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Hernia No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate anatomical knowledge with surgical skill than Hernia in all its varieties.-Sir Astley Paston Cooper (1804) A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity. The external abdominal hernia is the most common form, the most frequent varieties being the inguinal, femoral and umbilical, accounting for 75% of cases. The rarer forms constitute 1.5%, excluding incisional hernias. General features common to all hernias Etiology Causes of hernias : ■ Coughing ■ Straining ■ Obesity ■ Intra-abdominal malignancy Any condition that raises intra-abdominal pressure, such as a powerful muscular effort, may produce a hernia. Whooping cough is a predisposing cause in childhood, whereas a chronic cough, straining on micturition or straining on defecation may precipitate a hernia in an adult. Hernias are more common in smokers, which may be the result of an acquired collagen deﬁciency increasing an individual’s susceptibility to the development of hernias. It should be remembered that the appearance of a hernia in an adult can be a sign of intra-abdominal malignancy. Stretching of the abdominal musculature because of an increase in contents, as in obesity, can be another factor. Fat acts to separate muscle bundles and layers, weakens aponeuroses and favours the appearance of paraumbilical, direct inguinal and hiatus hernias. A femoral hernia is rare in men and nulliparous women but more common in multiparous women due to stretching of the pelvic ligaments. An indirect hernia may occur in acongenital preformed sac – the remains of the processus vaginalis. Peritoneal dialysis can cause the development of a hernia from a previously occult weakness or enlargement of a patent processus vaginalis.
Composition of a hernia As a rule, a hernia consists of three parts – the sac, the coverings of the sac and the contents of the sac. The sac The sac is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus. The neck is usually well deﬁned but in some direct inguinal hernias and in many incisional hernias there is no actual neck. The diameter of the neck is important because strangulation of bowel is a likely complication when the neck is narrow, as in femoral and paraumbilical hernias. The body of the sac varies greatly in size and is not necessarily occupied. In cases occurring in infancy and childhood, the sac is gossamer thin. In longstanding cases the wall of the sac maybe comparatively thick. The covering Coverings are derived from the layers of the abdominal wall through which the sac passes. In longstanding cases they become atrophied from stretching and so amalgamated that they are indistinguishable from each other. Contents These can be: • omentum = omentocele (synonym: epiplocele); • intestine = enterocele; more commonly small bowel but may be large intestine or appendix; • a portion of the circumference of the intestine = Richter’s hernia; • a portion of the bladder (or a diverticulum ) may constitute part of or be the sole content of a direct inguinal, a sliding inguinal or a femoral hernia; • ovary with or without the corresponding fallopian tube; • a Meckel’s diverticulum = a Littre’s hernia; • ﬂuid, as part of ascites or as a residuum thereof.
Classiﬁcation Irrespective of site, a hernia can be classiﬁed into ﬁve different types: ■ Reducible – contents can be returned to abdomen ■ Irreducible – contents cannot be returned but there are no other complications ■ Obstructed – bowel in the hernia has good blood supply but bowel is obstructed ■ Strangulated – blood supply of bowel is obstructed ■ Inﬂamed – contents of sac have become inﬂamed Reducible hernias The hernia either reduces itself when the patient lies down or can be reduced by the patient or the surgeon. The intestine usually gurgles on reduction and the ﬁrst portion is more difﬁcult to reduce than the last. Omentum, in contrast, is described as doughy and the last portion is more difﬁcult to reduce than the ﬁrst. A reducible hernia imparts an expansile impulse on coughing. Irreducible hernia In this case the contents cannot be returned to the abdomen but there is no evidence of other complications. It is usually due to adhesions between the sac and its contents or overcrowding within the sac. Irreducibility without other symptoms is almost diagnostic of an omentocele, especially in femoral and umbilical hernias. Note that any degree of irreducibility predisposes to strangulation. Obstructed hernia This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel. The symptoms (colicky abdominal pain and tenderness over the hernia site) are less severe and the onset more gradual than in strangulated hernias, but more often than not the obstruction culminates in strangulation. Usually there is no clear distinction clinically between obstruction and strangulation and the safe course is to assume that strangulation is imminent and treat accordingly.
