Hernias

Definition Types of hernias

Abnormal protrusion of the contents of a cavity through a >75% Inguinal hernia
weakness in its containing wall <10% femoral hernia
Umbilical hernia
Aetiology Periumbilical hernia
Congenital Incisional hernia
Persistent processus vaginalis (inguinal) Spigelian hernia
Persistent umbilical opening Obturator hernia

Acquired
Weakened abdo wall
- Ageing
- Previous surgery (incisional hernia)
- Steroid use
- Post-op surg site infection
- Smoking
Increased intraabdo pressure
- Pregnancy
- Obesity
- Ascites
- Chronic cough
- Heavy lifting Unusual hernia types
Richter’s hernia—only part of the bowel circumference is
Contents of a hernia trapped within the hernial sac. As a result, there is a partial
Peritoneal lining bowel obstruction with vomiting but the patient continues to
Omentum and/ or bowel pass flatus (below)
Characteristics
Reducible—contents re-enter containing cavity (usually the
abdomen) either spontaneously or with manipulation
Irreducible/ incarcerated—hernia persists despite manipulation
- May be due to narrow hernia neck
- Small defects are more dangerous than large defects
- At risk of strangulation
Obstructed
- Kinked bowel à obstruction ± strangulation of bowel
segment
Strangulated Sliding hernia—retroperitoneal structure such as the colon or
- Ischaemia of the bowel within the incarcerated/ urinary bladder slides down and forms the wall of the hernial
obstructed hernia sac
- Decreased lymphatic flowà↑venous pressure à↑ Pantaloon hernia—both a direct and indirect hernia occurring
bowel oedemaà impeded arterial inflowà infarction together

Inguinal hernia
Epidemiology Anatomy
M>F 12:1 Inguinal canal = deep ring + superficial ring
Inguinal lig runs from ASIS to pubic tubercle
2 peaks in incidence
- Congenital <5yo Deep inguinal ring
- Acquired >50yo Formed through transversalis fascia
Lies 1-2cm above midpoint of inguinal lig
Location
Superficial inguinal ring
Above and medial to the pubic tubercle Formed through a v-shaped defect in external oblique aponeurosis
Lies above and medial to pubic tubercle
Types of inguinal hernia
Direct: medial to the inferior epigastric artery Hasselbach’s triangle
Inferior: inguinal lig
Protrude anteriorly through transversalis fascia (Hasselbach’s
Lateral: inferior epigastric artery
triangle) Medial: rectal sheath

Indirect: lateral to the inferior epigastric artery Inguinal canal

In the inguinal canal descending to the scrotum
- Leaves the abdo via deep inguinal ring to follow an
oblique course through the inguinal canal
- Peritoneal sac may represent a patent or reopened
processus vaginalis
- May extend to the tunica vaginalis surrounding the testis
Pantaloon: combination of the both
Anterior wall: external oblique aponeurosis covers entire canal and internal
oblique covers lateral 1/3
Posterior wall: conjoint tendon medially, transversalis fascia entire canal
Superior wall: internal oblique and transversus abdominis (conjoint muscle
Inferior wall: inguinal lig
Contents: 3433
- 3 vessels: testicular artery and vein, artery and vein to vas,
cremasteric artery and vein
- 4 nerves: n to cremaster, sympathetic n, ilioinguinal n, genital
branch of genitofemoral n
- 3 fasciae: external spermatic fascia, cremasteric fascia, internal
spermatic fascia
- 3 others: spermatic cord, vas deferens, lymphatics
Clinical features
Lump, usually not symptomatic until exacerbated by any
condition that ↑intraabdo pressure
- Chronic cough
- Obesity
- Constipation
When exacerbated, cause dragging/ aching sensation
Indirect inguinal hernia
Usually asymptomatic in the morning then symptoms develop
throughout the day as the hernia moves down the canal
- If deep ring defect, it behaves like a direct hernia
Direct inguinal hernia
Abdo wall lump appears immediately on standing
Diagnosis
Clinical exam
- Remember to stand the patient
- Presence of cough impulse
- Reduction into its opening defect
- Once reduced, location of deep ring can be determined
USS/ CT if equivocal dx/ obstruction suspected
Differentiation of direct vs indirect often done intraoperatively
Conservative management for elderly with significant
morbidities
Open inguinal hernia repair
Day case, but admission for complications
5cm incision in groin area
Intestines are placed into their correct position by excising the
hernial sac near the spermatic cord and repairing the weak
area
The weak area is then strengthened with a synthetic mesh
(tension free lichtenstein repair)
Post op care
Patient should not drive or operate machinery for 24h
Routinely, patient will be prescribed painkillers but not abx
Avoid heavy lifting for 6-8 weeks
Operative management
Congenital inguinal repair should be done asap due to
increased risk of incarceration, strangulation and testicular
ischaemia
Symptomatic adult hernias should be repaired
Open Lichtenstein tension free repair
Utilises a patch of non-absorbable mesh to strengthen the
posterior wall of the inguinal canal
Local anaesthesia + sedation or general anaesthesia
Lap herniorrhaphy
Indications: bilateral hernias, recurrent hernias
Both techniques listed below require the use of mesh and are
considered tension free repairs
- Totally extraperitoneal repair
- Transabdominal preperitoneal patch repair
Complications of repair
Scrotal haematoma
Wound infection
Urinary retention
Chronic pain/ paraesthesia in the scrotum (labium majora in females) from
damage to the ilio-inguinal nerve
Testicular atrophy caused by inadvertent damage to the testicular artery
Recurrence
- <1% rate
- Due to poor operative technique
- Conditions like chronic cough, constipation or bladder outlet
obstruction also contribute to recurrence
Risks of procedure
General risks of surgery and GA: N/V, sore throat, cardiac,
resp, DVT/ PE risks depending on comorbidities
Risks specific to procedure
- Damage to blood vesselsà bleeding, haematoma
(require repeat operation)
- Testicular atrophy (<1%) when testicular artery is
damaged
- Infection of the wound or mesh (abx, removal of mesh if
infected)
- Nerve damage à chronic pain in groin that may resolve
after the operation but may persist
- Recurrence (1%)

