1. Hernia
Hernia
Dr Walid El Shazly
MD of General Surgey

2. Hernia
A hernia is a protrusion of a viscus or other structure beyond the normal coverings of the cavity in which it is contained.

3. Epidemiology
The first record of a hernia is in the Egyptian Papyrus Ebers (1550 BC) when it was regarded as a social stigma.
Abdominal hernias are common. They occur at all ages and in both sexes and account for approximately 10% of the general surgical workload.

4. Classification Congenital Acquired
In congenital hernias, there is a pre-formed sac patent processus vaginalis is a good example.
Acquired
Primary hernias
occur at natural weak points, such as femoral canal, lumbar region, umbilicus.
Secondary hernias
develop at sites of surgical or other injury to the wall e.g. after laparotomy or penetrating injury

5. Aetiology The two main factors predisposing to hernia are
increased intracavity pressure
a weakened abdominal wall.
In the abdomen, the raised pressure occurs as a result of:
heavy lifting
cough-chronic obstructive airways disease
straining to pass urine-benign prostatic hyperplasia or carcinoma
straining to pass faeces-constipation or large-bowel obstruction
abdominal distension-which may indicate the presence of an intra-abdominal disorder
change in abdominal contents- e.g. ascites, encysted fluid, benign or malignant tumour, pregnancy, fat.

6. Aetiology A weakened abdominal wall occurs in:
advancing age
malnutrition-either of
macronutrients (protein, calorie) or
micronutrients (e.g. vitamin C)
damage to, or paralysis of, motor nerves
abnormal collagen metabolism.
Often, multiple factors are involved. For example, the presence of a patent, congenitally formed sac may not cause a hernia until an acquired abdominal wall weakness or raised intra-abdominal pressure allows abdominal contents to enter the sac.

7. Inguinal hernia
Inguinal hernias account for 80% of all external abdominal hernias.
They occur at all ages, but are most common in infants and the elderly.
Inguinal hernias are 20 times more common in men than in women, and more frequently occur on the right side.

8. external oblique aponeurosis

11. internal oblique muscle

12. transversus abdominus

24. Direct Inguinal Hernia

26. Other causes of groin swelling
femoral hernia
hydrocele
encysted hydrocele of the cord
undescended or ectopic testis
lipoma of the cord
epididymal cyst.

27. DD of groin swelling(LN)

30. Complications
Irreducible
Obstructed
Strangulated
Inflamed.

31. Irreducible hernia
The contents cannot be returned to the body cavity in this type of hernia. The causes of irreducibility are:
narrow neck with rigid margins often in association with a capacious sac (e.g. femoral, umbilical)
adhesion formation between the contents and the sac (usually long-standing hernias).
Irreducible hernias have a greater risk of obstruction and strangulation than reducible ones.

32. Obstructed hernia
The obstructed hernia contains intestine in which the lumen has become occluded.
Obstruction is usually at the neck of the sac but may be caused by adhesions within it.
If the obstruction is at both ends of the loop, fluid accumulates within it and distension occurs (closed loop obstruction).
The term 'incarcerated' is sometimes used to describe a hernia that is irreducible but not strangulated. Thus, an irreducible, obstructed hernia can also be called an incarcerated one.

33. Strangulated hernia
Ten percent of groin hernias present for the first time with strangulation. The blood supply to the contents of the hernia is cut off.
The tissues undergo ischaemic necrosis.
If the contents of the sac of an abdominal hernia are not bowel, e.g. omentum, the necrosis is sterile
Strangulation of bowel is by far the most common and leads to infected necrosis (gangrene).

34. Inflamed hernia
 The contents are inflamed by any process that causes this in the tissue or organ that is not normally herniated, e.g.:
acute appendicitis
Meckel's diverticulitis
acute salpingitis.
It may be impossible to distinguish an inflamed hernia from one that is strangulated.

35. Investigation
Hernia is a clinical diagnosis. Investigations are rarely indicated or valuable.
Imaging
Herniography. This technique, which involves the injection of contrast medium into the peritoneal cavity and subsequent X-ray, is now rarely used
Ultrasound is being increasingly used to assess hernias that are difficult to define clinically, e.g. a Spigelian hernia.
CT and MRI have an occasional role in rare pelvic hernias (e.g. obturator hernia).

