HERNIA

Done by D1 group
objectives
Definition
Anatomy
Precipitating factors
Types
Clinical features
Preoperative assessment
Management and repair
Definition

A hernia is a protrusion of a
viscus or part of a viscus
through an abnormal
opening in the walls of its
containing cavity .
Anatomy
The inguinal canal :-
The inguinal canal is approximately 4 cm long and is directed obliquely
inferomedially through the inferior part of the anterolateral abdominal
wall. The canal lies parallel and 2-4 cm superior to the medial half of
the inguinal ligament.This ligament extends from the anterior
superior iliac spine to the pubic tubercle.
The inguinal canal has openings at either end :
The deep (internal) inguinal ring is the entrance to the inguinal canal.
It is thesite of an outpouching of the transversalis fascia. This is
approximately 1.25 cm superior to the middle of the inguinal
ligament
The superficial, or external inguinal ring is the exit from the inguinal
canal. It is a slitlke opening between the diagonal fibres of the
aponeurosis of the external oblique
Inguinal canal
walls of The inguinal canal :-
The anterior wall is formed mainly by the aponeurosis of the
external Oblique

. The posterior wall is formed mainly by transversalis fascia

The roof is formed by the arching fibres of the internal oblique and
transverse abdominal muscles.

The floor is formed by the inguinal ligament, which forms a shallow

trough. It is
reinforced in its most medial part by the lacunar
ligament.

Content :-
1. Spermatic cord ( round ligament of the uterus in female )
The Cord Itself.The contents of the spermatic cord are
(a) the ductus (vas) deferens and its artery .
(b) the testicular artery and venous (pampiniform) plexus.
(c) the genital branch of the genitofemoral nerve.
(d) lymphatic vessels and sympathetic nerve fibers.
(e) fat and connective tissue surrounding the cord and its coverings in
various amounts
2. Ilioinguinal nerve .
3. Ilioinguinal lymph node .
Femoral Canal
The major feature of the femoral canal is the femoral sheath. This
sheath is a condensation of the deep fascia (fascia lata) of the thigh
and contains, from lateral to medial, the femoral artery, femoral
vein, and femoral canal. The femoral canal is a space medial to the
vein that allows for venous expansion and contains a lymph node
(node of Cloquet). Other features of the femoral triangle include
the femoral nerve, which lies lateral to the sheath,

Wall of The Femoral canal

anterior is the inguinal ligament
posterior is the iliopsoas, pectineal, and long adductor muscles (floor).
Medial is lacunar ligament
Lateral is femoral vessle
Predisposing:

All hernias occur at the site of

WEAKNESS OF THE ABDOMINAL
WALL which are acted on by repeated
INCREASE in abdominal pressure
repeated INCREASE in abdominal
pressure is usually due to
Chronic cough
Straining
Bladder neck or urethral obstruction
Pregnancy
Vomiting
Sever muscular effort
Ascetic fluid
Types
Inguinal
Femoral
Epigastric
Para umbilical
Umbilical
Obturator
Superior lumbar
Inferioer lumbar
Gluteal
Sciatic
Incisional
 Indirect Inguinal Hernia
Hernia through the inguinal canal
Direct Inguinal Hernia
The sac passes through a weakness or defect of the transversalis
fascia in the posterior wall of the inguinal canal
Femoral Hernia
Hernia medial to femoral vessels under inguinal ligament
Umbilical Hernia
Hernia through the umbilical ring
Paraumbilical Hernia
A protrusion through the linea alba just above or sometimes just below the
umbilicus
Epigastric Hernia
Protrusion of extraperitoneal fat through the linea alba anywhere between
the xiphoid process and the umbilicus
Incisional Hernia
Hernia through an incisional site
Lumber Hernia
occur through the inferior lumber triangle of Petit
Inguinal hernia
History:
1. Age ( young vs. old)
2. Occupation ( nature ?? )
3. Local symptoms: Swelling, discomfort
and pain
4. Systemic symptoms: if there is
obstruction or strangulation
5. Precipitating factors
Inguinal hernia
Examination:
1. Inspection for site, size, shape and color.
2. Palpation for surface, temp, tenderness,
composition and reducibility.
3. Expansible cough impulse.
4. General exam: for common causes of
increase intra abdominal pressure
Indirect Versus Direct inguinal
hernias
Indirect is the most common form of
hernia and its usually congenital due to
patent processus viginalis

Direct usually acquired occur in old men

with weak abdominal muscles.
 Indirect Versus Direct inguinal hernias
Indirect Inguinal Hernia Direct Inguinal Hernia

Pass through inguinal canal. Bulge from the posterior wall of the inguinal
canal
Can descend into the scrotum. Cannot descent into the scrotum.
Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.
Reduced: upward, then laterally and backward. Reduced: upward, then straight backward.

