ABDOMINAL HERNIAS

Dr. Ali Marzok

Fasciae of the abdominal wall
There is no deep fascia over the trunk, only the superficial fascia.
In the lower abdomen, forms a superficial fatty layer (of Camper) and a deeper fibrous layer (of
Scarpa). The fatty layer is continuous with the superficial fat of the rest of the body, but the
fibrous layer blends with the deep fascia of the upper thigh, extends into the penis and scrotum
(or labia majora), and into the perineum as Colles’ fascia.
Nerve supply
The segmental nerve supply of the abdominal muscles and the overlying skin is derived from T7
to L1.
The muscles of the anterior abdominal wall
The rectus abdominis: arises on horizontal line from the 5th, 6th and 7th costal cartilages and is
inserted into the crest of the pubis. At the tip of the xiphoid, at the umbilicus and half-way
between, are three constant transverse tendinous intersections; and here they adhere to the
anterior rectus sheath.
The sheath in which the rectus lies is formed, to a large extent, by the aponeurotic expansions
of the lateral abdominal muscles
(a)Above the costal margin, the anterior sheath comprises external oblique aponeurosis only.
(b)From the costal margin to a point half-way between umbilicus and pubis, the external
oblique and the anterior part of the internal oblique aponeurosis form the anterior sheath.
(c)Below a point half-way between umbilicus and pubis, all the aponeuroses pass in front of the
rectus so that the anterior sheath here comprises the tendinous expansions of all three oblique
muscles blended together.
The arcuate line of Douglas, is the lower border of the posterior aponeurotic part of the rectus
sheath. At this point the inferior epigastric artery and vein (from the external iliac vessels) enter
the sheath, pass upwards and anastomose with the superior epigastric vessels which are
terminal branches of the internal thoracic artery and vein.
The rectus sheaths fuse in the midline to form the linea alba stretching from the xiphoid to the
pubic symphysis.

The lateral muscles of the abdominal wall comprise the external and internal oblique and the
transverse muscles. Their neurovascular bundles running between the second and third layer.
The obliquus externus abdominis (external oblique) arises from the outer surfaces of the
lower eight ribs and fans out into the xiphoid, linea alba, the pubic crest, pubic tubercle and
the anterior half of the iliac crest.
From the pubic tubercle to the anterior superior iliac spine its lower border forms the
aponeurotic inguinal ligament.

The obliquus internus abdominis (internal oblique) arises from the lumbar fascia, the anterior
two-thirds of the iliac crest and the lateral two-thirds of the inguinal ligament. It is inserted into
the lowest six costal cartilages, linea alba and the pubic crest.

The transversus abdominis arises from the lowest six costal cartilages, the lumbar fascia, the
anterior two thirds of the iliac crest and the lateral one-third of the inguinal ligament; it is
inserted into the linea alba and the pubic crest.
Note that the external oblique passes downwards and forwards, the internal oblique upwards
and forwards and the transversus transversely.
 ABDOMINAL HERNIA
Is the bulging of part of the contents of the abdominal cavity
through a weakness in the abdominal wall.

Anatomical causes of abdominal wall herniation:

1. Basic design weakness: Lumbar triangles and post. wall of inguinal canal.
2. Weakness due to structures entering and leaving abdomen: Testicular descend
through inguinal canal at birth, esophagus ( hiatus hernia ), femoral veins ( femoral
hernia ), obturator nerve ( obturator hernia ).
3. Developmental failures: Indirect inguinal hernia ( failure of processus vaginalis to
close ), failure of muscles to form strong unions during development ( diaphragmatic,
umbilical, and epigastric hernias ).
4. Genetic weakness of collagen: HGF, and Calcitonin gene- related peptide influence the
closure of processus.
5. Trauma ( sharp and blunt ): Surgical trauma is the most common.
6. Primary muscle and neurological diseases: As muscle wall hematoma.
7. Ageing and pregnancy.
8. Excessive intra- abdominal pressure.
 Abdominal wall hernia has 2 essential components:
* Defect in the wall:
1. Muscular; As in incisional hernia.
2. Fascia; Epigastric hernia.
3. Bony component; As with femoral hernia.
The small defects with rigid wall can trap the content and prevent it from free
movement in and out of the defect.

* Content:
-Extra peritoneal tissue ( as fat in the epigastric hernia, or bladder in direct inguinal
hernia).
-Peritoneum ( which may contain omentum and bowel ).

