Classification&investigations

of hernia
 HERNIA
 Protrusion of a viscus
or a part of a viscus
through an abnormal
opening in the walls of
its containing cavity
 HERNIA-some terms
 Reducible - contents can be reduced to
abdomen.
 Irreducible - contents cannot be reduced to
abdomen.
 Obstructed - bowel is obstructed; but has
good blood supply.
 Strangulated - blood supply is obstructed.
 Inflamed - contents has become inflamed.
 Incarcerated – hernia is stuck with sac.
 HERNIA-TYPES
Groin Hernia

Femoral Inguinal

Indirect Direct
 cont…
Abdominal Wall Hernia
Umbilical
Epigastric
Incisional
Unusual Hernia
Obturater
Lumbar
Spigelian
Interparietal
Sciatic
Perineal
 cont…
Special Problems
• Sliding
• Strangulated
• Recurrent
• Bilateral
Classification of Groin Hernia

Aims:
• serve as an anatomic blueprint for the
dissection and functional evaluation of the canal
and its contents.
• assist in determining the most appropriate
repair for the particular problem.
• help correlate postoperative symptoms, duration
of convalescence, and degree of disability.
• allow correlation of postoperative results and
long-term follow-up with the original problem.
The most popular classifications
Casten divided hernias into 3 stages:

• Stage 1: an indirect hernia with a normal

internal ring.
• Stage 2: an indirect hernia with an
enlarged or distorted internal ring.
• Stage 3: all direct or femoral hernias.
 The Halverson and McVay
classification
Divided hernias into 4 classes:

• Class 1: small indirect hernia.

• Class 2: medium indirect hernia.
• Class 3: large indirect hernia or direct
hernia.
• Class 4: femoral hernia.
 Ponka's system
• Defined 2 types of indirect hernia:
(1) uncomplicated indirect inguinal hernia.
(2) sliding indirect inguinal hernia.
• Three types of direct hernias:
(1) small defect in the medial aspect of
Hesselbach's triangle near the pubic tubercle.

(2) diverticular hernia in the posterior wall with

an otherwise intact inguinal floor.
(3) a large diffuse direct inguinal hernia of the
entire floor of Hesselbach's triangle.
 Nyhus Classification
Designed for the posterior approach based on the
size of the internal ring and the integrity of the
posterior wall.
• Type 1 - indirect hernia with a normal internal ring.
• Type 2 - indirect hernia with an enlarged internal ring.
• Type 3a - direct inguinal hernia;
• Type 3b - indirect hernia causing posterior wall
weakness;
• Type 3c - femoral hernia
• Type 4a- direct recurrent hernias.
• Type 4b - indirect recurrent hernias.
• Type 4c - femoral recurrent hernias.
• Type 4d – combined recurrent hernias.
 Gilbert classification
Designed for primary and recurrent
inguinal hernias done through an anterior
approach.
It is based on evaluating 3 factors:
• presence or absence of a peritoneal sac
• size of the internal ring
• integrity of the posterior wall of the canal
Types 1, 2 and 3 are indirect hernias; types 4 and
5 are direct.

• Type 1 -peritoneal sac passing through an intact

internal ring that will not admit 1 fingerbreadth (<1cm);
the posterior wall is intact.

• Type 2 -(the most common indirect hernia) peritoneal

sac coming through a 1-fingerbreadth internal ring (</=2
cm); the posterior wall is intact.

• Type 3 -peritoneal sac coming through a 2-

fingerbreadth or wider internal ring (>2 cm). frequently
are complete and often have a sliding component. They
begin to break down a portion of the posterior wall just
medial to the internal ring.
 cont..
• Type 4 -full floor posterior wall breakdown
or multiple defects in the posterior wall.
The internal ring is intact, and there is no
peritoneal sac.
• Type 5 -pubic tubercle recurrence or
primary diverticular hernias. There is no
peritoneal sac and the internal ring
remains intact.
 Rutkow and Robbins
In 1993 added a type 6 &7 to the Gilbert
classification.

• Type 6 - double inguinal hernias.

• Type 7- femoral hernia.

