1. Abdominal wall hernias

2. Abdominal wall hernia
Hernia is an abnormal protrusion of the whole or a part of viscus through an opening in the wall of the cavity.
Types:
External
Internal

3. Aetiology Increased abdominal pressure
Cough, urinary trouble, constipation, straining, ascites, intraabdominal malignancy.
Weakness of abdominal musculature :
Congenital sacs as processes vaginalis, patent canal of nuck in females
Acquired
Excess fat (obesity)
Muscle weakness following pregnancy
Surgical incisions – Nerve damage, Improper repair
Destruction of connecting tissue as smoker, Marfan’s syndrome
Familial

4. anatomical abnormalities
INTRODUCTION
 high insertion of the internal oblique muscle
 widening of the internal inguinal ring
 persistency of the vaginal peritoneum conduct
anatomical abnormalities +
 intra-abdominal pressure
ETIOPATHOGENY
Rev Col Bras Cir 1976;3(2):66-80.
Clin North Am 1998;78:

5. INTRODUCTION HERNIOGENESE COLLAGEN proportion type I and III quantity
deficiency
quantity
FASCIA
TRANSVERSALIS
HERNIOGENESE
Ann Surg 1993;218:
Eur J Clin Invest 1997;27:863-8.

6. Parts of the hernia 3 parts Sac Contents Covering of sac mouth neck
Body
Fundus

7. Contents Omentum - Omentocoel / epiplocele Intestine - Enterocoel
Bladder - Cystocoel
Part of Intestine - Richter’s
W type intestine - Maydl’s Hernia
Meckel’s diverticulum - Littre’s hernia

8. Common hernias
Inguinal (indirect or direct), Femoral, Umblical, Incisional
Epigastric,
Rare Hernias:
Lumbar, Spegilian, Obturator

9. Hernia sites

10. Some terms related to hernia
Reducible - Reducibility, cough impulse
Irreducible - Irreducible, impulse –ve
Obstructed - irreducibility intestinal obstruction
Strangulated - irreducibility + obstruction arrest of blood supply
Inflammed

11. Causes of irreducibility
adhesions of content to each other
adhesions of content with the sac
adhesions of one part of sac to other part
narrowed neck of sac

12. INGUINAL HERNIA

13. Epidemiology
The majority of abdominal wall hernias occur in the groin, totaling approximately 75% of the total incidence.
majority of inguinal hernias occur in males
Of inguinal hernia repairs, 90% are performed in males and 10% in females.
Approximately 70% of femoral hernia repairs are performed on female patients
females undergo nearly five times the number of inguinal hernia repairs as femoral hernia repairs
The most common type of groin hernia presenting in females remains the indirect inguinal hernia.

16. Anatomy of Inguinal Canal
4 cm in length from deep to superficial ring.
Deep ring is ‘U’ shaped in fascia transversalis which lies 1.25 cm above the mid inguinal point.
Superficial / External ring is in external oblique aponeurosis situated just above and lateral to crest of pubis.
Passes downward and medially from deep ring to superficial ring.

17. Anatomy of inguinal canal
Boundaries of inguinal canal
Ant : External oblique aponeurosis and few fibres of internal oblique laterally
Post : Fascia transversalis and conjoined tendon
Superior : Arched fibres of conjoined tendon
Inferior : Inguinal ligament

18. Anatomy Contents of inguinal canal
Spermatic cord, ilioinguinal nerve, genital br. of genitofemoral nerve.
Round ligament in females.
Vestigial remnant of processes vaginalis.

20. HASSELBACH TRIANGLE Hasselbach triangle inferior epigastric vessels
abdominal rectus muscle
Hasselbach triangle
inguinal ligament
internal inguinal ring

22. INGUINAL HERNIA
Types:
Indirect
Direct
Combined (Pantaloon)

23. Classification

24. Direct Inguinal Hernia

25. Clinical Features Swelling Dragging pain Features of complication
H/o increased abdominal pressure
Symptomless discovered accidentally

26. Examination Inguino scrotal swelling Expansile cough
Cannot get above the swelling
Reducibility
Finger Invagination Test
Deep Ring occlusion Test

27. (finger Invagination test)
Inguinal hernia
External ring test
(finger Invagination test)

28. Enterocoel vs. Omentocoel
Visible peristalsis
Consistency
Reduction of contents
Percussion Note
Bowel sounds

29. Differential Diagnosis of Inguinal Hernia
Inguinoscrotal swelling
Encysted hydrocoel of cord, varicocoel, lymph varix, funiculitis, lipoma of cord, torsion of testis, retractile testis
Groin swelling
Femoral hernia, sephana varix, enlarged nodes, psoas abscess, psoas bursa, undescended testis, ectopic testis, lipoma, aneurysm

30. Diagnosis
History
Physical Examination
Imaging (US, CT, Herniography)

31. Herniography Suspected hernia, but clinical diagnosis is unclear
Procedure done under flouroscopy following injection of contrast medium
Frontal and oblique radiographs are taken with and without increased intra-abdominal pressure

32. Complications Irreducibility : Dull aching pain / irreducible
Obstructed : irreducible + obstruction to lumen of bowel. Features of intestinal obstruction
Strangulated : irreducible + obstruction + impairment of blood supply. Tense / Tender / Toxic