Types of hernia by complexity:

1. Occult: not detectable clinically; may cause severe pain.
2. Reducible: a swelling which appears and disappears.
3. Irreducible: can not be reduced into the abdominal wall, high risk.
4. Strangulated: painful swelling with vascular compromise. Requires urgent surgery.
5. Infarcted: contents become gangrenous, high mortality.
History:
. Self diagnosis: is common, lump in the abdominal wall.
. Painless, aching/ heavy feeling.
. Severe pain suggests high risk of strangulation.
. Primary/ recurrent hernia after a previous surgery.
. General questions; anticoagulant intake, cardiac or respiratory problems.

Examination:
Patient should lie down at first, then stand during examination.
We may ask the patient to cough if no hernia is apparent during lying down.
Inspection: Normal skin color usually, if bruising present suggests venous engorgement, if
cellulitis present then hernia content is strangulating.

Palpation: Reducibility, cough impulse ( usually present but in cases where the neck is
tight and hernia is irreducible as in femoral hernia with misdiagnosis as a L.N ).
Tenderness.
When hernia is reduced, then assess the size, rigidity, and number of defects.
Associated pathology, signs of previous repair.
Scrotal content for groin hernia.
Investigations:
1. Plain X-ray: of little value. Hiatus and diaphragmatic hernias may appear on chest X-
ray.
2. Ultrasound: low cost, operator dependent.
- DDx of irreducible hernia with a mass/ fluid collection.
- When the nature of hernia contents is in doubt.
- DDx in early post operative period between recurrence and hematoma/ seroma.
3. CT Scan: presence of adhesions, number and size of muscle defects ( in incisional
hernia ), exclusion of other pathologies as ascites, malignancy, portal hypertension, ....
etc.
4. Contrast barium radiology: contrast may be injected directly into the peritoneum,
herniagram, especially in occult inguinal hernia.
5. MRI: diagnosis of sportsman`s groin, DDx between occult hernia from orthopedic
injury.
6. Laparoscopy: identify occult contralateral inguinal hernia (in up to 20% of patients ).
Management
Indications of surgery:
Not all hernias require repair.
- All femoral hernias , with high risk of strangulation, should be repaired
surgically.
- Irreducible hernias, especially with pain, tenderness, and skin color changes.
- High risk patients with irreducible hernia which can be reduced after
admission, adequate analgesia with muscle relaxation and reduction, because of
high recurrence rate.
- Large, especially recurrent incisional hernias.
- Planned surgery for cosmetic reasons, relief of symptoms of discomfort, or to
establish the diagnosis when in doubt.
Steps of Operative approach to hernia
1. Reduction of the hernia content into the abdominal cavity, removal of any non-
viable tissue and bowel repair if necessary.
2. Excision and closure of the peritoneal sac if present, or replacing it deep to the
muscles.
3. Re approximation of the walls of the neck of hernia if possible.
4. Permanent reinforcement of the abdominal wall defect with sutures or mesh.

Mesh in hernia repair

Prosthetic material, either net or a flat sheet, used to strengthen a hernia repair.
Uses:
1. Bridge a defect ( fixed over a defect, as a tension- free patch ).
2. Plug a defect ( plug of mesh pushed into the defect ).
3. Augment a repair ( reinforcement after closure with sutures).
Mesh types:

- Woven, knitted or sheet.

- Synthetic or biological.
- Light, medium, or heavy weight.
- Large pore, small pore.
- Non- absorbable, absorbable.

Positioning the mesh

* on lay ( outside the muscle in subcutaneous tissue ).
* Inlay ( within the defect ).
* Sub lay ( between fascial layers in the abdominal wall, immediately extra
peritoneally ).
* Intra peritoneally.

Initial fixation of mesh is by sutures, glue, or staples. In laparoscopic inguinal hernia,

no fixation is needed, as friction is sufficient to hold the mesh.
Sheet mesh Soft-Mesh
Knitted mesh
 Types of hernia
INGUINAL HERNIA

The most common hernia in men and women, but more common in men.
Types:
1. Indirect inguinal hernia ( lateral, oblique ), it is congenital.
2. Direct ( medial ), it is acquired.
3. Sliding ( lateral ), it is acquired.

