Hernia

Dr Teamir Negussie
Assistant Professor
Dept of Surgery
 What is a hernia?

• A hernia is an abnormal weakness or hole in an

anatomical structure which allows something inside to
protrude through.
• Abnormal protrusion of viscus or a part of it
through a weak point in the abdominal wall
• It is commonly used to describe a weakness in the
abdominal wall.
 The Basic Feature Of All Hernias

• Hernias by themselves usually are harmless, but nearly all

have a potential risk of having their blood supply cut off
(becoming strangulated).
• If the blood supply is cut off at the hernia opening in the
abdominal wall, it becomes a medical and surgical emergency.
• Usually they reduce on lying down ,or with direct pressure.
• Have an expansile cough impulse & Occur at a weak spot .
 A hernia consist of 3 parts:
1.Sac:
consist of a diverticulum of
peritoneum.

2.Contents:
Omentum, small or large intestine,
urinary bladder, Omentum, ovaries
malignant nodules or ascetic fluid.

3.Coverings:
derived from the layers of
abdominal wall.
 Complications Of Hernias
• Irreducible
the hernia contents cannot be manipulated back into the abdominal
cavity.
• Incarcerated
the contents of the sac are literally inpresiond in the sac of Hernia.
• Obstruction
the loop of the bowel become non functioning with normal blood
supply .
• Strangulated
cut off the blood supply to the content sac (tender).
 Causes of hernias
• Any condition that increases the pressure of the
abdominal & thoracic cavity may contribute to the
formation or worsening of a hernia.
– Obesity
– Heavy lifting
– Coughing
– Straining during a bowel movement or urination
– Chronic lung disease
– Fluid in the abdominal cavity
– Hereditary
– Surgery
 Types of Abdominal Hernia
• Inguinal
• Femoral
• Epigastric
• Para umbilical
• Umbilical
• Incisional
• lumbar
• Spigelian
• hiatus
 Signs and Symptoms of hernia
• The signs and symptoms of a hernia can range from
noticing a painless lump to the painful, tender, swollen
protrusion of tissue that you are unable to push back
into the abdomen—possibly a strangulated hernia.
– Asymptomatic reducible hernia
• New lump in the groin or other abdominal wall area
• May ache but is not tender when touched.
• Sometimes pain precedes the discovery of the lump.
• Lump increases in size when standing or when abdominal pressure is
increased (such as coughing)
• May be reduced (pushed back into the abdomen) unless very large
 Cont.
– Irreducible hernia
• Usually painful enlargement of a previous hernia that cannot be returned into
the abdominal cavity on its own or when you push it
• Some may be long term without pain
• Can lead to strangulation
• Signs and symptoms of bowel obstruction may occur, such as nausea and
vomiting
– Strangulated hernia
• Irreducible hernia where the entrapped intestine has its blood supply cut off
• Pain always present followed quickly by tenderness and sometimes symptoms
of bowel obstruction (nausea and vomiting)
• You may appear ill with or without fever
• Surgical emergency
• All strangulated hernias are irreducible (but all irreducible hernias are not
strangulated)
 Diagnosis
• If you have an obvious hernia, the doctor will not require any other tests

• If you have symptoms of a hernia the doctor may feel the area while increasing abdominal
pressure (having you stand or cough).

• This action may make the hernia able to be felt.

• All newly discovered hernias or symptoms that suggest you might have a hernia should
prompt a visit to the doctor.

• Hernias, even those that ache, if they are not tender and easy to reduce (push back into
the abdomen), are not surgical emergencies, but all have the potential to become serious.

• Referral to a surgeon should generally be made so that you can have surgery by choice
(called elective surgery) and avoid the risk of emergency surgery should your hernia
become irreducible or strangulated.
 Treatment
• Treatment of a hernia depends on whether it is reducible or irreducible
and possibly strangulated.
– Reducible
• Can be treated with surgery but does not have to be.
– Irreducible
• All acutely irreducible hernias need emergency treatment because of the risk of
strangulation.
– An attempt to push the hernia back can be made
– Strangulation
• Operation
• Prevention
– You can do little to prevent areas of the abdominal wall from being
or becoming weak, which can potentially become a site for a hernia.
Inguinal Hernia
 Inguinal canal
• Oblique passage in the lower part of the anterior abdominal wall.

• Extends from deep inguinal ring to superficial inguinal ring.

