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Inguinal hernias and abdominal wall defects

Murad Nuserat & Abd AL-Rahman Alhelw

Definition

• A hernia is the

protrusion of an organ
(intra-abdominal
contents) through a
defect in its containing
wall.

Composition of a hernia
1. The sac

2. The covering of

the sac

3. The content of the

sac

Composition of a hernia
1. The sac :

It is a diverticulum
of peritoneum and is
made up of three
parts :

The mouth,

The neck and

The body of the sac.

Composition of a hernia
2.

The covering:

3.

Coverings are derived from the layers of abdominal wall through which the sac
pass

Contents:

can be

Omentum = omentocle

Intestine = enterocele

Portion of circumference of intestine = Richter’s hernia

Portion of the bladder

Ovary(with or without oviduct)

Meckel’s diverteculum =Littre’s hernia

3. such as a powerful muscular effort.Etiology Any condition that raises intra-abdominal pressure. 4. Smoking and aging. may produce a hernia. leading to acquired collagen deficiency. Chronic cough. Obesity . 1. straining on micturition or straining on defecation. heavy lifting may precipitate a hernia in an adult. Whooping cough is a predisposing cause in childhood 2. ascites 5. intra-abdominal malignancy.

Types A hernia at any site may be: 1. Irreducible This one whose contents cannot be returned to the peritoneal cavity either because there are: • adhesions between the sac and contents. A reducible hernia imparts an expansile impulse on coughing. Reducible This is the one which the contents of the sac reduced spontaneously or can be pushed back manually. • Overcorwding within the sac . or • because of the narrow neck of the sac. 2.

The blood supply remains intact. This is a common cause of small bowel obstruction. Present with local then general abdominal pain and vomiting coughing tense + tender + no impulse on . 3.Irreducible hernia can be : 1. but there is no obstruction or interference with blood supply. the hernia simply will not reduce 2. Strangulated: the arterial blood supply to the contents of the sac is compromised. Obstructed: a hollow viscus is trapped within the sac and obstruction occurs. Incarcerated: there are adhesions between the sac and the contents. in such a hernia unless surgical relief is undertaken the contents of the sac will become gangrenous.

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External hernia Common hernia • inguinal • Femoral • Umbilical •Rare incisional hernia – – – – Spigelian Gluteal Obturator lumbar continue… .Classification A.

Internal hernia • Diaphragmatic hernia • Esophogial hernia • Paraesophogial hernia .Classification continue… B.

.Signs and Symptoms - • • A lump disappears. Physical Signs: • Reduced. and enlarges on straining and discomfort. • + ve cough impulse. in inspection and palpation Investigation: Hernia is diagnosed clinically. Investigations are rarely indicated or valuable. reappears.

Management hernias should be operatively repaired both to relieve symptoms and to eliminate the complications. . • Surgical techniques: • Herniotomy: removal of sac and closure of its neck. • Increase the strength of the abdomenal wall. • Herniorrhaphy: involves some sort of reconstruction to: • Restore the anatomy if this is disturbed.

the incidence of direct hernias increases . • As age of patient increases. .Inguinal hernia • Epidemiology: • Male : Female • by 9 to 1 ratio • young adults mostly have indirect inguinal hernia.

Inguinal hernia Inguinal Canal Anatomy • The internal inguinal ring is an opening in the transversalis fascia lateral to the inferior epigastric vessels. • The external inguinal ring is an opening in the external oblique aponeurosis. • The inguinal canal is the communication between .

• Anterior wall: • aponeurosis of external oblique (along entire length). and • lacunar ligament at the medial end . • internal oblique on lateral one third • Posterior: • fascia transversalis • conjoint tendonon in medial one third • Roof: • arching lowest fibers of internal oblique . and transversus abdominis • Floor (inferior): • inguinal ligament.

• genital branch of genitofemoral nerve. autonomic nerves. • lymphatics. lymphatics. testicular artery testicular veins (pampiniform plexus). genital branch of genitofemoral nerve. processus vaginalis. . Ilio inguinal nerve Female: • • Round ligament of the uterus. • sympathetic plexus. artery of the vas deference.Inguinal Canal Contents: Male: Spermatic cord structures: • • • • • • • • • • vas deferens.

