Rob Padwick MRCS MMedEd SpR General Surgery Abdominal Hernias Rob Padwick MRCS MMedEd SpR General Surgery

Aims Definition of hernia Overview of types of hernia Presentation and Management of common types of hernia Quick overview of the rest

What is the definition of a hernia? An abnormal protrusion of a viscus from the body cavity of its origin into another cavity of the body

Where can hernias occur? Via natural orifices Via natural ‘weaknesses’ Via iatrogenic orifices Via iatrogenic ‘weaknesses’

Types of Abdominal Hernia Hiatus Inguinal Femoral Umbilical/Paraumbilical Epigastric Incisional Parastomal Perineal Spygelian Lumbar Obturator ‘Internal’ Other diaphragmatic herniae

What can hernias do? Nothing Lump Pain Incarcerate; Obstruct; Something gets stuck Obstruct; Something gets stuck and blocks off Strangulate; Something gets stuck and loses its blood supply

Hiatus Hernia VERY COMMON! Via Oesophageal hiatus Most commonly stomach Occasionally transverse colon or small bowel if very large Rarely cause major problems

Hiatus hernia Types; Presentation; Rolling Sliding Asymptomatic Heartburn Acid reflux Cough Chest symptoms if very large

Diagnosis Chest X-Ray Barium Meal CT OGD

Hiatus hernia Complications; Treatment; Barrett’s Oesophagus Obstruction/incarceration/strangulation (rare) Treatment; None PPI Nissen’s Fundoplication

M>>F Inguinal Hernia Site; Types; Causes; Inguinal canal Right/Left groin Types; Direct Indirect Causes; Congenital Raised intra-abdominal pressure

The Inguinal Canal

The Inguinal Canal Contents; Spermatic Cord; Ilioinguinal nerve Vas deferens Testicular artery and veins Pampiniform plexus Artery to the Vas Ilioinguinal nerve Genital branch of Genitofemoral nerve Iliohypogastric nerve

Inguinal Hernia Presentation; Lump Pain Bowel obstruction Scrotal symptoms

Indirect Inguinal Hernia Take the ‘Indirect’ route; Exit abdomen via deep ring Through whole inguinal canal Exit superficial ring May enter scrotum

Direct Inguinal Hernia Take the ‘Direct’ route; Exit abdomen via Hesselbach’s Triangle Exit superficial ring Do not enter scrotum

Inguinal Hernia Complications; Pain Incarceration Obstruction Srangulation

Inguinal Hernia Treatment; Conservative (e.g. Truss) Surgery; Open Laparoscopic

Inguinal Hernia Complications of Surgery; Bleeding Infection Pain Bruising Parasthesia Recurrence Testicular problems; Small ball Blue ball Black ball No ball

Femoral Hernia Site; Into the femoral canal Via the femoral ring

F>M Femoral Hernia Presentation; Treatment; Lump Pain Symptoms of obstruction Treatment; Surgery F>M

Umbilical/Paraumbilical Hernias Site; Midline Into umbilical skin Umbilical; Relatively rare Most commonly in children Congenital defect Paraumbilical Very common!

Umbilical/Paraumbilical Hernias Presentation; Usually asymptomatic Lump Pain Treatment; Vast majority need none Repair if troublesome – most commonly contain omentum only

Epigastric Hernia Site; NB Divarication of rectus Midline Above paraumbilical herniae Rest see above NB Divarication of rectus

Incisional Hernia Site; Treatment; Via any surgical incision Depends on whether causing problems Leave alone Surgery

Parastomal Hernia Site; Treatment; Around stoma Conservative Surgery; Repair Resiting stoma

Perineal Site; Presentation; Treatment; Via perineal orifices; Pain Vagina Rectum Presentation; Pain Feeling of lump descending Urinary symptoms Bowel Symptoms Treatment; Conservative Surgery

Other Abdominal Hernias Spygelian; Through linea semilunaris Lumbar; Petit (inferior) Grynfeltt (superior) Internal Obturator; Through obturator canal Other diaphragmatic herniae; Bochdalek Morgagni

Questions?