1. Dr. Mohammed Maree Al-Makassed Hospital Surgical Department 2015.
Hernia
Dr. Mohammed Maree
Al-Makassed Hospital
Surgical Department
2015.

2. Hernia
A hernia is defined as the protrusion of an organ through the wall of cavity that normally contain it.

3. Abdominal Wall
The abdominal wall encloses the abdominal cavity, which holds the bulk of the gastrointestinal viscera
The embryologic phenomenon of the formation of spaces above and below the inguinal ligament is the result of two necessary developments
the space above the inguinal ligament, is the well known inguinal canal which is the testicular pathway from the retroperitoneal space to the scrotum
the spaces below the inguinal ligament which permit the exodus of the muscles, nerves, and vessels which are destined to provide for the lower extremity.

5. Layers of the Abdominal Wall

6. The Superficial Fascia
 It is divided into two layers:
fatty superficial layer (Camper’s fascia)
membranous deep layer (Scarpa’s fascia).

7. Muscles of the Abdominal Wall
There are five muscles in the abdominal wall. They can be divided into two groups:
Vertical muscles – There are two vertical muscles, situated near the mid-line of the body.(middle)
Flat muscles – There are three flat muscles, situated laterally (anterolateral)

8. The Flat Muscles The anterolateral portion
External Oblique
The largest and most superficial
Its fibres run inferomedially. 
Internal Oblique
deep to the external oblique.
smaller and thinner in structure,
its fibres running superiormedially
Transversus Abdominis
deepest of the flat muscles,
transversely running fibres.
Deep to this muscle is a well formed layer of fascia, called the transversalis fascia.

9. Nerve : Lower 6 thoracic spinal nerves
Origin :
Inferior border of lower 8 ribs
Insertion : Aponeurosis to linea alba from xiphoid to symphysis, iliac crest, anterior superior iliac spine
Nerve : Lower 6 thoracic spinal nerves

10. Origin : Iliac fascia, Anterior iliac crest, Lumbar aponeurosis
Insertion : Lower border of ribs 9-12, With aponeurosis to linea alba, Pecten pubis
Nerve : Lower 6 thoracic spinal nerves, 1st lumbar spinal nerve
lateral ½ of inguinal ligament (approx.), but does not arise from ligament

13. Umbilical Area
During the period of fetal circulation, the following embryologic entities are found at the umbilicus:
Left umbilical vein
Vitellointestinal duct
Vitelline artery and vein
Urachus
Two umbilical arteries

15. The Vertical Muscles The middle portion
Rectus Abdominis
It is split into two by the linea alba.
The lateral border called the linea semilunaris.
the muscle is intersected by fibrous strips, known as tendinous intersections.
The tendinous intersections and the linea alba give rise to the ‘six pack’ seen in individuals with low body fat.
Pyramidalis
superficially to the rectus abdominus.
located inferiorly, with its base on the pubis bone, and the apex attached to the linea alba.
It acts to tense the linea alba.

16. Rectus abdominis muscle
Origin : Crest of pubis and pubic symphysis
Insertion : Cartilages of ribs 5-7, Xiphoid process
Nerve : Intercostals 6-12

17. Pyramidal muscle

18. Rectus sheath

19. The Rectus Sheath
formed by the aponeuroses of the three flat muscles, and encloses the rectus abdominus and Pyramidalis muscles.
The anterior wall is formed by the aponeuroses of the external oblique, and of half of the internal oblique.
The posterior wall is formed by the aponeuroses of half the internal oblique and of the transversus abdominus.
midway between the umbilicus and the pubic symphysis, all of the aponeuroses move to the anterior wall of the rectus sheath. At this point, there is no posterior wall to the sheath; the rectus abdominus is in direct contact with the transversalis fascia.
The area of transition between having a posterior wall, and no posterior wall is known as the arcuate line.

