Hernia

 A hernia occurs when an organ or fatty tissue squeezes through a

weak spot in a surrounding muscle or connective tissue - fascia.
 Types of Hernia

 Inguinal hernia

 Umbilical hernia

 Hernia in cicatrice

 Sports hernia

 Internal hernia

 Diaphragmal hernia
Types of Hernia
Anatomy

 The inguinal canal is 4-6 cm long.

 The inguinal canal starts in the abdomen from the point

that the spermatic cord crosses the internal/deep inguinal
ring in the transversalis fascia (in women the Round
ligament).

 This canal finally ends in the external/surface inguinal

ring at the level of the abdominal muscles where the
spermatic cord passes from the aponeurosis of the external
oblique muscle.
Epidemiology

 About 75% of all hernias happen in the inguinal region.

 90% of them are in men and 10% in women.

 70% of femoral hernia repairs occur in women (although the

prevalence of inguinal hernia in women is 5 times that of femoral hernia.

 The most common inguinal hernia in women and in men is the indirect
inguinal hernia.

 The prevalence of hernia in men has two peak ages:

Under one and above 40.
Epidemiology

In the laparascopic repair of the hernia, the diagnosis of contralateral

hernia can be made.

Femoral hernia in the elderly and in those who had a previous hernia
repair is more common.

The prevalence of inguinal hernia increases with age (especially in

men).

Inguinal hernia in adults is mainly from an acquired weakness in the

abdominal wall (the most important one is a defect in the abdominal
muscle).
Etiology

 Inguinal hernia has two etiologies:

A) Congenital

B) Acquired

A) Congenital Hernia:

i. Congenital hernia consists most of the cases of pediatric hernias

ii. In the descent of the testes from the abdomen to the scrotum in the third trimester, a part of the peritoneum descends with it which is called the processus vaginalis.

i. In the weeks 36-40 of gestation this processus vaginalis closes.

i. Lack of closure of processus vaginalis results in a patent processus vaginalis which is a reason for the high prevalence of inguinal hernia in the preterm neonates.

i. A lot of the process vaginalises close in a few months after birth and its patency does not necessarily mean that a hernia will be formed.
Etiology

B) Acquired Hernia:
It seems that most cases of hernia come from an acquired defect in the abdominal wall and the reason for its formation is
:multifactorial

1- Strenuous physical activity can be a factor but it is not known whether the hernia is just from physical activity or in the
setting of a patent processus vaginalis.

2- A positive family history which can increase its incidence 8 times.

3- COPD increases the direct hernia risk.

4- Collagen deficiency associated diseases like collagen type I deficiency relative to type III.

5- An association exists between aneurisms and hernias.

Being overweight is to some extent protective (maybe it is from the more difficult diagnosis of hernia)
Symptoms

 The symptoms are variable from a hernia with no symptoms to one

with strangulation.

 Asymptomatic hernia is either found in physical exam, or the

patient himself realizes the bulging, or it is found during
laparascopy.

 Symptomatic patients mostly present with inquinal pain.

 Sometimes patients present with symptoms outside the inguinal

region such as a change in bowel habits, and/or urinary
symptoms (in the form of sliding hernia).
Symptoms

 With pressure on the nearby nerves, hernia can cause different symptoms such as a
general feeling of pressure, localized pain, and referred pain.

 The feeling of pressure and weight on the inguinal region especially after a daily
activity is common.

 A sharp pain indicates nerve entrapment and does not have anything to do with
physical activity.

 Neurogenic pains may refer to the scrotum or inside the thigh.

 A change in bowel habits or in the urinary symptoms can indicate involvement of

the bladder inside the hernial sac.
Symptoms

 Pain in the inguinal region without bulging is usually not due to a hernia.

 The duration and the way the symptoms progress is important

 Usually the patient can reduce the hernia but the bigger the hernia, the less likely it
is to reduce.

 The possibility of the incarceration of the hernia at the beginning of the progress
of hernia, for example during the first year , is more likely.

 The possibility of incarceration is neonates is more likely than in adults.

Physical Exam

 The history is usually indicative of hernia but the physical

exam is also an important part of the evaluation.

 The examination in obese patients is difficult.

 It is best that the patient is examined in an upright

position so that the inguinal region and the scrotum is
completely exposed.
Physical Exam

 A) First we look to see the bulging. If we do not have a bulging, we

place a finger inside the scrotum and raise it toward the external ring,
and ask the patient to cough or do the Valsalva maneuver until the
hernial contents fall.

The valsalva maneuver causes an unusual bulging and it is possible to

realize if this bulging can be reduced or not.

 B) We examine the contralateral side and compare the two sides to each
other.