• Directed downwards forwards and medially

• About 4cm long

• Superficial inguinal ring-
– triangular aperture in the aponeurosis of the ext oblique muscle .
– Lies 1.25 cm above the pubic tubercle .
– Normally it doesn’t admit the tip of the little finger.

• Deep inguinal ring –

– U shaped condensation of the fascia trasversalis
– Lies 1.25cm above the mid inguinal point.
 Boundaries
• Anterior – Ext. oblique aponeurosis & conjoined
muscle laterally.

• Posterior – Fascia transversalis & the conjoined

tendon.

• Superiorly – conjoined muscle.

• Inferiorly – inguinal ligament.

 Contents of inguinal canal

• Spermatic cord

• Ilioinguinal nerve

• Genital branch of genitofemoral nerve

• Females – Round ligament is present instead of spermatic cord.

• Spermatic cord constitutes- vas deferens, testicular & cremastic arteries ,
pampiniform plexus of veins, lymphatics Defense

• Defence mechanism of inguinal canal

• Obliquity of the inguinal canal.

• Shutter mechanism-due to conjoined tendon contraction

 Epidemiology
• Approximately 7% of all surgical outpatient.
• Accounts for 96% groin hernias (other 4% are femoral)
• Makes up 75% of all abdominal wall hernias
• Bilateral in 20% of cases
• Lifetime risk of inguinal hernia: 10%
• M:F 9:1 (Much more common in boys (90% of cases) than girls )
• In men the incidence rises from 11 per 10,000 person years aged 16-24
years to 200 per 10,000 person years aged 75 years or above.
• Affects 1-3% of young children
• Extremely common; represents the most frequent problem requiring
surgical intervention in the paediatric age group
• Definite familial tendency,
• More frequent on the right side as a result of later descent of the right
testis and delayed obliteration of the right processus vaginalis.
 Anatomical classification

• Indirect hernia – more common about 2/3 of

inguinal hernia .

• It is more common in young

• Direct hernia- more common in old

• Indirect hernia – the abdominal contents herniation
occurs through the deep ring into the inguinal
canal.
• Comes out through the superficial ring.
• It may extend into the scrotum.
• Depending upon extent it may be complete or
incomplete. follows pathway that testicles made
during prebirth development.
• This pathway normally closes before birth but
remains a possible place for a hernia.
• This type of hernia may occur at any age but becomes more
common as people age.
• Direct hernia – contents herniate directly through
the posterior wall of the inguinal canal through the
Hesselbach’s triangle
• It is a weakness in posterior wall of the inguinal
canal
• It is bounded laterally -inferior epigastric artery,

medially – lateral border of rectus abdominus muscle

inferiorly – inguinal ligament
• It rarely will protrude into the scrotum.
• The direct hernia almost always occurs in the middle-
aged and elderly because their abdominal walls
weaken as they age.
 Risk factors
In infants:
prematurity
male
In adults:
male
Obesity
Constipation
chronic cough
Heavy lifting
Smoking
Urinary obstructive symptoms
 Presentation
• Pain
• Localized pain
• Referred pain
• Generalized pain
• Nausea and vomiting
• Constipation
• Urinary symptoms
• At first appearance, it is easily reducible.
• With time it can no longer be reduced, it is irreducible or incarcerated.
• Strangulation: when visceral contents of the hernia become twisted or entrapped by
the narrow opening.

Strangulation usually leads to bowel obstruction with sudden, severe pain in the hernia,
vomiting and irreducibility.
Nyhus Classification System
 Diagnosis- Inspection
• Inguinal hernias are best examined with the patient
standing.
• Coughing may increase the size of the hernia.
• Site and shape of the hernia:
– those appearing above and medial to the pubic tubercle
are inguinal hernias
– those appearing below and lateral to the pubic tubercle
are femoral hernias
• whether the lump extends down into the scrotum
• any other scrotal swellings
• any swellings on the 'normal' side
• scar from previous surgery or trauma
 Palpation
• Confirm inspectory findings
• Examine the scrotum- Getting above the swelling is
not possible
• Consistency, temperature, tenderness and fluctuance.

• One should attempt to reduce the hernia:Ask the

patient to reduce. Otherwise flex and medially rotate
the hip and reduce
• If the hernia cannot be reduced the probable identity
of the hernia is: femoral > indirect inguinal > direct
inguinal
• Expansile cough impulse
• Deep ring occlusion test- reduce the swelling

• Locate the deep ring 1/2 “ above the midpoint of the

inguinal ligament and occlude it asking the patient to cough.
• Impulse seen- direct, not seen- indirect

• Leg raising test- Malgaigne’s bulgings seen

• Zieman’s method

• Swelling gurgles- enterocoele, firm/granular- omentocoele.

