HERNIA MODULE

SAHITYA SNIGDHA
ID NO: 19-1326-503
BLOCK 9B, GROUP 2
 Discuss the anatomy involved in inguinal hernia

ANATOMY:-
• Inguinal canal is an approximately 4- to 6-cm long cone shaped
region situated in the anterior portion of the pelvic basin.
• Boundaries of the inguinal canal-
a. External oblique aponeurosis anteriorly
b. Internal oblique muscle laterally
c. Transversalis fascia and transversus abdominis muscle
posteriorly
d. Internal oblique and transversus abdominis muscle superiorly
e. Inguinal (Poupart’s) ligament inferiorly
• Spermatic cord traverses the inguinal canal, and it contains three arteries, three
veins, two nerves, the pampiniform venous plexus, and the vas deferens.
• Additional important structures surrounding the inguinal canal include the
iliopubic tract, the lacunar ligament, Cooper’s ligament, and the conjoined
tendon .
• Iliopubic tract is an aponeurotic band that begins at the anterior superior iliac
spine and inserts into Cooper’s ligament from above.
• It forms on the deep inferior margin of the transversus abdominis and
transversalis fascia.
• Shelving edge of the inguinal ligament is a structure that connects the iliopubic
tract to the inguinal ligament.
• Iliopubic tract helps form the inferior margin of the internal inguinal
ring as it courses medially, where it continues as the anteromedial
border of the femoral canal.
• Lacunar ligament, or ligament of Gimbernat, is the triangular fanning
of the inguinal ligament as it joins the pubic tubercle.
• Cooper’s (pectineal) ligament is the lateral portion of the lacunar
ligament that is fused to the periosteum of the pubic tubercle.
• Conjoined tendon is commonly described as the fusion of the inferior
fibers of the internal oblique and transversus abdominis aponeurosis
at the point where they insert on the pubic tubercle.
 BLOOD SUPPLY
• Vascular space is situated between the posterior and anterior laminae
of the transversalis fascia, and it houses the inferior epigastric vessels.
• Inferior epigastric artery supplies the rectus abdominis. It is derived
from the external iliac artery, and it anastomoses with the superior
epigastric, a continuation of the internal thoracic artery.
• Epigastric veins course parallel to the arteries within the rectus sheath,
posterior to the rectus muscles.
• Inspection of the internal inguinal ring will reveal the deep location of
the inferior epigastric vessels
 INNERVATION
• Nerves of interest in the inguinal region are the
ilioinguinal, iliohypogastric, genitofemoral, and lateral
femoral cutaneous nerves.
• Ilioinguinal and iliohypogastric nerves -
a. Arise together from the first lumbar nerve (L1).
b. It emerges from the lateral border of the psoas major
and passes obliquely across the quadratus lumborum.
c. At a point just medial to the anterior superior iliac
spine, it pierces the transversus and internal oblique
muscles to enter the inguinal canal and exits through
the superficial inguinal ring.
• Iliohypogastric nerve-
a. Arises from T12–L1
b. It pierces the deep abdominal wall, it courses between the internal oblique and
transversus abdominis, supplying both.
c. It then divides into lateral and anterior cutaneous branches.
d. A common variant is for the iliohypogastric and ilioinguinal nerves to exit around the
superficial inguinal ring as a single entity
• Genitofemoral nerve –
a. Arises from L1 to L2
b. Courses along the retroperitoneum, and emerges on the anterior aspect of the psoas
c. It then divides into genital and femoral branches.
d. The genital branch enters the inguinal canal lateral to the inferior epigastric vessels,
and it courses ventral to the iliac vessels and iliopubic tract.
• Femoral branch-
a. Courses along the femoral sheath, supplying
the skin of the upper anterior thigh.
• Lateral femoral cutaneous nerve-
a. Arises from L2 to L3, emerges lateral to the
psoas muscle at the level of L4, and crosses the
iliacus muscle obliquely toward the anterior
superior iliac spine.
b. It then passes inferiorly to the inguinal
ligament where it divides to supply the lateral
thigh
• Preperitoneal anatomy seen in
laparoscopic hernia repair led to
characterization of important anatomic
areas of interest, known as

➢ Triangle of doom
➢ Triangle of pain
➢ Circle of death .
• Triangle of doom -bordered medially by the vas deferens and laterally by
the vessels of the spermatic cord. Contents of the space include the
external iliac vessels, deep circumflex iliac vein, femoral nerve, and
genital branch of the genitofemoral nerve.
• Triangle of pain -region bordered by the iliopubic tract and gonadal
vessels, and it encompasses the lateral femoral cutaneous, femoral
branch of the genitofemoral and femoral nerves.
• Circle of death -vascular continuation formed by the common iliac,
internal iliac, obturator, inferior epigastric, and external iliac vessels.
Discuss the difference between direct and indirect hernia and its
classification by location, size, and type
• Inguinal hernias are generally classified as direct, indirect, or femoral based
upon the site of herniation relative to surrounding structures.
• Indirect hernias protrude lateral to the inferior epigastric vessels, through the
deep inguinal ring.
• Direct hernias protrude medial to the inferior epigastric vessels, within
Hesselbach’s triangle. The borders of the triangle are the inguinal ligament
inferiorly, the lateral edge of rectus sheath medially, and the inferior epigastric
vessels superolaterally.
• Femoral hernias protrude through the small and inflexible femoral ring.
• Traverse the empty space between the femoral vein and the lymphatic
channels.
• The borders of the femoral ring include the iliopubic tract
and inguinal ligament anteriorly, Cooper’s ligament
posteriorly, the lacunar ligament medially, and the
femoral vein laterally.
• The Nyhus classification categorizes hernia defects by
location, size, and type
Discuss the anatomy of the abdominal wall
ANATOMY
• Embryology-
• The abdominal wall is derived from the mesoderm and envelops the
future abdominal contents as bilateral migrating layers originating
from the paravertebral area.
LAYERS OF ABDOMINAL WALL
•The abdominal wall consists of nine distinct layers:
1. Skin
2. Subcutaneous tissue
3. Superficial fascia
4. External oblique muscle
5. Internal oblique muscles
6. Transversus abdominus muscle
7. Transversalis fascia
8. Preperitoneal adipose tissue
9. Peritoneum.
MUSCLES OF ABOMINAL WALL
•The muscles of the abdominal wall consist of the
▪ Rectus abdominus medially
▪ The external oblique, internal oblique, and transversus abdominis
laterally.
• Divided by the linea alba, both rectus muscles originate at the pubic
symphysis and crest and insert on the xiphoid process, the fifth and
sixth ribs, and the seventh costal cartilage.
• Three tendinous insertions cross the rectus muscle along its length.
The muscle is contained within an aponeurotic sheath formed from
the fusion of differing components of the lateral fascial layer
• The external oblique arises from the eighth rib and inserts
medially into the linea alba and anterior iliac crests.
• The internal oblique originates from the thoracolumbar fascia.
• The deep muscular layer, the transversus abdominis muscle,
begins at the costal margin and lumbar fascia, runs
horizontally and anteriorly, and inserts on the linea alba,
xiphoid process, and pubis symphysis
• Along the posterior abdominal wall are folds corresponding to
underlying vasculature and embryologic remnants.
• The median umbilical fold is formed by the obliterated
urachus traveling from the dome of the bladder to the
umbilicus in the midline.
• The bilateral medial folds are formed by remnants of the
umbilical arteries.
• Lastly, the lateral folds are associated with the inferior
epigastric vessels.
VASCULATURE
• The deep blood supply of the abdominal wall is supplied mostly from the
inferior and superior epigastric arteries.
• The superior epigastric artery is the final branch of the internal thoracic artery.
• The abdominal wall is also supplied by branches of the subcostal and lumbar
arteries.
• Superficially, the abdominal wall subcutaneous and skin tissue is supplied by
branches of the superficial epigastric arteries, femoral arteries, superficial
external pudendal, and superficial circumflex arteries.
• Venous drainage of the abdominal wall is variable but typically follows the
aforementioned arteries.
LYMPHATICS
• Above the umbilicus, the lymphatics of the abdominal wall drain into
the superficial axillary nodes.
• Below the umbilicus, these drain into the inguinal nodes.
• Lymphatics near the umbilicus can drain along the falciform ligament
toward the hepatic nodes
INNERVATION
• Innervation of the abdominal wall is segmental, leading to a
dermatomal sensory pattern.
• Afferent branches of the T4 to L1 nerve roots provide sensation of the
abdominal wall.
• The muscles of the abdominal wall are innervated by the efferent
branches of spinal nerves T6 to T12.
Discuss each of the following conditions in terms of
cause, risk factors/ predisposing factors,
presentation, pathophysiology, diagnosis, treatment
and prognosis
GROIN MASS
 Inguinal hernia (indirect/direct)
• Inguinal hernias are generally classified as direct, indirect, or femoral
based upon the site of herniation relative to surrounding structures.
• Indirect hernias- protrude lateral to the inferior epigastric vessels,
through the deep inguinal ring.
• Direct hernias- protrude medial to the inferior epigastric vessels,
within Hesselbach’s triangle.
DIRECT INGUINAL HERNIA INDIRECT INGUINAL HERNIA

