Prof. Deepaka Weerasekera

HERNIA

HERNIA

Objectives

To discuss the surgical anatomy

To discuss the principles of treatment

on the basis of surgical anatomy

Definition:

Protrusion of viscus or part of a viscus,

through a defect or a weakness of the wall

of its containing cavity

Clinically:

A reducible lump with an expansile

cough impulse

Risk Factors

Straining

Chronic cough

Lifting heavy weights

Obesity

Pregnancy

Intra-abdominal malignancy (adults)

Classification

Irrespective of site,

1. Reducible: lump reduces it self or can be reduced

by patient or doctor

2. Irreducible: contents can’t be returned

3. Obstructed: irreducible hernia containing intestine; obstructed from without or within; no impairment of the blood flow

4. Strangulated: if the blood flow to the viscus in the hernial sac becomes compromised

5. Inflamed

INGUINAL HERNIA

Surgical Anatomy:

Superficial inguinal ring

Deep inguinal ring

Inguinal canal

Contents of the spermatic cord

Superficial Inguinal Ring

Deep Inguinal Ring

Indirect

Inguinal

Hernia

Contents of the spermatic cord

Three arteries

– Artery to vas deferens

– Testicular artery

– Cremasteric artery

Three nerves

– Ilioinguinal nerve

– Nerve to cremaster

– Autonomic nerves

Three fascial layers

– External spermatic fascia

– Cremaster

– Internal spermatic fascia

Three others

– Vas deferens

– Pampiniform plexus

– Lymphatics

Inguinal Hernia

Direct Inguinal Hernia: (10-15%)

• Is one that is due to weakened trasversalis fascia

in Hesselbach’s triangle

• Most unusual for the sac to pass into the scrotum

• Always acquired

• >50% bilateral

• Neck is large – i.e.: rarely strangulate

• Neck is medial to epigastric vessels

Indirect Inguinal Hernia: (commonest)

• Pass through the deep inguinal ring and extends

down the canal towards the scrotum

• “Inguinoscrotal”

• Common in males

• 30% bilateral

• 3 types:

1. Bubonocele

2. Funicular

3. Inguino-Scrotal (Complete)

Clinical Features

1. Lump

2. Increasing in size with straining

3. Pain (not always) Clinical Examination Examine in the standing position

can I get above the swelling ?

cough impulse

Examine in the lying down position

Look for the direction of the appearance of

the swelling oblique or direct

Define and obliterate the internal ring

Treatment

Principle

Reinforce the posterior wall of the

inguinal canal and to recreate the internal

ring

Conventional method: “ Bassini’ repair “

Approximation of the conjoint tendon to the medial

part of the inguinal ligament, behind the cord

without tension, using non-absorbable suture

material

New method: Lichtenstein's open Tension Free

Hernioplasty

Reinforce the posterior wall and reconstruct the

internal ring with a prolene mesh

Specific Complications of inguinal hernia

repair

Urinary retention

Bruising

Pain

Haematoma

Infection

Ischaemic orchitis – 0.5%

Recurrence – <0.5%

Femoral Hernia • 3rd common type

• 20% of hernias in females

• 5% of hernias in males

• Most liable to become strangulated due to

1. Narrow neck

2. Rigidity of femoral ring

• Neck is below and lateral to pubic tubercle

Clinical Features • 20-40 years of age

• Small in size

• Sometimes painful

(before strangulation)

Surgical Anatomy

Urgent operation (Give early date)

– Due to constant risk of strangulation

Treatment

Incisional Hernia

Umbilical Hernia

TYPES: 1. Congenital Umbilical Hernia

2. Acquired Umbilical Hernia

3. Para Umbilical Hernia

Congenital Umbilical

Hernia Para Umbilical Hernia

Congenital Umbilical Hernia

Minor defects in neonates are common but

usually repair spontaneously.

In older children

– Tend to have a narrow neck and folds of peritoneum

stuck within this neck

– Can get strangulated

– Most resolve before puberty

– Only repaired in symptomatic children

Acquired Umbilical Hernia

May be caused by,

– Pregnancy

– Ascites

– Ovarian cysts

– Fibroids

– Bowel distension

More commonly require surgical repair.

Scrotal Lumps

Differential diagnosis:

– Inguinoscrotal hernia

– Epididymal cyst

– Spermatocele

– Testicular tumours

– varicocele

Scrotal Lumps

Epiddymal Cyst

Scrotal Lump

Hydrocele

Scrotal Lump

Varicocele

Examination of Scrotal Contents

Inspection

Note ;

• Size

• Shape

• symmetry

Palpation

-Gently support scrotum on fingers

-Feel testis and other lumps between index finger

and thumb (Do not squeeze)

-Does the scrotum have two testis?

-Testis has unique sensation to the patient

-Can you define the testis and epididymis?

If it is a Scrotal Lump –

• Is it confined to the scrotum? – Can you

get above it?

• Does the lump transilluminate?

• Does it have an expansile cough impulse?

• Is it Tender?

THANK YOU