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2 general consideration
2 inguinal hernias
2 femoral hernia
2 incisional hernia
2 umbilial hernia
2 hernia of linea alba
 general consideration
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Àernia means a sprout, and protrusion.
External abdominal wall hernia is an abnormal protrusion of intra-
abdominal tissue or the whole or part of a viscera through an
opening or fascial defect in the abdominal wall.
most occur in the grion
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. intensity of abdominal wall decreased


 
 site that some tissues pass through the abdominal wall, eg. Spermatic
cord, round ligament of uterus
2 bad development of abdominal white line
3 incision, trauma, infection et al.
defect in collagen synthesis or turnover
2. any condition which increases intra-abdominal pressure
chronic cough, chronic constipation, dysuria, ascites, pregnancy, cry
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composed of:
G covering tissue: skin, subcutanous tissue
G hernial sac: protrusion of peritonum,
neck of the sac: is narrow where the sac emerges from
the abdomen body of the sac
G hernial contents: small intestine, major omentum
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. reducible hernia is one in which the contents of the sac return to the
abdomen spontaneously or with manual pressure when the patient is
recumbent.
2. irreducible hernia is one whose contents or part of contents cannot be
returned to the abdomen, without serious symptoms.
hernias are trapped by the narrow neck
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 is one in which the wall of a viscus forms a portion of the
wall of the hernia sac. It is may be colon ( on the left , caccum (on the
right or bladder (on either side .
Belongs to irreducible hernia
3. incarcerated hernia: is one whose contents cannot be returned to the
abdomen, with severe symptoms.
4. strangulated hernia: denotes compromise to the blood supply of the
contents of the sac.
incarcerated hernia and strangulated hernia are the two stages of a
pathologic course
m
 
 (intestinal wall hernia
a hernia that has strangulated or incarcerated a part of the intestinal
wall without compromising the lumen.


: a hernia that has incarcerated the intestinal diverticulum
(usually Meckel diverticulum .
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: reduction of the hernial contents
( intestine into abdominal cavity.
Inguinal hernias
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. Anatomic layers
 skin, subcutaneous tissue
2 external oblique muscle, aponeurosis
G Subcutaneous (external inguinal ring:
Triangular opening, in the aponeurosis of the external oblique just
superior and lateral to the pubic tubercle.
Inguinal ligament: it is formed as the lateral edge of the aponeurosis of
external oblique rolls upon itself and thickens into a cord, extending
from the anterior superior iliac spine to the pubic tubercle.
Lacunar ligament
Cooper¶s ligament (pectineal ligament
Sensory nerves: iliohypogastric nerve, ilioinguinal nerve

3 internal oblique muscle and tranverse abdominal muscle

Conjoined tendon ( flax inguinalis : the lower fibers of the internal
oblique muscle fuse with the lower most arching fibers of the
transverse muscle of the abdomen and insert with them into the pubic
tubercle, forming the conjoined tendon.
4 Transversalis fascia
Internal inguinal ring: is the point at which the spermatic cord or round
ligament passes through the transversalis fascia to enter the inguinal
canal.
surface marking: 2cm superior to the point midway between the
anterior superior iliac spine and the pubic tubercle.

Iliopubic tract: it is the thickest portion of the transversalis fascia in the

inguinal region. It parallels and lies just medial to the inguinal ligament.
5 extraperitoneal fat and peritoneum
2. Anatomy of inguinal canal
Contents: spermatic cord, round ligament, ilioinguinal nerve
Walls:
anterior: skin, superficial fascia, and external ablique aponeurosis
posterior: transversalis fascia
superior: conjoined tenden
inferior: inguinal ligament

3 Àesselbach¶s triangle
Bounded by the inguinal ligament, the inferior epigastric vessels, and
the lateral edge of rectus muscle.
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. congenital abnormality of anatomy
due to failure of fusion of the processus vaginalis peritonei after the
testis has descended into the scrotum.
2. acquired weakness or defect of abdominal wall

