1. HERNIA
Presenter:
Golnaz Malekzadeh

2. Defenition:
A hernia is an abnormal weakness or hole in an anatomical structure which allows something inside to protrude through.
It is commonly used to describe a weakness in the abdominal wall.

4. Signs and Symptoms
The signs and symptoms of a hernia can range from noticing a painless lump to the painful, tender, swollen protrusion of tissue that you are unable to push back into the abdomen—possibly a strangulated hernia.

5. Hernias by themselves usually are harmless, but nearly all have a potential risk of having their blood supply cut off (becoming strangulated).
If the blood supply is cut off at the hernia opening in the abdominal wall, it becomes a medical and surgical emergency.

6. Causes of Hernias
Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia.
Obesity
Heavy lifting
Coughing
Straining during a bowel movement or urination
Chronic lung disease
Fluid in the abdominal cavity
Hereditary

7. Complications lordosis Constipation Urine retention
Difficulty in breathing
Compartment syndrome
And ….

8. Types Of Hernia
1. External
2. Internal
3.intermittent

9. Clinical types of Hernia
1. reducible hernia is one in which the contents of the sac return to the abdomen spontaneously or with manual pressure when the patient is recumbent. 2. irreducible hernia is one whose contents or part of contents cannot be returned to the abdomen, without serious symptoms. hernias are trapped by the narrow neck

10. Clinical types , continued…
incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms. strangulated hernia: denotes compromise to the blood supply of the contents of the sac. incarcerated hernia and strangulated hernia are the two stages of a pathologic course Richter’s hernia (intestinal wall hernia ) a hernia that has strangulated or incarcerated a part of the intestinal wall without compromising the lumen. Sliding hernia is one in which the wall of a viscus forms a portion of the wall of the hernia sac. It is may be colon ( on the left), caccum (on the right) or bladder (on either side) . Belongs to irreducible hernia Littre hernia: a hernia that has incarcerated the intestinal diverticulum (usually Meckel diverticulum).

11. Hernia

13. Epigastric Hernia
Occurring between the navel and the lower part of the rib cage in the midline of the abdomen, these hernias are composed usually of fatty tissue and rarely contain intestine.
Men > Women
these hernias are often painless and unable to be pushed back into the abdomen when first discovered.

15. Umbilical Hernia
1- Congenital
2- Adault acquired

16. Congenital Umbelical Hernia
Common in infants
Close spontaneously if <1.5 cm
Repair if > 2 cm or if persists at age 5 years
Repair primarily or with mesh

17. Umbelical Hernia Women > men Risk factors Multiple Pregnancies
Prolonged labor
Ascites
Large Abdominal Tumors-CT scan may be indicated for some patients
Activities which result in strenuous physical activity(occupational or recreational :example weight lifting)

18. Umbelical Hernia repair
Morbitiy and incarceration rate considered to be high enough to warrant repair. One study showed incarceration twice that of femoral hernia .
Unfortunately, recurrence rates as high as % have been recorded.
patients with ascites ???

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40. Spieghelian Hernia

41. Spigelian Hernia
Rare
Hernia through subumbilical portion of semi-lunar line
Difficult to diagnose –Abdominal pain or mass noted in abdominal wall. Frequently tender over area
Clinical suspicion (location)
CT scan
Repair primarily or with mesh

44. Inguinal Hernia
a protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall.

52. Clinical Types of inguinal Hernia
indirect inguinal hernia:
the internal inguinal ring  the inguinal canal  external inguinal ring scrotum
direct inguinal hernia: Hesselbach’s triangle
Pantaloon type

55. Risk Factors Hereditary Smoking CDH Sedentary life style
acquired weakness or defect of abdominal wall
Increased intra abdominal pressure
And ….

56. Differences between indirect and direct hernia
feature
indirect
direct
age
children, young people
aged people
pathway of protrusion
coming down the inguinal canal, may enter the scrotum
pass through Hesselbach’s triangle, rarely enter the scrotum
contours of sac
elliptic, pear-shaped
semispheric, wide base
Relationship of spermatic cord with sac
Posterior to the sac
Anterior and lateral to the sac
Relationship of sac neck with inferior epigastric artery
Sac neck is lateral to it
Sac neck is medial to it
Incarcerated incidence
high
low

57. Physical exam

58. Silk Glove sign
Palpation of hernia sac on spermatic cord

64. Differential diagnosis
lymph node
lipoma
saphenous varicosity
mass

65. surgery complications
Recurrence
Neuralgia
Ilioinguinal
Iliohypogastric
Genitofemoral
Lateral cutaneous
Ischemic orchitis
Injury to vas deference
Wound infection
Bleeding

66. Femoral Hernia

68. Femoral Hernia All are acquired.
Are secondary to an expanded femoral ring.
Probably due to increased intra abdominal pressure
Diagnosis by physical exam.

75. Differential diagnosis
1. indirect inguinal hernia
2. lipoma
3. groin lymph nodes
4. long saphenous varix
5. iliolumbar tuberculous abscess

94. Incisional Hernia
an abnormal protrusion of a viscus through the musculoaponeurotic layers of a surgical scar.
Swelling and mass in the incision
Rarely incarcerate

95. Etiology Operative factors:
- types of incision: vertical incision, transrectus incision, midline incision, standard paramedian incision
- technique of closure
- suture material
Postoperative factors:
- increased intra-abdominal pressure
- Obesity
- Malnutrition
- Smoking
-Immune dificiency

96. Repair Bring together fresh fascial edges after trimming sac
Clean off fascial edges at least 1 cm back
Close with interrupted or continuous sutures
Even with careful technique recurrence rates as high as 50% have been reported

98. Taxis
1- Trendelenberg position 2-morphin+ diazpam 3-ice bag

99. Taxis Contra indications: Fever Lococytosis Positive abdominal sign
Erythema of skin

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