It may not be congenital Failure of the peritoneum to close

results in a patent processus
vaginalis (PPV) is very high in
preterm babies.
Chronic obstructive pulmonary No such ris factors
disease also significantly
increases the risk of direct
inguinal hernias, thought to be due
to repeated instances of intra-
abdominal pressure during
coughing.
A persistent herniation suggests a A controlled impulse suggests an
direct hernia indirect hernia
Impulse palpated on the dorsum of Transmission of the cough impulse
 RISK FACTORS

• The most likely risk factor for inguinal hernia is weakness in the abdominal
wall musculature.
• Several studies have documented strenuous physical activity as a risk factor
for acquired inguinal hernia.
• Chronic obstructive pulmonary disease also significantly increases the risk
of direct inguinal hernias, thought to be due to repeated instances of intra-
abdominal pressure during coughing.
• Collagen disorders such as Ehlers-Danlos syndrome are also associated with
an increased incidence of hernia formation
 PATHOPHYSIOLOGY

• Inguinal hernias may be congenital or acquired.

• Most adult inguinal hernias are considered acquired defects in the
abdominal wall.
• There is however, a known hereditary association that is not well
understood.
• The pain is thought to be due to compression of the nerves by the sac,
causing generalized pressure, localized sharp pain, or referred pain.
• Referred pain may involve the scrotum, testicle, or inner thigh.
PRESENTATION
• The most common symptom of inguinal hernia is a groin mass that
protrudes while standing, coughing, or straining.
• It is sometimes described as reducible while lying down.
DIAGNOSIS
• While very difficult to ascertain,
there are certain physical
examination maneuvers that can
be performed to help distinguish
direct vs. indirect inguinal hernias.
• The inguinal occlusion test entails
the examiner blocking the internal
inguinal ring with a finger as the
patient is instructed to cough.
IMAGING
The most common radiologic modalities include
• Ultrasonography (US)
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI).
TREATMENT
• Surgical repair is the definitive treatment of inguinal hernias.
• The most common reason for elective repair is pain.
• Incarceration and strangulation are the primary indications for urgent
repair.
 OPEN APPROACH
• The most commonly performed
type of hernia operation still
remains the open inguinal
hernia repair.
• These repairs can be performed
tension-free with mesh or by
reconstruction of the floor with
tissue.
• Tissue repairs are less common
and are primarily indicated in
infected fields.
TISSUE REPAIR
• Tissue-based herniorrhaphy is a suitable alternative
• when prosthetic materials cannot be used safely. Indications for tissue
repairs include operative field contamination,emergency surgery, and
when the viability of hernia contents is uncertain.
 TREATMENT
BASSINI REPAIR
• A major advancement in the treatment of IH
• Dissection of spermatic cord, dissection of hernia sac with ligation,
and extensive reconstruction of the floor of the canal
• Triple-layer repair to restore integrity
• IO, TA, TF are fixed to the shelving edge of inguinal ligament by
interrupted sutures
 TREATMENT
SHOULDICE REPAIR
• Lower recurrence rates than Bassini
• Success rates are equivalent to that of tension-free repairs
• Continuous suture in multiple layers distributes tension over
several layers and prevent herniation in between interrupted
sutures
• 4 layer imbricating tissue reconstruction using two separate
sutures
 TREATMENT
MCVAY REPAIR
• Ability to address both inguinal and femoral canal defects
• Added the concept of the relaxing incision as a tension reducing maneuver
– incision in the anterior rectus sheath beginning at the pubic tubercle
extended superiorly 2-4cm
• The upper margin of the transversalis fascia is sutured to Cooper’s ligament
 TREATMENT
DESARDA REPAIR
• Recently described
• consists of a mesh-free repair utilizing a strip of external oblique
aponeurosis
• Integrity of the fascia is preserved as much as possible.
• Excision of the sac is done in all cases except in small direct
hernias, where it is inverted.
 TREATMENT
PROSTHETIC REPAIRS
LICHTENSTEIN TENSION-FREE REPAIR
• Does not include routine division of the transversalis fascia
• The floor and internal ring are reinforced through the application of the
mesh
• The mesh is sutured to the anterior rectus sheath medially and to the
shelving edge of the inguinal ligament laterally
TREATMENT
PLUG AND PATCH TECHNIQUE
• A modification of the Lichtenstein repair (patch)
• Added placement of the mesh through the internal ring (plug)
• rolling a flat piece of polypropylene into a tight cylinder and plugged
through the internal ring
• The plug and patch could be placed without sutures
 TREATMENT
PROLENE HERNIA SYSTEM
• Combine the advantage of the anterior and preperitoneal repair in an open approach
• Mesh consist of two large flaps (an onlay and an underlay patch) with an intervening
connector
• Underlay – preperitoneal
• Overlay – rests along the floor
• Adds a preperitoneal reinforcement to an open tension-free repair
TREATMENT
PREPERITONEAL REPAIRS
• A number of surgeons have approached the preperitoneal space posterior to the
transversalis fascia through a lower midline or Pfannenstiel incision
• However, the superior results achieved by mesh repairs lend this approach to
historical significance only
• Advantages include avoiding entry to the ingunal canal so nerves coursing here
are not encountered and minimal manipulation of the spermatic cord
TREATMENT
LAPAROSCOPIC
• Capitalize on the preperitoneal approachusing a series of small incisions
• Preferred approach for bilateral hernia and recurrent hernia
• Transabdominal preperitoneal (TAPP)
• Totally extraperitoneal (TEP)
• Intraperitoneal only mesh (IPOM) – performed least
TREATMENT
Advantages of TEP over TAPP
• Abdominal cavity is not penetrated
• Decrease in possibility of injury to intra-abdominal organs and vascular structures
• Decreased trocar site herniation owing to preservation of the posterior rectus
sheath
• Obviates the need for peritoneal closure and therefore performed faster than
TAPP
• Decreased incidence of bowel obstruction and mesh erosion into bowel
TREATMENT
• Preperitoneal dissection in TEP is identical to TAPP but the access to the
preperitoneal space is unique to TEP
• Incision is carried only up to the anterior rectus sheath where a dissecting
balloon is placed and insufflated to create the preperitoneal space
TREATMENT
CONSERVATIVE MANAGEMENT
• Definitive treatment of all hernias is surgical repair
• Surgery can be delayed or avoided where the patient’s medical status prohibits
operative treatment
• Simple maneuvers to alleviate symptoms of pain, pressure and protrusion of
abdominal contents
• Recumbent position
• Truss – an elastic belt or brief to keep hernia reduced
TREATMENT
EMERGENT REPAIR
• Indications include incarcerated and strangulated inguinal hernia, sliding
hernia
• Incarcerated – irreducible due to large amount of intestinal contents within
the sac; dense and chronic adhesions of hernia contents to the sac; and a
small neck of hernia defect
• Incarceration without the sequelae of bowel obstruction is not
necessarily a surgical emergency
• Sliding hernia – only one wall of a hollow viscus is present within the hernia
sac
TREATMENT
• Hernias that are not strangulated and do not reduce with gentle pressure should
undergo taxis
• Under sedation and in a Trendelenburg position, the hernia sac is grasped with both
hands, elongated and then milked back through the hernia defect
• Strangulated – blood supply to incarcerated contents are compromised
• Symptoms of bowel obstruction: vomiting, constipation, distended abdomen
• Clinical signs: fever, leucocytosis, hemodynamic instability
• Taxis should not be applied as a potentially gangrenous bowel may be reduced
into the abdomen without being addressed
TREATMENT
• Upon opening the sac, bowel viability can be assessed by bowel colour,
temperature, presence of peristalsis and the Woods fluorescein test
• Ischemic portion is resected and viable portions anastomosed
• Mesh should not be used if the procedure has become clean-contaminated
 FEMORAL HERNIA

• Femoral hernias protrude through the small and inflexible femoral ring.
• They traverse the empty space between the femoral vein and the
lymphatic channels.
• The borders of the femoral ring include the iliopubic tract and inguinal
ligament anteriorly, Cooper’s ligament posteriorly, the lacunar ligament
medially, and the femoral vein laterally.
PATHOPHYSIOLOGY
• A femoral hernia follows the tract below the inguinal ligament through
the femoral canal.
• The canal lies medial to the femoral vein and lateral to the lacunar
(Gimbernat) ligament.
• Because femoral hernias protrude through such a small defined space,
they frequently become incarcerated or strangulated.
• Perihernial fasciae or muscles may be malformed.
 PRESENTATION