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Symptoms: pain, discomfort, dragging sensation
Sign: reducible or irreducible lump, expansile cough impulse
Reducing the hernia fully, compress the internal ring:
be controlled ± indirect not controlled -- direct
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feature indirect direct

age children, young people aged people
pathway of protrusion coming down the pass through
inguinal canal, may Àesselbach¶s triangle,
enter the scrotum rarely enter the scrotum
contours of sac elliptic, pear-shaped semispheric, wide base
compress the internal ring controlled controlled
after reduced
Relationship of spermatic Posterior to the sac Anterior and lateral to
cord with sac the sac
Relationship of sac neck Sac neck is lateral to it Sac neck is medial to it
with inferior epigastric
artery
Incarcerated incidence high low
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G  dydrocele of testis translucent test (+
G 2 communicated hydrocele
G 3 hydrocele of cord: not reducible
G 4 undescended testis
G 5 acute intestinal obstruction
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. nonoperative therapy
Indications:
< year old
elderly patients or with severe systemic disease--truss
2. operations for inguinal hernia
conventional repairs
Principles: excision or reduction of the hernial sac, high ligation of the sac,
and repair the walls of the inguinal canal
A: high ligation of hernia sac
Used in infants, and patients with severe local infection
B: repair of walls of the inguinal cancal
I repair of the anterior wall of the inguinal canal
Ferguson repair
II Repair of the posterior wall
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 : placing the latter in a subcutanous position
 M
 : lower edge of internal oblique muscle and the conjoined
tendon are approximated to Cooper¶s ligament on the iliopectineal line of
the pubis.
    the posterior wall of the inguinal canal is repaired by
dividing the transversalis fascia from the pubis to adjacent to the inferior
epigastric vessel, then imbricate sutures.
Internal ring: pass a fingertip

2 tension-free hernioplasty
insertion of a prosthetic mesh

3 laparoscopic repair of inguinal hernia

3. management rule of incarcerated and strangulated hernia
Indications for manual reduction:
 duration <3-4 hours, no local tenderness, no abdominal tenderness, no
rigidity of abdominal muscle
2 elderly patients or with other severe diseases, and the intestinal loop is
still alive
Usually requires emergency operation
4. Management rule of recurrent inguinal hernia
 true recurrent hernia
2 concomitant hernia
3 new occurring hernia
 Femoral hernia
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Femoral hernia is a protrusion of peritoneum through the femoral canal.
Usually in women >40 years
Causes: laxity of groin tissue elevated intra-abdominal canal
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Femoral ring ± fossa ovalis
Anterior: inguinal ligament
Posterior: pectineal ligament
Medial: lacunar ligament
Lateral: femoral vein
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Reducible femoral hernia: asymptomatic lump, localized intermittent
discomfort
Irreducible femoral hernia: constant lump and localized discomfort
Strangulated femoral hernia
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. indirect inguinal hernia
2. lipoma
3. groin lymph nodes
4. long saphenous varix
5. iliolumbar tuberculous abscess
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Dot be treated conservatively
Rule operation: excision or reduction of the hernial sac, and narrowing of
the stretched femoral opening
methods:
G M

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 ther abdominal external hernia
£ncisional hernia
Incisional hernia: an abnormal protrusion of a viscus through the
musculoaponeurotic layers of a surgical scar.
Wound dehiscence

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Preoperative factors
 perative factors:
types of incision: vertical incision, transrectus incision, midline
incision, standard parmedian incision
technique of closure
suture materia
Postoperative factors: increased intra-abdominal pressure, et al.
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Swelling and mass in the incision
Àernial ring
Rarely incarcerate
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 perative repair: the same way as a laparotomy wound is repaired, or use mesh

-
ilical hernia
 infantile umbilical hernia
 failure of fusion of umbilical ring, or weakened umbilical tissue
2 symptomless, reducible lump
3 usually disappear by the age of 2 years
4 rarely incarcerate
5 surgical repair >2 years
2 Adult umbilical hernia
 acquired hernia
2 more common in females
3 incarceration is common
4 surgical repair: excision of the sac, suture the hernia ring

Àernia of linea al
a

Epigastric hernia
It is a protrusion of preperitoneal fat and / or peritoneal sac through a gap
in the decussating fibers of the linea alba, usually the supraumbilical
portion of the linea alba.
Most are asymptomatic, or vague upper abdominal pain and nausea may
be present.
Surgical repair