HERNIAS

DEFINITION
 A hernia is an abnormal protrusion of a part or whole of viscus
through an abnormal opening in the wall of the cavity which
contain it.

AETIOLOGY
 Mainly two factors play in causing a hernia

I. Weakness of the abdominal muscles

II. Increased abdominal pressure which forces the content out
through the normal abdominal musculature

I. WEAKNESS OF THE ABDOMINAL MUSCULATURE

1. CONGENITAL WEAKNESS

a. Persistance of Processus vaginalis - cause indirect complete

inguinal hernia.
b. Patent canal of Nuck in female causes indirect inguinal
hernia.
c. Incomplete obliteration of umbilicus may lead to infantile
umbilical hernia.

2. ACQUIRED WEAKNESS

a. Excessive fat in the abdomen causes weakness of the

abdominal musculature. This cause the appearance of
inguinal hernia, paraumbilical hernia, hiatus hernia.
b. Muscle weakness may follow repeated pregnancy.
c. Surgical incision may lead to division of nerve fibres and thus
causes muscle weakness.
d. Incisional hernia develops through weakened abdominal
muscle following a previous operation.

YOGESH
II. INCREASED ABDOMINAL PRESSURE

1. Whooping cough in children

2. Chronic cough in bronchitis, tuberculosis
3. Bladder neck obstruction or urethra stricture
4. Enlarged prostate causing dysuria
5. Vomiting
6. Repeated pregnancy
7. Constipation

PATHOLOGY

 A hernia consists of three parts:

 The sac
 The contents of the sac
 The coverings of the sac

1. THE SAC

 It is a pouch of peritoneum which comes out through the

abdominal musculature.
 The sac contains abdominal viscus and it has coverings starting
from the skin to the sac itself.
 Sac can be divided into 4 parts:

 Mouth is the opening of the sac through which contents

enter the sac.
 Neck of sac is most constricted part and this part passes
through the abdominal musculature.
 Body is the main portion of the sac.
 Fundus is most redundant part of the sac.

 In children sac is quite delicate where as in adults sac is

comparatively thick.

YOGESH
2. THE CONTENTS

 The viscus which lies within the sac of a hernia is called the
contents.
 When the content is omentum, the hernia is called an
Omentocele.
 When the content is a loop of intestine called as Enterocele.
 When content is a portion of the circumference of the
intestine called as Richter’s hernia.
 When content is Meckel’s diverticulum called as Littre’s
hernia.

3. COVERINGS

 These are the layers of the abdominal wall which cover the
hernia sac.
 This includes the skin and muscles of the abdomen.

TYPES

 Common external hernia are:

1. Inguinal Hernia - about 73%
2. Femoral Hernia - about 17%
3. Umbilical Hernia - about 8.5%
4. Incisional Hernia

 Other 1.5% cases are rare hernia:

1. Epigastric Hernia
2. Lumbar Hernia
3. Spigelian Hernia
4. Obturator Hernia
5. Gluteal Hernia

YOGESH
 INGUINAL HERNIA
DEFINITION

 An inguinal hernia is the protrusion of part of the contents of the

abdomen through the inguinal region of the abdominal wall.
 This inguinal region is a weak part of the abdominal wall by the
presence of the inguinal canal, the deep inguinal ring and the
superficial inguinal ring

ANATOMY OF INGUINAL CANAL

 THE DEEP INGUINAL RING

 It is an opening in the fascia transversalis 1.25 cm above the mid

inguinal point.
 It is oval in shape, the long axis being vertical.
 It varies in size in different individuals and is much larger in
male than in female.
 Medially it is related to the inferior epigastric vessels.
 It transmits the spermatic cord in the male and the round
ligament of uterus in the female.

 THE INGUINAL CANAL

 The inguinal canal is a triangular slit almost horizontal in

direction which lies just above the inner half of the inguinal
ligament.
 It commences at deep inguinal ring and ends at the superficial
inguinal ring.
 In infants the superficial and deep inguinal rings are almost
superimposed and the obliquity of this canal is slight.
 In adults the inguinal canal is about 3.75cm and is directed
downwards and medially from deep to the superficial inguinal
ring.
 This canal has been developed due to descent of testis in the
embryonic life.