• Because of the position of this hernia, medial thigh pain is possible in

addition to groin pain
DIAGNOSIS
• Femoral hernias should be palpable below the inguinal ligament,
lateral to the pubic tubercle.
• In obese patients, a femoral hernia may be missed or misdiagnosed as
a hernia of the inguinal canal.
• In contrast, a prominent inguinal fat pad in a thin patient, otherwise
known as a femoral pseudohernia, may prompt an erroneous
diagnosis of femoral hernia.
 TREATMENT
• Femoral hernias carry higher complication risks, and so
surgical repair is performed earlier for these patients.
• Most commonly performed surgical repair is-
MCVAY REPAIR
• Ability to address both inguinal and femoral canal
defects
• Added the concept of the relaxing incision as a tension
reducing maneuver – incision in the anterior rectus
sheath beginning at the pubic tubercle extended
superiorly 2-4cm
• The upper margin of the transversalis fascia is sutured
to Cooper’s ligament
 Lymphadenopathy
• Adenopathy is disease of the lymph nodes, in which they are abnormal in size or consistency. Lymphadenopathy of an
inflammatory type (the most common type) is lymphadenitis, producing swollen or enlarged lymph nodes.
• Inguinal lymphadenopathy is a nonspecific finding that is characteristic of inflammatory pathology almost anywhere in
the groin or either lower extremity
• Cause-
• Swollen inguinal lymph nodes are caused by infections or injury affecting the lower body.
• This can include the:
• Groin,
• Genitals,
• urinary tract,
• Leg,
• foot
• Risk factors/predisposing factor
• Athlete’s foot: a fungal infection that usually begins with a scaly rash between the toes
• Jock itch: a fungal infection that causes a red, itchy rash in the groin area
• Vaginal or penile yeast infection: a common infection caused by an overgrowth of the
fungus Candida
• Urinary tract infection (UTI)
• Presentation-
• a lymph node larger than 0.4 inches, or 1 centimeter, in diameter is considered abnormal.
• Swollen lymph nodes in the groin may be painful to the touch and the skin over them may look
red and inflamed, depending on the cause.
• Pathophysiology-
• Lymphadenopathy reflects disease involving the reticuloendothelial system, secondary to an increase in normal
lymphocytes and macrophages in response to an antigen.
• Most lymphadenopathy in children is due to benign, self-limited disease such as viral infections.
• Other, less common etiologies responsible for adenopathy include nodal accumulation of inflammatory cells in
response to an infection in the node (lymphadenitis).
• Physical exam-
• Your doctor will examine your swollen lymph nodes for size, consistency, pain, and warmth. They’ll also check for
other lymphadenopathy and signs of infection and illness, including STIs.
• Urinalysis-
• You may be asked to provide a sample of your urine to check for signs of a UTI or other infection, including STIs.
• Pap test-
• A Pap test checks the cervix for abnormal cells and cervical cancer.
Treatment and Prognosis:
• Topical antibiotics for a skin infection
• OTC antifungal cream for athlete’s foot or jock itch
• OTC yeast infection treatments, such as creams or suppositories
• Oral antibiotics for infections, including some STIs
• Antiviral drugs, such as valacyclovir (Valtrex) and acyclovir (Zovirax) for genital
herpes
• Antiretroviral therapy for HIV
 ANEURYSM
• A femoral/ abdominal aortic aneurysms are bulging and weakness in the wall of the femoral
artery located in the thighg/abdomen
• these aneurysms can burst, which may cause life-threatening, uncontrolled bleeding.
• The aneurysm may also cause a blood clot, potentially resulting in leg amputation.
• CAUSE-
• The exact cause of femoral aneurysms is not known, though atherosclerosis may play a key role.
• Trauma to the artery may also cause a femoral aneurysm.
• RISK FACTORS/PREDISPOSING FACTORS-
• Have high cholesterol, Have high blood pressure, Smoke, Have a bacterial infection, Have had
blood-vessel reconstruction in one or both legs.
• PRESENTATION:
• Many cases of aneurysms have no symptoms. The most common symptom is pain below the
knee.
• DIAGNOSIS & TREATMENT :
• Ultrasound
• Computed tomography (CT) scan
• Magnetic resonance imaging (MRI) scan
• Angiography
• TREATMENT:
• Surgery is generally required to treat femoral aneurysms. Your surgeon will replace the artery
with a graft or create a bypass around the area of the artery where the aneurysm is located.
• It's important for you to carefully control high blood pressure with medication, if necessary
Abdominal wall mass
 INCISIONAL HERNIA

• Hernias that develop at sites of previous abdominal incisions are known

as incisional hernias.
• Up to 20% of midline incisions will develop hernias eventually.
• Vertical incisions may have a higher risk of hernia formation than
transverse or oblique incisions.
• Several patient derived factors increase the risk of hernia, including
diabetes, immunosuppressant use, obesity, smoking, malnutrition, and
connective tissue disorders.
 PATHOPHYSIOLOGY

• An incisional hernia is an iatrogenic condition that occurs in 2 - 10% of all

abdominal operations secondary to breakdown of the fascial closure of a
surgical procedure.
• Even after repair, recurrence rates approach 20-45%.
PRESENTATION:
• Because this hernia is usually asymptomatic, patients typically present
with a bulge at the site of a previous incision; the lesion may become
larger upon standing or with increasing intra-abdominal pressure
TREATMENT
• Surgical management of incisional hernias include either primary
tissue or mesh repairs.
• Hernias can also be repaired via a laparoscopic or open approach
• To reduce tension at the suture line associated with primary suture
repair the components separation technique was introduced in 1990.
• This procedure entails dividing portions of the bilateral external
oblique aponeuroses forming musculofascial advancement flaps.
• This technique can cause large skin flaps and initially had high rates of
infection.
 Spigelian Hernia:
• A spigelian hernia occurs through a defect in the spigelian fascia, defined by the
lateral edge of the rectus abdominis at the semilunar line (from costal arch to
pubic tubercle).
• Abnormal orientation of the semilunar and semicircular lines, along with obesity,
increased intra-abdominal pressure, aging, and rapid weight loss, leads to the
production of spigelian hernias.
• There are two subtypes of spigelian hernia, interstitial and subcutaneous.
• Distinguishing between these subtypes helps optimize the surgical approach
(when indicated) and is best done by means of Computed Tomography (CT)
 Epigastric Hernias
• Nonincisional hernias are named based on their location on the abdominal wall.
Epigastric hernias are defects in the abdominal wall located between the
umbilicus and the xiphoid process.
• These hernias are usually small but may be associated with multiple defects. They
result from multiple factors,including muscle weakness, congenitally weakened
epigastric fascia, or increases in intra-abdominal pressure.
• Epigastric hernias rarely contain bowel and usually contain portions of the
omentum or falciform ligament. Given the rarity of incarceration,repair of an
epigastric hernia is indicated for symptomaticpatients only.
• Laparoscopic repair can be attempted, but this type of hernia usually can be
managed with a small incisionwhere the defect is closed with interrupted sutures.
 UMBILICAL HERNIA

PATHOPHYSIOLOGY
• An umbilical hernia occurs through the umbilical fibromuscular ring,
which is usually obliterated by age 2 years.
• They are congenital in origin and are repaired if they persist in children
older than 2-4 years.
TREATMENT
• In children, umbilical hernia repair is best performed with general
anesthesia, whereas in adults, regional or local anesthesia can be
used.
• A semicircular incision in the infraumbilical skin crease exposes the
umbilical sac.
• A plane that is created to encircle the sac at the level of the fascial ring
expedites repair.
• The defect is closed primarily in a transverse direction with a single
layer of interrupted sutures.
• If the defect is very large, mesh is occasionally required.
• Although excessively wrinkled skin can appear cosmetically troublesome,
elasticity and growth usually corrects the problem because the skin
incision lies within the umbilical fold.
• In cases with severe redundant skin, removal of a circle of skin and
peritoneum to access the hernia, followed by a purse-string closure,
provides an excellent cosmetic result.
• A pressure dressing is applied for several days after repair.
RECTAL SHEATH HEMATOMA
• Disruption of one of the branches of the inferior epigastric artery as
well as an inability to tamponade the hemorrhage results in a rectus
sheath hematoma.
• This occurs commonly around the arcuate line where the artery and its
branches are relatively fixed causing vulnerability to shearing forces.
 RISK FACTORS
• Several risk factors are associated with rectus hematoma formation via either
proclivity to disruption of blood vessels or by inability to cease bleeding.
• Trauma to the abdominal wall, including iatrogenic trauma with laparoscopic
trocar placement, can lead to disruption of blood vessels.
• Vigorous contraction of the rectus muscle, either with coughing, sneezing, or
exercise, can also induce hemorrhage formation.
• Chronic pulmonary disease can lead to hemorrhage because of coughing fits.
• Patients on anticoagulation also present with higher risk of hematoma formation
 PRESENTATION

