Sie sind auf Seite 1von 46

HERNIAS

DANIEL IGO
What is a hernia?
A hernia is protrusion of an organ or the muscular wall
of an organ through the cavity that normally contains it.
As a rule, a hernia consists of three parts - the sac, the
coverings of the sac and the contents of the sac.
Hernias by themselves may be asymptomatic, but
nearly all have a potential risk of becoming
strangulated.
If the blood supply is cut off at the hernia opening in the
abdominal wall, it becomes a medical and surgical
emergency.
Pathophysiology of
Hernias
By far the most common hernias develop in the abdomen, when a weakness in
the abdominal wall evolves into a localized hole, or "defect", through which
adipose tissue, or abdominal organs covered with peritoneum, may protrude.
Hernias may or may not present either with pain at the site, a visible or
palpable lump, or in some cases by more vague symptoms resulting from
pressure on an organ which has become "stuck" in the hernia, sometimes
leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it
may be followed by or accompanied by an organ.
Most of the time, hernias develop when pressure in the compartment of the
residing organ is increased, and the boundary is weak or weakened.
Weakening of containing membranes or muscles is usually congenital, and
increases with age, but it may be caused by other factors, such as stretching of
muscles during pregnancy, losing weight in obese people, etc., or because of
scars from previous surgery.
Many conditions chronically increase intra-abdominal pressure, and hence
abdominal hernias are very frequent.
Causes of Hernia
Although abdominal hernias can be present at birth, others develop later in life. Some involve pathways formed during fetal
development, existing openings in the abdominal cavity, or areas of abdominal-wall weakness.

• Any condition that increases the pressure of the abdominal cavity may contribute to the formation or worsening of a hernia.
Examples include,

◦ heavy lifting,

◦ obesity

◦ coughing,

◦ straining during a bowel movement or urination,

◦ chronic lung disease, and

◦ fluid in the abdominal cavity.

• A family history of hernias can make you more likely to develop a hernia.
Complications of
Hernia
An untreated hernia may complicate by:
■ Inflammation - contents of sac have become inflamed
■ Irreducibility - contents cannot be returned to their nomal site
with simple manipulation
■ Obstruction - bowel in the hernia has good blood supply but
bowel is obstructed
■ Strangulation - blood supply of bowel is obstructed
Hydrocele of the hernial sac -The neck of the hernial sac gets
plugged with omentum or by adhesions. Fluid then
accumulates in the sac by secretion from the peritoneum ,
thus creating a hydrocele.
■ Haemorrhage
Hernias
Inguinal Hernia
Direct
Indirect
Femoral Hernia
Umbilical Hernia
INGUINAL HERNIA
Inguinal Hernia
Anatomy - The Inguinal Canal

In infants the superficial and deep


inguinal rings are almost
superimposed and the obliquity of
the canal is slight.

In adults the inguinal canal which is


about 3.75cm long, is directed
downwards and medially from the
deep to the superficial inguinal ring.

In the male, the inguinal canal


transmits the spermatic cord, the
ilioinguinal nerve and the genital
branch of the genitofemoral nerve.

In the female the round ligament


replaces the spermatic cord.
Inguinal Hernia
An inguinal hernia is a protrusion of abdominal cavity
contents through the inguinal canal. They are very common
(lifetime risk 27% for men, 3% for women), and their repair is
one of the most frequently performed surgical operations.
There are two types of inguinal hernia, direct and indirect,
which are defined by their relationship to the inferior
epigastric vessels.
Indirect inguinal hernias occur when abdominal contents
protrude through the deep inguinal ring, lateral to the inferior
epigastric vessels; this may be caused by failure of
embryonic closure of the processus vaginalis.
Direct inguinal hernias occur medial to the inferior epigastric
vessels when abdominal contents herniate through the
external inguinal ring.
Inguinal Hernia
Origin
In men, indirect hernias follow the same route as the descending
testes, which migrate from the abdomen into the scrotum during
the development of the urinary and reproductive organs.
The larger size of their inguinal canal, which transmitted the
testicle and accommodates the structures of the spermatic cord,
might be one reason why men are 25 times more likely to have an
inguinal hernia than women.
Although several mechanisms such as strength of the posterior
wall of the inguinal canal and shutter mechanisms compensating
for raised intra-abdominal pressure prevent hernia formation in
normal individuals, the exact importance of each factor is still
under debate.
Inguinal Hernia
Clinical Features

Hernias present as bulges in the groin area that can become more prominent when
coughing, straining, or standing up.