20. Rectus sheath

21. scrotum

23. The Inguinal Canal

24. The inguinal region Also known as the groin
located on the lower portion of the anterior abdominal wall.
The thigh inferiorly, the pubic tubercle medially, and the anterior superior iliac spine (ASIS) super laterally

26. Surface anatomy of the abdomen

27. Nine Regions

31. ventral hernias (abdominal wall hernia)
Incisional hernia.
Non-incisional (primary) : are generally named according to their anatomic location
Epigastric hernias are located in the midline between the xiphoid process and the umbilicus.
Umbilical hernias occur at the umbilical ring
Spigelian hernias can occur anywhere along the length of the Spigelian line or zone—an aponeurotic band at the lateral border of the rectus abdominis
Inguinal hernia
Femoral Hernia
Lumbar hernia (Grynfeltt-Lesshaft) or (Petit)
Obturator
Sciatic hernia

33. Inguinal hernia the most common type of hernia
more common in men than in women
types of inguinal hernias
Indirect inguinal hernia
Direct inguinal hernia

34. Indirect inguinal hernia
is a protrusion of abdominal-cavity contents through the inguinal canal
It results from a persistent processus vaginalis
the result of the failure of embryonic closure of the internal inguinal ring after the testicle passes through it

35. What is the inguinal canal?

36. pathway by which structures can pass from the abdominal wall to the external genitalia.

37. Development of the Inguinal Canal

38. Mid-Inguinal Point’ and ‘Midpoint of the Inguinal Ligament’

39. Boundaries The inguinal canal is made up of:
Anterior and posterior walls
Superficial and deep rings (openings)
Roof and floor (or superior and inferior walls)

40. An indirect inguinal hernia follows the tract through the inguinal canal

41. The anterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally (1/3).

44. The posterior wall is formed by the transversalis fascia.

45. The roof is formed by the transversalis fascia, internal oblique and transversus abdominis.

46. The floor is formed by the inguinal ligament

47. The inferior Epigastric artery and vein run medially and cephalad in the preperitoneal fat near the caudad margin of the internal inguinal ring.

50. Direction of indirect hernia

52. Indirect inguinal hernia

53. Direct inguinal Hernia
the peritoneal sac enters the inguinal canal though the posterior wall of the inguinal canal
In contrast to the indirect hernia, this is acquired in origin, due to weakening in the abdominal musculature.

54. Direct inguinal Hernia

58. Femoral hernia
which exit from the retroperitoneal space along the femoral vessels in the femoral canal,
Femoral hernia are more common in females than in males.

59. embryologically
The femoral sheath is formed embryologically by the evagination of elements of the abdominal wall by the outgrowth of the femoral vessels. The parietal fascial lining of the abdominal cavity which continues from the transversus abdominis to the iliopsoas musculature is essentially drawn into the proximal thigh by the primitive vascular elements

62. The femoral canal located below the inguinal ligament
Laterally to the pubic tubercle
bounded by
Anterior : the inguinal ligament
Posterior : pectineal ligament
Medially : lacunar ligament
Lateral : the femoral vein
contain : a few lymphatics, loose areolar tissue and occasionally a lymph node called Cloquet's node.
The function to allow the femoral vein to expand during periods of legs activity.

63. How are hernias diagnosed?
A medical history
A physical exam
Imaging tests, including x rays

64. A medical history Risk factors Being male.
Chronic cough. such as from smoking
Chronic constipation. Straining during bowel movements
obesity.
Pregnancy.
Certain occupations. job that requires standing for long periods or doing heavy physical labor
Premature birth. Infants who are born early are more likely to have inguinal hernias.
History of hernias. If you've had one inguinal hernia, it's much more likely that you'll eventually develop another — usually on the opposite side.
Benign prostatic hyperplasia
Ascitis
Abdominal Aortic Aneurysm

65. A physical exam is best performed with the patient standing
Inspection the groin area (asymmetry)
coughing may reveal a bulge
Bulge is above or below the inguinal ligament crease
Scrotal examination
The examiner should then stand to the side of the patient

66. Inguinal or femoral hernia

67. Is it Direct or Indirect Hernia

68. Any mass on groin examination should be attempted to reduce the hernia
Finally you have to answer the question?
Is it :
Reducible
Non- reducible :
Incarcerated ( vascularity not compromised)
Strangulated (vascularity compromised)

69. A hernia that cannot be reduced is described as incarcerated and generally requires surgical correction
If the blood supply to the incarcerated bowel is compromised, the hernia is described as strangulated, and the localized ischemia may lead to infarction and perforation.