36. Investigation Laparoscopy Exploratory operation
Unexpected hernias are sometimes discovered at the time of laparoscopy for undiagnosed abdominal pain.
Exploratory operation
In some infants with a convincing history from the mother, a hernia is not found on clinical examination. Exploratory operation can then be justified.

37. Principles of management
There is a particularly strong argument in favour of operation in those hernias that have a high incidence of complication,
inguinal hernia with a narrow neck
femoral hernia
those that have become irreducible.

38. preoperative preparation
Presenting or predisposing conditions such as
Benign prostatic hyperplasia
Obstructive airways disease may need treatment before the hernia is dealt with.

39. preoperative preparation
Large hernias that warrant repair require particularly diligent preoperative preparation in order to minimise the risk of the operation and to ensure a favourable long-term outcome.
Weight reduction should be encouraged.
Smoking is discouraged.
Treatment of intercurrent disease (e.g. hypertension, diabetes) is essential.

40. preoperative preparation
Therapeutic pneumoperitoneum is very occasionally necessary for giant hernias-when viscera are in a hernia sac for long periods of time, they lose the 'right of domicile' in the abdominal cavity; replacing them suddenly into the abdomen is associated with the dangers of
respiratory embarrassment
compression of the inferior vena cava
paralytic ileus.
These complications can be averted by preparing the patient and the abdominal cavity by repeated intraperitoneal injections of air over the 2 weeks before operation, up to a total of 2.5 L.

41. Surgical techniques
Herniotomy is the removal of the sac and closure of its neck. It is the first step in nearly every hernia repair and in some instances (e.g. infant inguinal hernia-see below) may be all that is required.
Herniorrhaphy involves some sort of reconstruction to:
restore the anatomy if this is disturbed
increase the strength of the abdominal wall
construct a barrier to recurrence.
Hernioplasty

42. Type 3 inguinal hernia
Inguinal hernia

43. Herniotomy

44. Herniotomy

45. Herniotomy

48. Lytle repair

49. Lytle repair

50. LOCAL TISSUE REPAIR Sholdice

52. Mc vay repair

54. Tension free hernioplasty

57. Strangulation

70. Richter's Hernia

71. Maydl's Hernia

72. Femoral Hernia

75. Inguinal swellings which may resemble a femoral hernia
Inguinal hernia Swelling is above and medial to the public tubercle
Saphena varix Compressible Palpable thrill on coughing
Femoral artery aneurysm Expanding pulsation Bruit
Enlarged lymph node Usually multiple Not fixed on deep aspect and therefore more mobile Seek cause-infection, tumour, lymphoma
Lipoma Soft but not reducible
Psoas abscess Fluctuant Lateral to femoral artery Associated swelling in the iliac fossa
Ectopic testis Empty scrotum

78. Femoral Hernia

79. Ventral Hernia

80. Umbilical hernia Congenital (infantile) umbilical hernia
Adult umbilical hernia
True umbilical hernia
In this condition, the protrusion is through the umbilical scar, everting the umbilicus
The cause is often secondary to an increase in the volume of contents of the abdominal cavity-e.g. due to obesity, ascites or large benign or malignant intra-abdominal tumours.
Para-umbilical hernia
The weakest area of the umbilical scar is at the superior aspect between the umbilical vein and the upper margin of the umbilical ring.
It is at this point that a para-umbilical hernia develops. The emerging sac displaces the umbilical scar, which lies below and slightly to one side.

81. Ventral hernia

86. Epigastric hernia
Three-quarters of epigastric hernias are asymptomatic and found incidentally on physical examination. When symptoms are present they are of two types:
local pain-often exacerbated by physical exertion
ill-defined pain-epigastric in site, often worse after meals

89. Incisional hernia Aetiology Preoperative factors
Age-the tissues of the elderly do not heal as well as those of the young.
Malnutrition
protein-calorie malnutrition
vitamin deficiency (vitamin C is essential for collagen maturation)
trace metal deficiency (zinc is required for epithelialisation).