They are rarely painful, and the bulge commonly disappears on lying down. The inability to
"reduce", or place the bulge back into the abdomen usually means the hernia is
'incarcerated' which is a surgical emergency.

Significant pain is suggestive of strangulated bowel (an incarcerated indirect inguinal hernia).
As the hernia progresses, contents of the abdominal cavity, such as the intestines, can
descend into the hernia and run the risk of being pinched within the hernia, causing an
intestinal obstruction.
If the blood supply of the portion of the intestine caught in the hernia is compromised, the
hernia is deemed "strangulated," and gut ischemia and gangrene can result, with potentially
fatal consequences.
The timing of complications is not predictable. Some hernias remain static for years, others
progress rapidly from the time of onset.
Provided there are no serious co-existing medical problems, patients are advised to get the
hernia repaired surgically at the earliest convenience after a diagnosis is made. Emergency
surgery for complications such as incarceration and strangulation carry much higher risk
than planned, "elective" procedures.
Indirect Inguinal
Hernia
An indirect inguinal hernia is an inguinal hernia that results from the failure of
embryonic closure of the internal inguinal ring after the testicle has passed through
it. Like other inguinal hernias, it protrudes through the inguinal ring. It is the most
common cause of groin hernia.

In the male fetus, the peritoneum gives a coat to the testicle as it passes through
this ring, forming a temporary connection called the processus vaginalis. In normal
development, the processus is obliterated once the testicle is completely
descended. The permanent coat of peritoneum that remains around the testicle is
called the tunica vaginalis. The testicle remains connected to its blood vessels and
the vas deferens, which make up the spermatic cord and descend through the
inguinal canal to the scrotum.

The internal inguinal ring, which is the beginning of the inguinal canal, remains as
an opening in the internal oblique muscle, which forms the muscular outer wall for
the spermatic cord. When the opening is larger than necessary for passage of the
spermatic cord, the stage is set for an indirect inguinal hernia. The protrusion of
peritoneum through the internal inguinal ring can be considered an incomplete
obliteration of the processus.
In indirect inguinal hernia, it passes through the deep inguinal ring and is located
lateral to the inferior epigastric artery. Hence, the conjoint tendon is not weakened.
Indirect Inguinal
Hernia
There are three types of indirect inguinal hernia
Bubonocele - The hernia is limited to the inguinal
canal
Funicular - The processus vaginalis is closed just
above the epididymis. The contents of the sac can be
felt seperately from the the testis which lies below the
hernia
Complete - A complete inguinal hernia is rarely
present at birth but is commonly encountered in
infancy. It also occurs in adoloscence or adult life. The
testes appear to lie within the lower part of the hernia.
Indirect Inguinal Hernia
Differentials
Male
Vaginal hydrocele
encysted hydrocele
spermatocele
femoral hernia
lipoma of the cord
Female
Hydrocele of the canal of Nuck
femoral hernia
Indirect Inguinal
Hernia
Treatment
Open surgery is the most common type of treatment,
accounting for 95 percent of inguinal repairs. This
procedure is done under local anesthesia and requires a
4- to 6-inch incision in the groin. The doctor then pushes
the herniated tissue back into place and sutures the
opening shut.
Laparoscopy is done under general anesthesia and
involves three small incisions (1/2 inch or less) in the
abdomen which is then inflated with carbon dioxide. A
laparoscope and other instruments are inserted through
the incisions. Using a monitor the surgeon pushes the
herniated tissue back into place and staples a patch over
the opening.
Direct Inguinal
Hernia
A direct inguinal hernia protrudes through a weakened area
in the transversalis fascia near the medial inguinal fossa
within an anatomic region known as the medial or
Hesselbach’s triangle, an area defined by the edge of the
rectus abdominis muscle, the inguinal ligament and the
inferior epigastric artery.
These hernias are capable of exiting via the external ring, but
unlike indirect inguinal hernias, they cannot move into the
scrotum.
Since their abdominal walls weaken as they age, direct hernia
tends to occur in the middle-aged and elderly. This is in
contrast to indirect hernias which, although their etiology
includes a congenital component, can occur at any age.
Direct Inguinal Hernia

Treatment
The principles of repair of a direct
hernia are the same as an indirect
hernia.
FEMORAL HERNIA
Femoral Hernia
Anatomy - The Femoral Canal

The femoral canal is located below the


inguinal ligament on the lateral aspect of the
pubic tubercle.