• This condition presents with acute abdominal pain and a palpable abdominal wall
mass.
• Rectus sheath hematoma may be mistaken with intraperitoneal pathology,
including appendicitis if on the right side.
• However, in patients with rectus sheath hematomas, pain usually increases with
contraction of the rectus muscles as opposed to intraperitoneal conditions.
• In addition, palpation of a mass that does not change during contraction of the
rectus muscle, known as Fothergill’s sign, is also associated with rectus sheath
pathology.
DIAGNOSIS
• The diagnosis should be confirmed via ultrasound or CT scan with
intravenous contrast.
• Obtaining a type and screen, hemoglobin/hematocrit, and coagulation
factors are critical in the management of these patients.
TREATMENT
• Treatment of patients with rectus sheath hematoma depends on the
hemodynamic stability of the patient as well as the size of the hematoma.
• Hemodynamically stable patients with small hematomas, stable serial
hemoglobin/hematocrits, and normal coagulation factors may be observed
without hospitalization.
• Hemodynamically stable patients with larger or bilateral hematomas and
decreases in hemoglobin should be monitored in the hospital setting, with
serial hemoglobin levels, compression of the hematoma, and bedrest.
• If anticoagulated, reversal is necessary and transfusions of packed red blood
cells may be required in some situations.
• Patients in hypovolemic shock should be aggressively resuscitated with
the use of blood products and treated via angiographic embolization.
• Angiographic intervention may also be required if the hematoma
increases in size or if clinical deterioration occurs.
• Surgical therapy can be performed if angiographic intervention has failed.
• Surgical treatment includes operative evacuation of hematoma and
ligation of bleeding vessels.
DIASTASIS RECTI
• Rectus abdominis diastasis (diastasis recti) is an anatomic term
referring to an abnormal separation of rectus muscles and a laxity at
the linea alba.
• A distance of two centimeters is usually considered abnormal in the
midline abdomen above the umbilicus.
• This can either be a congenital or acquired abnormality.
• This is not a true hernia as the midline fascia is intact, and as such
incarceration and strangulation do not occur.
 RISK FACTORS
• Risk factors for acquired rectus abdominis diastasis include conditions
that elevate intraabdominal pressure, including obesity and pregnancy, as
well as conditions which weaken the abdominal wall, including
connective tissue disorders or prior abdominal surgery.
• Risk factors of developing a diastasis recti after pregnancy include older
age at the time of pregnancy, multiple pregnancies, and recurrent
ceasarean sections.
• Postpartum exercise reduces the risk of developing diasthesis recti.
PRESENTATION
• Most patients with diastasis recti can be diagnosed based on physical
exam where a fusiform bulge is usually apparent.
• This bulge worsens with contraction of the rectus muscles or Valsalva
maneuver.
IMAGING:
• Ultrasonography can be used to confirm diathesis and rule out hernia.
• CT scan can also be used to confirm diagnosis and measure distance
between muscle pillars.
TREATMENT
• Rectus diastasis does not require surgical repair and may be improved
via weight loss and exercise.
• Indications for repair include disability of abdominal wall muscular
function or cosmesis.
• Surgical repair includes both open and laparoscopic plication of the
rectus sheath.
• Mesh can also be used to bridge the muscle; however, complication
rates increase with mesh usage.
• These procedures do, unfortunately, have a high risk of recurrence
long term and introduce a new risk of incisional hernia.
DESMOID TUMOR
• Desmoid tumors, also known as aggressive fibromatosis, are
fibroblastic neoplasms with aggressive infiltrative behavior but no
metastatic potential.
• These tumors can occur anywhere in the body but commonly occur in
the abdomen or abdominal wall.
RISK FACTORS
• Desmoids tumors are rare and usually occur sporadically.
• They are, however, also associated with familial adenomatous
polyposis (FAP), with an even greater risk in patients with Gardner’s
syndrome.
• Risk factors for sporadic development of desmoid tumors include
previous surgical incision, pregnancy, hormonal exposure, and trauma.
• Females have a higher predilection for formation of desmoid tumors.
DIAGNOSIS
• Diagnosis can be performed via core-needle or incisional biopsy.

• Larger tumor size, young patient age, and extra-abdominal tumor

location all predict poor recurrence free survival
 TREATMENT
• The gold standard of treatment of abdominal wall desmoid tumors, historically, is
margin-negative resection with immediate mesh reconstruction.
• There is also some evidence to suggest a period of close watchful waiting, as some
tumors appear to remain stable or even regress over time.
• Primary radiation therapy may be an option for patients who are not surgical
candidates.
• There may also be a role for systemic therapy, especially if tumors are unresectable.
• Options include hormonal therapy, nonsteroidal antiinflammatory agents, cytotoxic
chemotherapies (doxorubicin or carboplatin), or imatinib.
Groin pain
 SPORTS HERNIA

