LIDIA IONESCU3rd.Surgical Unit

HERNIA= a protrusion of an organ through its containing wall Herniation of the muscle through its fascial covering Herniation of the brain through a fracture of the

skull Herniation of an intra-abdominal organ through a

defect in the abdominal wall, pelvis or diaphragm-the term “hernia” is used to describe an abnormal opening in a patient’s muscle that will allow tissue or organs to pass through the opening in the muscle

Common types: Inguinal Umbilical Femoral Incisional hernia

Less common types: Epigastric Spigelian Obturator

FAILURE TO DIAGNOSE ANY TYPE OF STRANGULATED HERNIA

COMMON OR RARE

MAY LEAD TO THE PATIENT’S DEATH

Irreducibility- bowel obstruction- incarcerated bowel

Strangulation – bowel obstruction + necrotic bowel  

Inguinal hernia is common in men

Femoral hernia is more common in women

Occur at weak spots in the abdominal wall

Reduce on lying down or with direct manual pressure

Expansive cough impulse

Defects in the abdo wall: Structures pass through: indirect inquinal,

epigastric Muscles fail to overlap: spigelian, lumbar No muscles, only scar tissue: umbilical hernia

Loss of tissue strength: Direct inquinal hernia

Increased intra-abdo pressure Trauma

This type of hernia accounts for the vast majority of hernia surgical repairs.

An inguinal hernia is located in the inguinal region of the body where the thigh meets our pelvis.

The most common types of inguinal hernias are either direct or indirect hernias and these are found more often by far in men rather than women.

It is possible to develop three types of hernia in, or close to the inguinal region: direct inguinal; indirect inguinal; femoral.

Each opening (the deep and superficial inguinal rings) is visible and “protected” by two of the muscle layers.

The muscles and their aponeuroses were clearly defined and two of them (internal oblique and transversus abdominis) could be seen arching over the canal to form its roof and then its posterior wall (conjoint tendon).

Reducible hernia- hernia content can be pushed back into the abdomen

Irreducible hernia-incarcerated hernia- hernia content cannot be pushed back

Obstructing hernia- hernia containing a loop of bowel that is kinked and therefore obstructed

Strangulated hernia-the tissue contained in the hernia is ischemic due to interruption of the blood supply

Sliding hernia-when the wall of the hernia sac in part formed by the wall of another intra-abdominal organ( colon, bladder)

Richter’s hernia-one side of the bowel wall is trapped in the hernia

Intestinal obstruction- a loop of bowel passes through the abdo. wall defect and becomes mechanically obstructed.

Intestinal strangulation with gangrene/perforation – vascular pedicle to the herniated loop of bowel is also interrupted

Superficial inguinal ring- triangular defect in the aponeurosis of the EOM and the pubic crest

Deep inguinal ring- an oval opening in the fascia transversalis, 1,3 cm. above the mid-inguinal ligament. Medially- inf. epigastric vessels

Inguinal canal- oblique passage through the lower part of the anterior abdominal wall Spermatic cord Round ligament

1. Inguinal canal 2. Spermatic cord 3. Testis 4. Uterus 5. Round ligament 6. Lymph vessels 7. Superficial

inguinal nodes 8. Deep inguinal

ring 9. Superficial

inguinal ring

4 cm. long, between deep and superficial rings

Anterior wall- EOM aponeurosis Inferior wall- inguinal ligament Superior wall- conjoint tendon Posterior wall- transversalis fascia Hesselbach’s triangle- within the

posterior wall: inf.epi.art.- inguinal lig.-lateral border of the rectus sheath

Indirect inguinal herniae Passes through the deep inguinal ring, down

the inguinal canal May extend into the scrotum 5 times commoner than direct hernia

Direct inguinal hernia Passes through the Hesselbach triangle Posterior to the spematic cord Does not pass into the scrotum Less often associated with strangulation

Gender- all ages Occupation- heavy works Local symptoms- dragging sensation in

the groin Systemic symptoms- obstructive hernia-

vomiting, distension, colicky abdominal pain, absolute constipation

Position- above the inguinal ligament Tenderness- if strangulated Shape- “pear-shaped” with the “stalk” at

the external inguinal ring Composition- soft-gut, firm-omentum. Cough impulse Reducibility

Look for causes of a raised intra-abdominal pressure: Chronic bronchitis- caughing Chronic retention of urine- difficulty in micturition Chirrhosis - ascites Intra-abdominal masses

Look for signs of intestinal obstruction:- Abdominal distention- Visible peristalsis- High-piched bowel sounds

Femoral hernia

Vaginal hydrocele

Undescended testis

Lipoma

Femoral canal – space containing lymphatic and fat tissue

Femoral ring: inguinal ligament, Cooper’s ligament, pectineal line, femoral vein

Femoral ring is rigid- strangulation more likely

The bulge can be palpated in inguinal crease, below inguinal ligament

Obese patients- difficult to palpate Think to a complicated femoral hernia in

an obese patient with painful femoral area and bowel obstruction symptoms

More common in women Related with physical effort

Age - uncommon in kids Gender -women more affected Position - below and lateral to the pubic

tubercle Tenderness - not tender unless complicated Shape and size - spherical, small Surface - smooth Reducibility- firm pressure Cough impulse - tight ring- less likely

Inguinal hernia

Enlarged lymph nodes

Sapheno-varix

Ectopic testis Psoas abscess Lipoma

This type of hernia occurs at the level of the naval and are usually the result of the failure of the abdominal wall defect to close after the patients umbilical cord falls off as an infant. Most of these hernias defects will close in childhood by the age of 3-5.