• In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate. • Direct Hernia usually bulge at External Inguinal Ring. • On examination: • Palpable defect or swelling may be present . • Indirect Hernia usually bulge at Internal Inguinal Ring. but often asymptomatic. .Inguinal hernia Signs & symptoms: • Bulge that enlarges when stand or strain.

Inguinal hernia There are two types of inguinal hernia: • Direct inguinal hernia • Indirect inguinal hernia Indirect inguinal hernias are the most common type of hernia in both men and women. . They are 5 to 10 times more common in men than in women.

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• Indirect: Sac of peritoneum coming through internal ring. The origin is medially to the inferior epigastric vessels. 3. Etiology: • Direct: weakness of the posterior floor of the inguinal canal . peritoneal sac containing bowel . less commonly.Differences between direct and indirect hernias 1. through which omentum or bowel can enter. 2. The origin is lateral to the inferior epigastric artery. Origin and coarse: • Direct: Develops in the area of Hasselbach's triangle. • Indirect: Develops at the internal ring. Content: • Direct: Retroperitoneal fat.

Diagnosis • The patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal region • They may describe minor pain or vague discomfort associated with the bulge • Extreme pain usually represents incarceration with intestinal vascular compromise • Paresthesias may be present if inguinal nerves are compressed .

Diagnosis • Physical exam • The patient should be standing and facing the examiner • Visual inspection may reveal a loss of symmetry in the inguinal area or bulge • Having the patient perform valsalva’s maneuver or cough may accentuate the bulge • A fingertip is then placed in the inguinal canal. Valsalva maneuver is repeated • Differentiation between indirect and direct .

Hernia Exam .

Diagnosis • Physical exam • Incarcerated hernias sometimes can be reduced manually • Gentle continuous pressure on the hernial mass towards the inguinal ring is generally effective (Trendelenburg) .

Spermatocele . Hydrocele 7. Epididymitis 8. Muscle tear 3. Tendonitis 2. Varicose vein 6. Lipoma 5.Inguinal hernia • Differential diagnosis: 1. Lymphadenopathy 4.

. 3-10% direct. . Surgical emergency 50% indirect.Inguinal hernia • Complications: • Irreducibility. but without signs of obstruction or strangulation • Small Bowel Obstruction Usually urgent surgical repair • Strangulation.

Inguinal hernia • Both types (direct and indirect inguinal hernia) may occur at the same time and straddle the inferior epigastric artery. the hernia sac passes both medially and laterally to the epigastric vessels • This is called: Pantaloon hernia .

. herniorrhaphy ) unless there are specific contraindications.Management: • Inguinal hernias should always be repaired ( herniotomy. a permanent sutures. • Types of operations: 1. as in Shouldice repair (layered suture). a permanent mesh to decrease tension. 2.

• The basic operation is inguinal herniotomy. It is employed either by itself or as the first step in a repair procedure (herniorrhaphy) • Herniotomy and repair (herniorrhaphy) consists of: (1) excision of the hernial sac. fascial flaps or mesh implants. (2) and (3) must be achieved without tension resulting in the wound and various techniques exist to achieve this. and (3) further reinforcement of the posterior wall of the inguinal canal. . which entails dissecting out and opening the hernial sac. plus (2) repair of the stretched internal inguinal ring and the transversalis fascia.g. reducing any contents and then transfixing the neck of the sac and removing the remainder. Shouldice operation. e.

etc).Inguinal hernia management • Treatment of aggravating factors (chronic cough. prostatic obstruction. • Use of truss (appliance to prevent hernia from protruding) when a patient refuses operative repair or when there are absolute contraindications to operation .

Specific Surgical Procedures These are for repair of the floor of the inguinal canal (herniorrhaphy) • Lichenstein (Tension Free) Repair • McVay (Cooper’s Ligament) Repair • Shouldice (Canadian) Repair • Laproscopic Hernia Repair • Bassini Repair .

