1. HERNIAS MOSTAFA ABOU ALI PROFFESSOR OF SURGERY QASSIM UNIVERSITY
FACULTY OF MEDICINE

2. HERNIAS..DEFENITIONS
Hernia is a protrusion of an organ through the wall that normally contains it
The wall can be the abdominal wall, muscle fascia, diaphragm or foramen magnum.
Hernias can be congenital or acquired
Abdominal wall hernias are common
Account for approximately 10% of general surgical workload
Types Inguinal 73% femoral 17% umblical 8.5 % rare forms 1.5% ( incisional hernia is excluded.)

3. A HERNIA CONSISTS OF:
A sac
 Its coverings
Its contents ( all abdominal viscera
except liver and pancreas).

4. ABDOMINAL REGIONS WHERE HERNIAS OCCUR

5. HERNIAS…ETIOLOGICAL FACTORS
Acquired hernias:
Increased intra-abdominal pressure (e.g. straining or lifting )
Abdominal weakness (e.g. advancing age or malnutrition)

6. ANATOMY OF THE INGUINAL CANAL
Anterior border is the external oblique aponeurosis
Posterior border is the transversalis fascia
Inferior border is the inguinal ligament
Superior border is the conjoint tendon - the lower fibers of internal oblique and transversus abdominis

7. ANATOMY OF INGUINAL CANAL
Inguinal canal lies between the superficial
and deep inguinal rings
Deep ring lies deep to the mid-inguinal point Mid-inguinal point is half way between symphysis pubis and anterior superior iliac spine
Not the midpoint of the inguinal ligament
In men it contains vas deferens and testicular artery and veins
In women it contains the round ligament

12. INGUINAL HERNIAS…INCIDENCE.
3% adults will require operation for inguinal hernia
Male : female ratio is 12:1
Elective : emergency operation 12:1
Peak incidence is in the 6th decade
65% inguinal hernias are indirect
In females inguinal hernias are as common as femoral hernias

13. OBLIQE INGUINAL HERNIA
(I) Congenital theory :
Due to persistence of all or part of
processes vaginalis .
(II) Acquired theory :
Due to deficiency of factors (shutter
mechanism) which prevent herniation.

14. What is an Indirect Hernia?
Deep ring
Congenital or acquired weaknesses in TF
Location: lateral to deep epigastric vessels
Protrude through deep inguinal ring; may descend into the scrotum
Men

15. DIRECT INGUINAL HERNIA
Acquired weaknesses in TF
Location: Hesselbach’s
Emerge between the deep epig. artery and rectus abd. muscle and protrude into the ingu. canal but not into the SC.
More difficult to repair?!
Men

16. FACTORS PREVENTING HERNIATION
1- Oblique coarse of the inguinal canal .
2- Contraction of conjoint tendon during
coughing or straining (shutter mechanism) .
3- Contraction of cremasteric muscle :
Plugging of inguinal canal

17. CLINICAL FEATURES
Irreducible hernias have either a narrow neck or the contents adhere to the sac wall
Obstructed hernias contain obstructed but viable intestine
Strangulated hernias when the venous drainage from the sac contents is compromised

18. CLINICAL FEATURES Lump at an appropriate anatomical site
Increases in size on coughing or straining.
It reduces in size or disappears when relaxed or supine position.
Examination may show it to have a cough impulse and to be reducible

19. QUESTIONS MUST BE ANSWERED AT THE END OF GENERAL AND LOCAL EXAMINATION
1- Hernia or not ?
2- Rt or Lt ?
3- Is it inguinal or femoral ?
4- Is it direct or oblique ?
5- What is the content ?
6- Recurrent or not ?
7- Complicated or not ?
8- what is the predisposing factors ?

20. HERNIAS…COMPLICATIONS
Reducible
Irreducible
Obstructed or incarcerated
Strangulated

21. D.DIAGNOSIS of OIH 1- Other hernia direct inguinal hernia
femoral hernia
2- Hydrocele congenital & infantile
encysted hydrocele of the cord
3- Ectopic or undescended testicle
4- Psoas abscess
5- Inguinal adenitis
6- Endemic funiculitis
7- Lipoma of the cord

22. COMPLICATIONS Obstruction Irreducible abdominal pain,
distension and vomiting may occur
The hernia will be tense tender and irreducible
Strangulation
become red and tender,
No impulse on cough.
If contains bowel signs of obstruction.

23. Rt. INDIRECT ING. HERNIA

24. Ex. Ring Test?

25. INTERNAL RING TEST

26. HUGE LONG STANDING IDIH

27. COMPLETE
INDIRECT INGUINAL HERNIA

28. INGUINAL HERNIA REPAIR
RATIONALE
TENTION FREE REPAIR
MESH REPAIR

29. HERNIA…REPAIR
Irrespective of approach used the following will be achieved
Dissection of the sac
Reduction / inspection of the contents
Ligation of the sac
Approximation of the inguinal and pectineal ligaments

30. INGUINAL HERNIA.TYPES OF REPAIR
Bassini repair : Suturing conjoined tendon to inguinal ligament behind the cord .
Lytle repair: Plication of the fascia transversalis .
Shouldice repair : incision of the fascia & double breasting of it .
Halsted ‘s repair Bassini repair plus reinforced by suturing the 2 leaflets of external oblique together behind the cord

31. INGUINAL HERNIA.TYPES OF REPAIR
Tanner’s repair: add to the repair a releasing incision in the rectus sheath to in avoid tension suture line
Blood good’s repair: triangular flap of ant rectus sheath wall is turned downward behind its lateral border and sutured to the inguinal ligament .