YOGESH
 THE SUPERFICIAL INGUINAL RING

 It is an interval in the aponeurosis of the external oblique muscle

situated just above and lateral to crest of pubis.
 The aperture is somewhat triangular with its long axis oblique
corresponding to the course of the aponeurosis.
 Smaller in female.

 HESSELBACH’S TRIANGLE

 It is weak spot of anterior abdominal wall through which direct

inguinal hernia protrudes.
 It is triangle which bounded-
a. Medially - outer border of the rectus abdominis muscle.
b. Laterally - by the inferior epigastric vessels.
c. Below - by the medial part of the inguinal ligament.
d. The floor of the triangle formed by fascia transversalis.

INDIRECT OR OBLIQUE INGUINAL HERNIA

DEFINITION

 In Indirect Inguinal Hernia, the contents of the abdomen enter

the deep inguinal ring and transverse the whole length of
inguinal canal to come out through the superficial inguinal ring.
 This is much more common than direct inguinal hernia.
 The hernia usually occur when there is performed sac of
partially or completely patent processus vaginalis.
 Shortly after birth this processus vaginalis becomes obliterated
in normal individuals.
 Such obliteration occurs first at the deep inguinal ring, then just
above the testis and finally the remaining portion between the
deep inguinal ring and the upper pole of the testis is obliterated
to a fibrous cord.
 Indirect inguinal hernia is more commonly seen on the right side
through 1/3rd of the cases of the hernia is or will be bilateral.
 Particularly in children hernia is more common on the right side
due to later descent of the right testis.
YOGESH
TYPES

According to extent of hernia it can be divided into 3 groups

1. BUBONOCELE
 In this case, hernia is limited in the inguinal canal and the
processus vaginalis is closed at the superficial inguinal ring.
 This hernia presents as an inguinal swelling.
2. FUNICULAR HERNIA

 Here the processus vaginalis is closed at its lower end just

above the epididymis. So that contents of the hernia felt
separately from the testis and the testis lies below the hernia.
Most of this hernia occur in adults.
3. COMPLETE OR VAGINAL OR SCROTAL HERNIA

 Here the processus vaginalis is patent throughout.

 The hernia sac is continuous with the tunica vaginalis of the
testis.
 In this case, hernia descends down to the bottom of the
scrotum lying in front and at the sides of the testis.
 This testis can be felt posterior to the hernial sac with great
difficulty.
 Though it is a congenital hernia and commonly encountered in
children.

COVERINGS OF INDIRECT INGUINAL HERNIA

From inside outward hernia sac is covered by the following structures

1. Peritoneum
2. Extraperitoneal Fat
3. Internal Spermatic Fascia
4. Cremastric Fascia and Muscles
5. External Spermatic Fascia
6. Superficial Fascia
7. The Sikn
YOGESH
 DIRECT INGUINAL HERNIA

DEFINITION
 A direct inguinal hernia protrudes through the posterior wall of
the inguinal canal medial to the inferior epigastric vessels i.e
through Hesselbach’s triangle.
 Such hernia lies outside the spermatic cord, either behind or
above or below the cord.
 During operation most differentiating feature is that the neck of
the direct hernia lies medial to the inferior epigastric vessels,
whereas neck of the indirect hernia lies lateral to the inferior
epigastric vessels.
 Direct hernia is much rare and constitutes 15% of all cases.
More than 1/2 the cases are bilateral.
 Direct hernia is always an acquired type except the Ogilvie
hernia and occurs in elderly persons.
 It occurs in individuals with poor abdominal musculature as
shown by presence of elongated malgaignes bulges.
 Direct hernia almost always occurs in me.
 Women particularly never develop such hernia.
 Direct inguinal hernia rarely attains a large size if it comes out
through the superficial inguinal ring it never descends into the
scrotum. As the neck of a direct hernial sac is wide, it rarely gets
strangulated.
CLINICAL FEATURES
A. HISTORY
1. Age
 Inguinal hernia occur at any age.
 A direct hernia is mostly seen in older subjects.