Zollinger’s
• Most recently, proposed a unified
classification of groin hernias.
• Combines one of the most commonly
used individual classifications.
• Applicable to the anterior and
posterior approaches.
• Principal feature is the recognition
that a large indirect hernia defect also
imposes on the posterior wall, and in
effect becomes a combined defect.
 INGUINAL
 The first description of an inguinal hernia
appears in the Ebers papyrus (1555 B.C.).
Hippocrates (460-375 B.C.) mentions hernias of
the pubic and umbilical regions
 Kaspar Stromayr ( 1559 )  defined both direct
and indirect hernias 
 Most common site for hernias to develop in
adults,
 Second only to Umbilical Hernias in infants and
children.
 More common in men, they do occur in women
as well.
 Types-
direct&indirect
 INDIRECT
 Follows the tract through the
inguinal canal, from deep inguinal
ring to external ring.
 Contents follow the tract of the
testicle down into the scrotal sac in
men&into labia in women.
 Most common in young
men(<25yrs)
 M:F ratio-9:1
 Most common in right side.
 3 types –bubonocele
funicular
complete.
 DIRECT HERNIA
• Always acquired.
• Most common in older men.
• The sac passes directly
through a defect in the
transversalis fascia,in the
posterior wall of the inguinal
canal.
• The protruding mass,mainly
consists of extraperital fat.
• Risk of strangulation is
less,as the neck is wide.
Femoral Hernia

 Protrution of abdominal contents

through the femoral canal & pass
beneath the inguinal ligament &
lies just medial to femoral vein.
 3rd most common type of primary
hernia.
 F:M ratio – 2:1
 C/F- strangulation is the initial
presentation in 40% of femoral
hernia.
Variants of femoral hernia
Laugier’s hernia -through
lacunar ligament.
Cloquet’s hernia -lies under
pectineus fascia.
Teale Prevascular - anterior
to femoral vessels.
Serafini Retrovascular -
posterior to femoral vessels.
Narath’s hernia -due to
lateral displacement of psoas
muscle in congenital
dislocation of hip.
Epigastric Hernia
• Occurs through the
linea alba,midway
between xiphoid
process & umbilicus.
• Etiology-either a
congenital weakness or
acquired defect in the
abdominal wall due to
abnormal decussation
of fibres of the
aponeurosis.
• Affect manual workers
b/w 30-45 years.
Umbilical Hernia
 Omphalocele-due to failure of all or part of
the midgut to return to the coelom during
early fetal life.
 Occurs 1 in 6000 births.
 Two types
-with fascial defect

<4cm >4cm
 Gastroschisis

 Results from herniation of the bowel,

and rarely other structures, through a
small (2-5 cm) off-midline abdominal
wall defect.
 Protrudes into the amniotic cavity
usually in the right paraumbilical
region.
 No covering membrane is present.
 Affected patients have malrotated
bowel.
 Karyotypes are normal.
 Prognosis is usually favorable.
 Umbilical Hernia of Infants &
Children

 Through a weak
umbilicus,which may result
partially from failure of the
round ligament to cross the
umbilical ring & partially
from the absence of Ricket
Fascia.
 3rd most common surgical
disorder after hydrocele &
inguinal hernias in infants.
 Umbilical hernia

Umbilical hernia Omphalocele Gastroschisis

 Paraumbilical Hernia
 Occur as a result of defect in
the linea alba & umbilcal fascia.
 Affect women b/w 35-50 years.
 Causative factors
 Obesity

 Multiparity

 Flabbiness of abdominal
muscles.
 INCISIONAL or VENTRAL HERNIA
Occur in the area of any prior
surgical incision, and can vary in
size from very small, to very
large and complex.
 Develop as the result of
 Disruption along or adjacent to
the area of abdominal wall
suturing.
 Too much tension placed when
closing the abdominal incision.
 Poor healing.
 Precursors-post operative
cough&post operative
abdominal distension .
 Lumbar Hernia

