Abdominal wall hernias

Prof. Soria
A hernia is a protrusion of a viscus or part of a viscus through an abnormal
opening in the walls of its containing cavity.

The external abdominal hernia is the most common form, the most frequent
varieties being the inguinal, femoral and umbilical, accounting for 75% of cases.

The rarer forms constitute 1.5%, excluding incisional hernias.

General features common to all hernias

Aetiology
 Any condition that raises intra-abdominal pressure, may produce a hernia.
• Powerful muscular effort.
• Whooping cough (childhood)
• Chronic cough, straining on micturition or straining on defaecation (adult).
• Intra-abdominal malignancy.
• Stretching of the abdominal musculature because of an increase in contents (obesity,
pregnancy).

 Smokers (acquired collagen deficiency).

 Fat acts to separate muscle bundles and layers, weakens aponeuroses and favours the
appearance of paraumbilical, direct inguinal and hiatus hernias.
Hernias of the anterior abdominal wall, or ventral hernias, represent defects
in the abdominal wall fascia and muscle through which intra-abdominal or
preperitoneal contents can protrude.

Ventral hernias may be congenital or acquired.

They may develop from failed healing of an anterior abdominal wall incision
(incisional hernia).

The most common finding is a mass or bulge on the anterior abdominal wall,
which may increase in size with a Valsalva maneuver.

Ventral hernias may be asymptomatic or cause a considerable degree of

discomfort, and generally enlarge over time.

Physical examination reveals a bulge on the anterior abdominal wall that

may reduce spontaneously, with recumbency, or with manual pressure.
A hernia that cannot be reduced is described as incarcerated and requires
emergent surgical correction.

Incarceration of an intestinal segment may be accompanied by nausea,

vomiting, and significant pain.

Should the blood supply to the incarcerated bowel be compromised, the

hernia is described as strangulated, and the localized ischemia may lead to
infarction and perforation.
Primary ventral hernias (nonincisional) are also termed true ventral
hernias.

According to their anatomic location.

 Epigastric hernias.
 Umbilical hernias.
 Spigelian hernias
 Inguinal or inguino-scrotal hernias.
 Femoral hernias.
 Lumbar hernias
 Gluteal hernias
 Sciatic hernias
 Perineal hernias
Composition of a hernia

As a rule, a hernia consists of three parts – the sac, the coverings of the sac and the contents of the
sac. Many books mention other component (the ring)

The sac
The sac is a diverticulum of peritoneum, consisting of mouth, neck, body and fundus.

The covering
Coverings are derived from the layers of the abdominal wall through which the sac passes.

The ring
The abnormal opening through which the sac passes. No ring, no hernia.
Contents
These can be:
• omentum = omentocele (synonym: epiplocele);

• intestine = enterocele; more commonly small bowel but may be large intestine or appendix;

• a portion of the circumference of the intestine = Richter’s hernia;

• a portion of the bladder;

• ovary with or without the corresponding fallopian tube;

• a Meckel’s diverticulum = a Littre’s hernia;

• fluid, as part of ascites or as a residuum thereof.

INGUINAL
HERNIA

An inguinal hernia is a protrusion of abdominal

cavity contents through the inguinal canal.
 TYPES OF HERNIAS

Inguinal hernia direct .

Inguinal hernia indirect.

Pantaloon hernias.
 PATHOPHYSIOLOGY

In guys, the inguinal canal is a passageway between the

abdomen and the scrotum through which a cord called the
spermatic cord passes (the testicles hang from the spermatic
cord).

In girls the inguinal canal is passageway for a ligament that

holds the uterus in place.

Nearly all cases of inguinal hernias in teens are due to a

congenital defect of the inguinal canal.
 DIAGNOSIS
History and physical examination.

History:

Sudden appearance of a lump in the groin

The mass may be intermittently present and may be painful

It may get into the scrotum

It may be associated with strenuous activity

 DIAGNOSIS
Physical examination:

A mass may be visible, may depend on the patient’s position.

The mass may be tender. Bowel sounds may be audible.

The mass may be small or nonpalpable.

The examining finger should be placed along the spermatic cord at

the scrotum and passed into the external ring along the canal.

• A direct hernia causes a forward bulge low in the canal.

• An indirect hernia lightly touches the tip of the examining finger

during a maneuver that increases intraabdominal pressure.
 DIRECT INGUINAL
HERNIA

Direct inguinal hernias occur medial to the inferior

epigastric vessels when abdominal contents herniate
through a weak spot in the fascia of the posterior wall of the
inguinal canal, which is formed by the transversalis fascia.

Direct inguinal hernias occur in older people.

DIRECT INGUINAL HERNIA
 INDIRECT INGUINAL
HERNIA

Indirect inguinal hernias occur when abdominal contents

protrude through the deep inguinal ring, lateral to the
inferior epigastric vessels; this may be caused by failure of
embryonic closure of the processus vaginalis.

Indirect inguinal hernias are common in children and young

men.
INDIRECT INGUINAL HERNIA
 DIFFERENTIAL DIAGNOSIS

 Femoral hernia

 Epididymitis

 Testicular torsion

 Lipomas

 Inguinal adenopathy (Lymph node Swelling)

 Groin abscess

 Saphenous vein dilation, called Saphena varix

 Vascular aneurysm or pseudoaneurysm

 Hydrocele

 Varicocele

 Cryptorchidism (Undescended testes)

 CLOUSE ABSENT
TESTICULAR TORSION
PROCESSUS VAGINALIS
VARICOCELE INGUINAL ADENOPATHY
 MANAGEMENT

CONSERVATIVE SURGICAL
 SURGICAL

PREOPERATIVE TRANSOPERATIVE

• NPO
• IV cannula hydration
• Nasogastric tube
• Preparation of skin
• Prophylactic antibiotic
REPAIR ON INGUINAL HERNIAS
General principles for operative repair of inguinal hernias
include:

Return of the hernia contents into the peritoneal cavity.

Ligation of the base of the hernia sac.

Repair of the abdominal wall defect to prevent recurrence.

 COMPLICATIONS

Intestinal obstruction.

Intestinal strangulation with perforation or

gangrene.
FEMORAL
HERNIA

A femoral hernia is a bulging located near the groin and

thigh that occurs when a small part of intestine pushes
through the wall of the femoral canal. The femoral canal
houses the femoral artery, femoral vein, and nerves. It is
located just below the inguinal ligament in the groin.
 FEMORAL HERNIA

Women are three times more likely than men to suffer

from a femoral hernia.

The exact cause of femoral and other hernias are

unknown most of the time. You may be born with a
weakened area of the femoral canal, or the area may
become weak over time.
 FEMORAL HERNIA

Factors that can lead to overstraining include:

childbirth

constipation

heavy lifting

being overweight

difficult urination due to an enlarged prostate

chronic coughing
 SIGNS AND SYMPTOMS

Small to moderate sized hernias do not usually cause any

symptoms. In many cases, you may not even see the
bulge of a small femoral hernia.

Large hernias cause a bulge which may be visible in the

groin area near the upper thigh.

Pain

Symptoms of hernia can include pain, nausea, and

vomiting.
 DIAGNOSIS

History and physical examination.

Inspection and palpation of the area. In many cases, the bulging can be
seen and/or felt.
 TREATMENT

Femoral hernias that are small and asymptomatic may not

require specific treatment.

 Moderate to large sized femoral hernias require surgical

repair, especially if they are causing pain.
Bibliography

 Bayley and Love Short Practice of Surgery.

 Schwartz”s Principles of Surgery, 9th ed.
 Netter Atlas of Anatomy 4th ed.