HERNIA

dr. Muhammad Khadafi SpB

FOCUS :
HERNIA
• Inguinal Hernia
• Femoral Hernia
• Epigastric Hernia
HERNIA
1. Hernia Definition
2. Types of hernia
3. Anatomy
4. Precipitating factors
5. Clinical features
6. Assessment
7. Management and repair
1. DEFINITION
Hernia :
a protrusion of a viscus or part of a viscus through
an abnormal opening in the walls of its containing
cavity .

Hernia :
 ring
 sac
 content
2. TYPE

LOCATION :
- Inguinal - Femoral
- Epigastric - Para umbilical
- Umbilical - Obturator
- Superior lumbar - Inferior lumbar
- Gluteal - Sciatic
- Diafragma
2. TYPE

Another :
- Reponible - Irreponible
- Direct - Indirect
- Lateral - Medial
- Incarcerated - Strangulated
- Congenital - Acquired
- Incisional - Spigelian
- Littre - pantalon
- Richter - Sliding
Hernia :
• Inguinal hernia
Hernia through the inguinal
• Indirect Inguinal Hernia
Hernia through the inguinal
canal
• Direct Inguinal Hernia
The sac passes through a weakness or defect of the
transversalis fascia in the posterior wall of the inguinal canal
• Femoral Hernia
Hernia medial to femoral vessels under inguinal ligament
• Umbilical Hernia
Hernia through the umbilical ring
• Paraumbilical Hernia
A protrusion through the linea alba
just above or sometimes
just below the umbilicus
• Epigastric Hernia
Protrusion of extraperitoneal fat through the linea alba anywhere
between the xiphoid process and the umbilicus
• Incisional Hernia
Hernia through an incisional site
• Lumbar Hernia
occur through the inferior lumbar triangle of Petit
 3. ANATOMY
THE INGUINAL CANAL :
• The anterior wall is formed mainly by the aponeurosis of
the external Oblique
• The posterior wall is formed mainly by transversalis fascia
• The roof is formed by the arching fibres of the internal
oblique and transverse abdominal muscles.
• The floor is formed by the inguinal ligament, which forms a
shallow trough. It is reinforced in its most medial part by
the lacunar ligament.
THE INGUINAL CANAL :
 Inguinal canal is approximately 4 cm long
 It is directed obliquely inferomedially through the inferior
part of the anterolateral abdominal wall.
 The canal lies parallel and 2-4 cm superior to the medial
half of the inguinal ligament.
 Inguinal ligament extends from the anterior superior iliac
spine to the pubic tubercle.
THE INGUINAL CANAL :

 The deep (internal) inguinal ring

- It is the entrance to the inguinal canal.
- It is the site of an outpouching of the transversalis fascia.
- This is approximately 1.25 cm superior to the middle of the
inguinal ligament

 The superficial, or external inguinal ring

- It is the exit from the inguinal canal.
- It is a opening between the diagonal fibres of the aponeurosis
of the external oblique
Content of inguinal canal:
1. Spermatic cord ( round ligament of the uterus in female )
The Cord Itself.—The contents of the spermatic cord are
- The ductus (vas) deferens and its artery .
- The testicular artery and venous (pampiniform) plexus.
- The genital branch of the genitofemoral nerve.
- Lymphatic vessels and sympathetic nerve fibers.
- Fat and connective tissue surrounding the cord and its
coverings in various amounts
2. Ilioinguinal nerve .
3. Ilioinguinal lymph node .
 FEMORAL CANAL

 The major feature of the femoral canal is the femoral sheath.