• Always palpate the other inguino-femoral region as herniae

are often bilateral
 Percussion
The characteristics of hernias depend on their contents:
– bowel is hyper-resonant and has bowel sounds unless it is
strangulated
– omentum and fat is dull and does not have bowel sounds
Investigations
Ultrasound
• High Test Sensitivity (>90%)
• High Test Specificity
– Distinguish Incarcerated Hernia from firm mass
Herniography
• Suspected hernia, but clinical dx unclear
• Procedure done under flouroscopy following injection of contrast medium
• Frontal and oblique radiographs are taken with and without increased intra-
abdominal pressure
 Complications

Bowel incarcération ( acute, chronic ): The trapping of abdominal

contents within the Hernia itself

Strangulation: pressure on the hernial contents may compromise

blood supply (especially veins, with their low pressure, are
sensitive, and venous congestion often results) and cause
ischemia, and later necrosis and gangrene, which may become
fatal.

Small Bowel Obstruction

 Management
Non operative Treatment
• Watchful waiting: for asymptomatic or minimally
symptomatic
• Truss is a mechanical appliance ,belt with a pad applied
to groin after spontaneous or manual reduction of
hernia. The purpose is to maintain reduction and to
prevent enlargement.
 Surgery
Herniorrhaphy
( Lichtenstein, Shouldice, Bassini, Modified bassini)
Most commonly performed: Modified bassini & Lichtenstein
repair
They are "tension-free" repair
Open Mesh repairs
– Permanent mesh
– Commercial mesh
– Mosquito-net mesh
Biomeshes
– they can be used for repair in infected environment , an incarcerated hernia
– reduce the risk of inguinodynia
Laparoscopic repair
– transabdominal preperitoneal (TAPP)
– totally extra-peritoneal (TEP) repair
 Laparoscopic mesh surgery, as compared to open mesh surgery

Advantages Disadvantages
•Quicker recovery •Needs surgeon highly
experienced

•Less pain during first days Longer operating time

•Fewer postoperative Increased recurrence of

complications primary hernias if
such as infections, bleeding and surgeon not experienced
seromas enough

•Less risk of chronic pain

Complications are frequent (>10%).
– Foreign-body sensation
– Chronic pain
– Ejaculation disorders
– Mesh migration
– Mesh folding (meshoma)
– Infection
– Adhesion formation
– Erosion into intraperitoneal organs

• In the long term, polypropylene meshes face degradation

due to heat effects.
• obstructive azoospermia
Femoral Hernia
 Femoral Canal
• The major feature of the femoral canal
is the femoral sheath.
• This sheath is a condensation of the
deep fascia (fascia lata) of the thigh
and contains, from lateral to medial,
the femoral artery, femoral vein, and
femoral canal.
• The femoral canal is a space medial to
the vein that allows for venous
expansion and contains a lymph node
(node of Cloquet).
• Other features of the femoral triangle
include the femoral nerve, which lies
lateral to the sheath
 
 Femoral hernia
Age: uncommon in children , most common in old age
female .
Sex: women > men (but still commonest hernia in
women the inguinal hernia )
Discomfort and pain
Swelling in the groin
Femoral hernia is more likely to be strangulated than
the inguinal hernia
Narrow neck High risk for strangulation
Multiplicity: often bilateral
 Femoral hernia versus inguinal hernia

Femoral hernia Inguinal hernia

more common in females -1 more common in male -1

pass through the femoral canal -2 pass through the inguinal canal -2

neck of the sac is below and lateral -3 neck of the sac is above and medial -3
the pubic tubercle the pubic tubercle

more common to be strangulated -4 less common to be strangulated -4

must be treated surgically -5 can be treated without surgery -5

- the two diagnostic signs of hernia -6 + the two diagnostic signs of hernia -6

the sac mainly contains ; omentum -7 the sac mainly contain ; bowel -7
 Femoral hernia repair
Femoral hernias should be repaired very soon after the diagnosis has been
made because of the high risk of strangulation
There is no place for a truss for a femoral hernia
Different approaches :
Open VS Laparoscopic

Three approaches have been described for open surgery :

Infra-inguinal approach (Lookwood)
Supra-inguinal approach ( McEvedy)
Trans-inguinal approach ( Lotheissen)
Each technique has the principle of dissection of the sac with reduction
of its contents, followed by ligation of the sac and closure between the
inguinal and pectineal ligaments.
Epigastric Hernia
• It occurs through the linea alba midway between the xiphisternum &
the umbilicus

