1. Hernia
Kufa university
D.H. Zaini
4th stage
Lecture -5-

2. Direct
Hernia
. occur between 10-15% of inguinal hernia , half of them bilateral. . Always acquired. . The sac passes through weakness or defect of transversalis fascia in post . wall of canal . . Often pt. has poor abdominal musculature as shown by presence of elongated bulging called “malgaigne’s bulgings . . Woman never develop direct hernia practically (by brown). . Predisposing factors . Chronic cough . Heavy work (heavy lifting) . Damage to ileoinguinal N. mainly in previous appendicectomy (motor branch) lead to weakness of conjoined tendon .

3. Rarely large enough to descend to scrotum , not attain a large size
. Rarely large enough to descend to scrotum , not attain a large size. . The hernia mass consist mainly of extra peritoneal fat & neck of sac wide & so rarely get strangulation , the sac is smaller than hernia mass. . Prevesical hernia , funicular direct hernia pass through small defect in conjoined tendon (apponeurosis of 2 muscles int. oblique & tansversus ) . . Dual or saddle bag or pantaloon hernia means there is both direct & indirect hernia & usually seen intra operatively .

4. The most medial to inf. epigastric A. is direct & most lat. to A
The most medial to inf. epigastric A. is direct & most lat. to A. is indirect hernia.
This is most common cause of true or false recurrence.
. Direct inguinal hernia lies behind the spermatic cord.
. Direct ing. H. once treated, it usually not need removal of sac & only retained it ‘s content & herniorrhaphy & no herniotomy .
. But sometime in very large sac that it’s returned into peritoneal cavity difficult so may need herniotomy.
. Strangulation occur rarely because of wide neck but occur especially in pt. wearing a truss that are unfit for anesthesia or refuse surgery.

5. . Constricting agents in strangulation:-
- neck of sac.
- external ring in children.
- Rarely adhesion within the sac.
. Rx. Should be urgently (of strangulated hernia) because strangulation within short time may develop septicemia.
IV. Fluid.
Analgesia & sedation & AB.
NG tube for gastric decompression to prevent vomiting & inhalation pneumonia.
Urethral catheterization due to full bladder from volume over load.

6. .Recurrence a)) true recurrence
- within 1st 2 yrs.
- same hernia return on
b)) false recurrence
there is other type of hernia that is over looked .
Exp:- direct & indirect, femoral with inguinal.
. To prevent recurrence remove spermatic cord as it is barrier & called complete excision of cord & testes & complete closure of canal.
. Operation motioned above
. Complication (for herniorrhaphy mainly )

7. General. Retention. Respiratory. Cardiovascular & thromboembolic
* General . Retention . Respiratory . Cardiovascular & thromboembolic * Local 1- wound sepsis mainly due to poor & septic technique or towel may not so aseptic. 2- hematoma, bruising 3- lymphocele specially after repair of femoral hernia 4- wound sinus when foreign mesh T. used for repair that continually discharging. 5- division of spermatic cord especially in infancy because it is very thin &small 0.2,mn

8. 6- testicular ischemia especially after large or recurrent repair 7- testicular atrophy because of ischemia & pressure effect 8- hydrocele 9- nerve genito femoral branch (sensory) entrapment pain, numbness or parasthesia 10- recurrence especially after large hernia

9. Strangulated Inguinal Hernia
. Occur at any time & both sex
. Commonly occur in case of indirect , rarely direct
. Commonly following hernia for long time especially in those wearing truss or in irreducible
. Constrictive agents as mentioned above
Strangulation during infancy
- incidence 4%
- F\M \1 contain ovary or ovary with fallopian tubes
Should be treated urgently
May Rx conservatively by Iv fluid , AB, analgesia, sedation & NG tube with elevation of pelvis or buttock & manual reduction without vigorous manipulation.
Strangulated Inguinal Hernia