Inguinal canal:
Oblique, 4-5 cm long canal, extends between the deep inguinal ring ( in the
transversalis fascia, midway between ant. sup. iliac spine and pubic tubercle, 2-3 cm
above the pulsation of the femoral a. ), and the superficial inguinal ring ( v- shaped
defect in the ext. oblique aponeurosis ).
Boundaries:
- Roof: the conjoint tendon ( the int. oblique & the transversus m. ).
- Post. wall: transversalis fascia.
- Ant. wall: ext. oblique aponeurosis.
- Floor: inguinal ligament.
Contents:
- Male: testicular a., testicular vs., vas deferens, lymphatics.
- Female: round ligament.
- Iliohypogastric n., ilioinguinal n., and the genital br. of genitofemoral n.

* Indirect inguinal hernia:

Congenital, due to failure of a peritoneal tube ( which wraps around the testis on it`s
descend from abdominal cavity through inguinal canal into the scrotum, and called
tunica vaginalis ), to close totally or partially. Inguinal hernias of the neonates and young
children are always of this type. Also called lateral because it`s origin is lateral to the inf.
epigastric vessels.

* Direct inguinal hernia:

Acquired, due to stretching and weakening of the abdominal wall ( which is composed
only of the transversalis fascia covered by ext. oblique aponeurosis ), just medial to the
inf. epigastric vessels ( Hasselbach`s triangle= lat. are the IEV., med. is the lat. edge of
rectus abdominus m., inf. is the pubic bone ), more in elderly patients, broadly based, so
unlikely to strangulate.
* Sliding inguinal hernia:
Acquired, due to weakening of the abdominal wall, but at the deep inguinal ring lat. to
the IEVs., a sac composed of retroperitoneal fatty tissue with a peritoneal sac.

Pantaloon hernia: when both direct & indirect inguinal hernias present in the same
patient.

Diagnosis :
- Self diagnosis by the patient is common.
- Intermittent swellings lying above and lateral to the pubic tubercle, with cough
impulse.
- After reduction, the surgeon presses on the deep inguinal ring at the mid- inguinal
point, and asks the patient to cough, if it is controlled at this point then it is most
likely indirect hernia, if it appears medial to this point, then it is likely direct hernia.
- 10% of all patients present with bilateral inguinal hernias, and 20% have an occult
contralateral hernia.
Diagnostic difficulties:
- Lymph node, groin mass, or an abdominal mass: when inguinal hernia becomes
irreducible and tense with no cough impulse, it requires urgent U/S or CT scan.
- Hydrocele or testicular swellings: the surgeon should reach the upper limit of a
scrotal swelling.
- Saphena varix
- Femoral/ Spigelian hernias.

Investigations:
* Clinical mainly.
* U/S, CT scan, MRI, Herniography.

Classification
The European Hernia Society has recently suggested a simplified system of:
• primary or recurrent (P or R);
• lateral, medial or femoral (L, M or F);
• defect size in finger breadths assumed to be 1.5 cm.
A primary, indirect, inguinal hernia with a 3-cm defect size would be PL2.
 Management of inguinal hernia
- Early, asymptomatic, direct hernia, in elderly patients require no active treatment.
- Elective surgery:
* Children: Herniotomy is sufficient, in which we remove and close the sac.
* Adults: Herniorrhaphy must be added, due to the high recurrence rate.
1. Open suture repair ( Bassini ) procedure.
2. Open flat mesh repair ( Lichtenstein ): using synthetic polypropylene
mesh.
3. Open plug/ device/ complex mesh repair: insert shaped mesh plugs into
the defect.
4. Laparoscopic inguinal hernia repair: reduce the hernia and the sac into
the abdomen and place 10x15 cm mesh just deep to the abdominal wall extending
5 cm lat. to the deep inguinal ring and to the retropubic area.

Advantages of laparoscopic/ open hernia repair:

- Reduced postoperative pain.
- Less complications: as bleeding, infection, seroma.
- Rapid return to full activity.
Emergency inguinal hernia surgery:
- 5% of patients present with painful, irreducible inguinal hernias which may
progress into strangulated, and possibly infarcted bowel.
- Open surgery is preferred.
- Well resuscitation and good antibiotic cover.
- High morbidity and even mortality.

Complications of inguinal hernia surgery:

Early: pain, bleeding, urinary retention, anesthetic femoral n. blockage.
Medium: infection, seroma.
Late: chronic pain, testicular atrophy.
Femoral hernia
Anatomy:
There is a small space located medial to the femoral vein containing fat and lymphatic
tissue ( node of Cloquet ), which is exploited by the femoral hernia.
The walls of femoral hernia are, the femoral vein laterally, the inguinal ligament
anteriorly, the pelvic bone covered by the iliopectinal ligament posteriorly, and the
sharp lacunar ligament medially which impedes the reduction of the hernia. The
femoral canal is wider in females , so the femoral hernia is more common in females
than males, and in old patients the femoral defect increases, so it is more common in
elderly.