• It is a protrusion of extraperitonial fat from the site of entry of a small

blood vessel through the linea alba (fatty Hernia of linea alba)

• It is usually small in size, it may drag a pouch of peritoneum to form a

true hernia
• The neck is usually too small to allow a hollow viscous to enter it,
consequently the sac is empty or it contains small part of omentum
(not true hernia )

• It is probably as a result of sudden strain that tears the interlacing

fibers of linea alba
• Clinically; The patient is usually symptom less,
incidentally discovered during routine exam
• Pain & tenderness is due to strangulated fat.
• Referred pain & dyspepsia
• Treatment: Excision & repair of defect.
 Umbilical Hernia
– These common hernias (10-30%) are often noted at birth as a protrusion at
the bellybutton (the umbilicus).
– This is caused when an opening in the abdominal wall, which normally
closes before birth, doesn’t close completely.
– Even if the area is closed at birth, these hernias can appear later in life
because this spot remains a weaker place in the abdominal wall.
– They most often appear later in elderly people and middle-aged women
who have had children.
– Composition: contain bowel, resonant to percussion
– They reduce spontaneously when the child lies down
– Reducibility: easy
– Cough impulse: invariably present
– Intestinal obstruction extremely rare
– Surgical repair if persisted after 3rd birthday
 Acquired umbilical hernia

Hernia through the umbilical scar , so it is a true

umbilical hernia.
Not common and is usually secondary to increase intra
abdominal pressure.
The most common causes
pregnancy
ascites
ovarian cyst
fibroids
bowel distension
 Para-umbilical hernia
• Para umbilical usually middle age women obese or
multiparous
• It is a protrusion through the linea alba just above or the
umbilicus. As it enlarges it sags downward and can attain a
large dimensions
• The neck of the sac is narrow as compared with the size of
the sac & it’s contents ( omentum, small intestine or part of
the colon). Usually loculated due to adhesions.
• Clinically; more common in women, obese, multiparous &
35-50y of age.
• It becomes irreducible due to adhesions & strangulation may
occur.
• Pain colicky or dragging.
• The skin over it becomes reddened, smooth & may become
excoriated.
• Treated by division of adhesions & repair of defect “Mayo’s
repair”
 Incisional Hernia
_ Protrusion through surgical wound
– Abdominal surgery causes a flaw in the abdominal wall that must heal on its own.
– This flaw can create an area of weakness where a hernia may develop.
– This occurs after 2-10% of all abdominal surgeries, although some people are more at
risk.
– After surgical repair, these hernias have a high rate of returning (20-45%).
Causes
Midline ,vertical incision
Poor technique
Wound or chest infection
Obesity
Strangulation is rare but repair is advisable
Prevention
• Continuous Closure with Running Suture
• Monofilament slowly absorbable suture (PDS) #1 or 2
• Suture: Wound Length < 4:1
 .
Hiatus hernia

– occurs when the upper part of the stomach, which is joined to the oesophagus (gullet), moves up into the chest through
the hole (called a hiatus) in the diaphragm.
– It is common and occurs in about 10 per cent of people.
• It is most common in overweight middle-aged women and elderly people.
• It can occur during pregnancy.
• The diagnosis is confirmed by barium meal X-rays or by passing a tube with a camera on the end into the
stomach (gastroscopy).
• Symptoms include:
– Heartburn
– Sudden regurgitation
– Belching
– Pain on swallowing hot fluids
– Feeling of food sticking in the oesophagus
• Treatment:
• Losing weight nearly always cures it.
• Eating small meals each day instead of 2 or 3 large ones helps.
• Avoid smoking.
• Take antacid.
• Avoid spicy food.
• Avoid hot drinks.
• Avoid gassy drinks
 Types Cont.
• Spigelian hernia
– This rare hernia occurs along the edge of the rectus
abdominus muscle, which is several inches to the side of
the middle of the abdomen.
• Obturator hernia
– This extremely rare abdominal hernia happens mostly in
women.
– This hernia protrudes from the pelvic cavity through an
opening in your pelvic bone (obturator foramen).
– This will not show any bulge but can act like a bowel
obstruction and cause nausea and vomiting.
 Summary

• Hernias are common, morbid, and costly

• Best chance of success is mesh repair : uncontaminated field

• Laparoscopic vs Open still debated

• What can’t be cured must be endured