 through the posteriorabdominal wall at

some level in the lumbar region.
 The most common sites (95%) are:
Superiorly - Grynfeltt's triangle - occur
following an operation upon an infected kidney.
Inferiorly - Petit's triangle -often occur in young, athletic
women.
 C/F- "lump in the flank" associated with a dull, heavy,
pulling feeling, which is reducible, often tympanic when
the patient is erect.
 cont…
 Acquired hernia are due to
direct trauma, penetrating wound,
abscesses, poor healing of flank
incisions.
 Congenital hernias occur in
infants and are usually isolated
.
unilateral congenital defects.
 D/D-.cold abscesses,
haematomas, soft tissue
tumours, renal tumours and
phanton lumbar hernia.
 Lumbar hernias increase in size
and should be repaired when
Photograph showing the left
found. sided sac opened revealing
bowel
 Obturator Hernia
 Passes through Obturator Canal.
 F:M – 6:1.
 Agegroup- >60 years.
 C/F-
• Usually overlooked, as it is
covered by Pectineus.Becomes
apparent if limb is flexed,
abducted & rotated outward.
• P/V or P/R examination –
Computed tomography shows
swelling in the region of right-sided obturator hernia.
obturator foramen.
 Richter's Hernia
 Involves only a portion of the
circumferance of the
bowel,usually small intestine.
 Does not affect the passage of
bowel contents through the
bowel lumen. Hence, despite
strangulation, there is an
absence of intestinal
obstruction.
 Seen most often in women with
femoral hernia.
 Littre's Hernia

First described by Littre in 1700

 Littre's hernia is any hernia with a
Meckel diverticulum in the hernial sac.
Their distribution is:
50% inguinal
20% femoral
20% umbilical
10% miscellaneous
 More common in men on the right side.
There is pain, fever, and manifestations
of small bowel obstruction.
 Treatment is by repair of the hernia, and
excision of the diverticulum if possible.
 Perineal Hernia
 Protrudes through the muscles
and fascia of the perineal
floor
Primary
Acquired - perineal
prostatectomy, abdominoperineal
resection of the rectum, or pelvic
exenteration.
 TYPES:
• post operative
• medial sliding
• antero lateral
• postero lateral
 Congenital Diaphragmatic
Hernia
 It is caused by a defect in the hemidiaphragm,
usually the left.
 occurs once in 2200 births.
 Types
Hiatus hernia
• 99% axial ("sliding")
• 1% para-esophageal ("rolling")

Bochdalek hernia
• posterior: pleuroperitoneal membrane
• more common on LEFT

Morgagni hernia
• anterior: retrosternal muscle clefts
• most often on RIGHT
Gluteal & Sciatic Hernia

Rarest of abdominal hernias.

 Gluteal hernia - through the
greater sciatic foramen, either
above or below the piriformis.
 Sciatic hernia - through the
lesser sciatic foramen.
 D/D - lipoma or fibro-sarcoma
beneath the gluteus
maximus ,tuberculous abscess
& gluteal aneurysm

Perineal & Sciatic hernia

 Interparietal Hernia
 Hernial sac that passes between the
layers of the anterior abdominal wall.
 Varieties include:
• preperitoneal (20%) - the sac takes the
form of a diverticulum from a femoral or
inguinal hernia
• intermuscular (60%) - the sac passes
between the external and internal oblique
muscles.
• inguino-superficial (20%) - the sac
expands beneath the superficial
abdominal wall or the thigh.
 Most patients are males.
 C/F- intestinal obstruction due to
obstruction or strangulation of the
hernia.
Spigelian Hernia
 A variety of interparietal
hernia occur at the level of
arcuate line which lie
beneath the internal oblique
muscle.
 Age - >50 years.
 Both sex are equally
affected.
hernia involving the left lower
 C/F- a soft reducible mass quadrant anterior abdominal wall
seen lateral to the Rectus
muscle, below umbilicus.
 Sliding Hernia

