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Abdominal wall hernias
Abdominal wall hernia
• Hernia is an abnormal protrusion of the
whole or a part of viscus through an
opening in the wall of the cavity.
• Types:
– External
– Internal
Aetiology
• Increased abdominal pressure
Cough, urinary trouble, constipation, straining, ascites,
intraabdominal malignancy.
• Weakness of abdominal musculature :
– Congenital sacs as processes vaginalis, patent canal of nuck in
females
– Acquired
• Excess fat (obesity)
• Muscle weakness following pregnancy
• Surgical incisions – Nerve damage, Improper repair
– Destruction of connecting tissue as smoker, Marfan’s syndrome
• Familial
INTRODUCTION
 high insertion of the internal oblique
muscle
 widening of the internal inguinal ring
 persistency of the vaginal
peritoneum conduct
anatomical abnormalities
+
 intra-abdominal pressure
ETIOPATHOGENY
Rev Col Bras Cir 1976;3(2):66-80.
Clin North Am 1998;78:953-72.
INTRODUCTION
COLLAGEN
proportion
HERNIOGENESE
FASCIA
TRANSVERSALIS
COLLAGEN
quantity
COLLAGEN
type I and III
deficiency
Ann Surg 1993;218:754-60.
Eur J Clin Invest 1997;27:863-8.
Parts of the hernia
3 parts
• Sac
• Contents
• Covering of sac
mouth
neck
Body
Fundus
Contents
•
•
•
•
•
•
Omentum
- Omentocoel / epiplocele
Intestine
Enterocoel
Bladder
Cystocoel
Part of Intestine Richter’s
W type intestine Maydl’s Hernia
Meckel’s diverticulum Littre’s hernia
Common hernias
• Inguinal (indirect or
direct), Femoral,
Umblical, Incisional
Epigastric,
• Rare Hernias:
– Lumbar, Spegilian,
Obturator
Hernia sites
Some terms related to hernia
• Reducible
• Irreducible
-
Reducibility, cough impulse
Irreducible, impulse –ve
• Obstructed
-
irreducibility +
intestinal obstruction
irreducibility + obstruction +
arrest of blood supply
• Strangulated -
• Inflammed
Causes of irreducibility
•
•
•
•
adhesions of content to each other
adhesions of content with the sac
adhesions of one part of sac to other part
narrowed neck of sac
INGUINAL HERNIA
Epidemiology
•The majority of abdominal wall hernias occur in the
groin, totaling approximately 75% of the total incidence.
•majority of inguinal hernias occur in males
•Of inguinal hernia repairs, 90% are performed in males
and 10% in females.
•Approximately 70% of femoral hernia repairs are
performed on female patients
•females undergo nearly five times the number of
inguinal hernia repairs as femoral hernia repairs
•The most common type of groin hernia presenting in
females remains the indirect inguinal hernia.
Anatomy of Inguinal Canal
• 4 cm in length from deep to superficial ring.
• Deep ring is ‘U’ shaped in fascia transversalis
which lies 1.25 cm above the mid inguinal point.
• Superficial / External ring is in external oblique
aponeurosis situated just above and lateral to
crest of pubis.
• Passes downward and medially from deep ring
to superficial ring.
Anatomy of inguinal canal
Boundaries of inguinal
canal
• Ant : External oblique
aponeurosis and few fibres
of internal oblique laterally
• Post : Fascia transversalis
and conjoined tendon
• Superior : Arched fibres of
conjoined tendon
• Inferior : Inguinal ligament
Anatomy
Contents of inguinal canal
• Spermatic cord, ilioinguinal nerve, genital
br. of genitofemoral nerve.
• Round ligament in females.
• Vestigial remnant of processes vaginalis.
