GROUP - 3

HERNIA
-PAVITHRA MURUGANATHAN
-JACOB SABESTIAN
-MOSES
 A hernia is a protrusion of a viscus or part of a viscus
through an abnormal opening in the walls of its
containing cavity.

Another definition
Hernia is an abnormal protrusion of intraabdominal
contents through a relatively weakend portion of the
abdominal wall
 EPIDEMIOLOGY

• male : female = 9:1

• lifetime risk of developing a hernia: males 20-25%,
females 2%
 Approximately 75% of all hernias are inguinal; of these,
50% are indirect (male-to-female ratio, 7:1 )and 25% are
direct
 About 14% of hernias are umbilical
 About 10% of hernias are incisional or ventral (female-
to-male ratio, 2:1)
 Only 3-5% of hernias are femoral
 most common surgical disease of males
 Risk factors

 activities which increase intra-abdominal pressure:

 chronic cough, obesity,abdominal wall injuries
,straining on micturition or straining on
defaecation,pregnancy, ascites,
 Lifting of heavy weight.
 Age
 sex
 congenital abnormality
 previous hernia repair
 Family hx of hernia
 Contents of hernia

 hernia consists of three parts – the sac, the coverings

of the sac and the contents of the sac.
 Types of hernia

■ Reducible – contents can be returned to abdomen

■ Irreducible – contents cannot be returned but there are no
other complications
■ Obstructed – bowel in the hernia has good blood supply
but bowel is obstructed
■ Strangulated – blood supply of bowel is obstructed
■ Inflamed – contents of sac have become inflamed
 Anatomical classification

 • Inguinal hernia—occurring in inguinal canal.

 Femoral hernia—occurring in femoral canal.
 Obturator hernia.
 Diaphragmatic hernia.
 Spigelian hernia.
 Umbilical hernia.
 Epigastric hernia
 Classification -3

 Congenital—Common
It occurs in a preformed sac/defect. Clinically may
present at a later period due to any of the precipitating
causes like in indirect inguinal hernia.
 Acquired
It is secondary to any causes which raise the intra-
abdominal pressure leading into weakening of the area
leading to hernia.
 According to contents

 Omentocele—omentum.
 Enterocele—intestine.
 Cystocele—urinary bladder.
 Littre’s hernia—Meckel’s diverticulum.
 Maydl’s hernia.
 Richter’s hernia—part of the bowel wall.
 Inguinal hernia

Anatomy :
In adults ,the inguinal canal which is about 3.75 cm
long, is directed downwards and medially from the
deep to the superficial inguinal ring.
The inguinal canal has openings at either end :
a. The deep (internal) inguinal ring is the entrance to the
inguinal canal. It is the site of an outpouching of the
transversalis fascia. This is approximately 1.25 cm superior to
the middle of the inguinal ligament

b. The superficial, or external inguinal ring is the exit from

the inguinal canal. It is a slitlke opening between the
diagonal fibres of the aponeurosis of the external oblique
 In the male, the inguinal canal transmits the
spermatic cord, the ilioinguinal nerve and the genital
branch of the genitofemoral nerve. In the female, the
round ligament replaces the spermatic cord.
 Boundaries

 Anterior wall: formed by the external oblique

aponeurosis
 Inferior wall: formed by the inguinal ligament
(Poupart ligament)
 Roof (superior wall): made up of fibers of the
internal oblique and transversus abdominis
 Posterior wall (floor): formed by the transversalis
fascia
a. Hesselbach triangle: located within floor
b. Triangle constituents: formed laterally by the inf
erior epigastric artery, inferiorly by the inguinal ligament,
and superomedially by the lateral border of the rectus
sheath
 Indirect Inguinal hernia

 An indirect hernia travels down the canal on the

outer (lateral and anterior) side of the spermatic
cord.
 Indirect hernias are most common in the young,
 In adult males, 65% of inguinal hernias are indirect
and 55% are right-sided. The hernia is bilateral in
12% of cases.
 Types

 Bubonocele - the sac is confined to the inguinal canal.

 Funicular - the sac extends along the length of the inguinal
canal and through the superficial inguinal ring, but does
not extend to the scrotum or labium majora.
 Complete, scrotal or inguinoscrotal - the sac passes through
the inguinal canal and superficial inguinal ring and extends
into the scrotum or labium
 Direct inguinal hernia

 A DIH protrudes directly through the posterior wall

of the inguinal canal, medial to the inferior epigastric
artery and deep inguinal ring.
 The essential fault with a DIH is weakness of the
inguinal canal, and is invariably associated with poor
abdominal musculature.
 The neck of a DIH is usually larger than the body and
so strangulation is rare
 Clinical features of inguinal hernia

