Abdominal Wall Hernia

Objectives
■ Understand the term hernia
■ Basic anatomical knowledge
■ Clinical features of common hernia
■ Complications of hernias
■ Examination of a hernia
■ Differential diagnoses of a lump in the groin
■ Management of hernia
 Hernia

A protrusion of an organ or tissue outside its normal compartment

 Common External Hernias

■ ABDOMINAL WALL & GROIN

◆ Midline
• Umbilical
• Para- umbilical
• Epigastric
◆ Inguinal
• Direct/ Indirect/ Combined
◆ Femoral
◆ Incisional
Common Presentations
• A lump
• Comes and goes
• Appears on straining /coughing
• A pain
• Dragging pain/ Pain on exertion
• Incidental finding on examination/ imaging
• Presenting as a complication
• Incarceration/ Intestinal obstruction
Inguinal Hernia
• Commonest external hernia
• Male preponderance
• Infant / adult
• Direct / indirect / combined
• Weakness / increased pressure
• Cause pain / discomfort
• Carry risk of complications
• Treated surgically
Inguinal Hernia - History

OBJECTIVES
• Establish differential diagnoses
• Identify risk factors and significant co-morbid pathologies
• (e.g. increased intra-abdominal pressure due to ascites or chronic
airways disease).
Inguinal Hernia - History
• Onset
• Duration
• Symptoms
• Other hernia(e)
• Irreducibility
• Gastrointestinal system
• Respiratory system
• Surgery / anaesthesia
Inguinal Hernia - Examination
• Surface markings
• Anterior superior iliac spine
• Pubic tubercle
• Midpoint of inguinal ligament
Inguinal Hernia - Examination
OBJECTIVES
• Confirm diagnoses
• Out rule differentials
• Establish type
• Determine contents
• Reducibility
• Identify comorbid pathologies
Direct vs. Indirect

Direct Indirect
• Post wall • Deep ring
• Less common • 70%
• Older • Congenital
• Smaller • Scrotal
• Hasselbach • Deep ring
• Medial • Lateral
• Lower risk • Strangulate
Inguinal Hernia
• Examination
• Standing / Lying Supine
• Cough impulse
• Reducibility
• Contents
• Bowel sounds
• Scrotal contents
Differential

• Direct/Indirect/Combined
• Femoral hernia
• Hydrocele
• Lipoma
• Lymph node
• Testicular tumour
• Saphenous varix
Inguinal Anatomy

• The inguinal canal represents the oblique passage through

the anterior abdominal wall of the vas deferens (round
ligament)

• It is 5cm long and lies directly above the medial half of the
inguinal ligament
Inguinal Anatomy
• Floor:
• Transversalis fascia
• Medially the conjoint tendon
• Roof:
• External oblique aponeurosis
• Laterally the conjoint tendon
• Skin and superficial fascia
• Above:
• Conjoint tendon
• Below:
• The inguinal ligament
Inguinal Anatomy

• Three nerves:
• Ilio-inguinal (on not in)
• Sympathetic fibers
• Genitofemoral
• Three layers of fascia:
• Internal spermatic (transversalis f.)
• Cremasteric (conjoint tendon)
• External spermatic (ext. oblique)
Inguinal Anatomy

• Three arteries:
• Testicular (from the aorta)
• Artery of the vas (external iliac)
• Cremasteric (inferior epigastric)
• Three other structures:
• The vas deferens
• The pampiniform plexus of veins
• Lymphatics (to aortic nodes)
TESTIS CORD STRUCTURES
Inguinal Anatomy
Hernia Anatomy
Indirect Hernia
Direct Inguinal Hernia
Hernia Complications

• Incarceration

• Strangulation

• Intestinal obstruction
Varieties of Hernias
• Maydls
• W loop of intestine
• Richters
• Partial inclusion of intestinal wall
• Sliding hernia
• Bladder
• Sigmoid colon/ appendix
Richters’ Hernia
Maydls’ Hernia
Hernia Management
• Investigations
• None required for routine uncomplicated case
• Plain X-ray for suspected bowel obstruction
• Ultrasound in case of diagnostic uncertainty
• Herniogram rarely used
• Routine pre-op investigations
Hernia Treatment
• Surgery
• To relieve symptoms
• To prevent complications
• Operations
• Open hernia repair
• Laparoscopic hernia repair
• Pre-peritoneal
• Intra- abdominal
Open Hernia Repair
• Day-case surgery
• Anaesthesia
• General
• Local
• Operations
• Tension free Mesh repair (Lichtenstien)
• Darn repairs (Shouldice, Bassini)
Open Hernia Repair
• Incision above medial half of inguinal ligament
• External oblique opened from external ring to expose the cord and
overlying ilioinguinal nerve
• Internal (deep) ring exposed
• Hernial sac identified and reduced
• Prolene mesh inserted to reinforce posterior wall and deep ring
Open Hernia Repair
Open Hernia Repair
Open Hernia Repair
Open Hernia Repair
Open Hernia Repair
Laparoscopic Repair
Laparoscopic Repair
Laparoscopic Repair
Surgery Complications
• Trauma
• Nerve
• Artery (testicular atrophy)
• Intestine
• Haemorrhage
• Haematoma (infection)
• Infection
• Wound infection
• Chest Infection
Femoral Hernia
• Herniation through femoral canal
• Appears below and lateral to pubic tubercle
• Relatively uncommon
• Commoner in females
• Contains omentum or small intestine
• High risk of strangulation
• Repaired surgically
Femoral Hernia
Femoral Hernia Repair
Summary

• Inguinal hernia is the commonest external hernia

• Indirect hernias have a higher risk of strangulation
• Hernias are treated by surgery, to relieve symptoms and
prevent complications
• Femoral hernias have a high risk of strangulation
Recommended Reading

• Ellis H. Clinical Anatomy

• www.vesalius.com
TERIMA KASIH