It is bounded by the inguinal ligament


anteriorly, pectineal ligament posteriorly,
lacunar ligament medially, and the
femoral vein laterally.

It normally contains a few lymphatics, loose


areolar tissue and occasionally a lymph
node called Cloquet's node.

The function of this canal appears to be to


allow the femoral vein to expand when
necessary to accommodate increased
venous return from the leg during periods of
activity.
Femoral Hernia
Femoral hernias occur just below the inguinal ligament, when
abdominal contents pass through the femoral canal.
Femoral hernias are a relatively uncommon type, accounting for
only 3% of all hernias.
While femoral hernias can occur in both males and females,
almost all of them develop in women because of the wider bone
structure of the female pelvis.
Femoral hernias are more common in adults than in children.
Those that do occur in children are more likely to be associated
with a connective tissue disorder or with conditions that
increase intra-abdominal pressure.
Seventy percent of pediatric cases of femoral hernias occur in
infants under the age of one.
Femoral Hernia
Epidemiology
The female to male ratio is about 2:1,
but it is interesting that, whereas the
female patients are frequently elderly,
the male patients are usually between
the ages of 30 and 45. The condition is
more prevalent in women who have
borne children than in nulliparae.
Femoral Hernias
Clinical Features

They typically present when standing erect as a groin lump or bulge, which may
differ in size during the day, based on internal pressure variations of the intestine.

The bulge or lump typically is smaller or may not be visible in a prone position.

They may or may not be associated with pain. Often, they present with a varying
degree of complication ranging from irreducibility through intestinal obstruction to
frank gangrene of contained bowel.
The incidence of strangulation in femoral hernias is high. A femoral hernia has
often been found to be the cause of unexplained small bowel obstruction.
The obvious finding may be a lump in the groin. Cough impulse is often absent and
should not be relied on solely when making a diagnosis of femoral hernia. The
lump is more globular than the pear shaped lump of the inguinal hernia.
The bulk of a femoral hernia lies below an imaginary line drawn between the
anterior superior iliac spine and the pubic tubercle (which essentially represents
the inguinal ligament) whereas an inguinal hernia starts above this line.
Nonetheless, it is often impossible to distinguish the two preoperatively.
Femoral Hernia
Differential Diagnosis
An inguinal hernia
Saphena varix - a saccular enlargement of the termination of the
great saphenous vein, usually accompanied by other signs of
varicose veins.
An enlarged femoral lymph node
Lipoma
Femoral aneurysm
A distended psoas bursa
Rupture of the adductor lungus
Femoral Hernia
Diagnosis
The diagnosis is largely a clinical one, generally
done by physical examination of the groin.
However, in obese patients, imaging in the form
of ultrasonography, CT or MRI may aid in the
diagnosis.
An abdominal x-ray showing small bowel
obstruction in a female patient with a painful
groin lump needs no further investigation.
Femoral hernia
Treatment - Surgery

Younger surgeons frequently use laparoscopic surgery (also called minimally invasive surgery) rather than
"open" surgery. With key-hole surgery one or more small incisions are made that allow the surgeon to use a
surgical camera and small tools to repair the hernia.

Conventional open surgery requires an incision large enough for the surgeon's hands to enter the patient.

Either open or minimally invasive surgery may be performed under general or regional anaesthesia,
depending on the extent of the intervention needed. Three approaches have been described for open surgery.

■ Lockwood’s infra-inguinal approach

■ Lotheissen‘s trans-inguinal approach

■ McEvedy’s high approach

The infra-inguinal approach is the preferred method for elective repair. The trans-inguinal approach involves
dissecting through the inguinal canal and carries the risk of weakening the inguinal canal. McEvedy’s
approach is preferred in the emergency setting when strangulation is suspected. This allows better access to
and visualisation of bowel for possible resection. In any approach, care should be taken to avoid injury to the
urinary bladder which is often a part of the medial part of the hernial sac.