Bladder

Caecum

Hernial sac

 Occurs due to the slipping of the posterior parietal peritoneum on

the underlying retroperitoneal structures,such as sigmoid colon on
left & caecum on the right or by a portion of bladder on either
side.
 Seen exclusively in men.
Specific Investigations In
Hernia Patients
Ultrasonic scanning
hernia
 Diagnose both palpable&non
palpable spigelian hernia.
 Rapid,accurate,noninvasive
&easy to perform.
 Abdominal wall layers can be
delineated clearly.
 Hernial orifice seen as a
defect in the echoline from the Example of direct inguinal
hernia through the superficial
aponeurosis. ring on straining (transverse to
inguinal canal)
Herniography
 Positive contrast peritoneography
to diagnose hernia in the inguino-
femoral region & pelvis.
 Indications.
 Obscure groin pain and uncertain
finding in clinical examination.
 As a scientific purpose in
diagnosing recurrent hernia in
clinical trails.
 Preoperatively in high risk patients.
 Technique
• The procedure is performed under sterile conditions with
local anaesthesia. The patient lies in the supine position,
and the head-end of the examination table is slightly
elevated. The urinary bladder must be empty. The anterior
abdominal wall is punctured with a sheathed needle
approximately 34 cm to the left of and 34 cm below the
umbilicus, corresponding to the upper part of the left
sacroiliac joint at fluoroscopy. The puncture of the
peritoneum is facilitated by use of increased intra-
abdominal pressure (Valsalva). A total of 60-70 ml of a
water-soluble contrast medium is injected under
fluoroscopic control; nonionic contrast media (240 mg
iodine/ml) are recommended. The patient is turned prone,
and the table further elevated (30) to promote filling of
pelvic hernias.
• Frontal and oblique radiographs are taken with and without
increased intra-abdominal pressure. Supplementary supine
or erect views may be needed.
Interpretation of herniography
 Indirect-emerge from
lateral fosa; lateral to
lateralumbilical fold.
 Direct-bulging from
medial fossa.
 Femoral-more
inferiorly&posteriorly than
inguinal hernia
Complications
 Intestinal perforation.
 Hematoma & bleeding.
 Side effects of the contrast media.

Herniogram of bilateral hernia

Computer tomography
 Provides information about hernial orifice;the
sac&its contents.
 Bowel loops are identified & bowel gas delineated.
 Peristaltic movements of herniated bowel loops
demonstrated.
Biochemical Changes in
Collagen
 Collagen
• Major structural protein
found in connective tissue.
• Most abundant protien in the
body.
• Found in all connective
tissue such as
• Cartilage,bone,tendon,ligam
ents,fascia&skin.
 Synthesis
Intracellularly in the fibroblasts,
where a large polypeptide is
formed.
Polypeptide get hydroxylated
with proline&lysine and
glycosylated by glucose or
galactose to form
procollagen.
Procollagen is cleaved by
fibroblast specific
peptidases to tropocollagen,
which aggregate to form
collagen.
 Triple helix
Biosynthesis of a fibril-forming collagen.
 Structure of Collagen
 The basic unit of collagens
is a polypeptide consisting
of the repeating sequence
(Gly) - X - Y)n where X -
proline& Y-hydroxyproline.

 Glycine is one - third of

total amino acid content of
collagen followed by
hydroxyproline and proline
account for another one-
third of amino acid content
of collagen.
 Types…..
19 types in humans
Collagen type 1
- in bone, skin, tendon, muscles and walls of blood vessels.
Collagen type II
-in invertiberal discs and hyaline cartilage.
Collagen type III
- in spleen, muscle, and aorta.
Collagen type IV
-Found around different types of in the basement membranes and muscles.
Collagen type V
- in embryonic cell cultures and the basement membranes.
Collagen type VI
- in muscle and skin.
Quantitative analysis of collagen in the
transversalis fascia in inguinal hernia
• The TF from IIH patients had structurally well
preserved and homogeneously distributed
mature, elaunin, and oxytalan elastic fibers.  
 
 
 
 
 
• The TF from DIH patients had greater amounts
of mature elastic fibers, which were
characterized by thickening, curling, and
shortening. The oxytalan fibers were less
evident in TF from DIH patients.
 
 Conjoint tendon&Hernia
 Normally the conjoint tendon gets
inserted to the medial part of inguinal
ligament&pubiccrest.
 In majority of patients with Direct
High insertion
Hernia,there is high insertion of
conjoint tendon,thus producing a wide
HESSERT’S TRIANGLE(deep inguinal
ring+Hesselbach’striangle)& weakening
of TransversalisFascia at its medial part.
 So on straining(lifting a heavy
weight),they can suddenly develop
hernia ,as the TransversalisFascia gives Deep ring
away. Hesselbach’s
triangle
Conjoint tendon
Weak area