• Sports hernia is chronic groin pain that lasts more than 6-8 weeks in a patient who
engages in athletics or strenuous activity. The exact pathophysiology has yet to be
determined.
• Some favor a torn external oblique aponeurosis, torn conjoint tendon, without a
true fascial defect.
• Others feel a defect in the transversalis fascia that forms the posterior wall of the
inguinal canal, hence, an incipient hernia, is to be blamed.
• What is clearer is the mechanism of injury that leads to the pain. It is usually seen
in athletes engaged in sports requiring sudden turning and pelvic rotation.
• Soccer, hockey, and football players seem to be at high risk.
 DIAGNOSIS
• Patients will complain of unilateral groin pain on exertion. A specific episode
of injury that prompted the onset of pain can often be recalled.
• Most patients will have stopped playing sports or will report limitations to
their ability to play. On physical exam, there will not be a bulge.
• Patients will experience tenderness at the insertion of the rectus abdominis
at the pubic tubercle. The tenderness is more pronounced during a resisted
sit-up.
• The list of differential diagnoses for groin pain without a mass is long and
requires careful consideration.
• Luckily, most of the patients presenting with sports hernia will be
otherwise healthy and the location of the pain, exacerbating factors,
and exam findings will help to eliminate most diagnose
• When the diagnosis is not made with a careful history and physical,
imaging can be helpful.
• Ultrasound of the groin with the patient coughing or bearing down can
help to rule out a true inguinal hernia.
• MRI can evaluate for muscle or tendon tears, osteitis pubis, and stress
or avulsion fractures.
TREATMENT
• First line treatment is non-operative. Patients are asked to rest and avoid the
sport or movement that causes the pain. This may be combined with non-
steroidal anti-inflammatory medications and perhaps a short tapering course
of steroids.
• Core strengthening exercises build the ability to rotate the pelvis against
resistance. Most patients respond to non operative management.
• When the pain is felt to be related to a weakness of the transversalis fascia and
an incipient hernia, the patient may be offered surgical repair.
• Mesh reinforcement of the posterior wall of the inguinal canal can be
accomplished with a laparoscopic or an open technique.
Discuss the natural history of umbilical and inguinal
hernias in children versus adults
UMBILICAL HERNIAS IN CHILDREN:
• Failure of the umbilical ring to close results in a central defect in the linea alba.
• The resulting umbilical hernia is covered by normal umbilical skin and
subcutaneous tissue, but the fascial defect allows protrusion of abdominal
contents.
• Hernias less than a centimeter in size at the time of birth usually will close
spontaneously by 4 to 5 years of life and in most cases should not undergo
early repair.
• Sometimes the hernia is large enough that the protrusion is disfiguring and
disturbing to both the child and the family.
• In such circumstances, early repair may be advisable.
• Umbilical hernias are generally asymptomatic protrusions of the
abdominal wall.
• They are generally noted by parents or physicians shortly after birth.
• All families of patients with umbilical hernia should be counseled
about signs of incarceration, which is rare in umbilical hernias and
more common in smaller (1 cm or less) rather than larger defects.
• Incarceration presents with abdominal pain, bilious emesis, and a
tender, hard mass protruding from the umbilicus.
UMBILICAL HERNIAS IN ADULTS
• Are generally seen in clinically overweight, lifting heavy objects, or
patients with persistent cough.
• Women who have had multiple pregnancies have a higher risk of
developing an umbilical hernia.
• In adults, hernias are much more common in females
INGUINAL HERNIAS IN CHILDREN VS ADULTS:
INGUINAL HERNIAS IN CHILDREN
• Inguinal hernia results from a failure of closure of the processus
vaginalis; a finger-like projection of the peritoneum that accompanies
the testicle as it descends into the scrotum.
• Closure of the processus vaginalis normally occurs a few months prior
to birth.
• Therefore, the high incidence of inguinal hernias in premature infants.
• When the processes vaginalis remains completely patent, a
communication persists between the peritoneal cavity and the groin,
resulting in a hernia.
• Partial closure can result in entrapped fluid, which results in the presence
of a hydrocele.
• A communicating hydrocele refers to a hydrocele that is in
communication with the peritoneal cavity and can therefore be thought
of as a hernia.
• All congenital hernias in children are by definition indirect inguinal
hernias. Children also present with direct inguinal and femoral hernias.
INGUINAL HERNIAS IN ADULTS
• Inguinal hernias may be congenital or acquired.
• Most adult inguinal hernias are considered acquired defects in the abdominal wall.
• The most likely risk factor for inguinal hernia is weakness in the abdominal wall musculature;
however, there are several other risk-factors that have been studied.
• Most adult inguinal hernias are considered acquired defects in the abdominal wall.
• 12% of the patients with inguinal hernia revealed that a positive family history was associated
with an eightfold lifetime incidence of inguinal hernia.
• In adults chronic obstructive pulmonary disease can significantly increases the risk of direct
inguinal hernias, thought to be due to repeated instances of intra-abdominal pressure during
coughing.
• A protective effect of obesity can also be a risk factor.
Discuss the treatment of umbilical and
inguinal hernias in children
INGUNIAL HERNIA
• When the diagnosis of inguinal hernia is made in an otherwise normal child,
operative repair should be planned.
• Spontaneous resolution does not occur, and therefore a nonoperative approach
cannot ever be justified.
• An inguinal hernia in a female infant or child frequently contains an ovary rather
than intestine. Although the gonad usually can be reduced into the abdomen by
gentle pressure, it often prolapses in and out until surgical repair is carried out.
• In some patients, the ovary and fallopian tube constitute one wall of the hernial
sac (sliding hernia), and in these patients, the ovary can be reduced effectively
only at the time of operation. If the ovary is irreducible, prompt hernia repair is
indicated to prevent ovarian torsion or strangulation.
• Surgical repair of hernias can be performed open, laparoscopic, or
with robotic assistance.
• Surgical repair is the definitive treatment of inguinal hernias.
• The most common reason for elective repair is pain.
• Incarceration and strangulation are the primary indications for urgent
repair.
• An incarcerated hernia can be reduced and it requires light sedation.
Gentle pressure is applied on the sac from below in the direction of
the internal inguinal ring.
• Symptomatic hernias should be operated on electively, and minimally
symptomatic or asymptomatic hernias should undergo watchful
waiting.
• Repair of minimally symptomatic inguinal hernia in patients with
significant medical comorbidities surgery should be deferred and the
patient medically optimized .
• If the hernia cannot be reduced, or if evidence of strangulation is
present, emergency operation is necessary. This may require a
laparotomy and bowel resection.
TREATMENT OF INGUINAL HERNIA IN CHILDREN
• The repair of Pediatric Inguinal Hernia is done surgically by administering light
sedatives.
• This is a very challenging procedure and generally done by giving local anesthetics
to the children undergoing the operation.
• Following reduction of the incarcerated hernia, the child may be admitted for
observation, and herniorrhaphy is performed within the next 24 hours to prevent
recurrent incarceration.
• Alternatively, the child may be scheduled for surgery at the next available time
slot.
• Small incision is made in the skin crease in the groin directly over the internal
inguinal ring.
• Scarpa’s fascia is then seen and divided.
• External oblique muscle is dissected free from overlying tissue, and the location of
the external ring is confirmed.
• The external oblique aponeurosis is then opened along the direction of the external
oblique fibers over the inguinal canal.
• Undersurface of the external oblique is then cleared from surrounding tissue.
• The cremasteric fibers are separated from the cord structures and hernia sac, and
these are then elevated into the wound.
• Care is taken not to grasp the vas deferens.
• The hernia sac is then dissected up to the internal ring and doubly suture ligated.
• The distal part of the hernia sac is opened widely to drain any hydrocele fluid.
• When the hernia is very large and the patient very small, tightening of the internal
inguinal ring or even formal repair of the inguinal floor may be necessary.
• There has been quite widespread adoption of laparoscopic approach in the management
of inguinal hernias in children, especially those under the age of 2 years.
• This technique requires insufflation through the umbilicus and the placement of an
extraperitoneal suture to ligate the hernia sac.
• Proponents of this procedure emphasize the fact that no groin incision is used, so there is
a decreased chance of injuring cord structures, and that visualization of the contralateral
side is achieved immediately.
• There has been quite widespread adoption of laparoscopic approach in
the management of inguinal hernias in children, especially those under
the age of 2 years.
• This technique requires insufflation through the umbilicus and the
placement of an extraperitoneal suture to ligate the hernia sac.
• Proponents of this procedure emphasize the fact that no groin incision is
used, so there is a decreased chance of injuring cord structures, and that
visualization of the contralateral side is achieved immediately.
• The long-term results of this technique have been quite excellent.
 TREATMENT OF UMBILICAL HERNIA IN CHILDREN