 Inguinal hernias present with inguinal discomfort,

with or without a lump
 Pain may also be referred to the testis
 Severe inguinal or abdominal pain suggests
obstruction or strangulation.
 Indirect vs direct hernia

 IIH and DIH may be distinguished by firstly

reducing the hernia by gently pushing it upwards
and laterally. Then, the index and middle fingers are
placed firmly over the surface marking of the deep
ring and the patient is asked to cough. If the hernia is
controlled by pressure over the deep ring, then it is
presumed to be indirect. If the hernia appears medial
to the examiner's two fingers, then it is direct.
 Femoral Hernia:

 occur just below the inguinal ligament, when

abdominal contents pass through a naturally
occurring weakness in the abdominal wall called
the femoral canal.
 Femoral hernias are a relatively uncommon type,
accounting for only 3% of all hernias.
 Femoral hernias can occur in both males and
females, they occur approximately 10 times as
frequently in women than in men because of the
wider bone structure of the female pelvis.
 ANATOMY:

 The femoral canal is located below the inguinal ligament

on the lateral aspect of the pubic tubercle. It is bounded
by the inguinal ligament anteriorly, pectineal
ligament posteriorly, lacunar ligament medially, and
the femoral vein laterally.
 It normally contains a few lymphatics, loose areolar
tissue, and occasionally a lymph node called Cloquet's
node. The function of this canal appears to be to allow
the femoral vein to expand when necessary to
accommodate increased venous return from the leg
during periods of activity.
 CAUSES:

 Any activity or condition which increases pressure in the intra-

abdominal cavity may contribute to the formation of a hernia,
including:
 Obesity
 Heavy lifting
 Coughing
 Straining with urination or defecation
 COPD
 Ascites
 Peritoneal dialysis
 Ventriculoperitoneal shunt
 Femoral hernias are more common in multiparous females,
which results from elevated intra-abdominal pressure that
dilates the femoral vein and in turn stretches femoral ring
 Signs and Symptoms

 A bulge in the upper thigh next to the groin

 Most femoral hernias cause no symptoms. Groin
discomfort may worsen when standing, lifting heavy
objects, or straining.
 In severe cases, abdominal pain, nausea, and
vomiting
 TYPES:

 Reducible femoral hernia

 Irreducible femoral hernia
 Obstructed femoral hernia
 Strangulated femoral hernia
 Strangulated Hernias

 A strangulated femoral hernia occurs when the

hernia blocks blood supply to part of the bowel -
the loop of bowel loses its blood supply.
 Extreme tenderness and redness in the area of
the bulge
 Sudden pain that worsens in a short period of
time
 FeverRapid heart rate

 Nausea, vomiting, and severe abdominal pain may
occur with a strangulated hernia. A strangulated
intestine can result in necrosis (tissue death)
followed by gangrene (tissue decay). This is a life-
threatening condition requiring immediate
surgery. Left untreated, severe infection can occur. If
surgery is not performed immediately, the condition
can become life threatening, and the affected
intestine may die and need to be amputated.
 Diagnosis

 To diagnose a femoral hernia, a physical examination

of the groin area is performed. In obese patients,
imaging in the form of ultrasonography, CT or MRI
may aid in the diagnosis. In female patients, an
abdominal x-ray showing both a painful groin lump
and small bowel clearly suggests a femoral hernia.
Open Hernia Repair

 The surgeon makes an incision in the groin, moves

the hernia back into the abdomen. Repair is either
performed by suturing the inguinal ligament to the
pectineal ligament using strong non-absorbable
sutures or by placing a mesh plug in the femoral ring.
 Laparoscopic Femoral Hernia Repair
 Umbilical hernia

 An umbilical hernia is a health condition where

the abdominal wall behind the navel is damaged.
 It is commonly seen in preterm infants, and resolve
without any treatment by 2 or 3 years.
 Asymptomatic and present only as bulge of the
umblicus.when the contracting abdominal
wall causes pressure on the hernia contents. This
results in abdominal pain or discomfort. These
symptoms may be worsened by the patient lifting or
straining.
 Congenital causes.
 Acquired:
 An acquired umbilical hernia directly results from
increased intra-abdominal pressure caused
by obesity, heavy lifting, a long history of coughing,
or multiple pregnancies. Another type of acquired
umbilical hernias are incisional hernias, which are
hernia developing in a scar following abdominal
surgery, e.g. after insertion of laparoscopy trocars
through the umbilicus.
 TREATMENT
 Conservative treatment is indicated under the age of
2 years when the hernia is symptomless. Parental
reassurance is all that is necessary. Of hernias 95%
will resolve spontaneously. If the hernia persists
beyond the age of 2 years it is unlikely to resolve and
surgical repair is indicated.