Controlled: after reduction by pressure over Not controlled: after reduction by pressure
the internal (deep) inguinal ring. over the internal (deep) inguinal ring.

The defect is not palpable (it is behind the The defect may be felt in the abdominal wall
fibers of the external oblique muscle). above the pubic tubercle.

After reduction: the bulge appears in the After reduction: the bulge reappears exactly
middle of inguinal region and then flows where it was before.
medially before turning down to the scrotum.

Common in children and young adults. Common in old age.

 Male:

Female

Note that examination using finger and

thumb across the neck of the scrotum will
help to distinguish a swelling of inguinal
origin and one that is entirely intrascrotal
 Femoral hernia

Small femoral hernia may be unnoticed by

the patient or disregarded for years
perhaps until the day it strangulates.
Adherence of the greater omentum
sometimes causes a dragging pain. Rarely
a large sac is present .
 Femoral hernia
History
Age ; uncommon in children , most common
in old age female .
Sex; women > men (but still commonest
hernia in women the inguinal hernia )
The patient came with local symptoms
1- discomfort and pain
2- swelling in the groin
General ; femoral hernia is more likely to be
strangulated than the inguinal hernia
Multiplicity ; often bilateral
Femoral hernia versus inguinal
hernia
Inguinal hernia Femoral hernia

1- more common in male 1- more common in females

2- pass through the inguinal canal 2- pass through the femoral canal

3- neck of the sac is above and medial 3- neck of the sac is below and lateral
the pubic tubercle the pubic tubercle

4- less common to be strangulated 4- more common to be strangulated

5- can be treated without surgery 5- must be treated surgically

6- the two diagnostic signs of hernia + 6- the two diagnostic signs of hernia -

7- the sac mainly contain ; bowel 7- the sac mainly contains ; omentum
Umbilical hernia
Signs and symptoms
Age ; doesnt appear until the umbilical
cord has separated and healed .
No specific symptoms
Have wide neck and reduce easily , rarely
give intestinal obstruction.
Nature history ; 90 % disappear
spontaneously during the first year.
 Examination
Inspection
Site ; in the center of the umbilicus
Size and shape ; size can vary from vary small to
very large . Shape is usually hemispherical.
Palpation
Composition ; contain bowel , which makes it
resonant to percussion . They reduce
spontaneously when the child lies down .
Reducibility ; easy
Cough impulse; invariably present .
Acquired umbilical hernia

Hernia through the umbilical scar , so it is a

true umbilical hernia.
Not common and is usually secondary to
increase intra abdominal pressure.
The most common causes
1- pregnancy
2- ascitis
3- ovarian cyst
4- fibrodis
5- bowel distention
Incision hernia
Signs and symptoms
Previous operation or accidental trauma
Age ; all ages , but more common in old age.
Symptom ; lump ,pain ,intestinal obstruction ( distention ,colic,
vomiting ,constipation , sever pain in the lump )
Examination
1- reducible lump
2- expansile cough impulse
3- if the lump dose not reduse and dose not have cough impulse ,
than it may be not a hernia
Ddx
Tumor
Chronic abscess
Hematoma
Foreign body granuloma
Preoperative assessment

proper history and examination

identify high risk patients
prepare the preoperative notes :
consent..
pre op Dx
procedure planned
surgeons
Anasthesia anticipated (general , local,
spinal)
Preoperative assessment
Investigation data ( pre operative tests ) :
1. Lab :
* CBC : to check hemoglobin level anemia and WBCs
infections
* U&E : to check for any electrolyte imbalance
* LFTs : indicated in jaundiced patients and suspected hepatitis
or any clotting problems
* PT & PTT
* ABG
* grouping and cross matching
2. Imaging :
* Chest X ray : for all patients
3. ECG : for any patient who is more than 40 years of age
Preoperative assessment

current medications or allergies

any major (chronic) illness
pre op orders :
1. skin preparation
2. diet (NPO)
3. GIT preparation
4. Sedation
5. Preanesthetic medications
6. Other medications
7. Antibiotics
8. Blood transfusion ( if needed )
9. Bladder preparation
Management
and repair
 Inguinal Hernia Repair

Pre op
Evaluation
Reduction
&
preparation

Surgical
TTT
Surgical TTT

Choice of Inguinal floor

TTT of hernial sac
Anesthetic reconstruction
 Pre op evaluation &preparation

Watchful Waiting Surgical TTT

May be appropriate for pt with asymptomatic

hernia or elderly pt with minimal symptoms
or easily reduced inguinal hernia.

