Hernias Dr. Saleh M. Aldaqal MBBS, FRCSI,SBGS Assistant Professor and Consultant General And laparoscopic Surgery(france), Department of Surgery, Faculty of Medicine, King Abdulaziz University. www.dr-aldaqal.com

What is a hernia Hernia is derived from the Latin for "rupture" It is the protrusion of an organ or part of an organ through a defecte in the wall of the cavity normally containing it.

Types of hernia Inguinal Indirect or indirect Femoral Herniation through the femoral canal

Types of hernia Incisional Herniation through an area weakened by a scar Umbilical Paraumbilical Acquired defect above or below the umbilicus Epigastric in the midline of abdomen above the umbilicus caused by a defect in linea alba.

Groin Hernias Incidence: - Groin hernias are found in 5% of male population. - Represents 86% of all hernia cases. - It occurs 5 times more often in males than females. - Inguinal 96% ( indirect 75%, direct 25%). - Bilateral in 20% of cases - Right sided hernias are more frequent than left sided ones - Femoral 4%.

Indirect inguinal hernia Pathophysiology a. Nonobliterated processus vaginalis (congenital). b. Internal abdominal ring weakened fascia. Lateral to inferior epigastrics vessels .

Direct Inguinal Hernia Incidence: 25% of hernia cases The hernia contents enter the inguinal canal directly via a gap or defect in transversalis fascia, the floor of Hasselbach's Triangle. These hernias are generally considered to be acquired, and may be associated with heavy lifting, straining due to constipation, coughing, or prostatic enlargement.

Boundaries of Hasselbach's Triangle A. Medial boundary: Rectus abdominis B. Lateral boundary: Inferior epigastric vessels C. Inferior boundary: Inguinal ligament

Bilateral Hernia Definition: Simultaneous Right and Left Inguinal Hernia Common in children and elderly men If a left inguinal hernia is preesnt, there is a 25% risk of an occult right inguinal hernia

Symptoms A. Often asymptomatic (especially in direct hernias) B. Pain or dull sensation in groin

Complications A. Bowel incarceration ( acute, chronic ) B. strangulation C. Small Bowel Obstruction

Sliding Hernia Posterior wall of sac is a viscous. Seen in 3% of hernia procedures. Great care must be taken to avoid visceral damage during the repair.

Pantaloon Hernia Direct and indirect hernias co-existing on same side Etiology for some recurrences.

Richter's Hernia Antimesenteric boarder only of the small intestine is incarcerated in the deep inguinal ring, therefore intestinal obstruction may be absent, but gangrene of the bowel wall may occur.

FEMORAL HERNIA I. Epidemiology A. Accounts for 4% of Groin Hernias (96% are inguinal) B. More common in elderly women C. Gender predisposition: Female by 3 to 1 ratio 1. Femoral seen less than Inguinal Hernia even in women II. Pathophysiology A. Associated with increased intraabdominal pressure B. Hernia sac bulges into femoral canal . Femoral canal lies immediately medial to femoral vein

INCISIONAL HERNIA I. Pathophysiology A. Type of Ventral Hernia B. Develops in scar of prior laparotomy or drain site C. Risks for postoperative hernia development 1. Vertical scar more commonly affected than horizontal 2. Wound infection 3. Wound dehiscence 4. Malnutrition 5. Obesity 6. Tobacco abuse

Treatment Options All hernias should be surgically corrected to remove the risk of incarceration and strangulation. If there are compelling co-morbid medical conditions that preclude surgery, then a truss, or support hernia belt may be employed. A truss does not repair the hernia defect, but will afford some relief of symptoms. Modern methods of repair include open primary closure of the defect with sutures (Shouldice or "Canadian" Repair, Bassini Repair); patch closure with prosthetic materials (Polypropylene or Gortex) tension-free (Lichtenstein-type) and laparoscopic repair.