Repair is either performed by suturing the inguinal ligament to the pectineal ligament using strong non-
absorbable sutures or by placing a mesh plug in the femoral ring. With either technique care should be taken
to avoid any pressure on the femoral vein.
UMBILICAL HERNIA
Umbilical Hernia
An umbilical hernia is an abnormal bulge that can be seen or felt
at the umbilicus. This hernia develops when a portion of the lining
of the abdomen, part of the intestine, and/or fluid from the
abdomen, comes through the muscle of the abdominal wall.
Umbilical hernias are common, occurring in 10% to 20% of all
children. They are, however, more common in people of African
origin.
Low birth weight and premature infants are also more likely to
have an umbilical hernia. Boys and girls are equally affected.
Among adults, it is three times more common in women than in
men; among children, the ration is roughly equal.
An acquired umbilical hernia directly results from increased intra-
abdominal pressure and is most commonly seen in obese
individuals.
Umbilical Hernia

Umbilical Hernia
Umbilical Hernia
Presentation
A hernia is present at the site of the umbilicus in the newborn;
although sometimes quite large, these hernias tend to resolve without
any treatment by around the age of 5 years.
Obstruction and strangulation of the hernia is rare because the
underlying defect in the abdominal wall is larger than in an
inguinal hernia of the newborn.
The size of the base of the herniated tissued is inversely correlated
with risk of strangulation (i.e. narrow base is more likely to
strangulate).
Babies are prone to this malformation because of the process during
fetal development by which the abdominal organs form outside the
abdominal cavity, later returning into it through an opening which will
become the umbilicus.
Umbilical Hernia

Differential Diagnosis
Importantly this type of hernia must be distinguished from a
paraumbilical hernia, which occurs in adults and involves a
defect in the midline near to the umbilicus, and from
omphalocele.
Umbilical Hernia
Treatment
When the orifice is large (< 1 or 2 cm), 90% close within 3 years (some sources
state 85% of all umbilical hernias, regardless of size, and if these hernias are
asymptomatic, reducible, and don't enlarge, no surgery is needed (and in other
cases it must be considered).
In some communities mothers routinely push the small bulge back in and tape
a coin over the palpable hernia hole until closure occurs. This practice is not
medically recommended as there is a small risk of trapping a loop of bowel
under part of the coin resulting in a small area of ischemic bowel. The use of
bandages or other articles to continuously reduce the hernia is not
evidence-based.

An umbilical hernia can be fixed 2 different ways. The surgeon can opt to stitch
the walls of the abdominal or he/she can place mesh over the opening and
stitch it to the abdominal walls. The latter is of a stronger hold and is commonly
used for larger tears in the abdominal wall. Most surgeons will repair the hernia
6 weeks after the baby is born.
OTHER HERNIAS
Paraumbilical
Hernia
A paraumbilical hernia is a protrusion of the intestines or gut into
the abdomen through a weak point of the muscles or ligaments
near the navel. It can lead to discomfort when fatty tissue gets
trapped and a lump can be felt or seen. Whilst they are not usually
life-threatening, routine surgical treatment is usually advised to
prevent enlargement or strangulation of the gut.
Treatment
The protrusion is put back within the abdomen in the correct
position. Stitches are used to strengthen the weakness where
the hernia has broken through.
The operation is usually performed under a general
anaesthetic.
Spigelian Hernia
A Spigelian hernia is a hernia through the spigelian fascia, which is
the aponeurotic layer between the rectus abdominis muscle medially,
and the semilunar line laterally.
These hernias almost always develop at or below the linea arcuata,
probably because of the lack of posterior rectus sheath.
These are generally interparietal hernias, meaning that they do not lie
below the subcutaneous fat but penetrate between the muscles of the
abdominal wall; therefore, there is often no notable swelling.
Spigelian hernias are usually small and therefore risk of strangulation
is high. Most occur on the right side. Most develop around age 50.
Compared to other types of hernias they are rare.
Spigelian Hernia
Symptoms and Diagnosis
Patients typically present with either an intermittent mass, localized pain, or
signs of bowel obstruction.
Ultrasonography or a CT scan can establish the diagnosis, although CT scan
provides the greatest sensitivity and specificity.
Treatment
These hernias should be repaired because of the high risk of strangulation;
fortunately, surgery is straight-forward, with only larger defects requiring a
mesh prosthesis.