Incarcerated hernia The term ‘incarceration’ is often used loosely as an alternative to obstruction or strangulation but is correctly employed only when it is considered that the lumen of that portion of the colon occupying a hernial sac is blocked with faeces. In this case, the scybalous contents of the bowel should be capable of being indented with the ﬁnger, like putty. Strangulated hernia A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contents ischaemic. Gangrene may occur as early as 5–6 hours after the onset of the ﬁrst symptoms. Although inguinal hernia may be 10 times more common than femoral hernia, a femoral hernia is more likely to strangulate because of the narrowness of the neck and its rigid surrounds. Pathology: The intestine is obstructed and its blood supply impaired. Initially, only the venous return is impeded; the wall of the intestine becomes congested and bright red with the transudation of serous ﬂuid into the sac. As congestion increases the wall of the intestine becomes purple in colour. The intestinal pressure increases, distending the intestinal loop and impairing venous return further. As venous stasis increases, the arterial supply becomes more and more impaired. Blood is extravasated under the serosa and is effused into the lumen. The ﬂuid in the sac becomes blood-stained and the shining serosa dull because of a ﬁbrinous, sticky exudate. At this stage the walls of the intestine have lost their tone and become friable. Bacterial transudation occurs secondary to the lowered intestinal viability and the sac ﬂuid becomes infected. Gangrene appears at the rings of constriction, which become deeply indented and grey in colour. The gangrene then develops in the anti-mesenteric border, the colour varying from black to green depending on the decomposition of blood in the subserosa. The mesentery involved by the strangulation also becomes gangrenous. If the strangulation is unrelieved, perforation of the wall of the intestine occurs, either at the convexity of the loop or at the seat of constriction. Peritonitis spreads from the sac to the peritoneal cavity. Clinical features Sudden pain, at ﬁrst situated over the hernia, is followed by generalised abdominal pain, colicky in character and often located mainly at the umbilicus.
Nausea and subsequently vomiting ensue. The patient may complain of an increase in hernia size. On examination the hernia is tense, extremely tender and irreducible, and there is no expansile cough impulse. Unless the strangulation is relieved by operation, the spasms of pain continue until peristaltic contractions cease with the onset of ischaemia, when paralytic ileus (often the result of peritonitis) and septicaemia develop. Spontaneous cessation of pain must be viewed with caution, as this may be a sign of perforation. Strangulated hernias ■ Present with local then general abdominal pain and vomiting ■ A normal hernia can strangulate at any time ■ Most common in hernias with narrow necks such as femoral hernias ■ Require urgent surgery Inﬂamed hernia Inﬂammation can occur from inﬂammation of the contents of the sac, such as acute appendicitis or salpingitis, or from external causes, e.g. the trophic ulcers that develop in the dependent areas of large umbilical or incisional hernias. The hernia is usually tender but not tense and the overlying skin red and oedematous. Treatment is based on treatment of the underlying cause. Inguinal hernia Embryology To understand how to diagnose and treat inguinal hernias in children, one must understand their embryologic origin. It is very useful to describe these events to the parents, who often are under the misconception that the hernia was somehow caused by their inability to console their crying child or the child's high activity level. Inguinal hernia results from a failure of closure of the processus vaginalis, a fingerlike projection of the peritoneum that accompanies the testicle as it descends into the scrotum. Closure of the processus vaginalis normally occurs a few months before birth. This explains the high incidence of inguinal hernias in premature infants. When the processus vaginalis remains completely patent, a communication persists between the peritoneal cavity and the groin, resulting in a hernia. Partial closure can result in
entrapped fluid, which leads to the presence of a hydrocele. A communicating hydrocele is a hydrocele that is in communication with the peritoneal cavity and can therefore be thought of as a hernia. When the classification system that is typically applied to adult hernias is used, all congenital hernias in children are by definition indirect inguinal hernias. Children also present with direct inguinal and femoral hernias, although these are much less common. Surgical anatomy The superﬁcial inguinal ring is a triangular aperture in the aponeurosis of the external oblique muscle and lies 1.25cm above the pubic tubercle. The ring is bounded by a superomedial and an inferolateral crus joined by the criss-crossed intercrural ﬁbres. Normally the ring will not admit the tip of the little ﬁnger. The deep inguinal ring is a U-shaped condensation of the transversalis fascia and it