1. HERNIAS Dr David Swar General Surgery Qilu Hospital Shandong University

2. Definition A hernia is the protrusion of an organ through its containing wall.

3. Composition of a hernia 1. The sac 2. The covering of the sac 3. The content of the sac

4. Composition of a hernia 1. The sac : It is a diverticulum of peritoneum and is made up of three parts : The mouth, The neck and The body of the sac.

5. Composition of a hernia 2. The covering: Coverings are derived from the layers of abdominal wall through which the sac pass 3. Contents: can be Omentum = omentocle Intestine = enterocele Portion of circumference of intestine = Richter’s hernia Portion of the bladder Ovary(with or without oviduct) Meckel’s diverteculum =Littre’s hernia

6. Etiology Hernias occur at sites of weakness in the wall This weakness may be : Normal (physiological) weakness, related to the anatomical causes. Congenital abnormality. Acquired : Traumatic Diseases

7. Varieties A hernia at any site may be: 1. Reducible This is the one which the contents of the sac reduced spontaneously or can be pushed back manually. A reducible hernia imparts an expansile impulse on coughing. 2. Irreducible This one whose contents cannot be returned to the peritoneal cavity either because there are: adhesions between the sac and contents, or because of the narrow neck of the sac.

8. Varieties Irreducible hernia can be : 1. Incarcerated: there are adhesions between the sac and the contents, but there is no obstruction or interference with blood supply. the hernia simply will not reduce 2. Obstructed: a hollow viscus is trapped within the sac and obstruction occurs. The blood supply remains intact. This is a common cause of small bowel obstruction. 3. Strangulated: the arterial blood supply to the contents of the sac is compromised, in such a hernia unless surgical relief is undertaken the contents of the sac will become gangrenous.

10. Classification A. External hernia B. Internal hernia

11. Classification continue… A. External hernia Common hernia inguinal Femoral Umbilical incisional

12. Classification continue… A. External hernia Rare hernia Spigelian Gluteal Obturator lumbar

13. Classification continue… B. Internal hernia Diaphragmatic hernia Esophogial hernia Paraesophogial hernia

14. Signs and Symptoms - A lump disappears, reappears, and enlarges on straining and discomfort. Physical Signs: Reduced. + ve cough impulse. Investigation: Hernia is diagnosed clinically. Investigations are rarely indicated or valuable.

15. Management Treatment: hernias should be operatively repaired both to relieve symptoms and to eliminate the complications. Surgical techniques: Herniotomy: removal of sac and closure of its neck. Herniorrhaphy: involves some sort of reconstruction to: Restore the anatomy if this is disturbed. Increase the strength of the abdomenal wall. Construct a barrier to recurrence.

16. Inguinal hernia Epidemiology: Male : Female by 9 to 1 ratio young adults mostly have indirect inguinal hernia. As age of patient increases, the incidence of direct hernias increases.

17. Inguinal hernia Risk factors: ( increases intra-abdominal pressure ) Chronic cough. Constipation. Pregnancy. Straining at micturation. Severe muscular effort (lifting heavy objects). Ascites - fluid may increase the size of an existing sac.

18. Inguinal hernia Inguinal Canal Anatomy Anterior wall: aponeurosis of external oblique (along entire length), internal oblique on lateral one third Posterior: fascia transversalis conjoint tendonon in medial one third Roof: arching fibers of internal oblique,and transversus abdominis Floor (inferior): inguinal ligament, and lacunar ligamen at the medial end

19. Inguinal hernia Inguinal Canal Contents: Male: Spermatic cord structures : vas deferens, testicular artery testicular veins (pampiniform plexus), genital branch of genitofemoral nerve, artery of the vas deference, lymphatics, autonomic nerves, processus vaginalis. Ilio inguinal nerve Female: Round ligament of the uterus, genital branch of genitofemoral nerve, lymphatics, sympathetic plexus.

20. Inguinal hernia Signs & symptoms: Bulge that enlarges when stand or strain, but often asymptomatic. In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate. On examination: Palpable defect or swelling may be present. Internal Inguinal Ring. Indirect Hernia usually bulge at Internal Inguinal Ring. External Inguinal Ring. Direct Hernia usually bulge at External Inguinal Ring.

21. Inguinal hernia There are two types of inguinal hernia: Direct inguinal hernia Indirect inguinal hernia

22. Differences between direct and indirect hernias 1. Origin and coarse: Direct: Develops in the area of Hasselbach's triangle. The origin is medially to the inferior epigastric vessels. Indirect: Develops at the internal ring. The origin is lateral to the inferior epigastric artery. 2. Content: Direct: Retroperitoneal fat. less commonly, peritoneal sac containing bowel. Indirect: Sac of peritoneum coming through internal ring, through which omentum or bowel can enter. 3. Etiology: Direct: weakness of the posterior floor of the inguinal canal (acquired). Indirect: patent processus vaginalis (Congenital).

23. Differences between direct and indirect hernias Boundaries of Hasselbach's triangle: Medially: lateral border of rectus abdominis. Laterally: inferior epigastric vessels. Inferiorly: inguinal ligament.

