z

Hernia
Presented by Aparna Singh
Ref: A concise textbook of surgery by S.Das
z
Hernia

 A hernia is an abnormal protrusion of a part or whole of viscus

through an abnormal opening in the wall of the cavity.

 The common external hernia are:

1. Inguinal – about 73%

2. Femoral – about 17%

3. Umbilical – about 8.5%

4. Incisional – rarely
z
Aetiology

 Mainly 2 factors causes a hernia:

1. Weakness of the abdominal muscles

 It can be congenital weakness or acquired weakness

2. Increased abdominal pressure which forces the content out through

the normal abdominal musculature.

Eg. Chronic cough in bronchitis and tuberculosis

Vomiting

Constipation
z
Common external hernia

1. Femoral hernia :

 Common in females ( ratio 2:1 )

 More common on right side and 20% occurs bilaterally.

 Presents as a swelling in groin below and lateral to pubic

tubercle.
z

2. Umbilical hernia:

 Umbilical hernia can be congenital in newborn and infants (common in

males ) or acquired in adults ( common in females )

 It is herniation through a weak umbilical scar.

 It is common in infants and children, occurs commonly due to neonatal

sepsis.

 It is hemispherical in shape.

 Presents with a swelling in umbilical region within first few months after
birth, the size increases during crying.
z

3. Incisional hernia:

 It is herniation through a weak abdominal scar ( scar of previous

surgery )

 It is common in old age and obese individuals.

z
z
Inguinal hernia

 Define: Abnormal protrusion of part of the contents of the

abdomen through the inguinal region of the abdominal wall.
z
Anatomy

 Oblique passage in the lower part of the anterior abdominal wall.

 Extends from deep inguinal ring to superficial inguinal ring.

 Directed downward, forward and medially.

 About 4cm long.

z
Contents

1. Spermatic cord

2. Ilioinguinal nerve

3. Genital branch of genitofemoral nerve

4. Females: round ligament is present instead of spermatic cord.

5. Structures of the spermatic cord – vas deferens, testicular

artery and cremastic arteries, pampiniform plexus of veins and
lymphatics.
z
Mechanism
1. Obliquity of the inguinal canal:

 When there is rise in intra - abdominal pressure, the posterior

wall is close to the anterior wall and thus prevents coming out of
abdominal content through inguinal canal.

2. Shutter mechanism:

 The arched fibers of the internal oblique and transversus

abdominis will bring down towards the floor when they are
contracted during rise of intra – abdominal pressure.
z

Types of hernia
Anatomical types
• According to extent
• According to its type of exit
• According to its contents


Clinical types
z

According
to extent

Incomplete Complete

Bubonocele Funicular
z
Incomplete hernia

1. Bubonocele hernia

 The hernia is limited in the inguinal canal.

 This hernia presents as an inguinal swelling.

 The majority of the victims are young adults.

2. Funicular hernia

 In this case, sac crosses the superficial inguinal ring, but does not
reach the bottom of the scrotum.

 Most of this hernia occurs in adults.

z
z
Complete hernia

 In this case the hernia descends down to the bottom of the

scrotum lying in front and at the sides of the testis.

 The testis can be felt posterior to the hernial sac with great
difficulty.

 Though it is a congenital hernia and commonly

encountered in children, yet may not appear until adolescent or
adult life.
z
z

According to
its type of exit

Indirect
Direct hernia
hernia
z
Indirect hernia

 In indirect inguinal hernia the contents of the abdomen enter the

deep inguinal ring and transverse the whole length of the
inguinal canal to come out through the superficial inguinal ring.

 It may extend into the scrotum.

 Depending upon extent it may be complete or incomplete.

 This is much more common than direct inguinal hernia.

 More commonly seen on the right side, though 1/3rd of the cases
of this hernia will be bilateral.
z
z
Direct hernia

 A direct inguinal hernia protrudes through the posterior wall of

the inguinal canal medial to the inferior epigastric vessels i.e.
through Hesselbach’s triangle.

 Such hernia lies outside the spermatic cord, either behind or

above or below the cord.

 Direct hernia is much rare and constitutes 15% of all cases.

z
z
According to its contents

1. Enterocele

 When the sac contains intestine.