lies 1.25cm above the inguinal (Poupart’s) ligament, midway between the symphysis pubis and the anterior superior iliac spine. The transversalis fascia is the fascial envelope of the abdomen and the competency of the deep inguinal ring depends on the integrity of this fascia. The inguinal canal: In infants, the superﬁcial and deep inguinal rings are almost superimposed and the obliquity of the canal is slight. In adults, the inguinal canal, which is about 3.75cm long, is directed downwards and medially from the deep to the superﬁcial inguinal ring. In the male, the inguinal canal transmits the spermatic cord, the ilioinguinal nerve and the genital branch of the genitofemoral nerve. In the female, the round ligament replaces the spermatic cord. The anterior boundary comprises mainly the external oblique aponeurosis with the conjoined muscle laterally. The posterior boundary is formed by the fascia transversalis and the conjoined tendon (internal oblique and transversus abdominus medially). The inferior epigastric vessels lie posteriorly and medially to the deep inguinal ring. The superior boundary is formed by the conjoined muscles (internal oblique and transversus) and the inferior boundary is the inguinal ligament. An indirect hernia travels down the canal on the outer (lateral and anterior) side of the spermatic cord. A direct hernia comes out directly forwards through the posterior wall of the inguinal canal. Whereas the neck of the indirect hernia is lateral to the inferior epigastric vessels, the direct hernia usually emerges medial to this
except in the saddle-bag or pantaloon type, which has both a lateral and a medial component. An inguinal hernia can be differentiated from a femoral hernia by ascertaining the relation of the neck of the sac to the medial end of the inguinal ligament and the pubic tubercle; i.e. in the case of an inguinal hernia the neck is above and medial, whereas that of a femoral hernia is below and lateral. Digital control of the internal ring may help in distinguishing between an indirect and a direct inguinal hernia, although some reports have found that the preoperative diagnosis is incorrect as often as it is correct. Indirect (synonym:oblique) inguinal hernia This is the most common form of hernia. Indirect hernias are most common in the young, whereas direct hernias are most common in the old. In the ﬁrst decade of life, inguinal hernia is more common on the right side in the male. This is no doubt associated with the later descent of the right testis and a higher incidence of failure of closure of the processus vaginalis. In adult males, 65% of inguinal hernias are indirect and 55% are right-sided. The hernia is bilateral in 12% of cases. If both sides are explored in an infant presenting with one hernia, the incidence of a patent processus vaginalis on the other side is 60%. Natural history of inguinal hernias ■ Inguinal hernias in babies are the result of a persistent processus vaginalis ■ Indirect inguinal hernia is the most common hernia of all, especially in the young ■ Direct inguinal hernia becomes more common in the elderly Three types of indirect inguinal hernia occur : 1. Bubonocele. The hernia is limited to the inguinal canal. 2. Funicular. The processus vaginalis is closed just above the epididymis. The contents of the sac can be felt separately from the testis, which lies below the hernia. 3. Complete (synonym: scrotal). A complete inguinal hernia is rarely present at birth but is commonly encountered in infancy. It also occurs in adolescence or in
adulthood. The testis appears to lie within the lower part of the hernia.
Clinical features Notes on examination The clinician examines the patient from the front with the patient standing with legs apart. The patient is instructed to look at the ceiling and cough. If the hernia will come down, it usually does. The examiner looks and feels for the impulse and then addresses the following questions: • Is the hernia right, left or bilateral? • Is it an inguinal or femoral hernia? • Is it a direct or an indirect hernia? • Is it reducible or irreducible (the patient may have to lie down for this to be ascertained)? • Is the inguinal hernia incomplete or complete? • What are the contents? Looking at all ages, males are 20 times more commonly affected than females. The patient complains of pain in the groin or pain referred to the testicle when performing heavy work or taking strenuous exercise. When asked to cough, a small transient bulging may be seen and felt together with an expansile impulse. When the sac is still limited to the inguinal canal, the bulge may be better seen by observing the inguinal region from the side or even looking down the abdominal wall while standing behind the relevant shoulder of the patient. As an indirect inguinal hernia increases in size it becomes apparent when the patient coughs, and persists until reduced. As time goes on, the hernia comes down as soon as the patient stands up. In large hernias there is a sensation of weight and dragging on the mesentery. This may produce epigastric pain. If the contents of the sac are reducible, the inguinal canal will be found to be commodious.
