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Rob Padwick MRCS MMedEdSpR General Surgery
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Definition of hernia Overview of types of hernia Presentation and Management of common types of hernia
Quick overview of the rest
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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
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Via natural orifices Via natural ‘weaknesses’ Via iatrogenic orifices Via iatrogenic ‘weaknesses’
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Hiatus Inguinal Femoral Umbilical/
Paraumbilical Epigastric Incisional Parastomal Perineal
Spygelian Lumbar Obturator ‘Internal’ Other
diaphragmatic herniae
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• Nothing• Lump• Pain• Incarcerate;
– Something gets stuck• Obstruct;
– Something gets stuck and blocks off• Strangulate;
– Something gets stuck and loses its blood supply
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VERY COMMON! Via Oesophageal hiatus Most commonly stomach Occasionally transverse colon or small
bowel if very large Rarely cause major problems
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• Types;– Rolling– Sliding
• Presentation;– Asymptomatic– Heartburn– Acid reflux– Cough– Chest symptoms if very large
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Diagnosis
•Chest X-Ray•Barium Meal•CT•OGD
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Complications; Barrett’s Oesophagus Obstruction/incarceration/strangulation (rare)
Treatment; None PPI Nissen’s Fundoplication
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• Site;– Inguinal canal– Right/Left groin
• Types;– Direct– Indirect
• Causes;– Congenital– Raised intra-abdominal
pressure
M>>F
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Contents; Spermatic Cord;
Vas deferens Testicular artery and veins Pampiniform plexus Artery to the Vas
Ilioinguinal nerve Genital branch of Genitofemoral nerve Iliohypogastric nerve
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Presentation; Lump Pain Bowel obstruction Scrotal symptoms
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Take the ‘Indirect’ route; Exit abdomen via deep ring Through whole inguinal canal Exit superficial ring May enter scrotum
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Take the ‘Direct’ route; Exit abdomen via Hesselbach’s Triangle Exit superficial ring Do not enter scrotum
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Complications; Pain Incarceration Obstruction Srangulation
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Treatment; Conservative (e.g. Truss) Surgery;
Open Laparoscopic
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• Complications of Surgery;– Bleeding– Infection– Pain– Bruising– Parasthesia– Recurrence– Testicular problems;• Small ball• Blue ball• Black ball• No ball
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Site; Into the femoral canal Via the femoral ring
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Presentation; Lump Pain Symptoms of obstruction
Treatment; Surgery
F>M
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Site; Midline Into umbilical skin
Umbilical; Relatively rare Most commonly in children Congenital defect
Paraumbilical Very common!
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Presentation; Usually asymptomatic Lump Pain
Treatment; Vast majority need none Repair if troublesome – most commonly
contain omentum only
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Site; Midline Above paraumbilical herniae Rest see above
NB Divarication of rectus
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Site; Via any surgical incision
Treatment; Depends on whether causing problems Leave alone Surgery
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Site; Around stoma
Treatment; Conservative Surgery;
Repair Resiting stoma
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• Site;– Via perineal orifices;• Vagina• Rectum
• Presentation;– Pain– Feeling of lump descending– Urinary symptoms– Bowel Symptoms
• Treatment;– Conservative– Surgery
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• Spygelian;– Through linea semilunaris
• Lumbar;– Petit (inferior)– Grynfeltt (superior)
• Internal• Obturator;
– Through obturator canal• Other diaphragmatic herniae;
– Bochdalek– Morgagni
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