32. INGUINAL HERNIA.TYPES OF REPAIR
Shouldice or Liechtenstein now regarded as 'gold standard' as judged by low risk of recurrence
Laparoscopic hernia repair:
Should be reserved for bilateral or recurrent hernia

33. STRENTHENING OF THE POSTERIOR WALL OF TH ING. CANAL
SPERMATIC CORD
STRENTHENING OF THE POSTERIOR WALL OF TH ING. CANAL

35. INCESION
INDIRECT INGUINAL HERNIA MESH REPAIR

36. Hernia Sac
Vas Deference

37. Hernia Sac Twisted
Spermatic Cord with the Vas

38. Preparation of the Mesh for Mesh Repair

39. Right direct inguinal hernia, the sac was coming from the posterior wall of the inguinal canal. The cord is elevated separate from the sac.

40. Left direct inguinal hernia. the sac is separated from the cord.

41. direct inguinal hernia, the sac was fully reduced
Spermatic Cord

42. The superior edge of the mesh was tacked down to the aponeurosis or muscle of the internal oblique with a few interrupted sutures.
Mesh in place and fixed

43. Laparoscopic Trans-abdominal pre-peritoneal prosthetic Fixation.
Mesh in Place
Spermatic Cord

44. Peritoneal closure on the pre-peritoneal mesh

45. MORTALITY OF ELECTIVE HERNIA REPAIR
The mortality of elective hernia repair increases with age

46. MORTALITY OF STRANGULATED HERNIA REPAIR
10% patients with strangulation give no previous history of a hernia
The peak incidence of hernia strangulation is approximately 80 years
In those with acute onset of a hernia the greatest risk is in the first 3 months
Risk of strangulation depends on type of hernia
- Femoral is approximately 40%
- Direct inguinal is approximately 3%

47. MORTALITY OF STRANGULATED HERNIA REPAIR
The mortality of surgery for strangulated hernias has changed little over the past 50 years
Operative mortality remains at approximately 10%
Is ten times greater than that following an elective repair
Risk of death is dependent on:
-Age
-Presence of necrotic bowel requiring
resection

48. COMPLICATIONS OF HERNIA SURGERY
Urinary retention
Scrotal haematoma
Damage to the ileoinguinal nerve
Ischaemic orchitis
Recurrent hernia

49. TRUSSES 40000 sold annually in UK
20% purchased prior to seeing a doctor
45% have no instruction on fitting
75% fit whilst standing up!

50. RECURRENT INGUINAL HERNIA
Recurrence rate varies with herniorrhaphy technique and duration of follow up
With Bassini and darn repairs may be as high as 20%
With Shouldice and Lichtenstein repairs recurrence rates <1% have been reported

51. RECURRENT INGUINAL HERNIA
Factor involved in recurrence include:
- Inadequate preoperative selection
- Type of hernia
- Type of operation
- Postoperative wound infection

52. RECURRENT HERNIA REPAIR
Recurrent hernias should be repaired using a mesh technique
Can be performed as either an open or a laparoscopic procedure
Patients should be consented for a possible orchidectomy

53. FEMORAL HERNIAS…INCIDINCE.
Account for 7% of all abdominal wall hernia
Female : male ratio is 4:1
Commonest in middle aged and elderly women
Rare in children
More common in parous

54. ANATOMY OF THE FEMORAL CANAL
Anterior border is the inguinal ligament
Posterior border is the pectineal ligament
Medial border is the lacunar ligament
Lateral border is the femoral vein

58. FEMORAL SHEATH AND CANAL WI TH RELATIONS OF CONTENTS

59. Pubic Tubercle
Right Femoral Hernia

60. FEMORAL HERNIA…REPAIR
All uncomplicated femoral hernias should be repaired as an urgent elective procedure
Three classical approaches to the femoral canal have been described
Low (Lockwood)
Transinguinal (Lotheissen)
High (McEvedy)

61. SPECIAL TYPES OF HERNIA
Richter's hernia
Partial enterocele
presents with strangulation and obstruction

62. SPECIAL TYPES OF HERNIA
Maydl's hernia
W loop strangulation, Strangulated
bowel within abdominal cavity
Litter's hernia Strangulated Meckel's
diverticulum Can cause small bowel
fistula

63. CONGENITAL INGUINAL HERNA
Presence of an PATENT processes vaginalis .
The hernia reaches down to the bottom of the scrotum.
The testis lies among the contents of the sac
Although congenital , it may appear in adult life .
Herniotomy can be performed at any age provided a skilled anaesthetist and surgeon are available.

64. Incarcerated Congenital Inguinal Hernia

65. LEFT CONGENITAL INGUINAL HERNIA

66. SUBCUTANEIUS HERNIOTOMY
DISECTED SAC
VAS DEFRENCE

67. VD

68. TRANSFEXSION LIGATION AT THE NECK

69. Wound Closure With Subcuticulr Fine Sutures
Previous Rt. H Repair

70. CONGENITAL UMBLICAL HERNIA OXOMPHALUS MINOR

71. Infantile Umblical Hernia
Due to week umblical scar
Repair is not urgent as it can close spontaneously
If persist or became more wide, repair at 2y age.
Very rare to be complicated
Just remove the granuloma
No truss

72. ADULT AQUIRED PARAUMBLICAL HERNIA
PATIENT IS STRAINING

73. HUGE VENTRAL HERNIA
WITH PENDULUS ABDOMEN

74. HUGE VENTRAL HERNIA
WITH PENDULUS ABDOMEN