In infants the swelling appears when the child cries. It can be translucent in infancy and early childhood but never in an adult. In girls an ovary may prolapse into the sac. Differential diagnosis in the male In males the differential diagnosis includes the following: • vaginal hydrocele • encysted hydrocele of the cord • spermatocele • femoral hernia • incompletely descended testis in the inguinal canal – an inguinal hernia is often associated with this condition • lipoma of the cord – this is often a difﬁcult but unimportant diagnosis and it is usually not settled until the parts are displayed by operation. Note that examination using ﬁnger and thumb across the neck of the scrotum will help to distinguish between a swelling of inguinal origin and one that is entirely intrascrotal. Differential diagnosis in the female In females the differential diagnosis includes the following: • hydrocele of the canal of Nuck – this is the most common differential diagnostic problem; • femoral hernia. Treatment Operation is the treatment of choice. It must be remembered that patients who have a bad cough from chronic bronchitis should not be denied an operation, for these are the very people who are in danger of developing a strangulated hernia. In adults, local, epidural or spinal, as well as general anaesthesia, can be used.
Treatment of hernias ■ Surgery is the treatment of choice ■ Surgery is either open or laparoscopic ■ Any hernia can strangulate a) Herniatomy The basic operation is inguinal herniotomy, which entails dissecting out and opening the hernial sac, reducing any contents and then transﬁxing the neck of the sac and removing the remainder. It is employed either by itself or as the ﬁrst step in a repair procedure (herniorrhaphy). By itself it is sufﬁcient for the treatment of hernia in infants, adolescents and young adults. Any attempts at repair in such cases may, in fact, do more harm than good. In infants it is not necessary to open the canal, as the internal and external rings are superimposed. Excellent results are obtained. The operation is usually now performed as a day case unless there are additional medical or social problems. Herniotomy and repair (herniorrhaphy) consists of: (1) excision of the hernial sac (2) repair of the stretched internal inguinal ring and the transversalis fascia (3) further reinforcement of the posterior wall of the inguinal canal. (2) and (3) must be achieved without tension resulting in the wound and various techniques exist to achieve this, e.g. Shouldice operation, fascial ﬂaps or mesh implants.
b) Excision of the hernial sac (adult herniotomy) An incision is made in the skin and subcutaneous tissue 1.25cm above and parallel to the medial two-thirds of the inguinal ligament. In large, irreducible hernias the incision may be extended laterally or into the upper part of the scrotum. After dividing the superﬁcial fascia and securing haemostasis, the external oblique aponeurosis and the superﬁcial inguinal ring are identiﬁed. The external oblique
aponeurosis is incised in the line of its ﬁbres and the structures beneath carefully separated from its deep surface before completing the incision through the superﬁcial inguinal ring. In this way, the ilioinguinal nerve is safeguarded. With the inguinal canal thus opened, the upper leaf of the external oblique muscle is separated from the internal oblique muscle by blunt dissection. In the same way, the lower leaf is separated from the contents of the inguinal canal until the inner aspect of the inguinal ligament is seen. The cremasteric muscle ﬁbres may be divided longitudinally to display the spermatic cord, but this is by no means essential. • Excision of the sac. The indirect sac may be distinguished as a pearly white structure lying on the outer side of the cord and, when the internal spermatic fascia has been incised longitudinally, it can usually be dissected out and then opened between artery forceps. • Variations in dissection. If the sac is small it can be freed in toto. If it is of the long, funicular or scrotal type, or is extremely thickened and adherent, the fundus must not be sought because in doing so the blood supply to the testis may be compromised. The sac is freed within the inguinal canal and divided circumferentially such that the fundus remains in the scrotum. Care must be taken to avoid damage to the vas and spermatic artery when freeing the sac posteriorly. • An adherent sac Can be separated from the cord by ﬁrst injecting saline under the posterior wall from within (hydrodissection). A similar tactic is employed when dissecting the gossamer sac of infants and children. • Reduction of contents. Intestine or omentum is returned to the peritoneal cavity. Omentum is often adherent to the neck or fundus of the sac: if adherent to the neck it is freed and if adherent to the fundus of a large sac it may be transﬁxed, ligated and cut across at a suitable point. The distal part of the omentum, like the distal part of a large scrotal sac, can be left in situ (the fundus should, however, not be ligated).