The extent of bulging on the two sides can be a criteria for the diagnosis of
hernia on one or both sides.
Physical Exam

 The differentiation between a direct and an indirect inguinal hernia

in the physical exam:

There are different techniques for differentiating a direct from an

indirect hernia in physical exam.

- If the finger is inside the inguinal canal and the patient exerts
pressure or coughs and the hernia comes in contact with the tip of
the finger it is a direct hernia.

- If with closure of the internal ring with the finger while the patient
strains (coughs) the hernial sac does not bulge out the hernia is an
indirect one, and if the hernial sac bulges the hernia is a direct one.
Physical Exam

the examination of the femoral hernia is difficult. This

hernia presents under the inguinal ligament and the
presence of too much or too little fat in the inguinal region
can cause an error in the diagnosis. (Femoral
Psuedohernia)

Therefore even the presence of a smallest bulging under

the inguinal ligament has to raise the suspicion for a
femoral hernia.
Differential Diagnosis

1-Malignancy: Lipoma, metastasis, testicular tumors

2-Testicular primary conditions : Varicocele, Epididimitis, Testicular torsion,
Hydrocele, Ectopic testes, undescended testes
3- Aneurism or pseudoaneurism of the femoral artery
4- Lymphadenopathy
5- Sebacious cyst
6- Hydroadenitis
7- Nuck canal cyst (in women)
8- Varices
9-Psoas Abcess
10- Hematoma
11- Ascites
Diagnosis

 The diagnosis is based on history, physical exam and sometimes imaging.

Imaging in hernia:

 In some conditions physical exam cannot diagnose the hernia:

1- Overwieght individuals
2- Recurrent hernia
3- Hernias that are not found in the physical exam

In these conditions imaging is important

Diagnosis

 The most common radiologic conditions include sonography,

CT, MRI, and each has its own pros. and cons.

1-Sonography: It is inexpensive and does not have radiation.

In underweight individuals the movement of the posterior wall

and spermatic cord toward the anterior wall of the abdomen
can have false positive results (the false positive results of the
sonography is more than in the phyisical exam and MRI)
Diagnosis

2- CT scan: Although it gives more information but the

routine use of it is not recommended.

In one determined evaluation among the imaging techniques,

MRI was more truthful, and an accurate physical exam
was more truthful than sonography.
Treatment of inguinal hernia

 Bassini
 Shouldice
 Lichtenstein
 Kirschner , Hackenbruch
 TAPP
 TEP
 TIPP
Treatment

 The final treatment of inguinal hernia is surgery.

 Now using a mesh, hernia repair takes place.

 Mesh is the golden standard because less tension is produced and there is less recurrency.

 Because of the very good results of mesh the initial tissue repair is not used any more.

 Laparascopic surgery is used in bilateral and recurrent conditions or when another surgery like
prostate surgery has to take place at the same time.

 The laparascopic procedure is not different from the open surgery method in the recurrency rate. It has
less post-op complications and a sooner return to work. Intestinal obstruction and ileus is seen more
often after a laparascopic procedure.
Treatment

 Contraindications of laparascopy:

1- A previous surgery in the area (a surgery that the surgeon entered the
abdomen such as prostatectomy)
2-Primary medical condition

In recurrent cases, dissection in the scar tissue should not be made (due
to inability in exactly differentiating the anatomic parts.

In the treatment of hernia surgery is necessary, since with a conservative

method, the wall defect is not removed but has the tendency to
enlarge and cause incarceration.
Treatment

 Indications of conservative surgery:

1-Bad coexisting medical condition

2-A small asymptomatic hernia

3-An elderly person who is asymptomatic

Conservative treatment is not used in femoral hernia.

Anesthesia Method

 Anterior surgery can be done with, local, regional, or general anesthesia.

 Laparascopic surgery has to be done with general anesthesia.

 Local anesthesia: Lidocaine, Marcaine with or without epinephrine.

 The use of epinephrine in people with coronary problems is contraindicated.

 Before incision or prep inguinal nerve has to be blocked.

 Epidural anesthesia is also a proper method.

Complications

 Incarceration
 Hernia contents get stuck – and cannot be reduced
 Requires EXPEDITED surgery

 Obstruction
 When bowel is extruded through a hernia and becomes so tight that
 food cannot pass through that segment
 Causes severe pain, nausea, vomiting
 Requires URGENT surgery
Complications

 Strangulation
 When hernia contents – especially bowel – become
stuck so tightly
 that adequate blood flow cannot reach these contents
 Causes necrosis (death) of the strangulated contents
 Eventually results in perforation, peritonitis, sepsis,
and death
 Requires EMERGENT surgery
Emergency Surgery

 Strangulated Hernia: NO
TAXIS

1-Fever
2-Leukocytosis
3- Hemodynamic instability
4- Tender and warm hernia contents
5- Erythema in hernial sac

