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LIDIA IONESCU

3rd.Surgical Unit
HERNIA= a protrusion of an organ through its
containing wall
 Herniation of the muscle through its fascial covering
 Herniation of the brain through a fracture of the
skull
 Herniation of an intra-abdominal organ through a
defect in the abdominal wall, pelvis or diaphragm-
the term “hernia” is used to describe an abnormal
opening in a patient’s muscle that will allow tissue
or organs to pass through the opening in the muscle
Common types:
 Inguinal
 Umbilical
 Femoral
 Incisional hernia

Less common types:


 Epigastric
 Spigelian
 Obturator
FAILURE TO DIAGNOSE ANY TYPE OF
STRANGULATED HERNIA
COMMON OR RARE

MAY LEAD TO THE PATIENT’S DEATH


Irreducibility- bowel obstruction-
incarcerated bowel
Strangulation – bowel obstruction +
necrotic bowel  
Inguinal hernia is common in men

Femoral hernia is more common in women


Occur at weak spots in the abdominal wall
Reduce on lying down or with direct manual
pressure
Expansive cough impulse
Defects in the abdo wall:
 Structures pass through: indirect inquinal, epigastric
 Muscles fail to overlap: spigelian, lumbar
 No muscles, only scar tissue: umbilical hernia

Loss of tissue strength:


 Direct inquinal hernia
Increased intra-abdo pressure
Trauma
This type of hernia accounts for the vast
majority of hernia surgical repairs.
An inguinal hernia is located in the inguinal
region of the body where the thigh meets our
pelvis.
The most common types of inguinal hernias are
either direct or indirect hernias and these are
found more often by far in men rather than
women.
It is possible to develop three
types of hernia in, or close to the
inguinal region: direct inguinal;
indirect inguinal; femoral.
Each opening (the deep and
superficial inguinal rings) is
visible and “protected” by two
of the muscle layers.
The muscles and their
aponeuroses were clearly
defined and two of them
(internal oblique and
transversus abdominis) could be
seen arching over the canal to
form its roof and then its
posterior wall (conjoint tendon).
Reducible hernia- hernia content can be pushed back
into the abdomen
Irreducible hernia-incarcerated hernia- hernia content
cannot be pushed back
Obstructing hernia- hernia containing a loop of bowel
that is kinked and therefore obstructed
Strangulated hernia-the tissue contained in the hernia
is ischemic due to interruption of the blood supply
Sliding hernia-when the wall of the hernia sac in part
formed by the wall of another intra-abdominal organ(
colon, bladder)
Richter’s hernia-one side of the bowel wall is trapped
in the hernia
Intestinal obstruction- a loop of bowel passes
through the abdo. wall defect and becomes
mechanically obstructed.

Intestinal strangulation with


gangrene/perforation – vascular pedicle to the
herniated loop of bowel is also interrupted
Superficial inguinal ring- triangular defect in
the aponeurosis of the EOM and the pubic crest
Deep inguinal ring- an oval opening in the
fascia transversalis, 1,3 cm. above the mid-
inguinal ligament.
 Medially- inf. epigastric vessels
Inguinal canal- oblique passage through the
lower part of the anterior abdominal wall
 Spermatic cord
 Round ligament
1. Inguinal canal
2. Spermatic cord
3. Testis
4. Uterus
5. Round ligament
6. Lymph vessels
7. Superficial
inguinal nodes
8. Deep inguinal
ring
9. Superficial
inguinal ring
4 cm. long, between deep and superficial rings
Anterior wall- EOM aponeurosis
Inferior wall- inguinal ligament
Superior wall- conjoint tendon
Posterior wall- transversalis fascia
Hesselbach’s triangle- within the posterior
wall: inf.epi.art.- inguinal lig.-lateral border of
the rectus sheath
Indirect inguinal herniae
 Passes through the deep inguinal ring, down the
inguinal canal
 May extend into the scrotum
 5 times commoner than direct hernia

Direct inguinal hernia


 Passes through the Hesselbach triangle
 Posterior to the spematic cord
 Does not pass into the scrotum
 Less often associated with strangulation
Gender- all ages
Occupation- heavy works
Local symptoms- dragging sensation in the
groin
Systemic symptoms- obstructive hernia-
vomiting, distension, colicky abdominal pain,
absolute constipation
Position- above the inguinal ligament
Tenderness- if strangulated
Shape- “pear-shaped” with the “stalk” at the
external inguinal ring
Composition- soft-gut, firm-omentum.
Cough impulse
Reducibility
Look for causes of a raised intra-abdominal
pressure:
 Chronic bronchitis- caughing
 Chronic retention of urine- difficulty in micturition
 Chirrhosis - ascites
 Intra-abdominal masses

Look for signs of intestinal obstruction:


- Abdominal distention
- Visible peristalsis
- High-piched bowel sounds
Femoral hernia

Vaginal hydrocele

Undescended testis

Lipoma
Femoral canal – space containing lymphatic
and fat tissue

Femoral ring: inguinal ligament, Cooper’s


ligament, pectineal line, femoral vein
Femoral ring is rigid- strangulation more likely
The bulge can be palpated in inguinal crease,
below inguinal ligament
Obese patiernts- difficult to palpate
Think to a complicated femoral hernia in an
obese patient with painful femoral area and
bowel obstruction symptoms
More common in women
Related with physical effort
Age - uncommon in kids
Gender -women more affected
Position - below and lateral to the pubic
tubercle
Tenderness - not tender unless complicated
Shape and size - spherical, small
Surface - smooth
Reducibility- firm pressure
Cough impulse - tight ring- less likely
Inguinal hernia

Enlarged lymph nodes

Sapheno-varix

Ectopic testis
Psoas abscess
Lipoma
This type of hernia occurs at the level of the
naval and are usually the result of the failure of
the abdominal wall defect to close after the
patients umbilical cord falls off as an infant.
Most of these hernias defects will close in
childhood by the age of 3-5.
Remaining umbilical hernias however can
enlarge over time and require repair in the
adult patient.
90% of cases, defects are closed by the age of
one year

99% by 2 years of age

Surgery is contraindicated below the age of 3


years
Adult hernia through the umbilical scar

Secondary to a raised intra-abdominal pressure


Congenital umbilical hernia

Acquired umbilical hernia

Para-umbilical hernia
Acquired umbilical hernia

Appears through a defect that is adjacent to the


umbilical scar
This type of hernia  is a rare form of hernia
defect that can occur at the level of the
umbilicus but actually lateral to it.