• Isolation and ligation of the neck of the sac. Whatever type of sac is encountered, it is necessary to free the neck by blunt dissection until the parietal peritoneum can be seen on all sides. The dissection is considered complete only when the extraperitoneal fat has been encountered and the inferior epigastric vessels have been seen on the medial side. It used to be considered essential to open the sac to ensure that no bowel or omentum was adherent to the neck. If the sac is obviously empty, it is sufﬁcient to simply reduce it, close the internal ring and perform a herniorrhaphy if required. If the sac is opened, all contents should be reduced and the neck transﬁxed as high as possible before excising the sac. c) Repair of the transversalis fascia and the internal ring When the internal ring is weak and stretched and the transversalis is bulging, the repair should include a technique of narrowing the deep ring, e.g. the Lytle method of narrowing the ring with lateraldisplacement of the cord or the Shouldice method, whereby thering and fascia are incised and carefully separated from the deep inferior epigastric vessels and extraperitoneal fat before an overlapping repair (‘double breasting’) of the lower ﬂap behind the upper ﬂap is performed. In the classic Shouldice operation, a third and fourth layer of tension-free suturing, using monoﬁlament materials, polypropylene, polyamide or wire, are placed between the internal oblique aponeurosis arch and the inguinal ligament. d) Reinforcement of the posterior inguinal wall This is achieved by suturing without tension the tendinous aponeurotic arch of the internal oblique to the undersurface of the inguinal ligament and to the pubic tubercle (as described above in the Shouldice operation) or by reinforcing the posterior wall of the canal with a prosthetic mesh. Care is taken when suturing not to pick up the same tendinous bundle for each suture. Suturing of muscle bundles is of no value. The suturing method can include a rectus-relaxing incision (Halsted– Tanner). The Lichtenstein tension-free hernioplasty involves placement of an approximately 16 × 8cm (tailored to the individual patient’s requirements) mesh as an extra lamina,anterior to the posterior wall and overlapping it generously in all directions, including medially over the pubic tubercle(Fig. 57.10). Other historical techniques, which should now be abandoned because of poor results, include overlapping the external oblique behind the cord (making it lie subcutaneously). Special care is needed to avoid excessive narrowing of the new external ring, which could jeopardise the vascular supply to and the venous return from the testis.
e) Completion of operation If desired, the cremasteric muscle can be reconstituted: the external oblique is directly sutured or over- lapped, leaving a new external ring that should accommodate the tip of a ﬁnger. f) A truss A truss may be used when operation is contraindicated or when operation is refused. Its use should be mainly historical, as there are very few contraindications to surgery with today’s varietyof anaesthetic techniques. If a truss is to be worn, the hernia must be reducible. A rat-tailed spring truss with a perineal band to prevent the truss slipping will, with due care and attention, control a small or moderately sized inguinal hernia. A truss must be worn continuously during waking hours, kept clean and in proper repair and renewed when it shows signs of wear. It must be applied before the patient gets up and while the hernia is reduced. A properly ﬁtting truss must control the hernia when the patient stands with legs apart, stoops and coughs violently. If it does not it is a menace because it increases the risk of strangu-lation. There is no place for trusses in the management of infant hernias. If an infant hernia becomes suddenly irreducible, urgent operative repair is indicated. Otherwise, the infant hernia can be left alone until the child is over 3 months old, when routine day case repair can be performed. Direct inguinal hernia In adult males, 35% of inguinal hernias are direct. At presentation, 12% of patients will have a contralateral hernia in addition, and there is a fourfold increased risk of future development of a contralateral hernia if one is not present at the original presentation. A direct inguinal hernia is always acquired. The sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canal. In some cases the defect is small and is represented by a discrete defect in the transversalis fascia, whereas in others there is a generalised bulge. Often the patient has poor lower abdominal musculature, as shown by the presence of elongated bulgings (Malgaigne’s bulges). Women practically never develop a direct inguinal hernia (Brown). Predisposing factors are smoking and occupations that involve
straining and heavy lifting. Damage to the ilioinguinal nerve (previous appendicectomy) is another cause, because of the resulting weakness of the conjoined tendon. Direct hernias do not often attain a large size or descend into the scrotum. In contrast to an indirect inguinal hernia, a direct inguinal hernia lies behind the spermatic cord. The sac is often smaller than the hernial mass would indicate, the protruding mass mainly consisting of extraperitoneal fat. As the neck of the sac is wide, direct inguinal hernias do not often strangulate. Direct inguinal hernias ■ All are acquired ■ They are most common in older men ■ They rarely strangulate Funicular direct inguinal hernia (synonym: prevesical hernia) This is a narrow-necked hernia with prevesical fat and a portion of the bladder that occurs through a small oval defect in the medial part of the conjoined tendon just above the pubic tubercle. It occurs principally in elderly men and occasionally becomes strangulated. Unless there are deﬁnite contraindications, operation should always be advised. Dual (synonym: saddle-bag, pantaloon) hernia This type of hernia consists of two sacs that straddle the inferi- or epigastric artery, one sac being medial and the other lateral to this vessel. The condition is not rare and is a cause of recurrence, one of the sacs having been overlooked at the time of operation. Operation for direct hernia The principles of repair of direct hernias are the same as those of an indirect hernia, with the exception that the hernia sac can usually be simply inverted after it has been dissected free and the transversalis fascia reconstructed in front of it. This reconstruction of the posterior wall of the inguinal canal should be undertaken by the Shouldice repair or by using a mesh implant according to the Lichtenstein technique.