• If the child is asymptomatic and treatment is governed by the size of the

defect, the age of the patient, and the concern that the child and family
have regarding the cosmetic appearance of the abdomen.
• When the defect is small and spontaneous closure is likely, most surgeons
will delay surgical correction until 5 years of age.
• If closure does not occur by this time or a younger child has a very large
or symptomatic hernia, it is reasonable to proceed to repair.
• Repair of uncomplicated umbilical hernia is performed under general
anesthesia as an outpatient procedure.
• A small curving incision that fits into the skin crease of the umbilicus is
made, and the sac is dissected free from the overlying skin.
• The fascial defect is repaired with permanent or long-lasting absorbable,
interrupted sutures that are placed in a transverse plane.
• The skin is closed using subcuticular sutures.
TREATMENT OF UMBILICAL HERNIA IN ADULTS
• Umbilical Hernia in adults is generally trated with surgical procedures like
Open hernia repir or Laproscopically.
• Sometimes watchful waiting maybe recommended due to progressive
age which sometimes may lead to devastating consequences like bowel
ischemia gangrene and perforation.
• This leads to emergency hernia repair in 40% cases in the elderly.
• Pain - Pain after inguinal hernia repair is classified into acute or chronic
manifestations of three mechanisms: nociceptive (somatic),
neuropathic, and visceral pain.
• Postherniorrhaphyinguinodynia is a debilitating chronic complication
• Cord and Testes Injury - Injury to spermatic cord structures may result
in ischemic orchitis or testicular atrophy. Ischemic orchitis is most
com- monly caused by injury to the pampiniform plexus
• Injury to the vas deferens within the cord may lead to infertility.
• Chronic scarring may lead to vas deferens obstruction, resulting in
decreased fertility rates and a dysejaculation syndrome.
Complications of transabdominal laparoscopy include urinary retention, paralytic
ileus, visceral injuries, vascular injuries, and less commonly, bowel obstruction,
hypercapnia, gas embolism, and pneumothorax.
• Urinary Retention- The most common cause of urinary retention after hernia
repair is general anesthesia, which is routine in endoscopic hernia repairs.
Other risk factors for postoperative urinary retention include pain, narcotic
analgesia, and perioperative bladder distention.
• Ileus and Bowel Obstruction- The laparoscopic transab- dominal approach is
associated with a higher incidence of ileus than other modes of repair
• Visceral Injury- Small bowel, colon, and bladder are at risk for injury in
laparoscopic hernia repair. Bladder injuries are less common than visceral
injuries.
• Vascular Injury- The most severe vascular injuries usually occur in iliac or
femoral vessels, either by misplaced sutures in anterior repairs,
endoscopic tacker use, or by trocar injury or direct dissection in
laparoscopic repairs
• The most commonly injured vessels in laparoscopic hernia repair include
the inferior epigastrics and external iliac arteries.
• The presentation of an inferior epigastric vein injury and it may result in a
significant rectus sheath hematoma.
• Hematomas may present as localized collections or as dif- fuse bruising over the
operative site. Injury to spermatic cord vessels may result in a scrotal hematoma.
• Hematomas may present as localized collections or as diffuse bruising over the
operative site. Injury to spermatic cord vessels may result in a scrotal hematoma.
• Seromas are fluid collections that most commonly develop within one week of
synthetic mesh repairs. Large hernia sac remnants may fill with physiologic fluid
and mimic seromas.
• One potentially serious risk of not fixing a hernia is that it can become trapped
outside the abdominal wall—or incarcerated. This can cut off the blood supply to
the hernia and obstruct the bowel, resulting in a strangulated hernia. This requires
urgent surgical repair.
Written Report
Discuss the anatomy involved in inguinal hernia
• The inguinal canal is an approximately 4- to 6-cm long cone shaped region situated in the
anterior portion of the pelvic basin.
• The canal begins on the posterior abdominal wall, where the spermatic cord passes through a
hiatus in the transversalis fascia also known as the deep (internal) inguinal ring.
• The canal concludes medially at the superficial (external) inguinal ring, the point at which the
spermatic cord crosses a defect in the external oblique aponeurosis.
• The boundaries of the inguinal canal are the external oblique aponeurosis anteriorly, the
internal oblique muscle laterally, the transversalis fascia and transversus abdominis muscle
posteriorly, the internal oblique and transversus abdominis muscle superiorly, and the
inguinal (Poupart’s) ligament inferiorly.
• The spermatic cord traverses the inguinal canal, and it contains three arteries, three veins,
two nerves, the pampiniform venous plexus, and the vas deferens.
• It is enveloped in three layers of spermatic fascia. Additional important structures
surrounding the inguinal canal include the iliopubic tract, the lacunar ligament, Cooper’s
ligament, and the conjoined tendon.
• The iliopubic tract is an aponeurotic band that begins at the anterior superior iliac spine and
inserts into Cooper’s ligament from above.
• It forms on the deep inferior margin of the transversus abdominis and transversalis fascia.
• The shelving edge of the inguinal ligament is a structure that
connects the iliopubic tract to the inguinal ligament.
• The iliopubic tract helps form the inferior margin of the internal
inguinal ring as it courses medially, where it continues as the
anteromedial border of the femoral canal.
• The lacunar ligament, or ligament of Gimbernat, is the triangular
fanning of the inguinal ligament as it joins the pubic tubercle.
• Cooper’s (pectineal) ligament is the lateral portion of the lacunar
ligament that is fused to the periosteum of the pubic tubercle.
• The conjoined tendon is commonly described as the fusion of the
inferior fibres of the internal oblique and transversus abdominis
aponeurosis at the point where they insert on the pubic tubercle.
• Location and orientation of the inguinal canal within the
pelvic basin:Boundaries of the canal include: transversus
abdominus and transversalis fascia posterior; internal oblique
muscle superior; external oblique aponeurosis anterior;
inguinal ligament inferior. m. = muscle.
• Ligaments that contribute to the inguinal canal include
the inguinal ligament, Cooper’s ligament, and the lacunar
ligament. Theiliopubic tract originates and inserts in a
similar fashion to the inguinal ligament, but in a deeper
position. m. = muscle
Discuss the anatomy of the abdominal wall
• Embryologically, the abdominal wall is derived from the mesoderm
and envelops the future abdominal contents as bilateral migrating
layers originating from the paravertebral area.
• The abdominal wall consists of nine distinct layers:
• Skin
• subcutaneous tissue
• superficial fascia
• external oblique muscle
• internal oblique muscles
• transversus abdominus muscle
• transversalis fascia
• preperitoneal adipose tissue
• MUSCLES OF ABOMINAL WALL
• The muscles of the abdominal wall consist of the
• rectus abdominus medially
• the external oblique, internal oblique, and transversus abdominis laterally
• Divided by the linea alba, both rectus muscles originate at the pubic
symphysis and crest and insert on the xiphoid process, the fifth and sixth ribs,
and the seventh costal cartilage.
• Three tendinous insertions cross the rectus muscle along its length. The
muscle is contained within an aponeurotic sheath formed from the fusion of
differing components of the lateral fascial layer
• Along the posterior abdominal wall are folds corresponding to underlying
vasculature and embryologic remnants.
• The median umbilical fold is formed by the obliterated urachus traveling from
the dome of the bladder to the umbilicus in the midline.
• The bilateral medial folds are formed by remnants of the umbilical arteries.
• Lastly, the lateral folds are associated with the inferior epigastric vessels
VASCULATURE
• The deep blood supply of the abdominal wall is supplied mostly from
the inferior and superior epigastric arteries.
• The superior epigastric artery is the final branch of the internal thoracic
artery.
• The abdominal wall is also supplied by branches of the subcostal and
lumbar arteries.
• Superficially, the abdominal wall subcutaneous and skin tissue is
supplied by branches of the superficial epigastric arteries, femoral
arteries, superficial external pudendal, and superficial circumflex
arteries.
• Venous drainage of the abdominal wall is variable but typically follows
the aforementioned arteries.
LYMPHATICS
• Above the umbilicus, the lymphatics of the abdominal wall drain into the
superficial axillary nodes.
• Below the umbilicus, these drain into the inguinal nodes.
• Lymphatics near the umbilicus can drain along the falciform ligament toward
the hepatic nodes

INNERVATION
• Innervation of the abdominal wall is segmental, leading to a dermatomal
sensory pattern.
• Afferent branches of the T4 to L1 nerve roots provide sensation of the
abdominal wall.
• The muscles of the abdominal wall are innervated by the efferent branches of
spinal nerves T6 to T12.
Illustrate/Draw the anatomy involved in:
• Indirect hernia
• Indirect hernias protrude lateral to the inferior
epigastric vessels, through the deep inguinal ring.
Direct hernia
• Direct hernias protrude medial to the inferior epigastric vessels,
within Hesselbach’s triangle
• The inguinal triangle (Hesselbach's triangle) is a region of the deep
part of anterior abdominal wall and defined by the following
structures:
• Medial border: Lateral margin of the rectus sheath, also called linea
semilunaris.
• Inferior border: Inguinal ligament, sometimes referred to as Poupart's
ligament.
• Femoral hernia
• Femoral hernias protrude through the small and inflexible femoral ring.
• They traverse the empty space between the femoral vein and the lymphatic channels.
• The borders of the femoral ring include the iliopubic tract and inguinal ligament anteriorly,
Cooper’s ligament posteriorly, the lacunar ligament medially, and the femoral vein laterally.
• A femoral hernia follows the tract below the inguinal ligament through the femoral canal.
• The canal lies medial to the femoral vein and lateral to the lacunar (Gimbernat) ligament.
• Because femoral hernias protrude through such a small defined space, they frequently become
incarcerated or strangulated.
• Perihernial fasciae or muscles may be malformed. Because of the position of this hernia, medial
thigh pain is possible in addition to groin pain
Incisional hernia
• Hernias that develop at sites of previous
abdominal incisions are known as
incisional hernias.
• Hernias can develop at the site of any
previous abdominal incision.
• Vertical incisions may have a higher risk
of hernia formation than transverse or
oblique incisions.
• Several patients- derived factors increase
the risk of hernia, including diabetes,
immunosuppressant use, obesity,
smoking, malnutrition, and connective
tissue disorders.
• Local operative factors may also be
implicated, including technique, wound
infection, or high tension at the time of
closure.
Spigelian hernia
• Spigelian hernia (1-2%) of all hernia is the protrusion of
preperitoneal, fat peritoneal sac, or organ through a
congenital or acquired defects in the spigelian aponeurosis
(i.e. the aponeurosis of the transverse abdominal muscle
limited by the linea semilunaris laterally and the lateral edge
of the rectus muscle medially).
• Spigelian hernia belt “a transverse 6cm wide zone above the
interspinal plane.
• Hernias that occur along the arcuate line are known as
Spigelian hernias.
• While rare, these hernias form due to the anatomic weakness
of lack of a posterior rectus sheath below the arcuate line.
• As the hernia develops, peritoneum that passes through the
arcuate line will pass laterally toward the external oblique
muscle given the overlying aponeurosis.
• Most patients present with pain and swelling in the mid to
lower abdomen.
• Incarceration is common as up to 20% of patients present with
a nonreducible hernia.
Umbilical hernia
• Maybe congenital or acquired. Umbilical hernias are common in newborns, especially in premature
infants.
• Closure of an umbilical defect occurs after birth as the muscles of the rectus abdominis grow toward
one another.
• Most umbilical hernias close spontaneously by 5 years of age and can be monitored as they will
spontaneously resolve.
• In adults, umbilical hernias form because of increased abdominal pressure due to pregnancy,
obesity, or ascites.
• Females are at higher risk for this type of hernia than men.
• Small, asymptomatic hernias may be followed clinically.
• However, if an umbilical hernia enlarges in size, causes symptoms, or incarcerates surgical treatment
should be offered.
Rectus sheath hematoma
• A rectus sheath hematoma is an accumulation of blood in
the sheath of the rectus abdominis muscle.
• It causes abdominal pain with or without a mass
Diastasis recti
• Diastasis recti is the partial or
complete separation of the
rectus abdominis, or “six-
pack” muscles, which meet at
the midline of your stomach.
• Diastasis recti is very common
during and following
pregnancy.
Cases 1
A 62-year-old male presents with a two-month history of
intermittent pain and bulging in the left inguinal region.
A reducible hernia is noted on exam.
•Salient feature: 62 Y/M
•2-month history of intermittent pain and bulge in L inguinal region
•Chief complaint - Bulging in left inguinal region

•PRIMARY IMPRESSION: INGUINAL HERNIA

•What further data should be obtained from the patient's history and physical exam?

