HERNIA

• “Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it”

• Common Hernias– INGUINAL– UMBILICAL– FEMORAL– EPIGASTRIC– INCISIONAL

• Rare Hernias– SPIGELIAN– LUMBAR – GLUTEAL– SCIATIC– OBTURATOR

Factors: Weakness of abdominal musculature

• Congenital– Persistence of

processus vaginalis– Patent canal of Tuck– Incomplete

obliteration of umbilicus

• Acquired – Fat– Pregnancy– Incision– Infection– Connective tissue –

smoking, aging, CTD, systemic illness

Increased abdominal pressure

• Chronic constipation• Chronic cough• Bladder outlet obstruction – stricture,

prostrate• Straining – weight lifting• Intra-abdominal malignancy• Vomiting• Repeated pregnancy

• Sac• Covering • Contents– Omentocoele– Enterocoele– Cystocoele – Ovary

• Richter’s• Littre’s• Maydl’s

Classification

• Reducible• Irreducible• Obstructed/ Incarcerated• Strangulated

Reducible Hernia

• Characteristic signs– Reducibility– Cough impulse

Irreducible Hernia

• Due to– Adhesions– Narrowing of neck– Incarceration– Massive hernia inside scrotum

Obstructed Hernia

• Irreducibility + Intestinal obstruction• Features– No cough impulse– Irreducible– Painless– Non tender– Features of intestinal obstruction

Strangulated Hernia

• Blood supply of its contents impaired• Intestinal obstruction ±• Pathology– Intestinal obstruction– Dilation of hernial contents– Impairment of venous return– Stasis --------- Arterial impairment

• Appearance– Congested and bright red– Ecchymosis– Extravasation of blood into lumen/ sac– loss of tone– Translocation of gut bacteria – peritonitis/ sepsis– Gangrene

• Symptoms – Pain, vomiting– Ceases with onset of gangrene, ileus

• Signs – Ill looking– Tense, tender– Irreducible, no cough impulse– Acute intestinal obstruction– Peritonitis

Strangulated Omentocele

• No features of intestinal obstruction• Gangrene onset delayed

Strangulated Richter’s Hernia

• Features mimic gastroenteritis• Obstruction > 50 % of circumference• Colic, diarrhoes• Constipation - ileus

Maydl’s Hernia

• Retrograde strangulation• On opening sac – contents appear normal• Generalized peritonitis may set in early

Inflamed Hernia

• Outside– Abrasion, ill fitting truss

• Inside– Diverticulitis, appendicitis

• Signs of inflammation +• Not associated with intestinal obstruction

INGUINAL HERNIA

Anatomy

Inguinal canal

• Triangular slit 3.75 cm long• Above the inner half of inguinal ligament• Deep to superficial inguinal ring• Developed due to the descent of testis in

embryonic life

Deep Inguinal Ring• Opening in the fascia transversalis• 1.25 cm above mid inguinal point• Medially – inferior epigastric artery• Spermatic cord in males; round ligament in

females

Superficial Inguinal Ring

• Aponeurosis of external oblique – crurae• Above and lateral to pubic crest• Spermatic cord/ round ligament and illio-

inguinal nerves

• Anteriorly – skin, fascia, EO aponeurosis, lateral third – IO aponeurosis

• Posteriorly – transversalis fascia, medial ½ - conjoint tendon

• Above – transversus abdominins and internal oblique fibres

• Below – inguinal ligamnet

Contents

• Illioinguinal nerves• Spermatic cord– Vas defrens– Testicular artery, art to vas defrens, cremasteric– Pampiniform plexus of veins– Lymph vessels– Testicular plexus of sympathetic nerves, genital

branch of genitofemoral

Hassenbach’s Triangle

• Site of direct hernia• Medially – lateral border rectus abdominis • Laterally – inferior epigastric vessel• Inferiorly – inguinal ligament• Floor – fascia transversalis• Umbilical fold – obliterated umbilical artery

Mechanisms for preventing hernia

• Obliquity of inguinal canal• Shutter mechanism of fibres of IO, TA• Sphincter action of TA, IO at deep inguinal ring• Ball valve action of cremasteric• Fibres of internal oblique over deep inguinal

ring• Conjoint tendon

INDIRECT INGUINAL HERNIA

• More common• Young individuals• More common on the right side• On basis of extent– Bubonocele– Funicular hernia– Complete hernia

• Coverings– Peritoneum– Extraperitoneal fat– Internal spermatic fascia– Cremasteric fascia– External spermatic fascia– Superficial fascia– skin

DIRECT INGUINAL HERNIA

• Directly through the hasselbach’s triangle• Acquired (ex- Oglive hernia)• More common in elderly, malgaigne bulgings• Rarely gets strangulated

• Symptoms – Pain/ discomfort– Lump– Systemic symptoms – obstruction, strangulation– Predisposing factors – constipation, chronic

bronchitis, urinary obstruction– Past history

• Signs– REDUCIBILITY– COUGH IMPULSE– Position – d/f femoral hernia– Get above the swelling– Invagination test– Ring occlusion test

Rare Varieties

• Interstitial hernia– Between muscle layers of abdominal wall– Commonly associated with undescended testis– Preperitoneal– Intraperitoneal– Extraperitoneal

Rare Varieties

• Sliding hernia– Older men– Extraperitoneal bowel with sac of peritoneum– Caecum, pelvic colon, bladder– Strangulation of intestine within and outside the

peritoneum• Richter’s • Maydl’s• Littre’s

TREATMENT

• Conservative management• Surgical management

Conservative management : No Treatment

• Indications– Severe ill health– Short life expectency– Refuse operation

Conservative management : Truss

• Indications– Refuse operation– Old patients with severe co morbidities– Children ( c/I – undescended testis)