Routine F/U with health care professional

A Randomized trial concluded that this is an acceptable option for men with minimally symptomatic
inguinal hernia and that delaying repair until symptoms increase is safe due to low rate of incarceration. 23%
of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most
often hernia-related pain) , only 1 pt (0.3%) experienced acute hernia incarceration without strangulation
within 2years, a second had acute incarceration with
Bowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA
2006,295:285)
Pre op preparation
Most pt are treated surgically
Increase IAP abnormalities (Chronic cough,
Constipation, Bladder outlet obstruction)
should be evaluated and remedied to extent
possible before elective herniorrhaphy.
In case of intestinal obstruction and possible
strangulation, Broad spectrum AB,NG suction
may be indicated, correction of volume status&
elctroyles.
Reduction
Uncomplicated:
Manual Gentle pressure over hernia Gentle
traction over the mass sedation and
trendelenburg position.

Complicated (strangulated):
no attempt should be made to reduce the
hernia because of potential reduction of
gangrenous segment of bowel with the hernial
sac.
Surgerical TTT
1.choice of anesthetic:
elective open repair : Local is preferred
Laproscopic hernia repair: more
commonly under GA.
2.TTT OF HERNIAL SAC
INDIRECT: sac is dissected free from the cord
structures and creamsteric fibers. Sac should be
open away from any herniated contents.
Contents are then reduced, and the sac is
ligated deep to inguinal ring with an absorbable
suture

DIRECT:
Too broadly based for ligation and should not
be opened, simple freed from transversalis
fibers and inverted.
3.Inguinal Floor
Reconstruction

Some method of 3.Inguinal

Floor
reconstruction of the Reconstruction
inguinal floor is
necessary in all adult
hernia repairs to
prevent recurrence.
Open tension free Laproscopic &
Primary tissue repair
repair preperitoneal repairs
1.Primary tissue repair

Bassini repair: inferior arch of

transversalis fascia (TF) or conjoint
tendon is approximated to shelving
portion of inguinal ligament.

McVay:TF is sutured to cooper ligament.

Shouldice:TF is incised and

reapproximated.
2.Open tension free
repair
Lichtenstein repair &Patch and Plug
technique: Mesh is used to reconstruct
inguinal floor

Mesh plug technique : place mesh in the

hernial defect
Laproscopic &
preperitoneal repairs
TAPP (transabdominal prepeitoneal procedure): peritoneal space
entered by conventional lap at umbilicus and peritoneum overlaying
inguinal floor is dissected away as flap.

TEP (Total extraperitoneal repair): preperitoneal space is developed

with a balloon inserted between posterior rectus sheath and
peritoneum balloon inflated to dissect the peritoneal flaps awau
from posterior abdomianl wall and the direct and indirect spaces,
other ports inserted into this preperitoneal space without entering
peritoneal cavity.

After lap. Dissection and reduction of hernia sac , a large piece of

mesh is placed over inguinal floor
 Femoral hernia repair
Femoral hernias should be repaired very soon after the
diagnosis has been made because of the high risk of
strangulation.
There is no place for a truss for a femoral hernia.
Different approaches :
Open VS Laparoscopic
 Open surgery
Three approaches have been described for open
surgery :
1. Infra-inguinal approach (Lookwood)
2. Supra-inguinal approach ( McEvedy)
3. Trans-inguinal approach ( Lotheissen)
 Each technique has the principle of dissection
of the sac with reduction of its contents,
followed by ligation of the sac and closure
between the inguinal and pectineal ligaments.
Lockwoods infra-inguinal approach
The sac is dissected out below the
inguinal ligament via groin crease incision.
Then the sac is opened and the contents
are inspected and reduced into the
abdomen.
Then the neck of the sac is pulled down ,
ligated and allowed to retract through
femoral canal.
Then close the femoral canal by mesh
plug or non absorbable sutures.
McEvedys high approach
Vertical incision is made over the femoral
canal and continued upwards above the
inguinal ligament.
This incision provides good access to the
preperitoneal space and then to the
peritoneum itself.
Use finger dissection to sweep peritoneum
from anterior abdominal wall , so the neck
of the sac can be identified.
Dissect the sac , reduce the contents and
repair the defect by mesh or sutures.
Lotheissens trans-inguinal approach
The incision is made superior and parallel
to inguinal ligament extending from pubic
tubercle to mid inguinal point.
Hernia examination
Thank
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