History of present illness:

•Swelling in the left inguinal for how many months?
•Any pain over the swelling?
•Mode of onset?
•How did the swelling appear first?
•Where did the swelling appear first?
•Progress of the swelling size and extent at the time of onset?
•What happens to the swelling when the patient stands up, walks up and? when straining?
•What happens to the swelling when the patient lies down?
•Any swelling on the opposite side?
•Any period of reducibility?
•Any discharge?
•Any history of constipation or diarrhea?
•Any history of trauma?
•Heavy exerciser?
•Any associated symptoms like fever?
Past medical history
•Any previous surgeries or any other same condition

Social history
•Smoker?
•Alcoholic?

Family history
•Hernia or carcinoma or hydrocele in any other family members
PHYSICAL EXAMINATION:
i.The patient should be examined in a standing position to increase intra-abdominal pressure, with
the groin and scrotum fully exposed.
ii.Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within
the scrotum.
iii.If an obvious bulge is not detected, palpation is performed to confirm the presence of the hernia
iv.Palpation is performed by advancing the index finger through the scrotum towards the external
inguinal ring
v.The patient is then asked to perform a Valsalva maneuver to increase intraabdominal pressure.
These maneuvers will reveal an abnormal bulge and allow the clinician to determine whether the
hernia is reducible or not.
vi.Examination of the contralateral side affords the clinician the opportunity to compare the presence
and extent of herniation between sides.
vii.The inguinal occlusion test entails the examiner blocking the internal inguinal ring with a finger as
the patient is instructed to cough.
viii.A controlled impulse suggests an indirect hernia, while persistent herniation suggests a direct
hernia.
ix.Transmission of the cough impulse to the tip of the finger implies an indirect hernia, while an
impulse palpated on the dorsum of the finger implies a direct hernia.
x. When results of physical examination are compared against operative findings, there is a
probability somewhat higher than chance (i.e., 50%) of correctly diagnosing the type of hernia.
•What are the management options?
•They are three types of hernia repair.
•Open hernia repair:
●The most commonly performed type of hernia operation still remains the open inguinal hernia
repair.
●These repairs can be performed tension-free with mesh or by reconstruction of the floor with
tissue.
●Tissue repairs are less common and are primarily indicated in infected fields.
●The incision begins two fingerbreadths inferior and medial to the anterior superior iliac spine.
●It is then extended medially for approximately 6 to 8 cm.
•Laparoscopic hernia repair:
●Laparoscopic inguinal hernia repairs have increasingly popular given the noninferiority
studies, improved aesthetics, and increased surgeon experience with the procedure.
●The surgeons make the small cut in the lower abdomen & insert the laparoscope.
Robotic hernia repair:
Robotic platform to hernia repair has been adapted by general surgeons.
The endowrist capabilities provides greatly improved manual dexterity and a relatively short
learning curve.
Though both total extra peritoneal repair and trans abdominal preperitoneal repair can be
adapted to a robotic platform, the latter has gained more traction among surgeons.
Robotic hernia is used in small or weak areas. It can also be used to reconstruct the wall.
•What are the risks of operative and non-operative management?
•The most common complications of inguinal hernia repair include bleeding, infection,
seroma, urinary retention, ileus, and injury to adjacent structures.
•Complications specific to herniorrhaphy include hernia recurrence, chronic inguinal and
pubic pain, and injury to the spermatic cord or testis.
•Hernia Recurrence
●When a patient develops pain, bulging, or a mass at the site of an inguinal hernia
repair, clinical entities such as seroma, persistent cord lipoma, and hernia recurrence
should be considered.
●Common medical issues associated with recurrence include malnutrition,
immunosuppression, diabetes, steroid use, and smoking.
•Pain
●Pain after inguinal hernia repair is classified into acute or chronic manifestations of
three mechanisms: nociceptive (somatic), neuropathic, and visceral pain.
•Post herniorrhaphy inguinodynia is a debilitating chronic complication
•Cord and Testes Injury
Injury to spermatic cord structures may result in ischemic orchitis or testicular atrophy.
Ischemic orchitis is most commonly caused by injury to the pampiniform plexus
•Injury to the vas deferens within the cord may lead to infertility.
•Chronic scarring may lead to vas deferens obstruction, resulting in decreased fertility rates and a
dysejaculation syndrome.
Complications of transabdominal laparoscopy include urinary retention, paralytic ileus, visceral
injuries, vascular injuries, and less commonly, bowel obstruction, hypercapnia, gas embolism, and
pneumothorax.
•Urinary Retention-
●The most common cause of urinary retention after hernia repair is general anesthesia, which
is routine in endoscopic hernia repairs.
●Other risk factors for postoperative urinary retention include pain, narcotic analgesia, and
perioperative bladder distention.
•Ileus and Bowel Obstruction-
●The laparoscopic transabdominal approach is associated with a higher incidence of ileus than
other modes of repair
•Visceral Injury-
●Small bowel, colon, and bladder are at risk for injury in laparoscopic hernia repair. Bladder
injuries are less common than visceral injuries.
•Vascular Injury-
●The most severe vascular injuries usually occur in iliac or femoral vessels, either by
misplaced sutures in anterior repairs, endoscopic tacker use, or by trocar injury or direct
dissection in laparoscopic repairs
●The most commonly injured vessels in laparoscopic hernia repair include the inferior
epigastric and external iliac arteries.
●The presentation of an inferior epigastric vein injury and it may result in a significant rectus
sheath hematoma.
•Hematomas
●may present as localized collections or as diffuse bruising over the operative
site. Injury to spermatic cord vessels may result in a scrotal hematoma.
•Seromas
●are fluid collections that most commonly develop within one week of synthetic
mesh repairs.
•One potentially serious risk of not fixing a hernia is that it can become trapped
outside the abdominal wall—or incarcerated.
●Large hernia sac remnants may fill with physiologic fluid and mimic seromas.
•This can cut off the blood supply to the hernia and obstruct the bowel, resulting in a
strangulated hernia. This requires urgent surgical repair.
•What is the usual postoperative course and physical findings?
•A prescription for pain medication is given to upon discharge
•Light diet the first 24 hours after surgery resume regular (light) daily activities
beginning the next day
•Refrain from any heavy lifting or straining until approved by the doctor.
•Follow up appointment with doctor 2-3 weeks after procedure.
•Diet: patient should follow a light diet the first 24 hours after surgery, such as
soup, crackers, pudding, etc.
•Resume normal diet the day after surgery.
CASE 2: An elderly woman is on warfarin for a history of atrial fibrillation. Two
days ago, she fell in her kitchen and struck her abdomen on a chair. Since then,
she has noticed a painful bulge on the right side of her abdomen. It has gradually
grown bigger. She denies any other complaints. On exam, she has a tender, firm
mass on the right side of the umbilicus. It does not change with standing or lying
down and cannot be reduced.
DIFFERENTIAL DIAGNOSES RULE IN RULE OUT

cause a firm, irregular mass (-) pain cannot be reduced

LIVER ENLARGEMENT ( below the right rib cage, or
HEPATOMEGALY) on the left side in the
stomach

(urinary bladder over-filled firm mass on the right side

BLADDER DISTENTION with fluid) can cause a firm of the umbilicus
mass in the center of the
lower abdomen above the
pelvic bones, in extreme
cases it can reach as far up
as the navel.
Can cause a mass that is Painful bulge on the right
DIVERTICULITIS usually located in the left- side of her abdomen
lower quadrant.

An abdominal lump is a Cannot be ruled out

ABDOMINAL LUMP swelling or bulge that
(HERNIA) emerges from any area of
the abdomen. It most often
feels soft, but it may be
What diagnostics or imaging would you request to confirm your
diagnosis?
•Abdominal X-ray
•Ultrasound
•MRI
•CT

How will you manage this patient based on your primary impression?

•Surgical repair is the definitive treatment of inguinal hernias. The most

common reason for elective repair is pain.
•Incarceration and strangulation are the primary indications for urgent
repair.
•Symptomatic hernias should be operated on electively, and minimally
symptomatic or asymptomatic hernias should undergo watchful waiting.
CASE 3: A 6- year old female presents with swelling at the umbilicus. The parents
state that this has been present since birth. The patient has no other symptoms.
Physical examination is normal with the exception of a protrusion at the umbilicus
which is reducible with a defect of approximately 1.5 cm at the fascia.
•What is your primary impression? Why?
•Our primary impression is UMBILICAL HERNIA
•This is a case of acquired umbilical hernia which is common in newborns,
especially in premature infants.
•Most umbilical hernias close spontaneously by 5 years of age and can be
monitored as they will spontaneously resolve.
•Females are at higher risk for this type of hernia than men.