2. Occupations
 Strenuous work is often responsible for development of
hernia.
 Heavy work especially lifting weights, puts a great strain on
the abdominal muscles.

YOGESH
B. SYMPTOMS
1. Pain

 Commonest symptom of hernia is discomfort or pain.

 Patient complains of a dragging or aching type of pain in the
groin which get worse as the day passes.
 Pain continues so long as the hernia is progressing but
ceases when it fully formed.
 When the hernia becomes very painful and tender, it is
probably strangulated.
2. Lump

 Many hernia may cause no pain and he has noticed only a

swelling in the groin.
 But this is rare and some sort of discomfort is almost always
present.
3. Systemic Symptoms

 If hernia is obstructing the lumen of bowel cardinal

symptoms of intestinal obstruction will appear.
 These are colicky abdominal pain, vomiting, abdominal
distension and absolute constipation.
 If the patient is vomiting note the character of vomitus
whether bilious or faecal.
 Faecal smelling vomitus heralds ominous sign.

4. Other Complaints

 The cause of hernia must be enquired into persistent

coughing of whooping cough or chronic bronchitis,
constipation, dysuria die to benign enlargement of prostate
or stricture urethra.

YOGESH
C. LOCAL EXAMINATIONS
 The patient should be first examined by in the standing position
and then in the supine position.
 Majority of the hernia are better examined in the standing
position.
 Two classical signs of an uncomplicated hernia are –
 Impulse on coughing
 Reducibility
1. Position And Extent
 If swelling descends into the scrotum or labia majora it is
obviously an inguinal hernia.
 When it is confined to the groin, it should be differentiated from
a femoral hernia.
 Two anatomical structures are to be considered in this respect :
 The Pubic Tubercle
 The Inguinal Ligament.
 An inguinal hernia is positioned above the inguinal ligament and
medial to the pubic tubercle, where as a femoral hernia lies
below the inguinal ligament and lateral to the pubic tubercle.
2. To Get Above The Swelling
 This examination differentiates a scrotal swelling from an
inguino-scrotal swelling.
 The root of the scrotum is held between the thumb in front and
the other finger behind in an attempt to reach above the
swelling.
 In case of inguinal hernia one cannot get above the swelling
where as in case of pure scrotal swelling like vaginal hydrocele
one can get above the swelling.

3. Consistency

 If the inguinal hernia contains omentum the swelling feel

doughy and granular.
 If it contain intestine it feels elastic and a strangulated hernia
feels tense and tender.

YOGESH
4. Impulse On Coughing

 When there is no swelling a finger is placed on the superficial

inguinal ring and the patient is asked to cough.
 The root of scrotum can also be held between in the index finger
and thumb and the patient is asked to cough.
 An expansile impulse on cough can be felt as the contents of the
hernia will be forced out through the superficial inguinal ring
and will separate the thumb from the index finger.
 Impulse on coughing will be absent in case of strangulated
hernia, irreducible hernia and obstructed hernia.

5. Invagination Test

 When the little finger enters the ring if it goes upwards,

backwards, and outward it is an indirect hernia.
 If the impulse is felt on the tip of the finger it is an indirect
hernia.
 When the little finger goes directly backwards, it is a direct
hernia when patient coughs impulse is felt on the pulp of the
finger.

6. Ring Occlusion Test

 In this test indirect hernia will not buldge out but direct hernia
will show a bulge medial to the occluding finger.

DIFFERENTIAL DIAGNOSIS

1. Encysted hydrocele of the cord

 Fluctuation test and translucency test will be positive.

 One can very well get above the swelling.
 If the swelling is held at its upper limit and the patient is asked
to cough there will be no impulse on coughing.
 If the testis is pulled down the swelling will also come down and
become immobile. This is traction test.