HASSELBACH TRIANGLE
inferior epigastric vessels
abdominal rectus muscle
Hasselbach triangle
inguinal ligament
internal inguinal ring
INGUINAL HERNIA
• Types:
– Indirect
– Direct
– Combined
(Pantaloon)
Classification
Direct Inguinal
Hernia
Clinical Features
• Swelling
• Dragging pain
• Features of
complication
• H/o increased
abdominal pressure
• Symptomless
discovered accidentally
Examination
•
•
•
•
•
•
Inguino scrotal swelling
Expansile cough
Cannot get above the swelling
Reducibility
Finger Invagination Test
Deep Ring occlusion Test
Inguinal hernia
External ring test
(finger Invagination test)
Enterocoel vs. Omentocoel
•
•
•
•
•
Visible peristalsis
Consistency
Reduction of contents
Percussion Note
Bowel sounds
Differential Diagnosis of Inguinal Hernia
• Inguinoscrotal swelling
– Encysted hydrocoel of cord, varicocoel, lymph
varix, funiculitis, lipoma of cord, torsion of
testis, retractile testis
• Groin swelling
– Femoral hernia, sephana varix, enlarged
nodes, psoas abscess, psoas bursa,
undescended testis, ectopic testis, lipoma,
aneurysm
Diagnosis
• History
• Physical Examination
• Imaging (US, CT,
Herniography)
Herniography
• Suspected hernia, but clinical diagnosis is unclear
• Procedure done under flouroscopy following injection of
contrast medium
• Frontal and oblique radiographs are taken with and without
increased intra-abdominal pressure
Complications
• Irreducibility : Dull aching pain / irreducible
• Obstructed : irreducible + obstruction to lumen
of bowel. Features of intestinal obstruction
• Strangulated : irreducible + obstruction +
impairment of blood supply. Tense / Tender /
Toxic
Treatment
• Surgical
• Watchful waiting for elderly pt. with small
asymptomatic hernia
• Truss !!!!!!
Surgery
• Herniotomy: Excision of hernia sac, sufficient in
children
• Herniorrhaphy:
–
–
–
–
Bassini’s Repair
Shouldice Repair
Mc Vay
Preperitoneal
• Hernioplasty : Lichtenstein, Mesh graft application
Laparoscopic Repair
– TEP / TAPP
Bassini’s repair
Bassini (early 20th Century)
Transversus abdominis and internal oblique
musculoaponeurotic arches or conjoined tendon to
the inguinal ligament
EDUARDO BASSINI
Shouldice repair
Shouldice (1930s)
Multilayer imbricated repair of the
posterior wall of the inguinal canal
Mc Vay repair
McVay (1948)
Edge of the transversus abdominis aponeurosis to
Cooper’s ligament; incorporate Cooper’s ligament and
the iliopubic tract (transition suture)
Lichtenstein repair
First pure prosthestic, tension-free repair to achieve low recurrence rates
Types of Prosthesis
• Polypropylene mesh most common and
preferred
– allows for a fibrotic reaction to occur between
the inguinal floor and the posterior surface of
the mesh, thereby forming scar and
strengthening the closure of the hernia defect
• Polytetrafluoroethylene (PTFE) mesh
– often used for repair of ventral or incision
hernias in which the fibrotic reaction with the
underlying serosal surface of the bowel is
best avoided
Hernia mesh
Laparoscopic repair
Conservative treatment
Trusses can provide symptomatic relief
Treatment Algorithm
Complications
Different Types of Indirect Inguinal Hernia
•
•
•
•
Sliding Hernia (Hernia en glissade)
Richter Hernia : Part of Bowel
Littre’s hernia : Meckel’s diverticulum
Pantaloon Hernia : Both Direct and
Indirect Hernia
• Maydl’s hernia: a few segment of bowel
• Amiand’s hernia: hernia contains the
appendix
Spigelian Hernias
•
Lateral ventral hernia
– Junction of vertical semilunar line and horizontal semicircular line
(arcuate line)
•
This rare hernia occurs along the edge of the rectus abdominus muscle,
which is several inches to the side of the middle of the abdomen.
