Transcript HERNIAS

HERNIAS
Dr David Swar
General Surgery
Qilu Hospital
Shandong University
Definition

A hernia is the
protrusion of an
organ through its
containing wall.
Composition of a hernia
1.
The sac
2.
The covering of
the sac
3.
The content of the
sac
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.
Composition of a hernia
2.
The covering:

3.
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
Ovary(with or without oviduct)
Meckel’s diverteculum =Littre’s hernia
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
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.
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.
Classification
A.
B.
External hernia
Internal hernia
Classification continue…
A.
External hernia
Common hernia




inguinal
Femoral
Umbilical
incisional
Classification continue…
A.
External hernia
Rare hernia




Spigelian
Gluteal
Obturator
lumbar
Classification continue…
B.
Internal hernia
Diaphragmatic hernia

Esophogial hernia

Paraesophogial
hernia
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.
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.
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 .
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.
Inguinal hernia
Inguinal Canal Anatomy

Anterior wall:



Posterior:



fascia transversalis
conjoint tendonon in medial one
third
Roof:



aponeurosis of external oblique
(along entire length),
internal oblique on lateral one
third
arching fibers of internal
oblique ,and
transversus abdominis
Floor (inferior):


inguinal ligament, and
lacunar ligamen at the medial
end
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.
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 Inguinal
Ring.

Direct Hernia usually bulge at External Inguinal
Ring.
Inguinal hernia
There are two types
of inguinal hernia:


Direct inguinal
hernia
Indirect inguinal
hernia
Differences between direct
and indirect hernias
1.
2.
3.
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.
Content:
•
Direct: Retroperitoneal fat. less commonly, peritoneal sac
•
containing bowel .
Indirect: Sac of peritoneum coming through internal ring,
through which omentum or bowel can enter.
Etiology:
•
Direct: weakness of the posterior floor of the inguinal
•
canal (acquired).
Indirect: patent processus vaginalis (Congenital) .
Differences between direct
and indirect hernias

Boundaries of Hasselbach's
triangle:



Medially: lateral border of
rectus abdominis.
Laterally: inferior epigastric
vessels.
Inferiorly: inguinal ligament.
Inguinal hernia

Differential diagnosis:
1.
2.
3.
4.
5.
6.
7.
8.
Tendonitis
Muscle tear
Lymphadenopathy
Lipoma
Varicose vein
Hydrocele
Epididymitis
Spermatocele
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.

Inguinal hernia
Management:


Inguinal hernias should always be
repaired ( herniotomy, herniorrhaphy )
unless there are specific
contraindications.
Types of operations:
1.
2.
a permanent sutures, as in Shouldice
repair (layered suture).
a permanent mesh -greater frequency to
decrease tension.
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
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
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
Femoral hernia
Signs & symptoms:



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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.
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.
Femoral hernia
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.
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.
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
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
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
Incisional hernia

This occurs
through a defect
in the scar of a
previous
abdominal
incision.
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
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,
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 )
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.
Diaphragmatic hernia

Sliding:

in which the
gastroesophogeal
junction itself
slides through the
defect into the
chest.
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.
Hiatus hernia
Some other hernias

Spigelian hernia:


Littre's hernia:


A hernia that contains a Meckel's diverticulum in the sac.
Obturator hernia:


This is a hernia through the linea semilunaris at the lateral
border of the rectus sheath.
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).
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