CME of Hernias

Supervisor: Dr Lynette

Presenter: Hui Yi, Suresh

Slides prepared by: Hui Yi
 Inguinal hernia
Definition of hernia: Protrusion of part/whole of a viscus
through an abnormal opening in the walls of its containing
cavity

Hui Yi
 Inguinal canal
● Inguinal canal
○ 4-6 cm oblique passage in the
lower ant. abdominal wall
located just above inguinal
ligament
○ Deep inguinal ring - 2 cm above
midpoint of inguinal ligament
○ Superficial ring - above & medial
to pubic tubercle

*Midpoint of inguinal ligament - midpoint

between ASIS & pubic tubercle
*Mid-inguinal point - midpoint between
ASIS & pubic symphysis
 Contents of Inguinal Canal
● Males - spermatic cord, ilioinguinal nerve
● Females - round ligament of uterus, ilioinguinal
nerve
Direct VS Indirect
 Content of hernia
Sac Covering Content of Sac

A pouch of peritoneum Composed of layers of Part of structure that is herniated

● Neck abdominal walls through ● Intestine (Enterocoele)
● Body which the sac passes ● Omentum (Omentocele)
● Fundus ● Appendix (Amyands’)
● Part of bowel (Richter)
● Meckel’s Diverticulum (Littre’s)
Meckel diverticulum - incomplete obliteration of
vitelline duct, rules of 2 (w/n 2 feet of ileocecal
valve, 2 inches length, dvlp before 2 y/o
 How to approach?
+ve cough impulse
*Inguinal/femoral hernia Inspect the lump:
*Reducible/irreducible, ❖ Previous scars? Skin changes?
*Incarcerated/strangulate ❖ Contralateral site swelling?
d/obstructed
*Predisposing factors/RF Palpate:
1. Can get above the swelling
2. Lump: consistency, fluctuant, size, temperature, any
RF tenderness?
- Smoking 3. Extension to scrotal. Can feel testes?
- Chronic cough 4. Test for reducibility: ask pt to reduce the hernia if possible
- Heavy lifting 5. Deep inguinal ring occlusion test
- Constipation
- Straining to PU (BPH) Auscultate : bowel sound
- Increase of intra-abd
pressure TRO RF:
Auscultate for lungs
Any abdominal distension or abdominal mass?
PR to look for prostatomegaly
 DDx of inguinal swelling
Hernia ● Femoral Hernia
● Inguinal Hernia

Vascular ● Femoral Artery Aneurysm

● Saphenous Varix
● Varicocele

Lymphatics ● Inguinal lymphadenopathy

● Lymphoma

Soft Tissue / Bone ● Lipoma

● Groin Abscess
● Muscle / Soft Tissue Tumour– Rhabdomyosarcoma
● Bone Tumour

Nerves ● Neuroma

Others ● Undescended Testes

● Hydrocele of the spermatic cord (young boys)
 Management of hernia
Conservative tx
● RF modifications:
○ weight loss, avoid heavy lifting
○ Treat medical conditions causing chronic
cough, chronic constipation
○ TRUSS (hernia belt) for compression of
reducible hernia at deep ring, tight
undergarment
● Obstructed/strangulated hernia
○ Secure ABC + resuscitation
○ keep NBM, on IVD, RT on free flow & aspiration,
IV antibiotics (Flagyl & Cefobid), correct
electrolyte imbalances
○ AXR, CECT Abdomen, VBG, preop blood (FBC,
RP, electrolytes, Coag profile), GSH/GXM
Surgical tx:
*Principle - reduce bowel ± excise hernia sac,
reinforce posterior wall
● Open inguinal hernia repair (with or without
mesh)
○ Hernioplasty - reinforcement of posterior
inguinal canal wall with synthetic mesh
■ polypropylene mesh insertion and
suture
● Laparoscopic inguinal hernia repair
○ Transabdominal preperitoneal (TAPP) repair
○ Totally extra-peritoneal repair (TEP)
Post op complications
- Immediate to early
○ Acute retention of urine
○ Bruising, bleeding/scrotal hematoma Post op plan:
○ Iatrogenic injury to surround structures - 1. Monitor bleeding / scrotal
ilioinguinal nerve (upper anteromedial of hematoma
thigh) 2. Early mobilisation
3. Avoid heavy lifting for 6/12
- Early
4. Treat any medical
○ Infection of wound/mesh
conditions to avoid
○ Hematoma coughing, constipation
○ Wound dehiscence 5. WI D3 (open hernioplasty),
○ Pain no need STO
- Late 6. For TRUSS/tight
○ Chronic post-op groin pain undergarment
○ Recurrence
○ Ischemic orchitis (thrombosis of
pampiniform plexus)
Femoral hernia
Femoral hernia
- Uncommon, mostly in women
- swelling in the upper thigh just below inguinal ligament and medial to femoral pulse
- Usually irreducible and does not have cough impulse - need surgical femoral repair
Femoral VS Inguinal
Incisional hernia
Hui Yi
 Incisional hernia
Definition: abdominal wall hernia at the site of previous surgical
incision