These hernias are often difficult to diagnose


Protrusion of extraperitoneal fat through a
defect in the linea alba
Between xiphisternum and umbilicus
More frequent in men
In obese patients difficult to palpate
Epigastric pain
This hernia is the result of a separation of the muscle layers at the
site of a previous surgical incision.
The hernia defect may appear shortly after a surgical procedure or
many years after a surgical procedure has been performed.
Several risk factors that are associated with the development of an
incisional hernia:
 wound infection at the time of the original surgery,
 obese patient,
 diabetes,
 chronic steroid use,
 resumption of strenuous activity following the initial surgical
procedure before the muscular closure has had time to heal
properly.
Hernia through an acquired scar in the
abdominal wall
Caused by a previous surgical operation with
complicated wound:
 Hematoma
 Infection
Lump at the level of a scar

Tender lump if complicated: irreducibility or


obstruction
Non complicated incisional hernia is reducible
with cough impulse
This type of hernia is
typically a result of
the muscles of an old
incision breaking
down.
An incision in the
abdominal wall will
always be an area of
potential weakness
When the incision breaks
down an incisional
hernia develops.
An incisional hernia
may occur at any site
where an operation has
been perfomed
previously.
The scar represents a
weakened area, which if
stretched over time,
may allow the
underlying intestines to
bulge through. Repair is
often necessary.
Cooper's hernia: a femoral hernia with two sacs, the first being in the femoral
canal, and the second passing through a defect in the superficial fascia and
appearing immediately beneath the skin.

Littre's hernia: a hernia involving a Meckel’’s diverticulum . It is named after the


French anatomist Alexis Littre (1658-1726).
Lumbar hernia: a hernia in the lumbar region (not to be confused with a lumbar
disc hernia), contains the following entities:
 Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It is
named after French surgeon Jean Louis Petit (1674-1750).
 Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior
lumbar triangle). It is named after physician Joseph Grynfeltt (1840-1913).
Obturator hernia: hernia through obturator canal

Pantaloon hernia: a combined direct and indirect hernia, when the hernial sac
protrudes on either side of the inferior epigastric vessels.
Amyand’s hernia- appendix in the inguinal hernia sac
Properitoneal hernia: rare hernia located directly above the peritoneum,
for example, when part of an inguinal hernia projects from the deep
inguinal ring to the preperitoneal space.
Richter’s hernia: a hernia involving only one sidewall of the bowel,
which can result in bowel strangulation leading to perforation through
ischaemia without causing bowel obstruction or any of its warning signs.
It is named after German surgeon August Gottlieb Richter (1742-1812).
Sliding hernia: occurs when an organ drags along part of the
peritoneum, or, in other words, the organ is part of the hernia sac. The
colon and the urinary bladder are often involved.

Spigelian hernia, also known as spontaneous lateral ventral hernia.


Sport’s hernia: a hernia characterized by chronic groin pain in athletes
and a dilated superficial ring of the inguinal canal.
Velpeau hernia: a hernia in the groin in front of the femoral blood vessels
An 85-year-old-male arrived at hospital presenting a
right groin mass.
His history included hypertension, coronary artery
disease, of which all were receiving regular medical
treatment. Additionally, he had recently experienced
urinary frequency and nocturia.
A right groin mass had been protruding for 1 month
prior to hospital admission, which increased in size
when standing and before stool passage, but decreased
in size after stool passage or lying down. Mild
tenderness had been noted for 1 week. The mass was
not reducible.
Impression was inguinal hernia and the patient
was admitted for surgical intervention.
Laboratory data were within normal limits.
Blood pressure was well controlled.
The patient was scheduled for elective surgery.
The oblique conventional incision between
external and internal rings was used to achieve
a better approach. An appendix was found
completely within the indirect sliding hernia
sac .
The distal end of the appendix was trapped by the
external ring, leaving a mark on the appendix.
The body and base of the appendix was healthy and a
moderate amount of clear ascites was found in the
hernial sac.
The distal portion of the appendix was attached to the
distal portion of the hernial sac, which lay outside the
external ring of the right groin.
The mobilized cecum and ascending colon were far
away from the paracolic space, apparently sliding until
occupying the neck of the hernial sac.
Appendectomy was performed and hernioplasty was
done instantly with Bassini’s method.

The patient’s postoperative condition was uneventful


and he was discharged on the next day.

He was followed up at our OPD one week later and the


right groin looked good. Pathology revealed an acute
suppurative appendicitis
Amyand’s hernia is defined as an uninflamed appendix in an
inguinal hernia.

This rare condition was named after the first surgeon to perform
appendectomy, Claudius Amyand, an English surgeon of the 18th
century who first described this condition.

The incidence of Amyand’s hernia is estimated to occur in


approximately one percent of adult inguinal hernia repair cases.

Acute appendicitis occurs much less frequently, and perforated


appendix and periappendicular abscess formation within an
inguinal hernia sac is an extremely rare clinical entity.