10. Note conservative Rx & manual reduction used with caution in adult
Note conservative Rx & manual reduction used with caution in adult * Vigorous manipulation 1- contusion or rupture of intestinal wall 2- reduction en masse this mean that mass with obstructing agents &sac become intraperitonealy complain continue not relieve 3- reduction into a loculus of a sac 4- ruptured of sac & passed into extra peritoneal space

11. (Hernia-en-glissade). Is a result of slipping of post
... (Hernia-en-glissade) . Is a result of slipping of post. parietal peritoneum on underlying retro peritoneal structure . Post . wall of sac is not formed of peritonium alone but by:- L. Sigmoid colon & it’s mesentry R. Cecum either side portion of bladder & rarely small intestine (1-2000) . Occur mainly ( almost always) in male & 5\6 on L side . Bilateral sliding hernia is rare . Age > 40 years . Is very large & globular descending well into the scrotum . Should not be treated by truss because part of sac is part of intestine &should be operated by excision of sac &marsupelization . Cecum . appendix or portion of colon wholly in the sac is not a sliding hernia.
Sliding Hernia

12. Third most common type [ incisional is 2nd most common]. 20% of H
. Third most common type [ incisional is 2nd most common] . 20% of H. in woman 5% in men FIM 2\1 . More liable for strangulation it is the initial presentation in 40% of cases because of narrowness of neck & rigidity of canal . Femoral canal is most medial compartment of femoral sheath extend from femoral ring above into saphenous opening below cm 1.25 cm wide at the base which is directed upward .
Femoral Hernia

13. The space contain fat, lymph v. , L. N. of cloquet
. The space contain fat, lymph v., L.N. of cloquet. . It can not be controlled by truss . The canal is closed above by septum crurale , a conden sation of extraperitonel tissue pierced by lymphatic vessels and below by cribriform fascia. * boundaries Ant. Inguinal lig. post. . ileopectineal lig. (Astley cooper’s lig) . Pubic bone . Fascia over pectinus m . Med. Lacunar lig. Gumbernat ‘s lig. Lat. Femoral vein separated by thin septum. F\M 2\1 female are usually elderly while male from years.

14. Rare before puberty & R. side twice the L. 2:1
. 20% bilateral
. Usually passed unnoticed or may presented with obstruction or strangulation because it is small & it’s under underwear
. Fully distended femoral H. has the shape of retort and it’s bulbous extremity may be above the inguinal ligament , usually irreducible ape to strangulate.

15. DDx ....
1- inguinal hernia the neck above and medial to inguinal ligament.
2- saphena varix has pulse on cough saccular enlargement of large saphenous v with other signs of varix vein, disappear when pt. lie.
3- enlargement of femoral L.N. with infected wound or abrasion
4- lipoma
5- femoral aneurysm
6- psoas abscess fluctuating swelling
7-rupture of adductor longus with hematoma by history
8- distended psoas bursa the swelling decrease when the hip is flexed and there is osteoarthritis of the hip .
. Truss C.I in femoral hernia .

16. * Rx ..... Also there is a laparoscopic approach
Operations of 3 types
1)) High type opening above inguinal lig (Mc Evedy)
2)) low type opening below inguinal lig. (Lockwood)
3)) inguinal approach opening through inguinal canal ( Lotheissen)
in all cases the bladder must be emptied by catheterization.
N .B. Funicular hernia * narrow necked hernia
* operation is usually advised
* contain prevesical fat and portion of bladder
* occurs through a small oval defect in the medial part of conjoined tendon just above the pubic tubercule
* occur principally in elderly men, occasionally strangulated .

17. N. B. Dual hernia. Two sacs that straddle the inf. epigastric A
N.B. Dual hernia . Two sacs that straddle the inf. epigastric A. . The condition is not rare . One of the sacs have been overlooked during operation N.B. Repair of direct hernia is as the indirect except 1- hernial sac can usually be simply inverted after free dissection 2- transversalis fascia is simply reconstructed in front of it * The reconstruction should be done by shouldice repair or mesh implant according to Lichtenstein technique. * Bassini is not acceptable because of high recurrence rate and slow rehabilitation.