Important Point: Before surgery Serum and electrolytes, IV

Antibiotics, and NG Tube
Recurrence

 Depends on:

1-Patient condition: Nutrient deficiency, Immune deficiency,

Diabetes, Steroid use, Smoking

2-Surgical Technique: Inexperienced surgeon, Not fixing the

mesh, a Small mesh

3-Tissue: Infection, Tension, Ischemia

To reduce recurrence use a mesh

Diagnosis of Recurrence

 Bulging

 Can have no bulging or mass and still suspect recurrence

Sonography, CT, or MRI

 DDX of hernia recurrence:

1-Cord lipoma
2-Seroma
3-Weakness of external oblique muscle
4-Cough
Complications of Hernia Surgery

1-Pain

2-Spermatic Cord Damage and Ischemic Orchitis

3-Vas deferans cut

4-Wound infection

5-Seroma

6-Urinary Retention
 Sportsman’s Hernia

 Occult hernia, pubic pain in sportsmen, sportsmen’s hernia

Due to repetitive movement in lower extremity such as skiing, hockey, or American football, usually
hernia is not found in physical exam other than the time of surgery.

 Symptoms: Acute or chronic pain that gets worse with movement, coughing or sneezing and can
reduce the sportsman’s function. In the physical exam no bulging or evidence of hernia is seen and
pain and tenderness in the inguinal canal and the external ring is present.

 Diagnosis: Best choice is MRI.

 Treatment: Conservative, if after 6-8 weeks fails surgery

inguinal canal repair.
Pediatric Hernia

 Prevalence in children 0.8-44 % and in 10% bilateral.

 Prevalence of hernia is higher in, premature and LBW and on the right side.

 Hernia is more likely indirect in children.

 Diagnosis: Made by observation and during crying.

 DDx: UDT, Testicular Tumor, Hydrocele, Varicocele

 Treatment: to some extent emergency even if with no symptoms.

In premature neonates inguinal hernia repair before hospital discharge.

 Surgery Herniotomy (Cut in the inguinal area)

 Important Point: Method of exploring the opposite side is somewhat controversial. Now laparascopy is mostly used. But sonography has also been used.
Hernia in cicatrice

 Occur mostly after laparotomy in the middle line

 It also occut after laparoscopic operations

Hernia in cicatrice
Hernia in cicatrice
Hernia in cicatrice
Types of reconstruction

 Mesh onlay

 Mesh Sublay

 Plug in

 IPOM – laparoscopic - open

 Hiatal hernia

 It mostly occurs when the upper part of stomach pushes through

an opening in diaphragm and up in to the chest.

 Other side it can also happened by a protrusion of stomach

through a tear or weakness in the diaphragm
 Hiatal hernia

 Normally, the esophagus or food tube passes down through the

chest, crosses the diaphragm, and enters the abdomen through a
hole in the diaphragm called the esophageal hiatus. Just below the
diaphragm, the esophagus joins the stomach.
 Hiatal hernia

 There are 2 types of hiatal hernia

 Sliding hiatal hernia: - The sliding type, as its name implies,
occurs when the junction between the stomach and esophagus
slides up through the esophageal hiatus during moments of
increased pressure in the abdominal cavity. When the pressure is
relieved, the stomach falls back down with gravity to its normal
position. Approximately 90% of all hiatal hernias are the sliding
type.
 Hiatal hernia

 Paraesophageal hiatal hernia

 In paraesophageal hiatal there is no sliding up and down. A
portion of the stomach remains stuck in the chest cavity.
 These hernias remain in the chest at all times.
 This type is less common
 Hiatal hernia

 Increased pressure within the abdomen caused by:

 Heavy lifting or bending over.
 Frequent or hard coughing.
 Hard sneezing.
 Pregnancy and delivery.
 Vomiting.
 Constipation.
 Obesity.
Hiatal hernia – Clinical Manifestation
 The patient with sliding hernia may have,
 Heart burn
 Regurgitation and
 Dysphagia but at least 50% are Asymptomatic.
 The patient with paraoesophageal hernia usually feels a sense of
fullness after eating or may be asymptomatic.
Hiatal hernia - treatment

 Medical treatment for hiatal hernia may include prescription-

strength antacids & PPIs
 When hernia symptoms are severe and chronic acid reflux is
involved, surgery is sometimes recommended,
 the surgical procedure used is called Nissen fundoplication. (also
you can make Toupet, Dor)
 In fundoplication, the gastric fundus(upper part) of the stomach is
wrapped, or plicated, around the inferior part of the esophagus,
preventing herniation of the stomach through the hiatus in the
diaphragm and the reflux of gastric acid.