Diagnosis:
- The hernia appears in the upper leg rather than in the lower abdomen.
- The error in diagnosis is often ( DDx with inguinal hernia, L.N, saphena varix, femoral
a. aneurysm, psoas abscess, and ruptured adductor m. with hematoma ).
- 50% of present as emergency, irreducible and loses any cough impulse due to the
tight neck, and rapidly become strangulated.
- All patients with unexplained small bowel obstruction should undergo careful exam.
for femoral hernia.
Investigations:

. Plain X-ray.
. U/S.
. CT Scan.

Surgery for femoral hernia:

No alternative to surgery, and it is done with some urgency.

* Open approaches:
1. Low approach: simplest approach, only when no risk of bowel resection, open
the sac and then reduce the contents and the sac with suturing between inguinal
ligament and the fascia.
2. The inguinal approach: Pull the hernia from above and push from below to
reduce it, then the neck of hernia is closed with sutures or a mesh.
3. High approach: for emergency when the risk of bowel strangulation is high, we
open the peritoneum to inspect the bowel.

* Laparoscopic approaches:
Suitable for reducible femoral hernias, and not for emergency cases.
Ventral hernias
I. Umbilical hernia
* Umbilical hernia in children
. Common (up to 10% of infants), mainly in premature babies.
. Appear within few weeks of birth, often symptomless, increase in size with
crying, conical in shape.
. Equal sex incidence, but 8x higher in black infants than in white ones.
. Obstruction/ strangulation extremely uncommon among babies below 3
years.
. Etiology: delay in healing of the stump of the umbilical cord which usually
closes within a week of birth.
. Treatment:
- Conservative if symptomless and below 2 yrs., 95% will resolve
spontaneously.
If the hernia persists after 2 years, it is unlikely to resolve and surgery is
indicated.
*Umbilical hernia in adults
Stretching and thinning of the linea alba (the midline raphe) due to
conditions like pregnancy, obesity, and liver cirrhosis, predispose to
reopening of the defect. The opening is adjacent to ( mainly above) the
umbilicus. The defect is rounded, if small contains extra peritoneal fat/
omentum. In adults, large umbilical hernias can contain part of the bowel,
its neck is small, and prone to become irreducible, obstructed, and
strangulated.
C.F of umbilical hernias:
. Overweight patients mainly, women > men.
. Bulge is slightly to one side of the umbilicus ( crescent-shaped
appearance).
. Pain occasional ( due to tissue tension/ intermittent bowel obstruction).
. Skin is thinned in large hernias, dermatitis may present.
Treatment
-Small hernias may be left if asymptomatic.
-Larger hernias, which contain bowel preferably operated upon (open/
laparoscopically) because they easily get obstructed and strangulated.
II. Epigastric hernias
-Transverse defect in linea alba (elliptical) anywhere between xiphoid
process and umbilicus, usually midway.
-Mainly due to heavy physical activity.
-Maximum diameter usually < 1 cm.
-Contain extra peritoneal fat, if enlarged, it may contain a peritoneal sac.
C.F:
-Healthy, fit males, between 25-40 years old.
-pain may be severe (may mimic peptic ulcer).
-Soft, small midline swelling can be felt.
-Irreducible mainly, and sometimes tender.
-Cough reflex may present.
Treatment:
-Small epigastric hernias usually disappear spontaneously, due to fat
infarction.
-Surgery done for hernias with sufficient symptoms. Open surgery/
laparoscopy, mesh put if peritoneal sac present, after it`s removal and
closure, with closure of the linea defect with sutures.
III. Incisional hernias
Arise through a defect in musculo-fascial layers of the abdomen in the
region of postoperative scars.
Can be anywhere in the abdomen.
Incidence Is about 10-50% of open abdominal surgeries, 1-5% of
laparoscopic operations.
Predisposing factors:
1.Patient factors: as obesity, immunosuppression, chr. Cough, steroid
therapy, malnutrition with poor wound healing.
2.Wound factors: as wound infection, tissue weakness.
3.Surgical factors: as inappropriate suture materials or suture placement.
Serosanguinous fluid discharge is the classic sign of tissue disruption.
C.F
Localized swelling involving a small portion of the scar, but may be a diffuse
swelling involving the whole Scar. They tend to increase steadily with time
and the overlying skin may become thin over the large hernias .Recurrent
intestinal obstructions are common due to underlying adhesions, but
strangulations uncommon due to broad neck.
Treatment
Asymptomatic incisional hernias may not require treatment, just abdominal
belt to prevent hernia from increasing in size.
Surgery (open/ laparoscopy).

