DEFINITION & TYPES

OF HERNIA

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“ ‘HERNIA’
Greek - an offshoot / bulge
Latin - to tear / rupture
An abnormal protrusion of an organ
or part of an organ through
a defect / weakness in the wall of
the cavity normally containing it

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 Structural weakness
Anatomy, congenital, collagen diseases,
CAUSES aging, neurological & muscular diseases

Injury
Trauma (Sharp / blunt), surgical incision
(defective healing, poor technique)

Intra-abdominal pressure
Pregnancy, COPD, ascites, tumours,etc.
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DEFINITIONS
Reducible
Contents can be returned to
the abdomen when given
pressure on.
Incarcerated
Irreducible hernia with viable
contents, used synonymously
with obstructed hernia.
Contents of the hernial sac
are stuck to one another by
adhesions
Irreducible
Contents cannot be reduced
or pushed back into the
abdomen but no complication.
Mild / absent symptoms
Strangulated
Visceral contents of hernia
become twisted or entrapped
by narrow opening
Compromised blood supply,
ischaemic / necrotic contents
Painful / tender on palpation
Obstructed
The herniated part of bowel is
irreducible but has good
blood supply.
Sliding
Part of a viscus (e.g. colon) is
adherent to the outside of the
peritoneum (extraperitoneal)
forming the hernial sac
beyond the hernial orifice)
Usually on the left.
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 COMPOSITION OF A HERNIA

Sac Covering of Contents of

the sac the sac
Mostly the
diverticulum of Composed of Depending on
peritoneum the layers of the part of
abdominal wall abdomen that is
(Mouth, neck,
through which herniated
body, fundus)
the sac passes.
Omentum,
intestines, etc.

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TYPES OF HERNIA - ANATOMICALLY

Based on location
▰ Para-umbilical Hernia
▰ Inguinal Hernia
▰ Femoral Hernia } (70%) ▰ Incisional Hernia (9%)
▰ Hiatal Hernia
▰ Umbilical Hernia (14%)
▰ Spigelian Hernia
▰ Epigastric Hernia (7%)

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TYPES OF HERNIA

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TYPES OF HERNIA

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 Direct

INGUINAL
HERNIAS
¾ of all abdominal wall hernias Indirect

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DIRECT vs INDIRECT INGUINAL HERNIA

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 TYPES OF INDIRECT INGUINAL HERNIAS

1) Complete Hernia: Hernial 3) Bubonocele: Hernia does not

sac is patent up to the bottom come out of the superficial
of the scrotum (males) inguinal ring and is limited to the
or labia majora (females). inguinal canal.

2) Incomplete Hernia: The

process vaginalis sac is
patent up to root of scrotum
but it comes out through the
superficial inguinal ring. 11
 PHYSICAL EXAMINATION
Position of patient: First standing, then lie supine
Inspection:
▰Swelling: Pyriform shape
extending down – indirect;
circular shape – direct;
spherical shape, starts from
below the inguinal ligament –
femoral.
▰Skin: Normal (uncomplicated);
erythema (strangulated)
▰Impulses on coughing:
Momentary bulge (absent if neck
of the sac is obstructed )
Palpation:
▰Non-tender unless strangulated
▰Granular (omentocele); elastic
(enterocele)
Zieman’s Technique:
▰Differentiate
direct/indirect/femoral
Method: Place the index finger
(indirect) over the deep inguinal ring
the middle finger (direct) on the
superficial inguinal ring and the ring
finger (femoral) over the saphenous
opening and ask the patient to
Ring occlusion test:
▰Differentiate indirect/direct
Method: Performed in standing
position, ask patient to cough when
thumb is pressed on the deep
inguinal ring - bulge medial to thumb
(direct)
Percussion:
▰Resonance (enterocele); dullness
(omentocele or fatty tissue)
Auscultation: Not applicable
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 CLINICAL FEATURES

May be asymptomatic and found incidentally.

Site: Groin area
Onset: Gradual / acute (incarceration)
Character: Burning, gurgling, or aching pain with heavy or dragging sensation in
the groin
Radiation: Localized, may radiate to the scrotum
Associated symptoms: Weakness in groin, (if strangulated) nausea & vomiting,
fever and inability to pass gas / stool

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 CLINICAL FEATURES (continued)

Time / Duration: Constant, worse toward the end of the day or after prolonged
activity
Exacerbating factors: Worsen with Valsalva maneuvers. Activities that increase
intra-abdominal pressure, i.e. coughing, lifting, or straining, cause more abdominal
contents to be pushed through the hernia defect.
Severity: Mild to severe
Progression: Bulge of the hernia gradually increases in size, suddenly intensified
pain may indicate strangulation
* If bulge disappears while patient is in the supine position, clinical suspicion of a hernia should be
increased.

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 MANAGEMENT OF INGUINAL HERNIA

Hernia repair techniques – indicated in irreducible, symptomatic cases

1) Open or conventional hernia repair
2) Laparoscopic hernia repair

Gold standard - Mesh Repair

▰ Hernioplasty – Herniotomy plus reinforcement of the posterior wall
of the inguinal canal with a synthetic mesh
▰ Herniorrhaphy – Herniotomy plus repair of the posterior wall of the
inguinal canal
▰ Herniotomy – Removal of hernia sac without any repair of the
inguinal canal 15
 * PHS – PROLENE hernia system

OPEN INGUINAL HERNIA REPAIR

Mesh inserted to cover and support the
posterior inguinal canal. (Hernioplasty)

Before After

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LAPAROSCOPIC INGUINAL HERNIA
REPAIR
Performed under GA, extra-/ trans-peritoneally.
Not appropriate for large or irreducuble hernias.

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ADVANTAGES OF REPAIR TECHNIQUES

▰ Laparoscopic repair: ▰ Open hernia repair:

▻ Faster recovery times ▻ Fewer internal injuries
▻ Less risk of long-term ▻ Lower recurrence
pain rates in the context of
primary inguinal
▻ Lower risk of another
hernia
hernia recurrence
after a previous
recurrence
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THANK YOU!
Any questions?

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