24. Inguinal hernia Differential diagnosis: 1. Tendonitis 2. Muscle tear 3. Lymphadenopathy 4. Lipoma 5. Varicose vein 6. Hydrocele 7. Epididymitis 8. Spermatocele

25. Inguinal hernia Complications: Irreducibility, but without signs of obstruction or strangulation Small Bowel Obstruction, Usually urgent surgical repair Strangulation, Surgical emergency 50% indirect, 3-10% direct.

26. Inguinal hernia Management: Inguinal hernias should always be repaired ( herniotomy, herniorrhaphy ) unless there are specific contraindications. Types of operations: 1. a permanent sutures, as in Shouldice repair (layered suture). 2. a permanent mesh -greater frequency to decrease tension.

27. Inguinal hernia management Treatment of aggravating factors (chronic cough, prostatic obstruction, etc). Use of truss (appliance to prevent hernia from protruding) when a patient refuses operative repair or when there are absolute contraindications to operation

28. Inguinal hernia Both types (direct and indirect inguinal hernia) may occur at the same time and straddle the inferior epigastric artery. This is called: Pantaloon hernia

29. Femoral hernia The defect is in the transversalis fascia overlying the femoral ring at the entry to the femoral canal. The hernia passes through the femoral canal and presents in the groin, below and lateral to the pubic tubercle. It is more common in females and carries a higher risk of strangulation. Femoral canal-ant.by inguinal ligament,post by fascia over pectineus muscle,lat. by femoral vein n medial by lacunar ligament

30. Femoral hernia Signs & symptoms: A lump occurs below and lateral to the pubic tubercle. It may be reducible. It may not be noticed until it becomes tender and painful. This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstruction without an obvious cause. DD’s-saphena varix,enlarged inguinal LN,femoral artery aneurysm,rare femoral abscess.

31. Femoral hernia Surgical repair: An incision is made directly over the swelling. The sac is opened and the contents reduced and the sac removed. Femoral canal obliterated with 3 interrupted non absorbable suture. Treatment of strangulation or obstruction, if present. There is no place for a truss in the treatment of femoral hernia.

32. Femoral hernia

33. Umbilical hernia This occurs in children because of incomplete closure of the umbilical orifice. The majority close spontaneously during the first year of life. Surgical repair should only be carried out if the hernia has not disappeared by the age of 3 and the fascial defect is greater than 1.5cm in diameter.

34. Para-Umbilical hernia It occurs just above or just below the umbilicus, and is more common in obese females. Predisposing factors multiple pregnancies and obesity.

35. Para-Umbilical hernia The neck of the sac is usually narrow and therefore there is a high risk of strangulation. The most common content is omentum,then transverse colon and small intestine. Treatment: is by Contents of sac freed from it’s wall,excision of the sac, and fascial defect repaired by Upper flap overlapping the lower,a two layer overlapping repair thereby doubling the strength of repair (Mayo repair) >4 cm,recurrent-polypropylene mesh

37. Epigastric hernia This is usually a small protrusion through the linea Alba in the upper part of the abdomen. It consists of : extraperitoneal fat only, but May contain omentum or small bowel.

38. Epigastric hernia It may be extremely painful, probably because of trapping and ischaemia of extraperitoneal fat. Treatment is by enlaging the defect,excising the fat, simple suture of the defect with non-absorbable sutures. >4 cm propylene mesh placed retromuscular plane

39. Incisional hernia This occurs through a defect in the scar of a previous abdominal incision.

40. Incisional hernia Etiology : Age: Wound healing is poor in the older patient. Obesity. Postoperative wound infection. Postoperative wound haematoma. Raised intra-abdominal pressure postoperatively, e.g. coughing, straining, constipation, ileus. Steroid therapy. Type of incision: Midline vertical wounds have a higher incidence than transverse incisions. Poor suturing technique: Rarely does a suture break

41. Incisional hernia Sign & symptoms : A swelling protrudes through the wound. It May occur up to 5 years postoperatively. Many are large and involve the whole incision and consequently the neck of the sac is wide and the risk of strangulation rare. If the defect is small there is a greater risk of strangulation. Treatment-palliative-abd.belt - preoperative measures-reduce weight,treat cough,improve nutritional status.stop smoking. -surgery:excision of sac,identification n apposition, -large hernia-poly propylene mesh,

42. Richter’s hernia Part of the wall of the intestine becomes trapped in the defect. This is usually the antimesenteric border of the small bowel. The lumen is intact ( no obstruction )

43. Diaphragmatic hernia  Traumatic: rare and followed by injuries to chest and abdomen. The Lt diaphragm is affected more than Rt and is accompanied by herniation of stomach and spleen.  Hiatus: 1.Sliding. 2.Para-esophegial.

44. Diaphragmatic hernia Sliding: in which the gastroesophogeal junction itself slides through the defect into the chest.

45. Diaphragmatic hernia Para-esophageal in which the junction remains fixed while another portion of the stomach moves up through the defect. This can be dangerous as they may allow the stomach to rotate and obstruct.

46. Hiatus hernia

47. Some other hernias Spigelian hernia: This is a hernia through the linea semilunaris at the lateral border of the rectus sheath. Littre's hernia: A hernia that contains a Meckel's diverticulum in the sac. Obturator hernia: This hernia occurs through the obturator foramen. It is commoner in elderly females. Lumbar herniae: These occur in the lumbar region (below the 12th rib & above the iliac crest).

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