90. Incisional hernia Aetiology Preoperative factors
Sepsis-worsens malnutrition and delays anabolism.
Uraemia-inhibits fibroblast division.
Jaundice-impedes collagen maturation.
Obesity-predisposes to wound infection, seroma and haematoma.
Diabetes mellitus-predisposes to wound infection.
Steroids-have a generalised proteolytic effect.
Peritoneal contamination (peritonitis)-predisposes to wound infection.

91. Incisional hernia Operative factors
Type of incision-vertical incisions are more prone to hernia than are transverse ones.
Technique and materials-
tension in the closure impedes blood supply to the wound;
badly tied knots can work loose;
closure with rapidly absorbable suture material fails to support the abdominal wall for a sufficient time to permit sound union.
Type of operation- operations involving the bowel or urinary tract are more likely to develop wound infection.
Drains-a drain passing through the wound often results in a hernia.

92. Incisional hernia Postoperative factors
Wound infection-equal in importance with the wrong choice of suture material: there is enzymatic destruction of healing tissues; inflammatory swelling raises tissue tension and impedes blood supply; 5-20% of wound infections result in a hernia.
Abdominal distension-postoperative ileus increases the tension on a wound; stitches may cut out.
Coughing-generates wound tension.
Approximately 40% of incisional hernias occur with a documented episode of wound infection.

103. Interparietal hernia
The hernial sac lies between the layers of the abdominal wall.
The cause may be
congenital, when there is an associated abnormality of testicular descent
acquired in an area of weakness in the lateral aspect of the deep inguinal ring and inguinal canal (when the sac usually communicates with a concomitant indirect inguinal hernia).
The classification of such hernias is based on the anatomical location of the sac:
properitoneal (20%)
interstitial (60%)
superficial (20%).

104. Spigelian hernia
This is an interparietal hernia in the line of the linea semilunaris (the lateral margin of the rectus sheath, running from the tip of the ninth costal cartilage to the pubic crest).
The hernia is usually at the level of the arcuate line, below which all aponeurotic layers are reflected anterior to the rectus muscle.

105. Spigelian hernia Symptoms are: Signs are:
local pain that is worse on straining
lump
non-specific lower-quadrant discomfort which needs to be investigated in its own right
features of obstruction or strangulation.
Signs are:
tenderness at the site of the hernial orifice
lump which may be difficult or even impossible to feel.

106. Spigelian hernia
Recently, ultrasonography has proved useful in the demonstration of these hernias in patients with convincing histories but who lack clinical signs.
Repair is a simple matter of excising the sac and closing the defect.

107. Obturator hernia
In this condition, herniation occurs along the obturator canal, which carries the obturator nerve and vessels out of the pelvis.
It is most commonly seen in frail old ladies. The hernia starts as a pre-peritoneal plug and gradually enlarges, taking a sac of peritoneum with it.
A loop of bowel may enter the sac and reduce spontaneously.
A Richter's strangulation is common.

108. Lumbar hernia Congenital Acquired primary
Acquired secondary-the result of surgical incision.
Acquired hernias through an incision for lumbar approach to the kidney are not uncommon; however, with the decline in open renal surgery they are becoming less common.

109. Sciatic hernia
A sciatic hernia is the protrusion of a pelvic peritoneal sac through the greater or lesser sciatic foramen.
Clinical features
Patients present with discomfort
a swelling in the buttock
there may be symptoms of sciatic nerve compression.
If the hernia is large, there is a reducible mass in the gluteal area, made larger on standing.
Herniation of the ureters can cause urinary symptoms. There is an appreciable risk of strangulation.
Management
Treatment is by excision of the sac and closure of the defect by a transabdominal or transgluteal approach.

110. Perineal hernia These may be:
congenital
primary acquired
incisional.
Primary acquired perineal hernias occur in
middle-aged, multiparous women.
Their broad pelvis and the muscle-weakening effect of childbirth result in herniation through the pelvic floor.
Incisional perineal hernia follows 1% of combined abdominoperineal excisions of the rectum.

111. Perineal hernia Clinical features Management
There is usually a perineal swelling and discomfort when sitting.
A soft mass is found in the perineum, which is usually reducible. The wide neck has elastic margins.
These hernias rarely have dangerous complications.
Management
Repair is by a combined abdominal and pelvic approach.
The hernia is approached from below, the sac dissected free and reduced into the abdominal cavity.
A laparotomy is performed and the pelvic floor repaired from above.