Varied Spigelian hernia mesh repair techniques have been described, although
evidence suggests laparoscopy results in less morbidity and shorter
hospitalization compared with open procedures. Mesh-free laparoscopic suture
repair is feasible and safe.
This novel uncomplicated approach to small Spigelian hernias combines the
benefits of laparoscopic localization, reduction, and closure without the
morbidity and cost associated with foreign material.
Obturator Hernia
An obturator hernia is a rare type of abdominal wall hernia in which
abdominal content protrudes through the obturator foramen.
Because of differences in anatomy, it is much more common in women
than in men, especially multiparous and older women who have recently
lost a lot of weight.
The diagnosis is often made intraoperatively after presenting with
bowel obstruction. A gynecologist may come across this type of hernias
as a secondary finding during gynecological open surgery or
laparoscopy
The Howship-Romberg sign is suggestive of an obturator hernia,
exacerbated by thigh extension, medial rotation and adduction. It is
characterized by lancilating pain in the medial thigh/obturator
distribution, extending to the knee; caused by hernia compression of the
obturator nerve.
Epigastric Hernia
An epigastric hernia is a type of hernia which may develop in the
epigastrium. Epigastric hernias are most common in infants but may
occur in humans of any age.
They typically result from a minor defect of the linea alba between the
rectus abdominis muscles. This allows tissue from inside the
abdomen to herniate anteriorly. On infants, this may manifest as an
apparent 'bubble' under the skin of the belly between the umbilicus
and xiphisternum.
Epigastric hernias are rarely harmful, but they can be surgically
corrected for cosmetic reasons.
In general, any cosmetic operation to be performed on an infant will
be delayed until the infant is older and better able to tolerate
anaesthesia.
Epigastric Hernia
Richter’s Hernia

A Richter's hernia occurs when the antimesenteric wall of the intestine


protrudes through a defect in the abdominal wall. If such a herniation
becomes necrotic and is subsequently reduced during hernia repair,
perforation and peritonitis may result. A Richter's hernia can result in
strangulation and necrosis in the absence of intestinal obstruction. It is a
relatively rare but dangerous type of hernia.
Treatment
Surgery
Incisional Hernia
An incisional hernia occurs in an area of weakness caused by an incompletely-healed
surgical wound. Since median incisions in the abdomen are frequent for
abdominal exploratory surgery, ventral incisional hernias are termed ventral hernias. These
can be among the most frustrating and difficult hernias to treat.

Clinically, incisional hernias present as a bulge or protrusion at or near the area of a surgical
incision.
Virtually any prior abdominal operation can develop an incisional hernia at the scar area
(provided adequate healing does not occur), from large abdominal procedures (intestinal
surgery, vascular surgery), to small incisions (appendectomy, or
abdominal exploratory surgery).
While these hernias can occur at any incision, they tend to occur more commonly along a
straight line from the xiphoid process of the breastbone straight down to the pubic bone, and
are more complex in these regions.
Hernias in this area have a high rate of recurrence if repaired via a simple suture technique
under tension. For this reason, it is especially advised that these be repaired via a tension
free repair method using mesh (a type of synthetic material).
Incisional Hernia
Treatment

Traditional open repair of incisional hernias can be quite difficult and complicated operations.
The weakened tissue of the abdominal wall is re-incised and a repair is reinforced using a
prosthetic mesh. Complications frequently occur because of the large size of the incision
required to perform this surgery. These are primarily wound complications such as infection
of the incision. Unfortunately, a mesh infection after this type of hernia repair most frequently
requires a complete removal of the mesh and ultimately results in surgical failure. In addition,
large incisions required for open repair are commonly associated with significant
postoperative pain.

Laparoscopic incisional hernia repair is a new method of surgery for this condition. The
operation is performed using surgical telescopes and specialized instruments. The surgical
mesh is placed into the abdomen underneath the abdominal muscles through small incisions
to the side of the hernia. In this manner, the weakened tissue of the original hernia is never
re-incised to perform the repair and one can minimize the potential for wound complications
such as infections. In addition, performance of the operation through smaller incisions can
make the operation less painful and recovery quicker. Laparoscopic repair has been
demonstrated to be safe and a more resilient repair than open incisional hernia repair
Locations of
Hernias
References

http://www.medicalgeek.com/viva/10661-hernia-hyrdocele-sac-hydrocele-hernial-sac.html

http://en.wikipedia.org/wiki/Hernia

http://www.gpnotebook.co.uk/simplepage.cfm?ID=1120927767

http://www.shantivedhospital.com/hernia.htm

http://www.gla.ac.uk/ibls/US/fab/images/anatomy/femoral2.gif

http://www.emedicinehealth.com/hernia/article_em.htm

http://www.cincinnatichildrens.org/health/info/abdomen/diagnose/umbilical-hernia.htm

Das könnte Ihnen auch gefallen