Chapter 5

Hernias
Hernias
Definition
The protrusion of a viscus or part of a viscus, through its containing wall.
Inguinal hernia
The hernial sac emerges superior and medial to the pubic tubercle.
. It is the most common groin hernia in both males and females.
. There is a male to female predominance of approximately 5:1 in infants;
10:1 in adults in the UK.
. It is more common on the right than the left side at all ages (ratio 5:4).
. The incidence of strangulation is estimated to be between 0.3%and 3%per
year.
1
. It is classified as indirect or direct depending on the relationship of the
hernial sac to the inferior epigastric artery.
Indirect inguinal hernia
The hernial sac passes lateral to the inferior epigastric artery through the deep
ring of the inguinal canal:
. it accounts for virtually all groin hernias in infants (incidence approx-
imately 2%)
. it is twice as common as direct hernias in adults (occurs most frequently in
younger men)
. it occurs as frequently as femoral hernias in women
. it commonly extends into the scrotum (inguinoscrotal hernia)
. the incidence of strangulation is at least 10 times higher than for a direct
inguinal hernia.
Risk factors
Prematurity, twins, low birth weight, ethnicity (higher incidence in patients of
African origin).
86 Hernias
1 Royal College of Surgeons (1993) Clinical Guidelines for the Management of
Groin Hernia in Adults. Report of a working party convened by the Royal College of
Surgeons of England. London: Royal College of Surgeons.
Pathogenesis
Congenital. The sac is the remains of part or all of the processus vaginalis. In
infants all inguinal hernias result from intrauterine failure of the processus
vaginalis toclose. Inadults, a patent processus vaginalis opens under the stress of
raised intra-abdominal pressure (saccular theory of Russell).
Direct inguinal hernia
The hernial sac passes medial to the inferior epigastric artery through a defect in
the posterior wall of the inguinal canal:
. it occurs most frequently in older males
. it is exceptionally rare in women
. it rarely extends into the scrotum.
Risk factors
Smoking, chronic obstructive pulmonary disease (COPD), aortic aneurysm,
connective tissue disease.
Pathogenesis
It is thought to occur because of an acquired weakness in the posterior abdomi-
nal wall. The hernial sac passes directly forward througha defect in the posterior
wall of the inguinal canal.
Femoral hernia
The hernial sac emerges through the femoral canal and therefore passes inferior
and lateral to the pubic tubercle.
. Incidence increases with age (uncommon before 50 years).
. There is a female to male predominance of 2.5:1 in the UK.
. It is more common on the right than the left side at all ages (ratio 5:4).
. The sac may emerge from the femoral sheath through the fossa ovalis and
extend in any direction.
. It is the most common site for Richters hernia (see page 92).
. The incidence of strangulation is approximately 10 times higher than for
inguinal hernias.
2
Hernias 87
2 Gallegos NC, Dawson J, Jarvis Mand Hobsley M(1991) Risk of strangulation in
groin hernias. Br J Surg 78: 11713.
Risk factors
Multiparity, weight loss, previous inguinal hernia repair.
Pathogenesis
An acquired downward extension of peritoneum through the femoral canal.
This process is thought to occur due to stretching of the femoral canal by events
that raise intra-abdominal pressure, such as pregnancy and obesity. Further-
more, anatomical differences in the female pelvis may partly explain the increased
incidence of femoral hernias in women.
Differential diagnosis of a lump in the groin
. Inguinal hernia
. Femoral hernia
. Hydrocele of the cord or canal of Nuck: smooth, oval, transilluminates
. Lipoma of the cord: soft and lobulated with no cough impulse
. Undescended testis: always examine the scrotum and its contents
. Inguinal lymphadenopathy: often multiple and present both laterally and
medially to femoral vessels
. Saphenous varix: easily emptied by pressure or on lying supine. There is a
demonstrable thrill on coughing. May be bluish in appearance
. Ileofemoral aneurysm: expansile mass +/ bruit
. Psoas abscess: usually points lateral to the femoral vessels
. Lipoma of the fat in the femoral canal: difficult to differentiate clinically
from a femoral hernia.
Umbilical hernia
. It is common in neonates/infants but most resolve spontaneously
. Incidence in adults increases with age (uncommon before 40 years)
. There is equal incidence in males and females
. It is often irreducible.
Risk factors
Ethnicity (neonatal/infant hernia more common in black people), multiparity,
obesity, intra-abdominal malignancy, ascites, and continuous ambulatory peri-
toneal dialysis.
88 Hernias
Pathogenesis
Neonatal/infantile hernias are congenital and result from failure of closure of
the umbilical cicatrix. The hernial sac protrudes through this defect into the
subcutaneous tissues. Adult hernias are acquired and are a consequence of
increased intra-abdominal pressure upon the umbilical cicatrix, which stretches
and bulges outwards.
Incisional hernia
. Common; it may complicate up to 11% of abdominal wounds after
10 years
3
. There is equal incidence in males and females
. It occurs most commonly in lower midline abdominal incisions but can
occur at the site of any incision.
