HERNIA

Done by D1 group

objectives
Definition
Anatomy
Precipitating

factors

Types
Clinical

features
Preoperative assessment
Management and repair

Definition

A hernia is a protrusion
of a viscus or part of a
viscus through an
abnormal opening in the
walls of its containing
cavity .

Anatomy

The inguinal canal :-

The inguinal canal is approximately 4 cm long and 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.This ligament
extends from the anterior superior iliac spine to the pubic
tubercle.

The inguinal canal has openings at either end :

The deep (internal) inguinal ring is the entrance to the inguinal

canal. It is thesite 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 is the exit from the
inguinal canal. It is a slitlke opening between the diagonal
fibres of the aponeurosis of the external oblique

Inguinal canal

walls of 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.

Content :1.

Spermatic cord ( round ligament of the uterus in female )

The Cord Itself.The contents of the spermatic cord are

(a) the ductus (vas) deferens and its artery .
(b) the testicular artery and venous (pampiniform) plexus.
(c) the genital branch of the genitofemoral nerve.
(d) lymphatic vessels and sympathetic nerve fibers.
(e) 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 vessle

Predisposing:
All hernias occur at the site of
WEAKNESS OF THE ABDOMINAL
WALL which are acted on by
repeated INCREASE in abdominal
pressure

repeated INCREASE in
abdominal pressure is
Chronic cough
usually
due to
Straining
Bladder

neck or urethral
obstruction
Pregnancy
Vomiting
Sever muscular effort
Ascetic fluid

Types
Inguinal
Femoral
Epigastric
Para umbilical
Umbilical
Obturator
Superior lumbar
Inferioer lumbar
Gluteal
Sciatic
Incisional

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

Lumber Hernia

occur through the inferior lumber triangle of Petit

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

Inguinal hernia
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

Indirect Versus Direct inguinal

hernias
Indirect

is the most common

form of hernia and its usually
congenital due to patent
processus viginalis

Direct

usually acquired occur in

old men with weak abdominal
muscles.

Indirect Versus Direct inguinal hernias

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 internal (deep)
inguinal ring.

Not controlled: after reduction by

pressure over the internal (deep)
inguinal ring.

The defect is not palpable (it is

behind the fibers of the external
oblique muscle).

The defect may be felt in the

abdominal wall above the pubic
tubercle.

After reduction: the bulge appears in

the middle of inguinal region and
then flows medially before turning
down to the scrotum.

After reduction: the bulge reappears

exactly where it was before.

Common in children and young

adults.

Common in old age.

Note that examination using finger

and thumb across the neck of the
scrotum will help to distinguish a
swelling of inguinal origin and one
that is entirely intrascrotal

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
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
1- discomfort and pain
2- swelling in the groin
General ; femoral hernia is more likely to
be strangulated than the inguinal hernia
Multiplicity ; often bilateral

Femoral hernia versus inguinal

hernia
Inguinal hernia

Femoral hernia

more common in male- 1

more common in females- 1

pass through the inguinal- 2

canal

pass through the femoral- 2

canal

neck of the sac is above and- 3

medial the pubic tubercle

neck of the sac is below and- 3

lateral the pubic tubercle

less common to be- 4

strangulated

more common to be- 4

strangulated

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

the two diagnostic signs of- 6
+hernia

the two diagnostic signs of- 6

-hernia

the sac mainly contain ; bowel- 7

the sac mainly contains ;- 7

omentum

Umbilical hernia
Signs

and symptoms
Age ; doesnt 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.

Examination
Inspection
Site ; in the center of the
Size and shape ; size can

umbilicus
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 .

