ABDOMINAL WALL HERNIA

CONTENT

Groin Hernia
Umbilical Hernia
Epigastric Hernia
Spigelian Hernia
Lumbar Hernia
Incisional Hernia
Parastomal Hernia

Inguinal Hernia
Femoral Hernia

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Abdominal wall hernia

HERNIA

Herniaabdominal wall natural opening inguinal canal,

femoral canal, umbilicus, obturator canal epigastric

hernia,
incisional hernia.

1
hernia
peritoneum sac(hernial sac )
1
hernial sac small intestine omentum.
bowel wall Richters hernia ( )2 hernia
strangulation intestinal obstruction Meckels diverticulum
hernial sac Littres

hernia

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hernia
1. Reducibel hernia content hernia
2. Irreducible hernia content
obstruction neck
sac Irreducible

strangulation

3. Incarceration hernia Irreducible hernia

Groin Hernias
abdominal wall hernia indirect inguinal hernia(IIH) 60%, direct
inguinal hernia(DIH) 25%, femoral hernia(FH) 15%. 85% indirect
direct . Femoral hernia IIH hernia

Surgical Anatomy

3
Inguinal canal testis abdominal wall fetal life
tube of peritoneum(processus vaginalis) obliterated tunica
vaginalis testis testis( )3
Internal ring opening transversalis fascia 1 .. mid-inguinal
point( pubic
symphysis anterior superior iliac spine) medial inferior
epigastric artery
Internal canal ( 4) potential space anterior wall medial third
external ring enternal oblque aponeurosis inguinal ligament lateral
internal oblique specmatic cord floor inguinal ligament medial third
inguinal ligament superior ramus pubis middle fascia
pectineus

lacunar ligament

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4
External ring opening aponeurosis external oblique muscle medial

pubic tubercle.
-spermatic

cord
Abdominal Wall
Testis & Spermatic Cord
Transversalis fascia
Internal spermatic fascia
Internal oblique muscle
Cremasteric muscle
External oblique muscle
External spermatic fascia
Spermatic cord vas deferens, nerve, lymphatics. inguinal canal
cremasteric & internal spermatic fascia
inguinal ring cord
Indirect inguinal hernia deep
scotum external ring
Direct inguinal hernia posterior wall inguinal canal
neck sac IIH lateral inferior epigastric vessels DIH
medial inferior epigastric vessels

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INDIRECT INGUINAL HERNIA (IIH)

5
obliteration processus vaginalis( 5). Hernia
inguinal canal scrotum.

abdominal

wall
hernia. indirect
hernia small bowel,
interstitial

omentum appendix,

ovary, bladder, Meckels diverticulum, cecum

.
DIRECT INGUINAL HERNIA(DIH)
peritoneum Hesselbachs

triangle(
6).Direct hernia external ring scrotum
transversalis fascia scrotum

6
DIH neck irreducible, obstruction strangulation hernia
DIH underlying disease intraabdominal

pressure
chronic bladder neck obstruction IIH

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INGUINAL HERNIA IN FEMALE
10% inguinal hernia hydrocele inguinal hernia 10%
20% sliding hernia hernia ovary, fallopian tube
indirect hernia direct hernia
posteriot inguinal wall
high ligation os hernia sac excision round ligament
inguinal ring inguinal canal

(Inspection)
adolescant adult IIH lump groin
reducible

medial side upper thigh

inguinal ligament ( distribution ilioinguinal nerve)
DIH reducible

below

& lateral pubic tubercle famoral hernia

above & medial pubic tubercle inguinal hernia
(Palpation)
internal
ring ( reduction )
hernia IIH hernia medial DIH
scrotum external ring
impulse impulse IIH impulse
DIH

IIH DIH IIH scrotum

primary scrotal swelling swelling scrotum
lower
abdominal wall swelling
Herniography

contralateral hernia (Infant
and childhood) radioopaque
peritoneal cavity x-ray hernia sac
DIFFERENTIAL DIAGNOSIS INGUINAL HERNIA
1. Extraperitoneal fat
2. Femoral hernia
3. Incompletely descended testis
4. Varicocele
5. Inguinal lymphadenopathy
6. TraumaHaematoma

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7. Cystic hydrocele of spermayic cord
PRINCIPLE OF REPAIR
1. Open surgical approach
2. Laparoscopic approach

open approach
Indirect inguinal hernia
1. Young children : excision hernial sac (Herniotomy)
2. Older children & Adult : internal ring Herniotomy

internal ring non-absorbable suture (Transversalis fascia repair)
3. Older patient : posterior wall inguinal canal
posterior wall sac
posterior wall (Herniorhapphy) Bassinis
repair conjoint tendon pubic tubercle inguinal ligament
Direct hernia

hernial

sac invaginated of sac repair

posterior wall inguinal canal Bassinis operation synthetic mesh

Recurrence
recurrence rate 10% recurrence repair IIH IIH
incomplete excision of hernial sac recurrence repair DIH DIH
FEMORAL HERNIA

7
hernia femoral
ring femoral canal Femoral canal anterior
transversalis fascia inguinal ligament medial reflex portion iliopubic tractlacunar ligament (more superficially) Coopers ligament hernia extends
femoral canal fossa ovalis inguinal ligament

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omentum,
small bowel bladder( slide
medial wall of sac)