Risk factors
Poor surgical technique (incorrectly placed incision, inadequate wound closure,
haematoma, necrosis, sepsis), placing drains or stomas through wounds, age,
diabetes, jaundice, renal failure, obesity, malignancy, gross abdominal disten-
sion (obstruction, ascites).
Pathogenesis
Acquired weakness in the abdominal wall as a result of a surgical or accidental
wound. The hernial sac protrudes throughthe scar. Incisional hernias represent a
partial wounddehiscence where the deeplayers of the abdominal wall separate, but
the skin remains intact.
Complications of hernias
. Incarceration: contents of the hernia become stuck and cannot be reduced
. Obstruction
. Strangulation
Hernias 89
3 Mudge Mand Hughes LE(1985) Incisional hernia: a 10-year prospective study of
incidence and attitudes. Br J Surg 72: 701.
. Reductionenmasse: the hernial sac andits contents are reducedthroughthe
abdominal wall defect en masse. The contents remain compromised as they
continue to be constricted by the neck of the sac
. Spontaneous rupture of the hernial sac (particularly incisional hernia)
. Traumatic rupture of the hernia following blunt trauma when the hernia
is out.
90 Hernias
Special types of hernias
Simple strangulated hernia
The blood supply to the bowel inside the hernial sac is compromised (see
Figure 5.1).
Sliding hernia
This is a type of indirect inguinal hernia inwhichthe wall of the viscus forms part
of the wall of the hernial sac. On the right side the caecum is most commonly
involved, on the left the sigmoid colon (see Figure 5.2).
Special types of hernias 91
Figure 5.1 Simple strangulated hernia.
Figure 5.2 Sliding hernia.
Maydls (W loop) hernia
There are two loops of bowel in the sac. The bowel inside the abdomen (and
therefore outside the sac) is strangulated (see Figure 5.3).
Richters hernia
Aknuckle of bowel is caught in the sac (and may be strangulated), but there is no
obstruction (see Figure 5.4).
Littres hernia
This occurs when a Meckels diverticulum is caught in an inguinal hernial sac.
92 Special types of hernias
Figure 5.3 Maydls hernia.
Figure 5.4 Richters hernia.
Incarcerated/strangulated hernia
Pathogenesis
The contents of the hernia become stuck within the hernial sac. The constricting
agent is usually the neck of the sac which is often fibrosed and rigid where it
traverses the defect in the abdominal wall. If the hernia contains bowel, the
lumen may become obstructed by the neck of the hernial sac. Strangulation
occurs when the blood supply to the hernial contents is compromised causing
ischaemia and necrosis.
Symptoms
. Pain is usually the presenting symptom; typically there is a constant ache at
the site of the hernia that may be worse on movement. Severe painoccurs on
initial appearance of the hernia, or if the hernia is strangulated
. A new swelling in the groin or elsewhere in the abdominal wall may have
been noticed
. Patients with an existing hernia may complain that it is stuck
. Abdominal distension with absolute constipation and/or vomiting (sug-
gesting obstruction).
Signs
. Palpation of the hernia or hernial orifice may be painful
. Cough impulse may be absent
. The hernia may be irreducible
. Erythema of the overlying skin suggests strangulation
. Abdominal distension and tinkling bowel sounds suggest bowel obstruction.
Investigations
. Blood tests: a raised WCC may suggest that the hernial contents are
strangulated. CRP may also be elevated
. AXR: may showa knuckle of bowel at the site of the hernial orifice. Dilated
loops of bowel will be evident if there is an obstruction
. USS: consider if there is diagnostic uncertainty.
4
Incarcerated/strangulated hernia 93
4 USS has a sensitivity and specificity of approximately 90%and 80%respectively
for inguinal hernias. See Van den Berg JC, de Valois JC, Go PM and Rosenbusch G
(1999) Detection of groin hernia with physical examination, ultrasound, and MRI
compared with laparoscopic findings. Invest Radiol 34: 73943.
Treatment
. Admit
. Nil by mouth (NBM)
. Analgesia
. Fluid resuscitation
. If there is evidence of intestinal obstruction pass a nasogastric tube and
urinary catheter
. Accurate record of fluid balance must be kept
. If you suspect the hernia contains compromised bowel start empirical
antibiotics (cefuroxime and metronidazole)
. Prepare the patient for theatre.
5
Surgery will involve reduction of the
hernial contents, resection of any strangulated bowel, and repair of the
defect.
6
94 Incarcerated/strangulated hernia
5 If the hernia is incarcerated and there is no evidence the contents are com-
promised, a gentle attempt at manual reduction can be made. The patient should be
observed overnight following reduction in case of complications. With groin hernias,
when manual reduction is unsuccessful, lying the patient supine with the foot end of
the bed elevated 30408 may promote spontaneous reduction.
6 Meshcanbe usedif there is minimal contamination. See Wysocki A, PozniczekM,
Krzywon J and Bolt L (2001) Use of polypropylene prostheses for strangulated
inguinal and incisional hernias. Hernia 5: 1056.