 SURGERY
A small curved incision is made immediately below the
umbilicus. The neck of the sac is defined, opened and
any contents are returned to the peritoneal cavity. The
sac is closed and redundant sac excised. The defect in
the linea alba is closed with interrupted sutures.
 Incisional Hernia
 These arise through a defect in the musculofascial layers of the
abdominal wall in the region of a postoperative scar
 Incidence: 10–50 per cent of laparotomy incisions and 1–5 per cent of
laparoscopic port-site incisions.
 Predisposing Factors
 Patient factors : obesity, smoking in post operative period, general poor
healing due to malnutrition, immunosuppression or steroid therapy,
chronic cough, cancer, Causes which increases the intra-abdominal
pressure (BPH, straining, stricture urethra or rectum, ascites)
 Wound factors : poor quality tissues, wound infection
 Surgical factors : inappropriate suture material, incorrect suture
placement

 An incisional hernia usually starts as disruption of the musculofascial

layers of a wound in the early postoperative period
 classic sign of wound disruption is a serosanguinous discharge.
 Clinical Features
 Swelling in the scar region
 Pain
 bulging more prominent on standing and coughing, reduces
spontaneously on lying down
 Often bowel peristalsis may be visible under the skin
 Eventually features of irreducibility, obstruction, strangulation is
seen
(Strangulation is less frequent and most likely to occur when the
fibrous defect is small and the sac is large)
 subacute intestinal obstruction – abdominal
colic,vomiting,constipation and distention of abdomen
 Treatment
 Asymptomatic incisional hernias may not require treatment.
 The wearing of an abdominal binder or belt may prevent the
hernia from increasing in size.
 Laproscopic and open surgical repair possible.
 Investigations for hernia

 Plain radiograph – of little value

 Ultrasound scan – low cost, operator dependent
 CT scan – incisional hernia
 MRI – good in sportsman’s groin with pain
 Contrast radiology – especially for inguinal hernia
 Laparoscopy – useful to identify occult inguinal hernia
 Management principles

 Not all hernias require surgical repair

 Small hernias can be more dangerous than large
 Pain, tenderness and skin colour changes imply high risk of
Strangulation
 Femoral hernia should always be repaired
All surgical repairs follow the same basic principles:
 reduction of the hernia content into the abdominal cavity with
removal of any non-viable tissue and bowel repair if necessary;
 excision and closure of a peritoneal sac if present or replacing it
deep to the muscles;
 reapproximation of the walls of the neck of the hernia if possible;
 permanent reinforcement of the abdominal wall defect with sutures
or mesh.
 Mesh in hernia repair
 prosthetic material, either a net or a flat sheet, which is used to
strengthen a hernia repair.
 Mesh can be used:
 to bridge a defect
 to plug a defect
 to augment a repair

Types of mesh
 Woven, knitted or sheet
 Synthetic or biological – mainly synthetic

 Light, medium or heavyweight – light weight more popular

 Large pore, small pore – large pore causes less fibrosis and pain
 Intraperitoneal use or not – non-adhesive mesh on one side
 Non-absorbable or absorbable – mainly non-absorbable
Positioning of mesh
 strength of a mesh repair depends on host–tissue
 in-growth. Meshes should be placed on a firm,
wellvascularised
 tissue bed with generous overlap of the defect.
 The mesh can be placed:

 just outside the muscle in the subcutaneous space

(onlay); within the defect (inlay) – only applies to mesh
plugs in small defects;
 between fascial layers in the abdominal wall
(intraparietal or sublay);
 immediately extraperitoneally, against muscle or fascia
(also sublay);
 intraperitoneally.
 Management of inguinal hernia
 Operations for inguinal hernia
 Herniotomy
 Open suture repair
 Bassini
 Shouldice
 Desarda
 Open flat mesh repair (hernioplasty)
 Lichtenstein
 Open complex mesh repair
 Plugs
 Open preperitoneal repair
 Stoppa
 Laparoscopic repair
 TEP(totally extraperitoneal approach)
 TAPP (transabdominal preperitoneal approach)
 Management of femoral hernia

 Surgery with three approaches.

1. Low approach (Lockwood); in case of no risk of bowel resection.
2. The inguinal approach (lotheissen);
3. The high approach (McEvedy); in emergencies with high risk of bowel
strangulation.
 Laparoscopic approach; done electively for reducible hernias.
 Management of umblical hernia

 Congenital Umbilical Hernia: - Parental reassurance: 95%

resolve spontaneously by 2 years - If persists beyond two
years, surgical repair is indicated.
 True umbilical/paraumbilical hernia
 Defects < 1 cm: - Simple figure-of-eight suture - Repaired by a darn
technique
 Defects upto 2 cm: Mayo’s vest over pants repair
 Defects > 2 cm: Mesh repair
 Laparoscopic umbilical hernia repair
 Emergency repair of umbilical hernia
 Treatment

 Patients with symptomatic hernias are offered repair

 open or laparoscopic surgery.