•
90% located 0 - 6 cm above anterior superior iliac spine
– Sharp pain, swelling, easily reducible
– 20% present with incarceration
– median age = 50 years
– more common in males and on (R)
– Rare
•
PE
– Difficult to diagnose
– U/S or CT can aid in diagnosis
Treatment:
– Repair primarily or with mesh
Lumbar Hernia
• Congenital, spontaneous or traumatic
• Grynfeltt’s triangle
– 12th rib, internal oblique and sacrospinalis
muscle
– Covered by latissimus dorsi
• Petit’s triangle
– Latissimus dorsi,
external oblique and
iliac crest
– Covered by superficial
fascia
Pelvic Hernia
• Obturator hernia
– Most commonly in women
• Sciatic hernia
• Perineal hernia
Parastomal Hernia
• Variant of incisional hernia
• Paracolostomy > paraileostomy
• Low rate if through rectus
muscle
• Traditionally relocate stoma,
repair defect
• Concern for mesh erosion
• Laparoscopic/open repair
Incisional Hernia
• Risk factors
– Technical
– Wound infection
– Smoking
– Hypoxia/ ischemia
– Tension
– Obesity
– Malnutrition
• Laparoscopic vs. open repair
Epigastric Hernia
• Incidence 1-5%
• Men> women
• Pre-peritoneal fat protrusion
through decussating fibers at
linea alba
• Between xiphoid and umbilicus
• 20% multiple
• Repair primarily
Femoral Hernia
Anatomy of femoral triangle
Anatomy of Femoral Canal
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•
•
•
•
•
Closed above by femoral septum and on lower side –
cribriform fascia
Most medial compartment of femoral sheath
Extends from femoral ring to sephanous opening below
1.25 cm long and 1.25 cm wide at base
Contents : fat, lymphatic, lymph node of Cloquet
Oval opening ½” in diameter bounded
Anteriorly Inguinal ligament
PosteriorlyIliopectineal ligament,
pubic bone and fascia
over pectineus muscle
Medially Lacunar ligament
Laterally Septum separating form
femoral vein
Femoral Hernia
• Clinical features : More in
females, age >50, Rt. Side
70%, bilateral 20%
• Covering of femoral hernia :
– Skin, superficial fascia,
cribriform fascia, anterior
layer of femoral sheath, fatty
contents of femoral canal,
femoral septum, peritoneum
Differential diagnosis of Femoral Hernia
• Inguinal hernia, sephano varix, lymph
• node, lipoma, Aneurysm, Psoas abscess,
• psoas bursa, Ruptured adductor longus
Operation for Femoral Hernia
• Low (lockwood) Inguinal
ligament to Ileopectineal
line
• High (McEvedy) conjoint
tendon to ileopectineal line.
For strangulated hernia
• Lotheissen (Through
inguinal canal) conjoint
tendon or inguinal ligament
to pectineal ligament
Umbilical Hernia
Umbilical Hernia in adults
• May be supraumbilical or infraumbilical.
• Contents are usually omentum / small bowel /
Transverse colon
• Seldom reducible
• C/F : Mostly in females, obesity, usually >40
years, flabby abdominal muscles, repeated
pregnancy
• Pain, swelling, GI symptoms
• Treatment : Surgery (Reduction of wt.)
– Mayo’s op. Transverse elliptical incision. Double
breasting of linea alba.
Burst Abdomen (Abdominal Dehiscence)
•
•
•
•
•
•
•
1 – 2%
Usually on 6-8th day of operation
Serosanguinous discharge (Pink colour)
H/o feeling something giving way
Pain, shock
Features of intestinal obstruction
Bowel, omentum may protrude
Causes : 6S’s
•
•
•
•
•
Surgery (Peritonitis)
Sepsis
Sutures (Catgut)
Surgeon (Poor quality)
Sick patient (diabetes, malignancy,
uraemic, jaundice)
• Straining (cough / vomiting)
Take Home Points
• Hernias can involve the small bowel, appendix, a Meckel’s
diverticulum, ureter
• Incarceration with frank pain or strangulation are operative
emergencies and bowel can be saved if done within 4-6 hours
• An attempt at reduction should be made with a hernia, but operative
reduction is the only definitive treatment
• Femoral hernias have a high rate of incarceration and should be
repaired, but other inguinal hernias may be watched if asymptomatic
• With abdominal incisions, try not to put excessive tension or damage
the suture in any way as it can promote incisional hernias