Femoral hernia
Epidemiology Anatomy
F>M Femoral △
30% of all hernia repairs in women and <15 of all hernia Superior: inguinal lig
repairs in men Lateral: medial border of sartorius muscle
More common >70yo Medial: medial border of adductor longus
Floor: iliacus, psoas, pectineus, adductor longus
Location Roof: superficial fascia, great saphenous vein
Below and lateral to pubic tubercle Contents: (VAN medial to lateral) fem vein, fem artery, fem n

Clinical features Femoral canal

Small lump immediately below the inguinal lig and just lateral Anterior: inguinal lig
to its medial attachment to the pubic tubercle Medial: lacunar lig
Cough impulse rarely detected due to narrow neck of hernial Lateral: fem vein
sac Post: pectineal lig
- Due to narrow neck, more likely to strangulate but Contents: lymph node (Cloquet’s node) and fat
localising signs usually absent
30% present with bowel obstruction
Management
DDx All fem hernias should be surgically repaired
Fen canal lipoma
Saphena varix (SFJ varices)
Fem lymph node
Fem artery aneurysm
Fen artery pseudoaneurysm (post angiography)
Sarcoma (leio/ rhabdomyosarcoma)
 Other hernias
Umbilical hernia Spigelian hernia
True umbilical hernia Defect between lateral border of the rectus abdominis and
Always congenital linea semilunaris
Through umbilical cicatrix Hernial sac comes to lie interstitially between the layers of
May close spontaneously by 3y of age internal and external oblique and transversus abdominis
Following this, there is little likelihood of improvement and Difficult to diagnose
surgical repair should be considered Usually requires imaging—CT
- Should be surgically repaired after 3yo Direct surgical repair indicated

Periumbilical
Always acquired
Not through the umbilicus itself
Common in obese patients and multiparous women
Occasionally strangulate
- Assess case by case basis risk vs benefit for surgery

Incisional hernia
Up to 10% of laparotomy incisions eventually herniate
Predisposing factors
- Post op wound infection
- Abdo obesity
- Poor muscle quality (smoking, anaemia)
- Multiple operations through the same incision
- Poor choice of incision Obturator hernia
- Inadequate closure technique Defect through obturator canal (lateral pelvis into thigh)
Causes medial thigh pain in cutaneous distribution of the
Clinical features obturator nerve
Lump and defect: vary from small (more dangerous) to Very challenging to diagnose – CT required
complete defects High risk of obstruction
Incisional hernias may be asymptomatic at presentation but
tend to progressively enlarge
May cause strangulation (rare)

Management
Repair indicated for pain or strangulation
Mesh used for larger defects (>4cm)