1. Hernias
Dr. Gold-Deutch Ruthie

2. H e r n i a -
Protrusion of abdominal viscera outside the abdominal cavity through a
natural or acquired defect (not include internal hernias).

10. Inguinal hernia True incidence of inguinal hernia is not known.
overall incidence in adults %
male / female ratio : 1
25 – 40 years old – 8 %
over 75 years old > 45 %
Children per 1000 live births
High incidence in premature infants
male / female ratio : 1
Almost all are indirect hernias
Direct hernias < 1%

11. Presence of a preformed sac -
Etiology
Presence of a preformed sac -
Patent processus vaginalis prime cause of
indirect hernia in infants and children
Repeated elevations in intra-abdominal pressure -
COPD- coughs
BPH
Constipation / colonic obstruction
Strains
Pregnancy
Ascites
Peritoneal dialysis
Ventriculo-peritoneal shunt

12. High intra-abdominal pressure Weak areas -Ttransversalis fascia
Etiology (cont’)
High intra-abdominal pressure Weak areas -Ttransversalis fascia
Internal inguinal ring 
Direct hernia
Weakening of the body muscles and the tissues with time -
lack of physical exercise, adiposity, multiple pregnancies,
loss of weight as may occur after illness or operation.
Multifactorial
Abnormalities in the structure of collagen - (recurrent
hernias, familial tendency)

13. Clinical manifestations Present at birth or appear afterward
In adults – more insidious
(rapid onset – “acute” indirect hernia following an unusual
exertion)
Discomfort in the groin, small bulge crease when intra-peritoneal
pressure raises - reduces when patient lies down - Reducible hernia
Patient learns to reduce it manually
Early stages – pain
Later - unaesthetic bulge of the groin and scrotum interferes daily
activities and causes a heavy dragging sensation
Adhesions between the sac and content - Irreducible hernia
Incarcerated hernia
Strangulated hernia

16. Examination
Bulge that increases in size with coughing and can be reduced in supine
position (gurgling sound)
Small hernias – when the patient stands, a cough impulse can be felt at
the tip of the finger, introducing it into the inguinal canal through the
external ring by invaginating the scrotum.
Differentiation between indirect and direct hernias is of academic interest only
The true nature of the hernia is revealed at operation and is handled
accordingly.
Incarcerated / strangulated - tense, swollen, tender, red, edematous, inflamed

17. Indications for operation
Risk of hernia operation is negligible, recurrence rate is small that there is hardly any reason not to operate all hernias as soon as they are diagnosed.
Elderly patient should be operated on electively because of the associated medical problems, rather than citing these problems as causes for not operating.
Bassini repair
Shouldice repair
Lichtenstein’s (tension free) repair – polypropylene mesh
Mcvay (cooper’s ligament) repair
Laparoscopic repair – TEPA - Totally Extra-Peritoneal Approach
TAPP - Trans-Abdominal Pre-Peritoneal repair

28. Complications - Systemic complications – urinary retention
Local complications – wound - hematoma, seroma, infection
scrotum and cord – swelling, hematoma
Ischemic orchitis
Testicular atrophy
cut vas deferens
Ilioinguinal neuritis
Open herniorrhaphy Ilioinguinal n. + Iliohypogastric n.
Laparoscopic repair Lateral femoral cutaneus n.
(Meralgia Paresthetica - pain and paresthesias in anterolateral
thigh) + genitofemoral n.
Recurrence – indirect hernia %
direct hernia %
recurrent hernia – 35 %

29. Kinds of hernias Inguinal hernia Femoral hernia Umbilical hernia
Epigastric = Supraumbilical hernia
POVH – post operative venteral hernia
Spigelian hernia
Hiatal hernia
Lumbar hernias
Perineal hernias
Obturator hernia
Paracolostomy = para stomal hernia
Littre’s hernia
Maydle’s hernia
Internal hernia
Richter’s hernia
Sliding hernia

42. Sliding Hernia is defined as one in which a viscus makes up part of the wall of the hernial sac.