Risk factors:
- Emergency op - double risk compared to elective
- BMI>25 obese
- Midline incision - 74% compared to non midline
- Postoperative wound infection - increase risk of incisional
hernia by 70%
- DM, steroid use, smoking, advancing age
- Malnutrition

Complications
- Intestinal obstruction
- Incarceration, strangulation
 Treatment of incisional hernia
1. Conservative:
- Offer corset or truss (hernia belt)
- Weight loss and control the risk
factors

2. Surgical:
- Offer if complications of hernia are
present (intestinal obstruction,
strangulation, incarceration)
- Open/laparoscopic surgery with
mesh intraperitoneal onlay mesh
position (IPOM)
- Mesh placed betw abd wall
and intestine/omentum
Ventral hernia
Hui Yi
Umbilical & paraumbilical hernia
Umbilical Hernia Paraumbilical Hernia

Location Occur through the umbilical Occur around the umbilical

scar scar

Site of Umbilical orifice Adjacent to umbilical orifice

hernia
defect Neck of sac wide, everted Neck of sac narrow, umbilicus
umbilicus crescent shaped

Etiology Delayed spontaneous closure of Reopening of previously closed

umbilical ring following umbilical ring or surrounding
physiological herniation of tissues
midgut → patent umbilical orifice

RF Congenital - can wait up to 4 yrs Always acquired - obesity & lax

for spontaneous closure abdominal wall, >intra-abd
Acquired - obesity & lax pressure
abdominal wall, >intra-abd
pressure
Umbilical hernia Paraumbilical hernia
Examination of umbilical & paraumbilical
hernia
1. INSPECTION
a. Body habitus (obesity→ IAP)
b. Abdominal scars (incisional hernia?)
c. Bulge prominence w neck flexion
d. Visible cough impulse
e. Visible peristalsis through skin
Issues of concern :
- Narrow neck of hernia sac (higher risk of strangulation /infarction)
- Fistula formation w discharge of contents (enterocutaneous)
2. PALPATION
a. Size of defect
b. Reducibility
c. Cough impulse
3. AUSCULTATION
a. Bowel sounds
Tx of umbilical & paraumbilical hernias
CONSERVATIVE MANAGEMENT
● For small, asymptomatic hernia (particularly in pt w increased
perioperative morbidity)
● Congenital umbilical hernia (90% spontaneously close by 4 y/o)
● Treat underlying medical conditions that may worsen hernia (obesity,
chronic cough, optimize comorbids)

SURGICAL MANAGEMENT
● Patients with incarcerated, obstructed, or strangulated umbilical
hernia
● Surgical repair with mesh (KIV bowel resection KIV proceed)
 Epigastric hernia
Epigastric hernia: protrusion of intra-abd contents
through linea alba, betw xiphoid process &
umbilicus

Symptomatic - open/laparoscopic surgical repair.

Mesh used depending on size of hernia defect (>1cm
require mesh)
 Spigelian hernia
Definition: herniation along semilunar line, commonly
adjacent to the arcuate line (below umbilicus)

P/w small lump at lower lateral edge of rectus abdominis

m/s.

A/w high risk of strangulation

 Divarication of recti
Stretching of linea alba → widening of gap betw rectus abdominis m/s
(no defect of abdominal wall, thus it is not a hernia)

RF: aging, multiparity

P/w bulging upon sitting up

Mx: physiotherapy to strengthen abdominal wall, corset/TRUSS (surgical

intervention not necessary as it is not hernia, mostly cosmetic
issue/symptomatic)
References
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548139/
2. https://teachmesurgery.com/perioperative/gastrointestinal/incisional-her
nia/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787661/#:~:text=Incisiona
l%20hernia%20repair%20involves%20placing,mesh%20%5BIPOM%5D%20
position).
4. https://www.ncbi.nlm.nih.gov/books/NBK499927/
5. Bailey & Love's Short Practice Of Surgery, 27Th Edition
6. https://generalsurgery.ucsf.edu/conditions--procedures/femoral-(thigh)-h
ernia.aspx