70. Varieties of inguinal hernia
Sliding inguinal hernia (hernia en glissade)
Maydl’s hernia (hernia en W)
Littre hernia
Richter’s hernia
Amyand inguinal hernia
Pantaloons hernia

71. Sliding inguinal hernia

72. Maydl’s hernia
Maydl's hernia 
(Hernia-in-W)
Czech surgeon Karel Maydl.

73. Littre hernia
Any hernia containing the Meckel diverticulum.

74. Richter's hernia
A Richter's hernia occurs when the antimesenteric wall of the intestine protrudes through a defect in the abdominal wall A Richter's hernia can result in strangulation and necrosis in the absence of intestinal obstruction. It is a relatively rare but dangerous type of hernia.

75. Amyand inguinal hernia
Appendix in the hernial sac

76. Pantaloons hernia

77. Umbilical hernia Congenital umbilical hernia Acquired umbilical hernia
Para-umbilical hernia

78. Congenital umbilical hernia
Omphalocele
Gastroschisis.
Umbilical hernia at birth
In Omphalocele, viscera protrude through an open umbilical ring and are covered by a sac derived from the amnion.
In gastroschisis, the viscera protrude through a defect lateral to the umbilicus and no sac is present.
Umbilical hernia at birth most hernias close spontaneously by 5 years.
If closure does not occur, elective surgical repair is usually advised
Adults with small, asymptomatic umbilical hernias should be followed clinically

79. Do not forget chromosomal defects
Omphalocele
Do not forget chromosomal defects

80. gastroschisis

82. Spigelian hernia
The hernial orifice usually located along the semilunar line(Spigelian line) through the transversus abdominis aponeurosis (Spigelian fascia), close to the level of the arcuate line. The majority are found in a transverse band lying 0-6 cm cranial to a line running between both anterior superior iliac spines referred to as the Spigelian hernia belt.

85. Incisional Hernias Risk factors : Obesity. Surgical site infections
10% to 20% of patients may develop hernias at incision sites following open abdominal surgery.
Risk factors :
Obesity.
Surgical site infections
primary wound healing defects.
multiple prior procedures.
prior incisional hernias.
technical errors during repair

86. Incisional Hernias

87. Incisional Hernias surgical management :
primary versus mesh repair
open versus laparoscopic repair.
Mesh can be placed as an underlay deep to the fascial defect (intra- or preperitoneal), an interlay either bridging the gap between the defect edges or within the abdominal wall musculoaponeurotic layers (intraparietal), or an onlay (superficial to the fascial defect).

88. Incisional Hernias

91. Imaging

92. treatment
Primary repair
Mesh repair
Open
Laparoscopic

94. TEP

95. TAPP

96. Open inguinal hernia repair

101. COMPLICATIONS Hernia Recurrence Pain Nociceptive (somatic) pain
is the most common.
result of ligamentous or muscular trauma and inflammation
reproduced with abdominal muscle contraction
Neuropathic pain occurs as a result of direct nerve damage or entrapment
Visceral pain refers to pain conveyed through afferent autonomic pain fibers. It is usually poorly localized and may occur during ejaculation as a result of sympathetic plexus injury.

102. COMPLICATIONS Cord and Testes Injury ischemic orchitis
caused by injury to the pampiniform plexus and not to the testicular artery
It usually manifests within 1 week of inguinal hernia repair ,enlarged, indurated, and painful testis,
it is almost certainly self-limited
testicular atrophy
Caused by Injury to the testicular artery
which is manifest over a protracted period.

103. Injury to the vas deferens within the cord may lead to infertility
Urinary Retention.
Ileus and Bowel Obstruction
Visceral Injury.(Lap)
Vascular Injury
Hematomas and Seromas

104. The ilioinguinal nerve
arise from (L1).
enter the inguinal canal and exits through the superficial inguinal ring
It supplies somatic sensation to the skin of the upper and medial thigh.
In males, it also innervates the base of the penis and upper scrotum.
In females, it innervates the mons pubis and labium majus

105. The ilioinguinal nerve

106. The ilioinguinal nerve

107. iliohypogastric nerve
arises from T12–L1.
it courses between the internal oblique and transversus abdominis, supplying both

109. The genitofemoral nerve
Arises from L1–L2
courses along the retroperitoneum, and emerges on the anterior aspect of the psoas.
divides into genital and femoral branches.
The genital branch enters the inguinal canal lateral to the inferior epigastric vessels
Exit through the superficial inguinal ring and supplies the ipsilateral scrotum and cremaster muscle.
In females, it supplies the ipsilateral mons pubis and labium majus. The femoral branch courses along the femoral sheath, supplying the skin of the upper anterior thigh