YOGESH
 2. Varicocele
 It is a condition in which the veins of the pampiniform plexus
become dilated and tortuous.
 Usually left side is affected probably because :
 The left spermatic vein is longer than the right
 The left spermatic vein enters the left renal vein at a right
angle.

TREATMENT
 Operation is undoubtedly the treatment of choice in a case of
inguinal hernia
 Treatment can be divided into two groups:
1. Conservative
2. Operative

1. CONSERVATIVE TREATMENT

 TRUSS

 A TRUSS does not cure a hernia with the sole exception of

the new born infants.
 A TRUSS is used to prevent the hernia to come out of the
superficial inguinal ring.
 Requirements are — hernia should be easily reducible and
that the patient should be reasonably intelligent

Mode of Action

a. Truss acts by pressing the anterior wall against the

posterior wall.
b. It also presses on the deep inguinal ring and prevents the
hernia to come out.
c. Adhesions gradually develop in the Inguinal canal so that
the hernia may not find access to come out.

YOGESH
2. OPERATIVE TREATMENT

 Three types of operation are usually performed for inguinal

hernia:
i. Herniotomy
ii. Herniorrhaphy
iii. Hernioplasty

i. HERNIOTOMY

 In this operation neck of the sac is transfixed and ligated and

then the hernial sac is excised.
 No repair of the inguinal canal is performed.
 It is indicated—
(a) In infants and children in whom there is a performed sac .
(b) In case of young adults with very good inguinal musculature.

ii. HERNIORRHAPHY

 It consist of herniotomy + repair of the posterior wall of the

inguinal canal by apposing the conjoined tendon to the inguinal
ligament.
 The suture material which is used for such repair is usually non
absorbable material e.g proline or silk .
 Some surgeons still favour a thick chromicised catgut.
 The repair is usually done behind the spermatic cord which is
known as Bassini’s operation.
 It is indicated:
a) In all cases of indirect hernia except in children.
b) In adult patients whose muscle tone is quite good.

YOGESH
iii. HERNIOPLASTY

 This means herniotomy + reinforced repair of the posterior wall

of the inguinal canal by filling the gap between the conjoined
tendon and inguinal ligament by autogenous material or by
heterogeneous material.

 Autogenous Material

 It means patient own tissue.

 The material used are :
1. Strip of fascia lata from the lateral side of the thigh. This is
obtained either by a long incision on the lateral side of the
thigh or by small incision with the help of a fasciatome. In
case of long incision the gap in the fascia lata is closed.
2. A strip of the external oblique aponeurosis.
3. A flap of the anterior rectus sheath which is turned down to
cover the inguinal canal.
4. Skin flap may be used in two ways — an elliptical portion
of the skin is tensely sutured to the conjoined tendon and
inguinal ligament to cover the posterior wall (dermoplasty)
or the skin is made into a ribbon ( skin ribbon) which is
now used as a strip same as fascia lata or external oblique
aponeurosis.
5. The strip of fascia lata or skin or external oblique
aponeurosis is threaded into a gallies needle. This is a wide
cutting needle with a big eye. Now the suture material is
used to ‘dam’ between the conjoined tendon and the
inguinal ligament.

YOGESH
  Heterogenous Material
 Prolene or a stainless steel wire has been used for darning.
 Prolene mesh or stainless steel mesh has also been used.
 Such mesh has been used to cover the gap between the
conjoined tendon and the inguinal ligament with a suture
ligament.

Indications

1. Cases of indirect hernia — in patients with poor muscle

tone
2. All cases of direct hernia
3. All cases of recurrent hernia
4. Patients who do strenuous jobs or suffering from chronic
bronchitis , enlarged prostate etc.

YOGESH
 BIBLIOGRAPHY

1. A Textbook of Surgery – S.Das

2. SRB’s Manual of Surgery – Shri Ram Bhatt
3. Manipal’s Surgery – Shenoy

YOGESH