2. Omentocele

 When the sac contains omentum ( a fold of peritoneum which

connects the stomach with other abdominal organs )

3. Cystocele

 When a part of the urinary bladder is inside the sac.

z
Clinical types

1. Reducible - contents can be returned into the abdominal cavity.

2. Irreducible – contents cannot be returned into the abdominal cavity.

3. Obstructed – irreducible and has intestinal obstruction, but the

blood supply is not impaired.

4. Strangulated - irreducible and also has intestinal obstruction with

arrest of the blood supply.

5. Inflammed – it is a rare condition which occurs when contents like

appendix is inflammed.
z
Rare varieties
1. Sliding hernia

 It is a hernia in which a piece of extraperitoneal bowel may

slide down into the inguinal canal pulling a sac of peritoneum
with it.
z
2. Richter’s hernia

 In this condition only a portion of the circumference of the

bowel becomes strangulated.

 It is particularly dangerous as operation is frequently delayed

because the clinical features resembles gastroenteritis.

 Intestinal obstruction may not be present until and unless half

of the circumference of the bowel is involved.
z

3. Littre’s hernia

 In this condition Meckel’s diverticulum is a content of the

hernial sac.
z

4. Maydl’s hernia

 In this condition two loops of bowel remain in the sac and the
connecting loop remains within the abdomen and becomes
strangulated.

 The loops of the hernia look like a ‘W’.

 z
Risk factors
 In infants:

 Prematurity

 Male

 In adults:

 Male

 Obesity

 Constipation

 Chronic cough

 Heavy lifting

 Smoking

 Urinary obstructive symptoms

z
Clinical features

 Abdominal pain

 Lump – a swelling in the groin

 Nausea and vomiting

 Constipation

 Urinary symptoms
 z
Diagnosis
 Inspection:

 Inguinal hernias are best examined with the patient in standing position.

 Coughing may increase the size of the hernia.

 Site and shape of the hernia:

 Those appearing above and medial to the pubic tubercle are femoral hernia.

 Those appearing below and lateral to the pubic tubercle are femoral hernia.

 Whether the lump extends down into the scrotum

 Any other scrotal swellings

 Scar from previous surgery or trauma

z

 Systemic examination:

 Examine respiratory system

 Per rectal examination

 Abdominal

 External genitalia
 z
Investigations
 Routine:

 Complete blood count

 Urine routine

 Blood sugar

 Renal function test

 Blood grouping

 ECG and chest X- ray

 Herniography

 Suspected hernia, but clinical diagnosis unclear

 Procedure done fluoroscopy following injection of contrast medium

 Frontal and oblique radiographs are taken with and without increased intra – abdominal
pressure
z
Treatment

 Non operative treatment

 Watchful waiting: for asymptomatic or minimally symptomatic

 Truss is a mechanical appliance, belt with a pad applied to groin

after spontaneous or manual reduction of hernia.

 The purpose is two fold: to maintain reduction and to prevent

enlargement.
z
Operative treatment

 Surgery :

1. Herniotomy

2. Herniorrhaphy

3. Hernioplasty

4. Laparoscopic
z
Herniotomy

 In this operation the neck of the sac is transfixed and ligated and
then the hernial sac is excised.

 No repair of the inguinal canal is performed.

 It is indicated :

 In infants and children in whom there is a preformed sac.

 In case of young adults with very good inguinal musculature.

z
Herniorrhaphy

 It consist of herniotomy and repair of the posterior wall of the

inguinal canal by apposing the conjoined tendon to the inguinal
ligament.

 The sutur material which is used for such repair is usually non
absorbable material e.g. proline or silk.

 It is indicated :

 In all cases of indirect hernia except in children.

 In adult patient whose muscle tone is quiet good.

z
Hernioplasty

 This means herniotomy and reinforced repair of the posterior

wall of the inguinal canal by filling the gap between the
conjoined tendon and iguinal ligament by autogenous material
or by heterogenous material.

 Indications :

 Cases of indirect hernia – in patients with poor muscle tone

 All cases of direct hernia

z
Laparoscopic repair
z
Complications

 Bowel incarceration : the trapping of abdominal contents within

the hernia itself.

 Strangulation : pressure on the hernial contents may

compromise blood supply and cause ischemia, and later
necrosis and gangrene, which may become fatal.

 Small bowel obstruction.

z