 This sheath is a condensation of the deep fascia (fascia lata) of
the thigh and contains, from lateral to medial, the femoral
artery, femoral vein, and femoral canal.
 The femoral canal is a space medial to the vein that allows for
venous expansion and contains a lymph node (node of Cloquet).
 Other features of the femoral triangle include the femoral
nerve, which lies lateral to the sheath
Wall of The Femoral canal
 Anterior is the inguinal ligament
 Posterior is the iliopsoas, pectineal, and long adductor
muscles (floor).
 Medial is lacunar ligament
 Lateral is femoral vessel
4. PRECIPITATING FACTORS
All hernias occur at the site of WEAKNESS OF THE
ABDOMINAL WALL which are acted on by
repeated INCREASE in abdominal pressure :
• Chronic cough
• Straining
• Bladder neck or urethral obstruction, BPH
• Severe muscular effort
• Pregnancy
• Vomiting
repeated INCREASE in abdominal pressure :
• Obesity
• Heavy lifting
• Coughing
• Straining during a bowel movement or urination
• Chronic lung disease
• Fluid in the abdominal cavity/ ascites
• Hereditary
5. CLINICAL FEATURES
 The signs and symptoms of a hernia can range from noticing
a painless lump to the painful, tender, swollen protrusion of
tissue that you are unable to push back into the abdomen—
possibly a strangulated hernia.
 Asymptomatic reducible hernia
- New lump in the groin or other abdominal wall area
- May ache but is not tender when touched.
- Sometimes pain precedes the discovery of the lump.
- Lump increases in size when standing or when abdominal
pressure is increased (such as coughing)
- May be reduced (pushed back into the abdomen) unless
very large
 Irreducible hernia
• Usually painful enlargement of a previous hernia that
cannot be returned into the abdominal cavity on its own
or when you push it
- Some may be long term without pain
• Can lead to strangulation
• Signs and symptoms of bowel obstruction may occur,
such as nausea and vomiting
 Strangulated hernia
• Irreducible hernia where the entrapped intestine has
its blood supply cut off
• Pain always present followed quickly by tenderness
and sometimes symptoms of bowel obstruction
(nausea and vomiting)
• You may appear ill with or without fever
• Surgical emergency
• All strangulated hernias are irreducible (but all
irreducible hernias are not strangulated)
INGUINAL HERNIA
 History :
1. Age ( young vs. old)
2. Occupation ( nature ?? )
3. Local symptoms: Swelling, discomfort and pain
4. Systemic symptoms: if there is obstruction or strangulation
5. Precipitating factors

 Examination :
1. Inspection for site, size, shape and color.
2. Palpation for surface, temp, tenderness, composition and
reducibility.
3. Expansible cough impulse.
4. General exam: for common causes of increase intra
abdominal pressure
 INGUINAL HERNIA DIRECT VS INDIRECT
Indirect Inguinal Hernia Direct Inguinal Hernia

Pass through inguinal canal. Bulge from the posterior wall of the inguinal canal

Can descend into the scrotum. Cannot descent into the scrotum.
Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.
Reduced: upward, then laterally and backward. Reduced: upward, then straight backward.

Controlled: after reduction by pressure over the Not controlled: after reduction by pressure over the
internal (deep) inguinal ring. internal (deep) inguinal ring.

The defect is not palpable (it is behind the fibers of The defect may be felt in the abdominal wall above
the external oblique muscle). the pubic tubercle.

After reduction: the bulge appears in the middle of After reduction: the bulge reappears exactly where it
inguinal region and then flows medially before was before.
turning down to the scrotum.

Common in children and young adults. Common in old age.

 INGUINAL HERNIA DIFFERENTIAL DIAGNOSE
Male :
 Femoral hernia
 Vaginal hidrocele
 Spermatocele
 Undescended testis
 Lipoma of the cord
 Tumor testis
Female :
 Hydrocele of the canal of nuck. Is a fluid filled distal part of
the sac of an indirect hernia with narrow proximal part it
present with a smooth fluctuant swelling without a cough
impulse which will translluminate
 Femoral hernia
FEMORAL HERNIA

Small femoral hernia may be unnoticed by the patient or

disregarded for years perhaps until the day it strangulates.
Adherence of the greater omentum sometimes causes a
dragging pain. Rarely a large sac is present .
FEMORAL HERNIA
 FEMORAL HERNIA
History
 Age; uncommon in children, most common in old age female.
 Sex; women > men (but still commonest hernia in women the
inguinal hernia )
 The patient came with local symptoms
 discomfort and pain
 swelling in the groin
 General : femoral hernia is more likely to be strangulated than
the inguinal hernia
 Often bilateral
FEMORAL HERNIA & INGUINAL HERNIA

Inguinal hernia Femoral hernia

1- more common in male 1- more common in females

2- pass through the inguinal canal 2- pass through the femoral canal

3- neck of the sac is above and medial the 3- neck of the sac is below and lateral the
pubic tubercle pubic tubercle

4- less common to be strangulated 4- more common to be strangulated

5- can be treated without surgery 5- must be treated surgically

6- the two diagnostic signs of hernia + 6- the two diagnostic signs of hernia -

7- the sac mainly contain ; bowel 7- the sac mainly contains ; omentum
FEMORAL HERNIA DIFF DIAGNOSE

