Hernia

General Surgery, Renhe Hospital, Three Gorges University，

Zhang-Xianlin

Hernia

Definition ：• Protrusion of an organ (intestine ,brain)

or tissue outside its normal body cavity or constricting sheath .

• Abdominal hernia is the protrusion of the abdominal content outside abdominal wall.

Causes of Abdominal Hernia

1. Anatomical defect of the abdominal wall.

2. Acquired weakness of the abdominal wall .

Surgical Anatomy

rectus abdominis(腹直肌 )

Rectus sheath（腹直肌鞘）

External oblique(腹外斜肌 )

pubic symphysiscrural ligament

Surgical Anatomy

脐 bellybutton

chorda spermatica

outer ring

inner ring

腹股沟解剖

inguinal groove

Surgical Anatomy

股管解剖 femoral canal

Surgical Anatomy

Types of Abdominal Hernia

Epigastric

paraumbilical

Umbilical

lumbar

Spigelian(半月疝 )

femoral

inguinal

The Basic Feature Of All Hernias

• They occur at a weak spot .• They reduce on lying down ,or with direct pressure. • The have an expensile cough impulse.

A hernia consist of 3 parts:

1.Sac:

consist of a diverticulum of peritoneum.

2.Contents:

Omentum, small or large intestine, urinary bladder, Omentum, ovaries malignant nodules or ascetic fluid.

3.Coverings:

derived from the layers of abdominal wall.

Complications Of Hernias

• Irreducible

• the hernia contents cannot be manipulated back into the abdominal cavity.

• Incarcerated • the contents of the sac are literally inpresiond in the sac of Hernia.

• Obstruction

• the loop of the bowel become non functioning with normal blood supply .

• Strangulated

• cut off the blood supply to the content sac (tender).

Inguinal Hernia

Protrusion of abdominal contents through the inguinal region

Inguinal Hernia

Differences between indirect and direct hernia

featureindirectdirect

agechildren, young peopleaged people

pathway of protrusioncoming down the inguinal canal, may enter the scrotum

pass through Hesselbach’s triangle, rarely enter the scrotum

contours of sacelliptic, pear-shapedsemispheric, wide base

compress the internal ring after reduced

controlled not controlled

ReducedUpwards, laterally and back ward

Upward and strait backward

Relationship of sac neck with inferior epigastric artery

Sac neck is lateral to it Sac neck is medial to it

Incarcerated incidence

highlow

Inguinal Hernia in Children

Most common is indirect hernia • Patent processes vaginalis

1. Inguinal hernia

2. infantile hydrocele

3. An encysted hydrocele of the cord

• Hydrocele Vs Hernia • More in premature infants

Treatment Notes

• Incarcerated hernia in infancy can almost always be managed by manipulative reduction with subsequent scheduled herniotomy.

• The one exception is In baby girl because the ovaries may be part of the sac content.

Special Varieties of Inguinal Hernia

• Pantaloon Hernia • Maydl’s Hernia • Sliding Hernia • Richter’s Hernia • Litter’s Hernia

Femoral Hernia

Left Femoral Hernia

Femoral Hernia

• Protrusion of abdominal content through the femoral canal .

• More common in females.

• Below and laterally to the pubic tubercle.

• Narrow neck High risk for strangulation.

CASES Case (1) - Asymptomatic, reducible groin swelling in the elderly A 71-year-old man, who has had two myocardial infarcts and

hypertension, presents with a groin bulge, present only when he coughs. It has never been painful.

Case (2) - Asymptomatic reducible groin swelling A fit 34-year-old policeman presents with a three month history of a

progressively enlarging inguino-scrotal swelling. It has not been painful but is becoming more difficult to reduce digitally.

Case (3)- Irreducible groin swelling This otherwise fit 92-year-old lady noticed a groin swelling six

months ago. At first it reduced spontaneously when she lay down but for the past four weeks it has been present constantly, is irreducible, and she now has twinges of pain.

DDx of Lump In The Groin

1. Inguinal Hernia 2. Femoral Hernia3. Enlarged lymph node 4. Sapheno –varix 5. Ectopic testis 6. Psoas abcess7. Psoass bursa 8. Lipoma

Ask in your History

• Lump: duration, first symptoms, associated symptoms, progression, persistent ,other sites ,cause

• Does it reduce on lying down? • Have there been episodes of pain in the swelling? • Have there been episodes of abdominal pain? • Does the patient have any febrile symptoms?• History of rectal bleeding • History of trauma or septic focus in the lower limbs • Causes of increase of intrabdominal pressure • Previous surgeries ?