33. Treatment
Surgical
Watchful waiting for elderly pt. with small asymptomatic hernia
Truss !!!!!!

34. Surgery Herniotomy: Excision of hernia sac, sufficient in children
Herniorrhaphy:
Bassini’s Repair
Shouldice Repair
Mc Vay
Preperitoneal
Hernioplasty : Lichtenstein, Mesh graft application
Laparoscopic Repair
TEP / TAPP

35. Bassini’s repair Bassini (early 20th Century) EDUARDO BASSINI
Transversus abdominis and internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligament
EDUARDO BASSINI

36. Shouldice repair Shouldice (1930s)
Multilayer imbricated repair of the posterior wall of the inguinal canal

37. Mc Vay repair
McVay (1948)
Edge of the transversus abdominis aponeurosis to Cooper’s ligament; incorporate Cooper’s ligament and the iliopubic tract (transition suture)

38. Lichtenstein repair
First pure prosthestic, tension-free repair to achieve low recurrence rates

39. Types of Prosthesis Polypropylene mesh most common and preferred
allows for a fibrotic reaction to occur between the inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closure of the hernia defect
Polytetrafluoroethylene (PTFE) mesh
often used for repair of ventral or incision hernias in which the fibrotic reaction with the underlying serosal surface of the bowel is best avoided

40. Hernia mesh

41. Laparoscopic repair

42. Conservative treatment
Trusses can provide symptomatic relief

43. Treatment Algorithm

44. Complications

45. Different Types of Indirect Inguinal Hernia
Sliding Hernia (Hernia en glissade)
Richter Hernia : Part of Bowel
Littre’s hernia : Meckel’s diverticulum
Pantaloon Hernia : Both Direct and Indirect Hernia
Maydl’s hernia: a few segment of bowel
Amiand’s hernia: hernia contains the appendix

46. Spigelian Hernias Lateral ventral hernia
Junction of vertical semilunar line and horizontal semicircular line (arcuate line)
This rare hernia occurs along the edge of the rectus abdominus muscle, which is several inches to the side of the middle of the abdomen.
90% located cm above anterior superior iliac spine
Sharp pain, swelling, easily reducible
20% present with incarceration
median age = 50 years
more common in males and on (R)
Rare PE
Difficult to diagnose
U/S or CT can aid in diagnosis
Treatment:
Repair primarily or with mesh

47. Lumbar Hernia Congenital, spontaneous or traumatic
Grynfeltt’s triangle
12th rib, internal oblique and sacrospinalis muscle
Covered by latissimus dorsi
Petit’s triangle
Latissimus dorsi,
external oblique and
iliac crest
Covered by superficial
fascia

48. Pelvic Hernia Obturator hernia Most commonly in women Sciatic hernia
Perineal hernia

49. Parastomal Hernia Variant of incisional hernia
Paracolostomy > paraileostomy
Low rate if through rectus muscle
Traditionally relocate stoma, repair defect
Concern for mesh erosion
Laparoscopic/open repair

50. Incisional Hernia Risk factors Technical Wound infection Smoking
Hypoxia/ ischemia
Tension
Obesity
Malnutrition
Laparoscopic vs. open repair

51. Epigastric Hernia Incidence 1-5% Men> women
Pre-peritoneal fat protrusion through decussating fibers at linea alba
Between xiphoid and umbilicus
20% multiple
Repair primarily

52. Femoral Hernia

53. Anatomy of femoral triangle
Anatomy of Femoral Canal
Closed above by femoral septum and on lower side – cribriform fascia
Most medial compartment of femoral sheath
Extends from femoral ring to sephanous opening below
1.25 cm long and 1.25 cm wide at base
Contents : fat, lymphatic, lymph node of Cloquet
Oval opening ½” in diameter bounded
Anteriorly - Inguinal ligament
Posteriorly- Iliopectineal ligament, pubic bone and fascia over pectineus muscle
Medially - Lacunar ligament
Laterally - Septum separating form femoral vein

54. Femoral Hernia
Clinical features : More in females, age >50, Rt. Side 70%, bilateral 20%
Covering of femoral hernia :
Skin, superficial fascia, cribriform fascia, anterior layer of femoral sheath, fatty contents of femoral canal, femoral septum, peritoneum

55. Differential diagnosis of Femoral Hernia
Inguinal hernia, sephano varix, lymph
node, lipoma, Aneurysm, Psoas abscess,
psoas bursa, Ruptured adductor longus

56. Operation for Femoral Hernia
Low (lockwood) Inguinal ligament to Ileopectineal line
High (McEvedy) conjoint tendon to ileopectineal line. For strangulated hernia
Lotheissen (Through inguinal canal) conjoint tendon or inguinal ligament to pectineal ligament

57. Umbilical Hernia

58. Umbilical Hernia in adults
May be supraumbilical or infraumbilical.
Contents are usually omentum / small bowel / Transverse colon
Seldom reducible
C/F : Mostly in females, obesity, usually >40 years, flabby abdominal muscles, repeated pregnancy
Pain, swelling, GI symptoms
Treatment : Surgery (Reduction of wt.)
Mayo’s op. Transverse elliptical incision. Double breasting of linea alba.

59. Take Home Points
Hernias can involve the small bowel, appendix, a Meckel’s diverticulum, ureter
Incarceration with frank pain or strangulation are operative emergencies and bowel can be saved if done within 4-6 hours
An attempt at reduction should be made with a hernia, but operative reduction is the only definitive treatment
Femoral hernias have a high rate of incarceration and should be repaired, but other inguinal hernias may be watched if asymptomatic
With abdominal incisions, try not to put excessive tension or damage the suture in any way as it can promote incisional hernias