The ‘Bassini’ darn operation is no longer acceptable because of its high recurrence rate and slow rehabilitation. Laparoscopic herniorrhaphy Over the last 10 years, minimally invasive techniques have been developed for the treatment of inguinal hernias. Two techniques are described, a transabdominal approach (TAPP) and a preperitoneal approach (TEP). The TAPP approach establishes a pneumoperitoneum and places a synthetic mesh preperitoneally by dissecting the peritoneum off the hernial oriﬁces and positioning the mesh beneath the peritoneum before closing the peritoneum over the mesh. The TEP approach is completely preperitoneal. The preperitoneal plane is opened by either balloon dissection or direct dis- section via a paraumbilical incision. The hernial oriﬁces can be identiﬁed bilaterally and any hernia sac reduced. Placing a large mesh over the hernial oriﬁces in the preperitoneal plane completes the repair. There is some discussion about the requirement for mesh ﬁxation, and various techniques are available to ﬁx the mesh in place. In the UK, there has been a generaltrend away from TAPP repairs as the incidence of complications is higher than with the TEP repair. However, the TEP repair is technically more difﬁcult to perform and is associated with a longer learning curve. In experienced hands, the recurrence rate for TEP repairs is less than 1%. Laparoscopic repairs can be applied to primary, bilateral and recurrent inguinal hernias as well as to femoral hernias. The National Institute for Clinical Excellence (NICE) in the UK has produced guidelines on the use of laparoscopic surgery for inguinal hernias and has recommended the consideration of the TEP laparoscopic technique for any inguinal hernia, unilateral, recurrent or bilateral, but only in laparoscopic centres where there are surgeons experienced in the technique. Strangulated inguinal hernia The pathological and clinical features of strangulated inguinal hernias have been described earlier in this chapter. Strangulation of an inguinal hernia occurs at any time during life and in both sexes. Indirect inguinal hernias strangulate more commonly, the direct variety not so often because of the wide neck of the sac. Sometimes a hernia strangulates on the ﬁrst occasion that it descends; more often strangulation occurs in patients who have worn a truss for a long time and in those with a partially reducible or an irreducible hernia.