IV. Spigelian hernias

Affect all ages, most common in elderly.
Affect males and females equally.
Mostly appear beneath the umbilicus, near the edge of the rectus sheath.
Arise through a defect in the spigelian fascia which is the aponeurosis of the
transversus abdominis muscle.
Young patients usually have intermittent pain due to pinching of the fatty
content, and the mass may/ may not be palpable due to the intact overlying
ext. oblique. Old patients may have palpable, reducible hernia, with
symptoms of intermittent bowel obstruction.
Treatment
Surgical, due to the risk of strangulation (narrow neck).
Spigelian hernia
V. Lumbar hernia
Types
1.Inferior lumbar hernias: through inf. Lumbar triangle of petit( the most
common type).
Boundaries: inf. Iliac crest, lat. Ext. oblique aponeurosis, med. Latissimus
dorsi.
2.superior lumbar hernias: through sup. Lumbar triangle, bounded sup. By
lower costal margin, med. By sacrospinalis m., and lat. By the post. Edge of
int. oblique m.
DDx
1.Lipoma.
2.Cold (T.B) abscess.
3.Pseudohernia (due to muscle paralysis by a nerve injury).
Treatment
Surgery is indicated because they tend to increase in size.
Laparoscopic and open surgery.
VI. Parastomal hernia
The muscle defect created by colostomy or ileostomy can increase in size
with time and ultimately lead to massive herniation around the stoma.
Difficult for patients to manage the stoma and the stoma appliance bags
poorly fit, leading to leakage.
Rate is > 50%.
Treatment
The ideal way is to close the stoma and rejoin the bowel, but not always
possible.
Open suturing and mesh techniques ( high recurrence rates).
Laparoscope op. ( still recurrence )
By Prophylactic use of mesh at time of formation of stoma, new parastomal
hernias rate reduced significantly.
Parastomal hernia Traumatic hernia
VII. Traumatic hernias
Types
1.Through stab wound sites (incisional).
2.Through splits in muscles following blunt trauma.
3.Through bulging due to muscle atrophy caused by nerve injuries/ traumatic denervation.
C.F
- History of trauma or operation.
- Non- anatomic location of the hernia.
Treatment
Surgery done for symptomatic or narrow neck hernias ( by CT Scan).

Perineal hernia
This type of hernia is very rare and includes:
• postoperative hernia through a perineal scar, which may occur after excision of the rectum;
• median sliding perineal hernia, which is a complete prolapse of the rectum;
• anterolateral perineal hernia, which occurs in women and presents as a swelling of the labium
majus;
• posterolateral perineal hernia, which passes through the levator ani to enter the ischiorectal
fossa.
Treatment
A combined abdominoperineal operation is generally the most satisfactory for the last two
types of hernia. The hernia is exposed by an incision directly over it. The sac is opened and its
contents are reduced. The sac is cleared from surrounding structures and the wound closed.
Obturator hernia
- Obturator hernia, which passes through the obturator canal, occurs six times more
frequently in women than in men.
- Most patients are over 60 years of age.
- The leg is usually kept in a semiflexed position and movement increases the pain.
- In more than 50% of cases of strangulated obturator hernia, pain is referred along obturator
nerve by its geniculate branch to the knee.
- On vaginal or rectal examination the hernia can sometimes be felt as a tender swelling in the
region of the obturator foramen.
- These hernias have often undergone strangulation, by the time of presentation.
Treatment
Operation is indicated. The diagnosis is rarely made preoperatively and so it is often
approached through a laparotomy incision.

Gluteal and sciatic hernias

Both of these hernias are very rare.
A gluteal hernia passes through the greater sciatic foramen, either above or below the
piriformis.
A sciatic hernia passes through the lesser sciatic foramen.
Differential diagnosis must be made between these conditions and:
• a lipoma or other soft tissue tumour beneath the gluteus maximus;
• a tuberculous abscess;
• a gluteal aneurysm
sciatic hernia