•What diagnostics or imaging would you request to confirm your diagnosis?

•Umbilical hernia is diagnosed during a physical exam.
•Sometimes imaging studies such as an abdominal ultrasound or a CT scan are
used to screen for complications.
(CT and MRI provide static images that are able to delineate anatomy, to detect
hernia, and to exclude potentially confounding diagnoses.

•How will you manage this patient based on your primary impression?
•Surgical repair is the best recommendation management for this patient. An
elective procedure is the best choice.
•Umbilical hernias in children will close by their own mostly. But in this patient, it's
not closed even at the age of 6, then it should be repaired by operation.
CASE 4: A 22-year-old female presents to the office with a pea-sized protrusion in
the midline of the abdomen approximately 5 cm above the umbilicus. The patient
initially had pain at the time of presentation, but now just notices that the mass is
still present. She has no other symptoms. Her examination is consistent with the
history with a 5mm non-reducible mass present at the midline, non-tender with no
skin changes.
DIFFERENTIAL DIAGNOSIS RULE IN RULE OUT

Protrusion above
umbilicus at midline
EPIGASTRIC HERNIA

Pea sized protrusion Painful

LYMPHADENOPATHY Non reducible mass

Protrusion in the midline No prior history of surgery

INCISIONAL HERNIA Non reducible mass No redness

No pain
Protrusion in the midline Severe pain

UMBILICAL HERNIA Non reducible mass Fever

Constipation
•What diagnostics or imaging would you request to confirm your diagnosis?
•Abdominal ultrasound
•Ct scan

•How will you manage this patient based on your primary impression?
•Primary impression: Epigastric hernia
•Surgical management includes either primary tissue or mesh repairs
•Laparoscopic or open approach
CASE 5: A 26-year-old male presents with persistent pain in the left groin area. This has
not been associated with any bulging, emesis, constipation, or other abdominal pain.
The patient has recently joined an adult hockey league and has played weekly for the
last several months, but has avoided playing for the last 2 weeks. The pain improves
with ibuprofen. There is tenderness on palpation of the rectus muscle at the pubic
tubercle.
 DDX Rule in Rule out

Sports hernia Groin pain, persistent pain,

left groin, sports injury,
pubic tubercle tenderness

Osteitis pubis persistent Pelvic pain, Pain extending to inner

most common in athletes thigh or lower abdomen,
Clicking in the front of the
pelvis.

Age between 30-50

Inguinal hernia Groin pain, persistent, bulge in the area on either
side of your pubic bone,
emesis, constipation,
abdominal pain
 DDX Rule in Rule out

Epididymitis persistent groin pain swollen, red or warm

scrotum, Testicle pain and
tenderness, Discharge
from the penis

UTI Pelvic pain, persistent Dysuria, abnormal urine

pain color, increase urination
frequency, fever, vomit

Avulsion fracture of groin persistent Pelvic pain, pain, weakness, altered

most common in gait, and point tenderness
adolescent athletes

Testicular Torsion Swelling in the groin area Nausea

vomiting
B. What diagnostics or imaging would you request to confirm your
diagnosis?
1.Ultrasound
2.X ray
3.CT scan

C. How will you manage this patient based on your primary impression?
•Management should consist of rest, avoidance of sports, and nonsteroidal anti-
inflammatory medications)
•Hernias related to sports usually responds to the rest and non-operative therapy
•Patient should be advised to avoid any strenuous activity or practice for their
respective sport as well as to avoid using unnecessary pain medications.
•Surgery should be done if patient does not respond to non-operative therapy.
CASE 6: A 30-year-old male presents with a mass gradually enlarging at one of the
port sites from his laparoscopic colon resection for familial polyposis. This is not
painful and he has noticed the mass over the last year. On examination, there is a
firm 1.5 cm mass present at the port site which was not appreciated at an
examination a year ago. The best initial therapy for this lesion is:
 DDX RULE IN RULE OUT

Weight loss, Leukemia or to see if

anemia is present
LYMPHOMA Fatigue

Swollen abdomen

Chest pain or cough

Pain, swelling, redness and Inguinal soft tissues, low
disfiguring bruises, BP and increasing heart
HEMATOMA
confusion, seizures. rate

Swelling of the scrotum Testicle to contract

TESTICULAR TORSION Abdominal pain

Nausea and vomiting

Wound infection after the Cannot be ruled out
sx
INCISIONAL HERNIA
Swelling

Lump in the abdomen

•What diagnostics or imaging would you request to confirm your diagnosis?
•CT scan of abdomen and pelvis
•Though the diagnosis of this patient can be made only through biopsy, the margin
of the tumor should be recognized for the biopsy.
•Since biopsy is not yet done, placing the patient on chemo would be a bad
management. So, CT scan would be beneficial.

•How will you manage this patient based on your primary impression?
•Primary impression: INCISIONAL HERNIA
•Most injuries and bruises can be treated with resting, icing, compression, and
elevating the area.
•These measures usually help to reduce inflammation and diminish its symptoms
•Chemotherapy uses drugs to destroy fast-growing cells, such as cancer cells.
•Radiation therapy.
•Surgery is performed as quickly as possible to restore blood flow
CASE 7: 4-month-old male is sent for evaluation after presenting to the pediatrician
with a bulge in the right groin which was not reducible. The patient was transported
by car and fell asleep during the drive. By the time of evaluation, the mass has
disappeared. The child is otherwise healthy and has no abdominal distension. When
he cries, a mass appears in the right groin and extends to the scrotum but reduces
with gentle compression. Both testicles are descended and in normal position.
The next step in the management of this patient is:
REPAIR OF RIGHT INGUINAL HERNIA
•Both the testicles are descended and in Normal position So there is no need of
Emergent operative repair.
•By the time of evaluation is given so there is no need to do Ultrasound of
Abdomen.
•Right inguinal hernia is the bulge in the area on either side of your pubic bone,
which becomes more obvious when you're upright, especially if u cough or strain.
•Sometimes the hernia will be visible only when an infant is crying, coughing or
straining during a bowel movement
•Recommend surgery to fix an inguinal hernia that's painful or enlarging.
•Orchiopexy should not be performed before 6 months of age, as testes may
descend spontaneously during the first few months of life. The highest quality
evidence recommends orchiopexy between 6 and 12 months of age.
CASE 8: A 50-year-old woman presents with pain in the upper thigh and swelling in
this area. The patient notes that the swelling has gotten worse and the area is painful
to touch. The patient has also developed nausea and emesis over the last few days.
On examination, there is a mass near the femoral vessels with tenderness and
overlying erythema. The mass cannot be reduced. A radiograph of the abdomen
demonstrates dilated intestine.
The most likely diagnosis is FEMORAL HERNIA.
•Symptoms of a femoral hernia include a lump in the groin or inner thigh and groin
discomfort. It may cause stomach pain and vomiting in severe cases.
•Large hernias may be more noticeable and can cause some discomfort. A bulge
may be visible in the groin area near your upper thigh.
•The bulging may become worse and can cause pain when you stand up, lift
heavy objects, or strain in any way.
•A femoral hernia results from internal tissues pushing through a weak point in the
muscle wall, near the groin or inner thigh.
 DDX RULE IN RULE OUT

LIPOSARCOMA Occurs in legs and arms mass near the femoral

vessels
Pain of the mass

Nausea

swelling fever

ENLARGED LYMPH Pain Other respiratory

NODE problems

Most common in neck,

underarm
swelling discoloration from blood

HEMATOMA Pain Under skin

Fracture of thigh bone

•How will you manage this patient?
•In adults, femoral hernias that enlarge, cause symptoms, or become
incarcerated are treated surgically.
•Recovery time varies depending on the size of the hernia, the technique used,
and the age and health of the patient.
•The two main types of surgery for hernias are as follows:
i.Open Hernia Repair
■In open hernia repair, also called herniorrhaphy, a person is given
local anesthesia in the abdomen or spine to numb the area, general
anesthesia, or a combination of the two.
■The surgeon makes an incision in the groin, moves the hernia
back into the abdomen.
Repair is either performed by suturing the inguinal ligament to the pectineal
ligament using strong non-absorbable
 i.Laparoscopic Femoral Hernia Repair
•Laparoscopic surgery is a minimally invasive procedure performed using general
anesthesia.
■The surgeon makes several small incisions in the lower abdomen
and inserts a laparoscope-a thin tube with a tiny video camera
attached to one end. The camera sends a magnified image from
inside the body to a monitor, giving the surgeon a close-up view of
the hernia and surrounding tissue. While viewing the monitor, the
surgeon uses instruments to carefully repair the hernia using
synthetic mesh.
•People who undergo laparoscopic surgery generally experience a somewhat
shorter recovery time. However, the doctor may determine laparoscopic surgery is
not the best option if the hernia is very large or the person has had pelvic surgery.
THANK YOU