Rob Padwick MRCS MMedEdSpR General Surgery

Definition of hernia Overview of types of hernia Presentation and Management of common types of hernia

Quick overview of the rest

What is the definition of a hernia?

An abnormal protrusion of a viscus from the body

cavity of its origin into another cavity of the

body

Via natural orifices Via natural ‘weaknesses’ Via iatrogenic orifices Via iatrogenic ‘weaknesses’

Hiatus Inguinal Femoral Umbilical/

Paraumbilical Epigastric Incisional Parastomal Perineal

Spygelian Lumbar Obturator ‘Internal’ Other

diaphragmatic herniae

• Nothing• Lump• Pain• Incarcerate;

– Something gets stuck• Obstruct;

– Something gets stuck and blocks off• Strangulate;

– Something gets stuck and loses its blood supply

VERY COMMON! Via Oesophageal hiatus Most commonly stomach Occasionally transverse colon or small

bowel if very large Rarely cause major problems

• Types;– Rolling– Sliding

• Presentation;– Asymptomatic– Heartburn– Acid reflux– Cough– Chest symptoms if very large

Diagnosis

•Chest X-Ray•Barium Meal•CT•OGD

Complications; Barrett’s Oesophagus Obstruction/incarceration/strangulation (rare)

Treatment; None PPI Nissen’s Fundoplication

• Site;– Inguinal canal– Right/Left groin

• Types;– Direct– Indirect

• Causes;– Congenital– Raised intra-abdominal

pressure

M>>F

Contents; Spermatic Cord;

Vas deferens Testicular artery and veins Pampiniform plexus Artery to the Vas

Ilioinguinal nerve Genital branch of Genitofemoral nerve Iliohypogastric nerve

Presentation; Lump Pain Bowel obstruction Scrotal symptoms

Take the ‘Indirect’ route; Exit abdomen via deep ring Through whole inguinal canal Exit superficial ring May enter scrotum

Take the ‘Direct’ route; Exit abdomen via Hesselbach’s Triangle Exit superficial ring Do not enter scrotum

Complications; Pain Incarceration Obstruction Srangulation

Treatment; Conservative (e.g. Truss) Surgery;

Open Laparoscopic

• Complications of Surgery;– Bleeding– Infection– Pain– Bruising– Parasthesia– Recurrence– Testicular problems;• Small ball• Blue ball• Black ball• No ball

Site; Into the femoral canal Via the femoral ring

Presentation; Lump Pain Symptoms of obstruction

Treatment; Surgery

F>M

Site; Midline Into umbilical skin

Umbilical; Relatively rare Most commonly in children Congenital defect

Paraumbilical Very common!

Presentation; Usually asymptomatic Lump Pain

Treatment; Vast majority need none Repair if troublesome – most commonly

contain omentum only

Site; Midline Above paraumbilical herniae Rest see above

NB Divarication of rectus

Site; Via any surgical incision

Treatment; Depends on whether causing problems Leave alone Surgery

Site; Around stoma

Treatment; Conservative Surgery;

Repair Resiting stoma

• Site;– Via perineal orifices;• Vagina• Rectum

• Presentation;– Pain– Feeling of lump descending– Urinary symptoms– Bowel Symptoms

• Treatment;– Conservative– Surgery

• Spygelian;– Through linea semilunaris

• Lumbar;– Petit (inferior)– Grynfeltt (superior)

• Internal• Obturator;

– Through obturator canal• Other diaphragmatic herniae;

– Bochdalek– Morgagni