 Inguinal hernia
 Saphena varix
 Lumph node enlargement
 Lipoma
 Aneurysme
 Abscess
 Cyst
 UMBILICAL HERNIA
• Signs and symptoms
• Age ; doesn’t appear until the umbilical cord has
separated and healed .
• No specific symptoms
• Have wide neck and reduce easily , rarely give intestinal
obstruction.
• Nature history ; 90 % disappear
spontaneously during the first year.
 UMBILICAL HERNIA
 Examination
 Inspection
- Site ; in the center of the umbilicus
- Size and shape ; size can vary from vary small to very large .
- Shape is usually hemispherical.
 Palpation
- Composition ; contain bowel , which makes it resonant to
percussion . They reduce spontaneously when the child lies
down .
 Reducibility ; easy
 Cough impulse; invariably present .
 UMBILICAL HERNIA ACQUIRED
 Hernia through the umbilical scar , so it is a true umbilical
hernia.
 Not common and is usually secondary to increase intra
abdominal pressure.
 The most common causes
- pregnancy
- ascites
- ovarian cyst
- bowel distention
 INCISIONAL HERNIA
 Previous operation or accidental trauma
 Age ; all ages , but more common in old age.
 Symptom ; lump ,pain ,intestinal obstruction ( distention ,colic, vomiting
,constipation , sever pain in the lump )
 Examination
- reducible lump
- expansile cough impulse
- if the lump doesn’t reduse and does
not have cough impulse , than it
may be not a hernia
 Ddx
- Tumor
- Chronic abscess
- Hematoma
- Foreign body granuloma
EPIGASTRIC HERNIA
• Occur in the upper part of the abdominal wall - in an area
known as the epigastrium, which is above the navel and
just below the breastbone.
• Epigastric hernias can be present from birth.
• May vary in size, and it is possible to have more than one
epigastric hernia at a time.
• Typically, an epigastric hernia is small, with only the lining
of the abdomen breaking through the surrounding tissue.
• Larger hernias, however, may cause fatty tissue or part of
the stomach to push through.
EPIGASTRIC HERNIA
EPIGASTRIC HERNIA
6. ASSESSMENT
 History and examination
 Identify high risk patients
 Informed consent.
 Procedure planned
 Surgeons
 Anasthesia
7. MANAGEMENT
Treatment of a hernia depends on whether it is reducible or
irreducible and possibly strangulated.
 Reducible
Can be treated with elective surgery
 Irreducible
All acutely irreducible hernias need Emergency surgery
because of the risk of strangulation.
 Strangulation
Emergency surgery
HERNIA SAC
• INDIRECT:
sac is dissected free from the cord structures and
creamsteric fibers. Sac should be open away from any
herniated contents. Contents are then reduced, and the sac
is ligated deep to inguinal ring with an absorbable suture

• DIRECT:
Too broadly based for ligation and should not be opened,
simple freed from transversalis fibers and inverted.
INGUINAL FLOOR RECONSTRUCTION
Some method of reconstruction of the inguinal floor is necessary
in all adult hernia repairs to prevent recurrence.
1. Primary tissue repair
2. Open tension free repair
3. Laparoscopic & preperitoneal repair
1. Primary tissue repair
• Bassini repair : inferior arch of transversalis fascia (TF) or
conjoint tendon is approximated to shelving portion of
inguinal ligament.
• McVay repair : TF is sutured to cooper ligament.
• Shouldice repair: TF is incised and reapproximated.

2. Open tension free repair

• Lichtenstein repair & Patch and Plug technique: Mesh is used
to reconstruct inguinal floor
• Mesh plug technique : place mesh in the hernial defect
3.Laparoscopic & preperitoneal repairs
• TAPP (transabdominal preperitoneal procedure): peritoneal
space entered by conventional lap at umbilicus and peritoneum
overlaying inguinal floor is dissected away as flap.

• TEP (Total extraperitoneal repair): preperitoneal space is

developed with a balloon inserted between posterior rectus
sheath and peritoneum  balloon inflated to dissect the
peritoneal flaps awau from posterior abdomianl wall and the
direct and indirect spaces, other ports inserted into this
preperitoneal space without entering peritoneal cavity.

• After lap. Dissection and reduction of hernia sac , a large piece

of mesh is placed over inguinal floor
 FEMORAL HERNIA REPAIR
• Femoral hernias should be repaired very soon after the
diagnosis has been made because of the high risk of
strangulation.
• Different approaches :
Open VS Laparoscopic
OPEN SURGERY
Three approaches have been described for open surgery :
1. Infra-inguinal approach (Lookwood)
2. Supra-inguinal approach ( McEvedy)
3. Trans-inguinal approach ( Lotheissen)
Each technique has the principle of dissection of the sac with
reduction of its contents, followed by ligation of the sac and
closure between the inguinal and pectineal ligaments.