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
Direct Inguinal Hernia Indirect Inguinal Hernia
Bulge from the posterior wall of the inguinal
canal
Pass through inguinal canal.
Cannot descent into the scrotum. Can descend into the scrotum.
Medial to inferior epigastric vessels. Lateral to inferior epigastric vessels.
Reduced: upward, then straight backward. Reduced: upward, then laterally and
backward.
Not controlled: after reduction by pressure
over the internal (deep) inguinal ring.
Controlled: after reduction by pressure
over the internal (deep) inguinal ring.
The defect may be felt in the abdominal wall
above the pubic tubercle.
The defect is not palpable (it is behind the
fibers of the external oblique muscle).
After reduction: the bulge reappears exactly
where it was before.
After reduction: the bulge appears in the
middle of inguinal region and then flows
medially before turning down to the
scrotum.
Common in old age. Common in children and young adults.

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
Femoral hernia Inguinal hernia
1- more common in females 1- more common in male
2- pass through the femoral canal 2- pass through the inguinal canal
3- neck of the sac is below and lateral
the pubic tubercle
3- neck of the sac is above and medial
the pubic tubercle
4- more common to be strangulated 4- less common to be strangulated
5- must be treated surgically 5- can be treated without surgery
6- the two diagnostic signs of hernia - 6- the two diagnostic signs of hernia +
7- the sac mainly contains ; omentum 7- the sac mainly contain ; bowel


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



Inguinal Hernia Repair
Reduction
Surgical
TTT
Pre op
Evaluation
&
preparation
Surgical TTT
Choice of
Anesthetic
TTT of hernial sac
Inguinal floor
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
reconstruction of the
inguinal floor is
necessary in all adult
hernia repairs to
prevent recurrence.
3.Inguinal
Floor
Reconstruction
Primary tissue repair
Open tension free
repair
Laproscopic &
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

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