1. Hernias, and Intraperitoneal abscess
Sheng Yan MD, PhD
The First Affiliated Hospital
Zhejiang University

2. General consideration
Definition
Hernia means a sprout, and protrusion.
External abdominal wall hernia is an abnormal protrusion of intra-abdominal tissue or the whole or part of a viscera through an opening or fascial defect in the abdominal wall.
most occur in the groin

3. Historical Hernias
Hernias have been documented throughout history with varying success at either reduction or repair.

4. Trusses & Techniques

6. Camper’s
Scarpa’s Fascia

10. Inguinal canal
Contents: spermatic cord, round ligament, ilioinguinal nerve
anterior: skin, superficial fascia, and external ablique aponeurosis
posterior: transversalis fascia
superior: conjoined tenden
inferior: inguinal ligament
Hesselbach’s triangle
Bounded by the inguinal ligament, the inferior epigastric vessels, and the lateral edge of rectus muscle.

11. scrotum

12. Anatomy

14. Pathological anatomy The hernia composed of:
covering tissue: skin, subcutanous tissue
hernial sac: protrusion of peritonum,
neck of the sac: is narrow where the sac emerges from
the abdomen body of the sac
hernial contents: small intestine, major omentum

15. Etiology 1. intensity of abdominal wall decreased common factors:
1) site that some tissues pass through the abdominal wall, eg. Spermatic
cord, round ligament of uterus
2) bad development of abdominal white line
3) incision, trauma, infection et al.
defect in collagen synthesis or turnover
2. any condition which increases intra-abdominal pressure
chronic cough, chronic constipation, dysuria, ascites, pregnancy, cry

17. Causes of indirect inguinal hernia
1. congenital abnormality of anatomy
due to failure of fusion of the processus vaginalis peritonei after the
testis has descended into the scrotum.
2. acquired weakness or defect of abdominal wall

18. Clinical manifestation and diagnosis
Symptoms: pain, discomfort, dragging sensation
Sign: reducible or irreducible lump, expansive cough impulse
Reducing the hernia fully, compress the internal ring:
be controlled – indirect not controlled -- direct

19. Hernia Exam

21. Differential diagnosis 1 hydrocele of testis translucent test (+)
2 communicated hydrocele
3 hydrocele of cord: not reducible
4 undescended testis
5 acute intestinal obstruction

22. Clinical types
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
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), cecum (on the right) or bladder (on either side).
Belongs to irreducible hernia

23. 3. incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms. 4. 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. Littre hernia: a hernia that has incarcerated the intestinal diverticulum (usually Meckel diverticulum). Reductive incarcerated hernia: reduction of the hernial contents ( intestine ) into abdominal cavity.

24. Sliding hernia
viscera forms a portion of the wall of the hernia sac

25. Richter——intestinal wall
Littre ——intestinal diverticulum

26. incarcerated hernia: is one whose contents cannot be returned to the abdomen, with severe symptoms
Reductive incarcerated hernia

27. 4/21/2017

28. strangulated hernia:
denotes compromise to the blood supply of the contents of the sac

29. Indirect Hernia Route Note:
The hernia sac passes outside the boundaries of Hesselbach's triangle and follows the course of the spermatic cord.

30. Direct Hernia Route Note:
The hernia sac passes directly through Hesselbach's triangle and may disrupt the floor of the inguinal canal.

31. 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
compress the internal ring after reduced
Un-controlled
controlled
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

32. Treatment 1. nonoperative therapy Indications: <1 year old
elderly patients or with severe systemic disease--truss

33. 2, Specific Surgical Procedures
Lichenstein (Tension Free) Repair
Bassini Repair
McVay (Cooper’s Ligament) Repair
Shouldice (Canadian) Repair
Laproscopic Hernia Repair

34. Bassini Repair
Is frequently used for indirect inguinal hernias and small direct hernias
The conjoined tendon of the transversus abdominis and the internal oblique muscles is sutured to the inguinal ligament

35. McVay Repair AKA: Cooper’s ligament Repair
Is for the repair of large inguinal hernias, direct inguinal hernias, recurrent hernias and femoral hernias
The conjoined tendon is sutured to Cooper’s ligament from the pubic cubicle laterally

36. McVay Repair
Note:
This repair reconstructs the inguinal canal without using a mesh prosthesis.

37. Inguinal Lig Conjoint tendon Spermatic cord Ferguson
Repair the anterior wall of the inguinal canal
Inguinal Lig
Conjoint tendon
Spermatic cord
Ferguson repair

38. Shouldice Repair AKA: Canadian Repair
A primary repair of the hernia defect with 4 overlapping layers of tissue.
Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be under tension, leading to swelling and patient discomfort.

39. Lichtenstein Repair AKA: Tension-Free Repair
One of the most commonly performed procedures, using prosthetic materials
A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord

41. Lichtenstein Repair Note:
Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

42. Laparoscopic Hernia Repair
Early attempts resulted in exceptionally high reoccurrence rates
Current techniques include
Transabdominal preperitoneal repair (TAPP)
Totally extraperitoneal approach (TEP)

43. Types of Laparoscopic Inguinal Hernia Repair
IPOM (IntraPeritoneal On-lay Mesh) repair. A mesh is placed intra-abdominally covering the hernia defect and then secured to the abdominal wall. Very popular at the beginning of laparoscopic experience, it has since been abandoned.
TAPP  (Trans Abdominal Pre-Peritoneal) repair. With this technique, the pre-peritoneal space is accessed from the abdominal cavity and a mesh is then placed and secured. This is procedure of choice for recurrent inguinal hernias or in case of incarcerated bowel – visualized.
TEP (Totally ExtraPeritoneal) repair. The mesh is again placed in the retroperitoneal space, but in this case, the space is accesed without violating the abdominal cavity. This is probably the most physiological repair although technically more demanding. The procedure of choice for bilateral inguinal hernia repairs

44. Trochar placement for both TEP & TAPP

47. Laparoscopic Mesh Repair
Note:
Viewed from inside the pelvis toward the direct and indirect sites. A broad portion of mesh is stapled to span both hernia defects. Staples are not used in proximity to neurovascular structures.

48. Femoral ring
Inguinal lig.
Femoral hernia
Cooper Lig.
Femoral V.

50. OPERATION
McVay REPAIR
Direct suture

51. The incision most common for hernia: trans-rectus incision
The major reason for incisional hernia :
incisional infection 50%
Incisional Hernia

52. Poor nutritional status

53. Incision hernia

54. Incision hernia

57. Intraperitoneal abscess

58. Gross: Supra-mesocolic spaces: falciform lig.
Right sub-phrenic space: suprahepatic space / infrahepatic space
Left subphrenic space: - space bet. left lobe of liver & stomach
- lesser sac

59. Gross: Infra-mesocolic spaces:
Right lateral paracolic / right medial paracolic gutter
Left medial paracolic / left lateral paracolic gutter

60. ANATOMY: Microscopic: Gross: Mesothelium – 1.8 m2
Mesothelial cells (cuboidal cells/flattened cells)
Stomata
Basement membrane
Connective tissue (collagen, elastic fiber, fibroblast, adipose, endothelial cells, mass cells, machrophage).
Gross:
Intra-abdominal area: (intraperitoneal / retroperitoneal)
Intra-peritoneal Space – defined by mesothelial membrane
a. visceral peritoneum
b. parietal peritoneum

63. Thanks
Welcome questions!