.
The inferior epigastric vessels are bounded only by loose areolar tissue below the arcuate line. Trauma to this portion of the inferior deep epigastric artery may result in considerable hemorrhage. Because hematomas commonly dissect into the retroperitoneal space, large quantities of blood may be lost before outward evidence of hematoma is detectable.
Superior epigastric arteries — The superior epigastric artery is a terminal branch of the internal thoracic artery . It enters the rectus sheath at the seventh costal cartilage and descends on the posterior surface of the rectus muscle . The superior and inferior epigastric arteries freely anastomose with one another at the level of the umbilicus to provide a generous collateral circulation between the subclavian and external iliac arteries. These vessels communicate laterally with the intercostals, subcostal, and lumbar arteries, as well as the ascending branch of the deep circumflex iliac artery . Deep branches of this vessel supply the posterior rectus sheath and the peritoneum with muscular branches and anterior perforating branches supplying skin and subcutaneous tissues.
Deep circumflex iliac arteries — The deep circumflex iliac artery also branches from the external iliac artery or, less frequently, from a common origin that includes the inferior epigastric artery . Its course is lateral and vertical behind the inguinal ligament. It then turns medially at the iliac crest, where it pierces the transversus abdominis muscle. Between the transversus abdominis and internal oblique muscles, numerous connecting branches supply the lower and lateral abdominal wall. Anastomoses with the intercostal and lumbar vessels supply branches to all the flank muscles.
Musculophrenic arteries — The musculophrenic artery is also a branch of the internal thoracic artery . It lies behind the costal cartilage to supply the intercostal spaces and upper abdominal wall. Anastomoses from intercostal and subcostal vessels to the deep circumflex iliac vessels occur in the deep layer.
Superficial arteries — The superficial vasculature of the abdominal wall is located in the subcutaneous tissues and consists of branches of the femoral artery, including the superficial epigastric (or superficial inferior epigastric), superficial external pudendal, and superficial circumflex arteries.
The superficial epigastric vessels run diagonally in the subcutaneous tissues from the femoral artery toward the umbilicus . They can be identified on a line between the palpable femoral pulse and umbilicus just superficial to Scarpa's fascia. As they approach the umbilicus, the arteries branch extensively.
The external pudendal arteries have a medial and diagonal course from the femoral artery and supply the region of the mons pubis. These vessels branch extensively as they approach the midline. Following incision, bleeding is typically heavier here than in other subcutaneous areas of the abdomen.
The superficial circumflex iliac vessels proceed from the femoral vessels to the flank. The superficial vessels follow the general pattern of the deep vessels and arise from the iliac or femoral vessels. The exception is that the superficial inferior epigastric vessels have no superior counterparts.
the channels of the upper abdominal wall, above the level of the umbilicus, drain primarily to the anterior axillary (ie, pectoral) lymph nodes and, to a lesser extent, to the internal mammary chain
below the level of the umbilicus, drain to the inguinal nodes and then to the iliac chain of nodes
Lymphatics adjacent to the umbilicus drain toward the liver through the falciform ligament
defect in the abdominal midline between the umbilicus and the xiphoid process .They represent 1.6 to 3.6 percent of all abdominal wall hernias and 0.5 to 5 percent of all operated abdominal wall hernias. two to three times more common in men and are most commonly diagnosed between the ages of 20 and 50
Epigastric hernias that involve a peritoneal sac (true hernias) usually contain only omentum, and only rarely small intestine. Epigastric hernias can also occur with only protrusion of extraperitoneal fat through the linea alba without a peritoneal sac (false hernia). and most often can be performed as a day surgery procedure under local anesthesia. As for all ventral hernias, we suggest mesh reinforcement if the hernia is incisional and/or if the defect is larger than 1 cm in diameter. Recurrence after epigastric hernia repair is rare.
Also referred to as periumbilical hernia is a ventral hernia located at or near the umbilicus. In adults, umbilical hernias are most often acquired due to increased intra-abdominal pressure brought on by obesity, abdominal distension, ascites, or pregnancy.
Omentum or preperitoneal fat is contained within the hernia sac.
Coexist with rectus abdominis diastasis (RAD) Umbilical hernias have been detected in up to 90 percent of pregnant women
Cirrhotic patients are prone to developing umbilical hernias due to increased intra-abdominal pressure (from ascites) and impaired healing
Vertical incisions have a higher risk for hernia than transverse/oblique incisions, and upper abdominal incisions are more susceptible to hernia than lower abdominal incisions
but can present as late as 10 years after surgery
Preoperative CT imaging is recommended for complex ventral hernias defined by a large size (>10 cm in width) and/or significant loss of domain (>20 to 30 percent of the viscera residing outside the abdominal cavity in the hernia sac)
A 32-year-old healthy woman, gravida 6 with two living children, presented at our clinic for the termination of pregnancy at 18 weeks of gestation. Her only previous abdominal surgeries had been two cesarean sections. The physical examination showed a gravid uterus; the rectus sheath was deficient in the midline infraumbilical area, a finding consistent with an incisional hernia. This defect had been present since the patient's last cesarean section 2 years earlier. A medical termination of the pregnancy was performed with the use of a 0.1% solution of ethacridine lactate, which was instilled extraamniotically through a Foley catheter
For this reason, almost all Spigelian hernias are interparietal in nature, and only rarely will the hernia sac lie in the subcutaneous tissues anterior to the external oblique fascia. A large Spigelian hernia is most often found lateral and inferior to its defect in the space directly posterior to the external oblique muscle; the hernia cannot develop medially due to the intact rectus muscle and sheath.
The hernia is nevertheless covered by the intact external oblique aponeurosis
Pantaloon hernia :hernia that involves a direct and indirect hernia on the same side of the groin.
It contains the spermatic cord and the ilioinguinal nerve in the male and the round ligament of the uterus and the ilioinguinal nerve in the female.
It is about 6cm long and extends from the deep inguinal ring to the superficial inguinal ring (external ring).
Vas deferens
3 nerves ( genital branch of genitofemoral supply cremasteric muscle, ilioinguinal supply scrotum and groin and sympathetic)
3 arteries ( testicular artery , artery to vas deferens from inferior vesical , cremasteric artery) ,
lymphatics drain to para-aortic
Pampiniform venous plexus
Processus vaginalis