Remaining umbilical hernias however can enlarge over time and require repair in the adult patient.

90% of cases, defects are closed by the age of one year

99% by 2 years of age

Surgery is contraindicated below the age of 3 years

Adult hernia through the umbilical scar

Secondary to a raised intra-abdominal pressure

Congenital umbilical hernia

Acquired umbilical hernia

Para-umbilical hernia

Acquired umbilical hernia

Appears through a defect that is adjacent to the umbilical scar

This type of hernia  is a rare form of hernia defect that can occur at the level of the umbilicus but actually lateral to it.

These hernias are often difficult to diagnose

Protrusion of extraperitoneal fat through a defect in the linea alba

Between xiphisternum and umbilicus More frequent in men In obese patients difficult to palpate Epigastric pain

This hernia is the result of a separation of the muscle layers at the site of a previous surgical incision.

The hernia defect may appear shortly after a surgical procedure or many years after a surgical procedure has been performed.

Several risk factors that are associated with the development of an incisional hernia: wound infection at the time of the original surgery, obese patient, diabetes, chronic steroid use, resumption of strenuous activity following the initial surgical

procedure before the muscular closure has had time to heal properly.

Hernia through an acquired scar in the abdominal wall

Caused by a previous surgical operation with complicated wound: Hematoma Infection

Lump at the level of a scar

Tender lump if complicated: irreducibility or obstruction

Non complicated incisional hernia is reducible with cough impulse

This type of hernia is typically a result of the muscles of an old incision breaking down.

An incision in the abdominal wall will always be an area of potential weakness

When the incision breaks down an incisional hernia develops.

An incisional hernia may occur at any site where an operation has been perfomed previously.

The scar represents a weakened area, which if stretched over time, may allow the underlying intestines to bulge through. Repair is often necessary.

Cooper's hernia: a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing immediately beneath the skin.

Littre's hernia: a hernia involving a Meckel’’s diverticulum . It is named after

the French anatomist Alexis Littre (1658-1726). Lumbar hernia: a hernia in the lumbar region (not to be confused with a

lumbar disc hernia), contains the following entities: Petit's hernia: a hernia through Petit's triangle (inferior lumbar triangle). It

is named after French surgeon Jean Louis Petit (1674-1750). Grynfeltt's hernia: a hernia through Grynfeltt-Lesshaft triangle (superior

lumbar triangle). It is named after physician Joseph Grynfeltt (1840-1913). Obturator hernia: hernia through obturator canal

Pantaloon hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels.

Amyand’s hernia- appendix in the inguinal hernia sac

Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space.

Richter’s hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation leading to perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter (1742-1812).

Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved.

Spigelian hernia, also known as spontaneous lateral ventral hernia. Sport’s hernia: a hernia characterized by chronic groin pain in

athletes and a dilated superficial ring of the inguinal canal. Velpeau hernia: a hernia in the groin in front of the femoral blood

vessels

An 85-year-old-male arrived at hospital presenting a right groin mass.

His history included hypertension, coronary artery disease, of which all were receiving regular medical treatment. Additionally, he had recently experienced urinary frequency and nocturia.

A right groin mass had been protruding for 1 month prior to hospital admission, which increased in size when standing and before stool passage, but decreased in size after stool passage or lying down. Mild tenderness had been noted for 1 week. The mass was not reducible.

Impression was inguinal hernia and the patient was admitted for surgical intervention.

Laboratory data were within normal limits. Blood pressure was well controlled.

The patient was scheduled for elective surgery.

The oblique conventional incision between external and internal rings was used to achieve a better approach. An appendix was found completely within the indirect sliding hernia sac .

The distal end of the appendix was trapped by the external ring, leaving a mark on the appendix.

The body and base of the appendix was healthy and a moderate amount of clear ascites was found in the hernial sac.

The distal portion of the appendix was attached to the distal portion of the hernial sac, which lay outside the external ring of the right groin.

The mobilized cecum and ascending colon were far away from the paracolic space, apparently sliding until occupying the neck of the hernial sac.

Appendectomy was performed and hernioplasty was done instantly with Bassini’s method.

The patient’s postoperative condition was uneventful and he was discharged on the next day.

He was followed up at our OPD one week later and the right groin looked good. Pathology revealed an acute suppurative appendicitis

Amyand’s hernia is defined as an uninflamed appendix in an inguinal hernia.

This rare condition was named after the first surgeon to perform appendectomy, Claudius Amyand, an English surgeon of the 18th century who first described this condition.

The incidence of Amyand’s hernia is estimated to occur in approximately one percent of adult inguinal hernia repair cases.

Acute appendicitis occurs much less frequently, and perforated appendix and periappendicular abscess formation within an inguinal hernia sac is an extremely rare clinical entity.