Essentials MA MURPHY FRCSI Back to Department of Surgery Trinity College Dublin Abdominal Wall Hernia Essentials MA MURPHY FRCSI

Objectives Understand the term hernia Basic anatomical knowledge Clinical features of common hernia Complications of hernias Examination of a hernia Differential diagnoses of a lump in the groin Management of hernia

Hernia A protrusion of an organ or tissue outside its’ normal compartment

Common External Hernias ABDOMINAL WALL & GROIN Midline Umbilical Para- umbilical Epigastric Inguinal Direct/ Indirect/ Combined Femoral Incisional

Common Presentations A lump Comes and goes Appears on straining /coughing A pain Dragging pain/ Pain on exertion Incidental finding on examination/ imaging Presenting as a complication Incarceration/ Intestinal obstruction

Inguinal Hernia Commonest external hernia Male preponderance Infant / adult Direct / indirect / combined Weakness / increased pressure Cause pain / discomfort Carry risk of complications Treated surgically

Inguinal Hernia - History OBJECTIVES Establish differential diagnoses Identify risk factors and significant co-morbid pathologies (e.g. increased intra-abdominal pressure due to ascites or chronic airways disease)

Inguinal Hernia - History Onset Duration Symptoms Other hernia(e) Irreducibility Gastrointestinal system Respiratory system Surgery / anaesthesia

Inguinal Hernia - Examination Surface markings Anterior superior iliac spine Pubic tubercle Midpoint of inguinal ligament

Inguinal Hernia - Examination OBJECTIVES Confirm diagnoses Out rule differentials Establish type Determine contents Reducibility Identify co-morbid pathologies

Direct V’s Indirect Direct Post wall Less common Older Smaller Hesselbachs Medial Lower risk Indirect Deep ring 70% Congenital Scrotal Lateral Strangulate

Inguinal Hernia Examination Standing / Lying Supine Cough impulse Reducibility Contents Bowel sounds Scrotal contents

Differential Direct /Indirect/Combined Femoral hernia Hydrocele Lipoma Lymph node Testicular tumour Saphenous varix

Inguinal Anatomy The inguinal canal represents the oblique passage through the anterior abdominal wall of the vas deferens (round ligament) It is 5cm long and lies directly above the medial half of the inguinal ligament

Inguinal Anatomy Floor Transversalis fascia Medially the conjoint tendon Roof External oblique aponeurosis Laterally the conjoint tendon Skin and superficial fascia Above Conjoint tendon Below The inguinal ligament

Inguinal Anatomy Three nerves Ilio-inguinal (on not in) Sympathetic fibers Genitofemoral Three layers of fascia Internal spermatic (transversalis f.) Cremasteric (conjoint tendon) External spermatic (ext. oblique)

Inguinal Anatomy Three arteries Testicular (from the aorta) Artery of the vas (external iliac) Cremasteric (inferior epigastric) Three other structures The vas deferens The pampniform plexus of veins Lymphatics (to aortic nodes)

TESTIS CORD STRUCTURES

Inguinal Anatomy

Hernia Anatomy

Indirect Hernia

Direct Inguinal Hernia

Hernia Complications Incarceration Strangulation Intestinal obstruction

Varieties of Hernias Maydls W loop of intestine Richters Partial inclusion of intestinal wall Sliding hernia Bladder Sigmoid colon/ appendix

Richters’ Hernia

Maydls’ Hernia

Hernia Management Investigations None required for routine uncomplicated case Plain X-ray for suspected bowel obstruction Ultrasound in case of diagnostic uncertainty Herniogram rarely used Routine pre-op investigations

Hernia Treatment Surgery To relieve symptoms To prevent complications Operations Open hernia repair Laparoscopic hernia repair Pre-peritoneal Intra- abdominal

Open Hernia Repair Day-case surgery Anaesthesia General Local Operations Tension free Mesh repair (Lichtenstien) Darn repairs (Shouldice, Bassini)

Open Hernia Repair Incision above medial half of inguinal ligament External oblique opened from external ring to expose the cord and overlying ilioinguinal nerve Internal (deep) ring exposed Hernial sac identified and reduced Prolene mesh inserted to reinforce posterior wall and deep ring

Open Hernia Repair

Open Hernia Repair

Open Hernia Repair

Open Hernia Repair

Open Hernia Repair

Laparoscopic Repair

Laparoscopic Repair

Laparoscopic Repair

Surgery Complications Trauma Nerve Artery (testicular atrophy) Intestine Haemorrhage Haematoma (infection) Infection Wound infection Chest Infection

Femoral Hernia Herniation through femoral canal Appears below and lateral to pubic tubercle Relatively uncommon Commoner in females Contains omentum or small intestine High risk of strangulation Repaired surgically

Femoral Hernia

Femoral Hernia Repair

Summary Inguinal hernia is the commonest external hernia Indirect hernias have a higher risk of strangulation Hernias are treated by surgery, to relieve symptoms and prevent complications Femoral hernias have a high risk of strangulation

Recommended Reading Ellis H. Clinical Anatomy www.vesalius.com