• Contraindications– Irreducible hernia– Undescended testis– Chronic bronchitits, strenous labour– Associated with large hydrocele– Not intelligent enough to position properly

• Dangers– Pressure atropht of muscles of inguinal region– Ostruction or strangulation– Used with partially reduced hernia – may cause

trauma– Improper cleanliness – unhealthy skin– Adhesions between sac and canal– Chance of strangulation remains

Operative treatment

• Herniotomy– Neck of sac transfixed, ligated and excised– Infants and children; young men with good

musculature• Herniorrhaphy– Herniotomy + repair of postrior wall– Indirect hernias– Adults with good muscle tone

Hernioplasty

• Herniotomy + reinforcement of posterior wall• Autologous– Fascia lata– External oblique aponeurosis– Anterior rectus sheath flap– Skin flap – dermoplasty/ skin ribbon

• Heterogenous – Prolene – Stainless steel

• Indications– Indirect hernia – poor muscle tone– Direct hernia– Recurranthernia– Predisposing factors – chronic cough,etc

Treatment of Strangulated Hernia

• Emergency surgery• Resuscitation• Reduction of hernia– Foot end elevation– Ice pack– NG, IV fluids– Analgesia, antibiotic

• Assess viability – Green/ black color– Flaccid , lustureless appearance– No peristalssis– Blood stained, foul smelling fluid in sac

• Bowel viable - HERNIORRHAPHY

• Bowel nonviable – Linear patch of gangrene – invagination– Loop of bowel – resection and anastomosis if gen

condition permits– Bowel large intestine – exteriorisation

RECURRENT INGUINAL HERNIA

• Types of hernia– Sliding– Large/ long standing– Large direct hernia

• Types of patients – chronic cough• Inadequate preoperative preparation

RECURRENT INGUINAL HERNIA

• Operative faults– Failure to ligate sac– Tension in repair – Use of absorbable sutures– Bleeding – infection– Fault in selection of operation

• Postoperative care– Wound infection– Lifting heaavy weights– Persistence of predisposing factors

• Appearance of new hernia

FEMORAL HERNIA

• Femoral ring – femoral canal – saphenous opening

• More common in– Females– Old age

• Most liable to strangulate

Anatomy

Coverings of the sac of femoral hernia

• Skin• Superficial fascia• Cribriform fascia• Anterior layer of femoral sheath• Fatty contents of femoral canal• Femoral septum• Peritoneum

Rare types of femoral hernia

• Prevascular hernia(Velpeu’s) – ass with posterior dislocation (Narath’s hernia)

• Retrovascular hernia - Serafini

• Pectineal hernia – Cloquet’s• External femoral hernia –

Hesselbach’s• Lacunar hernia – Lingier’s

• Symptoms– Swelling– Pain– Systemic symptoms

• Zeimenns technique• Invagination technique• Ring occlusion test• Position of swelling

Treatment

• No conservative management• Surgery – herniorrhaphy

– High operation(McEvedy’s)

– Lottheissen’s

– Lockwood

UMBILICAL HERNIA

• Three major types– Exomphalos– Umbilical hernia in infants and children– Paraumbilical hernia in adults

Exomphalos

• Minor– Small sac– Summit attached to the umbilical cord– Treatment • twisting of umbilical cord and strapping

Exomphalos

• Major • Umbilical cord attached to inferior

aspect of swelling• Contains intestines, liver• Surgical emergency• Immediate decompression and

reduction

Umbilical hernia in children and infants

• Weak umbilical scar following neonatal sepsis• Usually asymptomatic• 90% cured within 12 – 18 months• > 18 months – surgery

Paraumbilical hernia of adults

• Supraumbilical or infraumbilical• Adhesions - seldom reducible • Predisposing factors –– Women– Obesity– Repeated pregnancy

• Treatment – Mayo’s operation

EPIGASTRIC HERNIA(Fatty Hernia of Linea Alba)

• Through fibres of linea alba• Blood vessels pierce linea alba• Initially extraperitoneal fat only• M.c. – young muscular men with strenous

activity• Usually irreducible, no cough impulse• If symptomatic - surgery

INCISIONAL HERNIA(Ventral Hernia)

• Defect with patient– Obesity– Chronic cough perioperative period– Undue abdominal distention– Malnutrition

• Operative– Injury to nerves– Careless wound closure– Hemorrhage – infection– Tube drainage through laparotomy wound– Midline infraumbilical

• Postoperative– Infection– Postop cough, distention– Postop peritonitis– Early removal of sutures– Postop steroid therapy

Types of incisional hernia

• Type 1– Upper abdomen/ midline lower abdomen– Wide gap in musculature– Low risk of strangulation

• Type 2– Lateral part of abdomen– Small defect– Strangulation risk high

Treatment

• Prevention of incisional hernia– Weight reduction– Correct nutritional defects– Treat chronic cough– Careful closure of abdomen– Prevent post op wound infection

• Conservative management– Reducible type 1

• SURGICAL MANAGEMENT

LUMBAR HERNIA

• Superior lumbar hernia

• Inferior lumbar hernia

Incisional lumbar hernia

• Renal surgery with post op infection• Paralysis of lumbar muscles(phantom hernia)• Treatment– Primary hernia – herniorrhaphy– Incisional hernia

OBTURATOR HERNIA

• Rare; old women• Through obturator

foramen• Thigh flexed, abducted and

externally rotated• Referred pain to knee joint• Strangulation - surgery

SPIGELEAN HERNIA

• Interparietal hernia• At level of arcuate line,

lateral to rectus• Treatment - surgery

• Gluteal hernia

• Sciatic hernia

CONCLUSION

• Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it

• Inguinal hernia most frequent• Usual mode of treatment is surgical

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