Physical Exam• Before Physical Exam,pay attention to: • Introduce your self ,• Take permission,

• Patients privacy ,

• Position standing up

• Exposure bilateral inguinal region and the groin

Physical Exam• From in front :1. Inspection lump: site, shape scrotum: does it extend to the

scrotum 2. Palpation : (decide is it hernia or not)Ask the patient about pain before you palpate • Can you go above it• Can you palpate the testis • If it is a hernia type • Define pubic tubercle

Can you go Above it?

Physical Exam

Physical Exam• Feel from the sides

1. Aim to examine the lump

( tenderness, temperature, size ,shape, site, composition (

2. Reducible?? How?? Ask the pts if you couldn’t

3. Controlled when you pressure over deep inguinal ring ?

4. Expensile cough impulse

5. Direction of reappearance

Physical Exam

Physical Exam• Percussion of the sac

• Auscultation of the sac

• Feel the other side

• Abdominal examination

• Cardiovascular and respiratory assessment

Treatment of groin hernias

Approach• conservative (reassure the patient) • a truss (now a rare treatment option) • OperateTreatment of groin hernias can be summarized: • Direct inguinal hernia - rarely operate unless

there is a specific indication. • Indirect inguinal hernia - usually operate. • Femoral hernia - always operate unless there is

a contraindication.

Treatment of groin hernias

• Direct inguinal hernia Most require no treatment. Patients with pure direct inguinal bulges are at

virtually no risk of complications. Most are elderly and reassurance is usually appropriate.

• Indirect inguinal hernia Most require operative treatment as the risks of irreducibility and obstruction

are higher. Advise repair unless the patient’s general health is such that the risks of operation outweigh the possible benefits.

The operation for inguinal hernia may be: 1. sutured, e.g. Bassini, Shouldice 2. open mesh, e.g. Lichtenstein 3. laparoscopic mesh, e.g. TAPP (transabdominal preperitoneal), TEP (total

extra peritoneal) 4. in babies, simple herniotomy is all that is required.

Femoral hernia repair

Femoral hernia treatment :

1. high approach

2. low approach

3. inguinal approach

Left Femoral Hernia

Direct inguinal Hernia

lump

Right Indirect Inguinal Hernia

www.icareunit.com

包块 lump

Left Indirect Inguinal Hernia

Left Indirect Inguinal Hernia

Bilateral indirect inguinal hernia

Bilateral indirect inguinal hernia

Emergency presentation with small bowel obstruction, tender irreducible groin swelling

A previously fit 58-year-old woman has been aware of a groin hernia for several years. It has recently become irreducible. Today it has become acutely painful and she has colicky abdominal pain, distension and vomiting. She has now become confused, clammy, hypotensive and oliguric

What is you approach?

Epigastric Hernia

• It occurs through the linea alba midway between the xiphisternum & the umbilicus.

• It is a protrusion of extraperitonial fat from the site of entry of a small blood vessel through the linea alba (fatty Hernia of linea alba).

• It is usually small in size, it may drag a pouch of peritoneum to form a true hernia.

Epigastric Hernia

• The neck is usually too small to allow a hollow viscous to enter it, consequently the sac is empty or it contains small part of omentum. (not true hernia )

• It is probably as a result of sudden strain that tears the interlacing fibers of linea alba.

Epigastric Hernia

• Clinically; The patient is usually a manual worker, 30-50y in age, symptom less, incidentally discovered during routine exam

• Pain & tenderness is due to strangulated fat.

• Referred pain & dyspepsia is most probably related to DU, GS etc.

• Treatment: Excision & repair of defect.

Epigastric Hernia

Umbilical Hernia

• True umbilical Common in children.

• Intestinal obstruction extremely rare.

• Surgical repair if persisted after 3rd birthday .

Para-umbilical hernia

• Para umbilical usually middle age women obese or multiparous

• It is a protrusion through the linea alba just above or the umbilicus. As it enlarges it sags downward and can attain a large dimensions

• The neck of the sac is narrow as compared with the size of the sac & it’s contents ( om-entum, small intestine or part of the colon). Usually loculated due to adhesions.

Para-umblical Hernia

• Clinically; more common in women, obese, multiparous & 35-50y of age.

• It becomes irreducible due to adhesions & strang-ulation may occur. Pain colicky or dragging.

• The skin over it becomes reddened, smooth & may become excoriated.

• Treated by division of adhesions. & repair of defect “Mayo’s repair”

Para-umblical Hernia.

Para-umlical Hernia

Paraumlical Hernia

Incisional Hernia

• Protrusion through surgical wound • Occur after 3-5% of abdominal operation • Causes

1. Midline ,vertical incision

2. Poor technique

3. Wound or chest infection

4. Obesity • Strangulation is rare but repair is advisable

Incisional hernia.

Thank You