Acquired umbilical hernia

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
1- pregnancy
2- ascitis
3- ovarian cyst
4- fibrodis
5- bowel distention

Incision hernia

Signs and symptoms

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
1- reducible lump
2- expansile cough impulse
3- if the lump dose not reduse and dose not have cough
impulse , than it may be not a hernia
Ddx
Tumor
Chronic abscess
Hematoma
Foreign body granuloma

Preoperative assessment
proper

history and examination

identify high risk patients
prepare the preoperative notes :
consent..
pre op Dx
procedure planned
surgeons
Anasthesia anticipated (general ,
local, spinal)

Preoperative assessment
Investigation

data ( pre operative tests ) :

1. Lab :
* CBC : to check hemoglobin level anemia and
WBCs infections
* U&E : to check for any electrolyte imbalance
* LFTs : indicated in jaundiced patients and
suspected hepatitis or any clotting problems
* PT & PTT
* ABG
* grouping and cross matching
2. Imaging :
* Chest X ray : for all patients
3. ECG : for any patient who is more than 40 years
of age

Preoperative assessment

current

medications or allergies
any major (chronic) illness
pre op orders :
1. skin preparation
2. diet (NPO)
3. GIT preparation
4. Sedation
5. Preanesthetic medications
6. Other medications
7. Antibiotics
8. Blood transfusion ( if needed )
9. Bladder preparation

Manageme
nt and
repair

Inguinal Hernia Repair

Pre op
Evaluation
&
preparation

Reduction

Surgical
TTT

Surgical TTT

Choice of
Anesthetic

TTT of hernial sac

Inguinal floor
reconstruction

Pre op evaluation
&preparation
Watchful Waiting

Surgical TTT

May be appropriate for pt with

asymptomatic hernia or elderly pt
with minimal symptoms or easily
reduced inguinal hernia.
Routine F/U with health care
professional
A Randomized trial concluded that this is an acceptable option for men with minimally
symptomatic inguinal hernia and that delaying repair until symptoms increase is safe
due to low rate of incarceration. 23% of pt initially treated with watchful waiting
crossed over to surgical ttt due to increase in symptoms (most often hernia-related
pain) , only 1 pt (0.3%) experienced acute hernia incarceration without strangulation
within 2years, a second had acute incarceration with
Bowel obstruction at 4 years, corresponding to frequency of acute intervention of

Pre op preparation
Most

pt are treated surgically

Increase IAP abnormalities (Chronic
cough, Constipation, Bladder outlet
obstruction) should be evaluated and
remedied to extent possible before
elective herniorrhaphy.
In case of intestinal obstruction and
possible strangulation, Broad spectrum
AB,NG suction may be indicated,
correction of volume status& elctroyles.

Reduction
Uncomplicated:
Manual

Gentle pressure over hernia

Gentle traction over the mass
sedation and trendelenburg position.

Complicated

(strangulated):
no attempt should be made to reduce
the hernia because of potential
reduction of gangrenous segment of
bowel with the hernial sac.

Surgerical TTT
1.choice

of anesthetic:
elective open repair : Local is
preferred
Laproscopic hernia repair: more
commonly under GA.

2.TTT OF HERNIAL 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.

3.Inguinal Floor
Reconstruction
Some

method of
reconstruction of
the inguinal floor is
necessary in all
adult hernia repairs
to prevent
recurrence. Primary tissue repair

Inguinal.3
Floor
Reconstruction

Open tension free

repair

&Laproscopic
preperitoneal repairs

1.Primary tissue repair

Bassini

repair: inferior arch of

transversalis fascia (TF) or conjoint
tendon is approximated to shelving
portion of inguinal ligament.

McVay:

TF is sutured to cooper
ligament.

Shouldice:

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

Laproscopic &
preperitoneal repairs

TAPP (transabdominal prepeitoneal 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.
There is no place for a truss for a femoral hernia.
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.

Lockwoods infra-inguinal
approach

The sac is dissected out below the

inguinal ligament via groin crease
incision.
Then the sac is opened and the
contents are inspected and reduced
into the abdomen.
Then the neck of the sac is pulled
down , ligated and allowed to retract
through femoral canal.
Then close the femoral canal by
mesh plug or non absorbable sutures.

McEvedys high approach

Vertical

incision is made over the

femoral canal and continued upwards
above the inguinal ligament.
This incision provides good access to
the preperitoneal space and then to
the peritoneum itself.
Use finger dissection to sweep
peritoneum from anterior abdominal
wall , so the neck of the sac can be
identified.
Dissect the sac , reduce the contents
and repair the defect by mesh or
sutures.

Lotheissens trans-inguinal
approach
The

incision is made superior and

parallel to inguinal ligament
extending from pubic tubercle to
mid inguinal point.

Hernia examination

Thank
You