 What is a hernia?

An abnormal protrusion of the contents of a cavity

through a weakness in its containing wall.
 Aetiology:
 Congenital
 Acquired

1. Due to a weakened wall [age, previous surgery, steroids, smoking]

2. Increased intra-abdominal pressure [chronic cough, heavy lifting,
obesity, ascites]

HERNIAS CAN BE
1.Reducible Wider the “NECK” of
2.Irreducible a hernia = lower the
3.Obstructed risk of complications
4.Strangulated
 About 75% of all hernias happen in the inguinal region.

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

 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 50.

 Hesselbacks Triangle
RIP
R – Rectus abdominis
muscle
I – inferior epigastric vessels
P – Poupart's ligament
[inguinal ligament]
Can be direct or indirect according to their surgically defined
relationship to the inferior epigastric artery.
1. Indirect hernias are in the inguinal canal, descending to the
scrotum.
Leave the abdomen via the deep inguinal ring to follow an oblique
course through the inguinal canal.

2. Direct hernias protrude anteriorly through transversalis fascia

(Hasselbach’s triangle).

Pantaloon hernia describes a combination of both.

 Patient may describe a “lump”.
 Usually not symptomatic until exacerbated.
 Symptoms are typically exacerbated by any condition which
raises intra-abdominal pressure (chronic cough, obesity,
constipation).
 When exacerbated, cause dragging / aching sensation.
 Indirect inguinal hernia: Usually asymptomatic in the morning,
then symptoms develop throughout the day as the hernia moves
down the canal. An indirect hernia with a large deep ring defect
behaves like a direct hernia.
 Direct inguinal hernia: abdominal wall lump appears
immediately on standing.
Clinical examination.
oExamine systematically looking for the presence of a cough-
impulse and reduction of the hernia to its opening defect.
oOnce reduced, the location of the deep ring can be determined.
oDifferentiation between direct / indirect hernias often
intraoperative.
oRemember to stand the patient.

Ultrasound / CT
May be useful if equivocal diagnosis / obstruction suspected.
1-Malignancy: Lipoma, metastasis, testicular tumors
2-Testicular primary conditions : Varicocele, Epididymitis, Testicular torsion,
Hydrocele, Ectopic testes, undescended testes
3- Aneurism or pseudoaneurysm of the femoral artery
4- Lymphadenopathy
5- Sebaceous cyst
6- Hydroadenitis
7- Nuck canal cyst (in women)
8- Varices
9-Psoas Abcess
10- Hematoma
11- Ascites

1. Conservative
Who?
1. Bad coexisting medical
condition
2. A small asymptomatic hernia
3. An elderly person who is
asymptomatic
How?
Avoid exacerbation of hernia
Support – hernia belt
2. Surgical
Indications?
- Congenital inguinal
hernia should be
repaired at the earliest
possible opportunity
because of increased
risk of incarceration,
strangulation and
testicular ischaemia.
- Symptomatic inguinal
hernias in adults should
be repaired.
Open Lichtenstein tension free repair
Utilises a patch of non-absorbable mesh to strengthen
the posterior wall of the inguinal canal.
Local anaesthesia plus sedation, or general
anaesthesia.
Laparoscopic herniorrhaphy
Indications are bilateral hernias or a recurrent hernia.
The two main techniques are:
Totally extraperitoneal (TEP) repair and
transabdominal preperitoneal patch (TAPP) repair,
both of which require the use of mesh and are
considered tension-free repairs.
1) Scrotal haematoma.
2) Wound infection.
3) Urinary retention.
4) Chronic pain / paraesthesia in the scrotum (or labium majora in females) from
damage to the ilio-inguinal nerve.
5) Testicular atrophy caused by inadvertent damage to the testicular artery.
6) Recurrence rates less than 1%.
• Infection most important risk for recurrence.
• Poor operative technique.
• Avoidance of mesh for reinforcement of weak musculature.
• Conditions such as chronic cough, constipation or bladder outlet obstruction
also contribute to recurrence.