Lichtenstein Repair AKA: Tension-Free Repair One of the most commonly performed procedures A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord .

Lichtenstein Repair Note: Open mesh repair. Minimal tension is used to bring tissue together. . Mesh is used to reconstruct the inguinal canal.

• Femoral canal-ant.by inguinal ligament. • The hernia passes through the femoral canal and presents in the groin. below and lateral to the pubic tubercle. • It is more common in females and carries a higher risk of strangulation. lat. by femoral vein and medial by lacunar ligament .Femoral hernia • The defect is in the transversalis fascia overlying the femoral ring at the entry to the femoral canal.post by fascia over pectineus muscle and cooper’s ligament.

Signs & symptoms: • A lump occurs below and lateral to the pubic tubercle. • It may not be noticed until it becomes tender and painful. • DD’s-saphena varix. It may be reducible.enlarged . • This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstruction without an obvious cause.

. • There is no place for a truss in the treatment of femoral hernia. if present. • Treatment of strangulation or obstruction.Surgical repair: • An incision is made directly over the swelling. • Femoral canal obliterated with 3 interrupted non absorbable suture. • The sac is opened and the contents reduced and the sac removed.

Femoral hernia .

• Surgical repair should only be carried out if the hernia has not disappeared by the age of 2 and the fascial defect is greater than 1.5cm in diameter. • The majority close spontaneously during the first year of life. .Umbilical hernia • This occurs in children because of incomplete closure of the umbilical orifice.

. • Predisposing factors • multiple pregnancies and • obesity. and is more common in obese females.Para-Umbilical hernia • the hernia does not occur through the umbilical scar but is a protrusion through the linea alba • It occurs just above or just below the umbilicus.

recurrent-polypropylene mesh . • The most common content is • omentum . • Treatment: is by • Contents of sac freed from it’s wall. and fascial defect repaired by • Upper flap overlapping the lower.Para-Umbilical hernia • The neck of the sac is usually narrow and therefore there is a high risk of strangulation. a two layer overlapping repair thereby doubling the strength of repair (Mayo repair) • >4 cm.excision of the sac.then • transverse colon and small intestine.

creascent shaped .Paraumbilical Hernia.

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but May contain omentum or small bowel.Epigastric hernia • This is usually a small protrusion through the linea Alba in the upper part of the abdomen. • It consists of : • • extraperitoneal fat only. .

probably because of trapping and ischaemia of extraperitoneal fat.excising the fat.Epigastric hernia • It may be extremely painful. • Treatment • is by enlaging the defect. simple suture of the defect with non-absorbable sutures . • >4 cm propylene mesh placed retromuscular plane .

.Incisional hernia • This occurs through a defect in the scar of a previous abdominal incision.

• Poor suturing technique: Rarely does a suture break . • Type of incision: Midline vertical wounds have a higher incidence than transverse incisions. • Postoperative wound infection.g. • Obesity.Incisional hernia Etiology : • • Age: Wound healing is poor in the older patient. e. • Raised intra-abdominal pressure postoperatively. • Postoperative wound haematoma. constipation. ileus. • Steroid therapy. straining. coughing.

• If the defect is small there is a greater risk of strangulation .belt • . • Treatment-palliative-abd.treat cough. • It May occur up to 5 years postoperatively.improve nutritional status.Incisional hernia • Sign & symptoms : • A swelling protrudes through the wound.preoperative measures-reduce weight.identification and . • Many are large and involve the whole incision and consequently the neck of the sac is wide and the risk of strangulation rare.stop smoking. • -surgery:excision of sac.

Richter’s hernia • Part of the wall of the intestine becomes trapped in the defect. • The lumen is intact ( no obstruction ) . • This is usually the antimesenteric border of the small bowel.

Some other hernias • Spigelian hernia: • This is a hernia through the linea semilunaris at the lateral border of the rectus sheath. • Littre's hernia: • A hernia that contains a Meckel's diverticulum in the sac. • Obturator hernia: • This hernia occurs through the obturator foramen. It is commoner in elderly females. . • Lumbar herniae: • These occur in the lumbar region (below the 12th rib & above the iliac crest).

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