In order of frequency, the constricting agent is: (1) the neck o the sac (2) the external inguinal ring in children (3) adhesions within the sac (rarely). Contents Usually the small intestine is involved in the strangulation, with the next most frequent being the omentum; sometimes both are involved. It is rare for the large intestine to become strangulated in an inguinal hernia, even when the hernia is of the sliding variety. Strangulation during infancy The incidence of strangulation in infancy is 4% (Gross) and the ratio of girls to boys is 5:1. More frequently, the hernia is irreducible but not strangulated. In most cases of strangulated inguinal hernia occurring in female infants, the content of the sac is an ovary or an ovary plus its fallopian tube. Treatment of strangulated inguinal hernia The treatment of strangulated hernia is by emergency operation. Vigorous resuscitation with intravenous ﬂuids, nasogastric aspiration and antibiotics is essential, although operation should not be unduly delayed in moribund patients. It is also advisable to empty the bladder, if necessary by catheterization. Preoperative treatment of strangulated inguinal hernias ■ Resuscitate with adequate ﬂuids ■ Empty stomach with nasogastric tube ■ Give antibiotics to contain infection ■ Catheterise to monitor haemodynamic state Inguinal herniotomy for strangulation An incision is made over the most prominent part of the swelling. The external oblique aponeurosis is exposed and the sac, with its coverings, is seen
issuing from the superﬁcial ring. In all but very large hernias it is possible to deliver the body and fundus of the sac together with its coverings and (in the male) the testis on to the surface (it is not necessary to deliver the testis if the fundus of the sac can be adequately exposed). Each layer covering the anterior surface of the body of the sac near the fundus is incised and, if possible, stripped off the sac. The sac is then incised and any ﬂuid, which may be highly infective, drained effectively. The external oblique aponeurosis and the superﬁcial inguinal ring are divided. A ﬁnger is then passed into the opening in the sac and, employing the ﬁnger as a guide, the sac is slit along its length. If the constriction lies at the superﬁcial inguinal ring or within the canal, it is readily divided by this procedure. When the constriction is at the deep ring, by applying artery forceps to the cut edge of the neck of the sac and drawing them downwards, and at the same time retracting the internal oblique upwards, it may be possible to continue slitting the sac over the ﬁnger towards the point of constriction. When the constriction is too tight to admit a ﬁnger, a grooved dissector is inserted and the neck of the sac is divided with a knife in an upward and inward direction, i.e. parallel to the inferior epigastric vessels, under vision. Once the constriction has been divided, the strangulated contents can be drawn down. Devitalised omentum is excised after being securely ligated. Viable intestine is returned to the peritoneal cavity. Doubtfully viable and gangrenous intestine is excised by localised resection. If the hernial sac is of moderate size and can be separated easily from its coverings, it is excised and closed by a purse-string suture. When the sac is large and adherent, much time is saved by cutting across the sac circumferentially, as described earlier. Having tied or sutured the neck of the sac, a repair can be made if the condition of the patient permits. If the incision has been soiled or gangrenous bowel resected, the use of prosthetic mesh may be questionable, although some authorities have successfully utilised polypropylene mesh with antibiotic cover. Biosynthetic meshes made from collagen or dermis are also available and, because they are totally absorbed, are more suited to use in a contaminated environment. Conservative measures These are indicated only in infants. The child is given analgesics and placed in gallow’s traction (the judgement of Solomon position). In 75% of cases reduction is effected and there appears to be no danger of gangrenous intestine being reduced (Irvine Smith).
Note that vigorous manipulation (taxis) has no place in modern surgery and is mentioned only to be condemned. Its dangers include: • contusion or rupture of the intestinal wall; • reduction-en-masse: ‘The sac together with its contents is pushed forcibly back into the abdomen; as the bowel will still be strangulated by the neck of the sac, the symptoms are in no way relieved’ (Treves); • reduction into the a loculus of the sac; • the sac may rupture at its neck and the contents are reduced, not into the peritoneal cavity but extraperitoneally Non-operative treatment of hernias ■ Only indicated in children ■ Forcible reduction must never be attempted Maydl’s hernia (synonym: hernia-in-W) Maydl’s hernia is rare. The strangulated loop of the W lies within the abdomen, so local tenderness over the hernia is not marked. At operation, two comparatively normal-looking loops of intestine are present in the sac. After the obstruction has been relieved, the strangulated loop will become apparent if traction is exerted on the middle of the loops occupying the sac. Results of operations for inguinal hernia Recurrence Reported recurrence rates vary between 0.2% and 15% depending on the technique employed. Only by using a meticulous technique, principally concentrating on reinforcement of the posterior wall of the inguinal canal using the Shouldice technique or mesh hernioplasty, can a recurrence rate of less than 2% be achieved. Only 50% of recurrences will become apparent within 2 years. In a few cases ‘false’ recurrences occur, i.e. another type of hernia occurs – direct after indirect, femoral after inguinal. However, to the patient it is a recurrence. Recurrence of hernias
■ The recurrence rate after surgery should be less than 2% ■ Some recurrences will be new hernias
1. Bailey and Love's Short Practice of Surgery - 25th Edition. 2. Schwartzs Principles of Surgery, 9 Ed - 2010.
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