Femoral hernia upper inner aspect of thich ( 8)

inguinal hernia inguinal hernia above & medial
pubic tubercle femoral hernia below lateral femoral hernia reduce
femoral hernia J-shaped reduce
SURGERY
Femoral hernia obstruction strangulation
excision sac femoral ring inguinal ligament
pectineal ligament approach 3
1. Below inguinal ligament
2. Transinguinal ligament
3. Above inguinal ligament (McEvedy approach)
access hernia contains
strangulation
STRANGULATED HERNIA
content morbidity-mortality

supply tissue ischaemia

venous drainage arterial
gangrene

pain
colicky pain steady severe pain fever,
tachycardia Local sign of inflammation tenderness

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hernia ( femoral hernia tenderness rule out strangulation
)
strangulation intestinal obstruction Richters hernia
intestinal obstruction hernia femoral hernia
indicator strangulation
late sign case irreducible inguinal hernia
TREATMENT
strangulation
emergency

surgery

1. fluid & electrolyte

2. Monitored vital sign & urine output
3. Antibiotic
gangrene bowel resection bowel
SLIDING INGUINAL HERNIA
hernia
sac 5%
inguinal hernia ( 4:1)
Sliding hernia internal hernia ring
irreducible

strangulation

hernia complete
sliding

excision sac damage

organ colon ischaemia

repair hernia adequate

repair of defect posterior inguinal wall

COMPLICATION OF GROIN HERNIORRHAPHY
Intraoperative complication
1. Bleeding
2. Trauma to the vas deferens
3. Bladder injury
4. Testicular ischaemia
5. Intestinal damage
6. Damage to femoral vein
Postoperative complication
1. Retention of urine
2. Testicular swelling or atrophy
3. Hydrocele of the cord
4. Nerve damage
5. Recurrent hernia

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Ventral Hernias
weakness

anterior abdominal wall linea alba

Epigastic hernia umbilicus Umbilical & Paraumbilical hernia lateral border
of rectus sheath Spigelian hernia scar tissue old surgical incision
Incisional hernia
Umbilical Hernia
IN INFANT
premature infant, nigro infant, Umbilical hernia
incomplete closure of fascial defect umbilical hernia 4
conservative treatment
2
defect >1 cm 6
strangulation ( )
IN INFANT
hernia

in adult umbilicus paraumbilical

overweight multiparous neck peritoneal sac
irreducible & strangulation adult umbilical hernia
cirrhosis with ascites, congestive heart failure, nephrosis, peritoneal

dialysis severe medical condition

complication
incarcerate rupture
Epigastic Hernia

9

linea alba
herniation

extraperitoneal fat peritoneum containing omentum local pain
swelling pain
(
traction tissue trapped hernia
)

midline
( xiphisternum

) 20%

symptomatic hernias
recurrent 15%

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Obturater Hernia

10
obturator canal : = 6 : 1
Rare hernia external hernia
>50

strangulate

neck sac firm fibrous bony edges

clinical small bowel obstruction 20% upper inner aspect
hernia hernia sac canal obturator nerve vessel
posterolateral (Obturator nerve key structure obturator hernia
ventral rami L2, L3, L4 mixed nerve motor nerve
adductor sensory nerve hip joint knee joint cutaneous branch

obturator nerve hernia weakness
adductor group deep tendon reflex
refer pain
)
content small
bowel ileum
Richters type hernia
The obturator sign (Howship-Romberg sign) positive 50% pathognomonic
sign obturator hernia
(sensory branch obturator nerve)
extension, adduction medial rotation
rectum vagina obturator region
laparotomy intestinal obstruction reduce
content gentle traction / fibers obturator membrane defect
suture mesh
hernia vertical incision
inguinal ligament aspect femoral vessels

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peritonitis prognosis 10-20%
malnutrition
Spigelian Hernia

rare hernia defect lateral border rectus abdominis

pubic symphysis
muscle(linea semilunaris) linea semilunaris ( umbilicus
inguinal hernia
Hernia irreducible

strangulate reduce defect

40-70 , : = 1.5 : 1, 90% hernia belt
dissection ligament of sac repair defect

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Lumbar Hernia

12
lumbar region congenital weakness injury muscular wall of loin
Superior lumbar triangle strangulation 10% repair
defect
mesh prosthesis
Incisional Hernia
defect wound
infection
wound dehiscence. Predisposing factor obesity,

wound haematoma, steroid therapy,

abdominal distension, general condition delay wound healing malnutrition neck
hernia sac strangulate gut obstruction gut obstruction
relate adhesion band discomfort,

Preoperative

postoperative

intercurrent disease cardiac, pulmonary disease

care overweight,
Parastomal Hernia

Stoma bulges stoma
( paracolostomy paraileostomy ) intestinal obstruction
Excision hernia sac repair defect
recurrence . recurrence stoma

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1. Niall J OHiggins Hernia. In Niall J OHiggins, Geoffrey D. Chisholm, Robin C.N. Williamson: Surgical
management,2 ed :Butterworth-Heinemann Ltd. 1991:665-672.
2. Condon RE. Hernias of the abdominal wall. In Nyhus LM, Condon RE. Hernia 4 ed. Philadelphia :JB
Lippincott Co, 1992:319-425.
3. A.P.M. Forrest,D.C. Carter, I.B. Macleod. Principles and practice of surgery 3 ed: Churchill Livingstone
1994:350-361.
4. :Less common hernia: , , ,
. 10 : , 2535;369-401
5. John E Skandalagis, Panajiotis N Skandalakis, LeeJohn skandalakis. Surgical anatomy and technique,
Springer-Verlag 1995:123-204.