hernia

HERNIADR BASHIR YUNUS

Surgery resident

AKTH

4/23/[email protected]

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DEFINATION

The abnormal Protrusion of a viscous or part of it from the wall of the cavity in which it is enclosed through an abnormal or weak opening.


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AETIOLOGY

1. Congenital – preformed sac- processus vaginalis

2. Defect in or weakness of, the wall of the abdominal cavity which predispose to it.

Ageing

Infection with resulting weak scar

Multiple pregnancies

Obesity

Injury to nerve e.g gridiron incision


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AETIOLOGY

3. Increase in intra-abdominal pressure

• Causes of straining

Chronic cough

Chronic urinary obstruction

Chronic constipation

• Ascites

4. Familial collagen disorder- prune belly syndrome


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PATHOLOGY

Comprises of :

Covering

Sac

ContentThe sac is a diverticulum of the peritoneum with mouth, neck, body and fundus.


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PATHOLOGY

• Hernias without neck and large mouth; incisional hernia and direct hernia

• Hernias without sac – epigastric hernia-protrusion extra peritoneal fat.

• The body of sac is thin in children and indirect sacs but thick in long standing and direct hernias.


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Contents of hernia sac• Omentum – omentocele- difficult to reduce the

later part, initial part may reduce easily.• Intestine – enterocele• Two loops of intestine in a manner of W -Maydl’s

hernia• Appendix – may become adherent and rarely acute

appendicitis occur.• Meckel’s diverticulum – litter’s hernia• urinary bladder-cystocele or as sliding hernia

when it forms part of the wall. • Adnexia• Fluid – from congested bowel or omentum


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complications

1. Irreducibilityadhesionoedemasliding herniaimpacted faecesnarrow neck

2. Obstruction 3. incarceration4. Strangulation5. Rupture of sac – trauma, pressure necrosis of

overlying skin6. Fistula formation – Richter's hernia


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Complications

6. Reduction –en- mass

7. Hemorrhage

8. Hydrocele of sac

9. Extension of intra abdominal inflammation

10.Extension of intra abdominal tumour.

11. Torsion of omentum


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INGUINAL HERNIA

• ANATOMY

• TYPES

• CLINICAL FEATURES

• DIFFENTIAL DIAGNOSIS

• TREATMENT

• POST-OP. COMPLICATION


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INGUINAL REGION4/23/2015

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[email protected]


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INGUINAL CANAL

• A canal 4cm long located in the lower part of the anterior abdominal wall above the groin, directed downwards, medially and forward.


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INGUINAL CANAL

Embryology – formed from the herniation of the gubernaculum testis and the processus vaginalis which makes it possible for the testis and spermatic cord to pass from the abdomen to the scrotum in males and the round ligament to the libiamajus in female.


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INGUINAL CANAL

• EXTENT

Deep inguinal ring(U-shaped opening on the transversalis fascia 1.25cm above and perpendicular to the mid inguinal point) to the superficial inguinal ring (opening on the external oblique aponeurosis).


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INGUINAL CANAL

• BOUNDRIESAnterior wall is formed by the aponeurosis of the external oblique, and reinforced by the internal oblique muscle laterally.Posterior wall is formed by the transversalis fascia(re-enforced superficially aponeurotic fibers of transversus abdominis) and conjoint tendon medial half.Roof is formed by the internal oblique, transversus abdominis and transversalis fasciaFloor is formed by the inguinal ligament (a ‘rolled up’ portion of the external oblique aponeurosis) and thickened medially by the lacunar ligament.


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BOUNDRIES


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BOUNDRIES


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INGUINAL CANAL

• CONTENT

▫ Spermatic cord (men)

▫ Round ligament (women)

▫ Ilioinguinal nerve


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INGUINAL CANAL

Spermatic cord

The classic and memorable description of the contents of spermatic cord in the male are:• 3 arteries: cremasteric, differential and testicular art.• 3 nerves: genital branch of the genitofemoral nerve

(L1/2), autonomic and visceral afferent fibres, ilioinguinal nerve (N.B. outside spermatic cord but travels next to it)

• 3 fascial layers: external spermatic, cremasteric, and internal spermatic fascia.

• 3 other structures: pampiniform plexus, vas deferens (ductus deferens), testicular lymphatics


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Hesselbach’s Triangle(inguinal triangle)


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INGUINAL CANAL

• Hesselbach’s TriangleThe triangular part of the posterior wall of the inguinal canal.• Boundaries

▫ Inferior: Medial half of inguinal ligament▫ Medial: Linea semilunaris(lateral border of rectus

abdominis)▫ Lateral : Inferior epigastric artery

• Surgical importance▫ Not reinforced by conjoint tendon▫ Potentially weak area▫ Direct Inguinal hernias protrude through it


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NATURAL MECH. PREVENTING HERNIA

• Obliquity of the canal

• Internal oblique muscle opposite the deep ring

• Shutter action of the arched fibers of internal oblique and transversus abdominis

• Plugging action of the spermatic cord due to contraction of the cremasteric muscle

• Sliding valve action of the U-shape internal ring


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INGUINAL HERNIA

Inguinal hernias occur in the inguinal canal. Commonest hernia in both sexes. It occurs in 16% of males. It accounts for 95% of hernias in male and 40-50% of hernias in females.


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INGUINAL HERNIA

• TYPES

▫ Indirect

▫ Direct

An indirect inguinal hernia enters the inguinal canal through the internal inguinal ring and passes obliquely downwards and medially into the canal. Direct passes into the canal via Hesselbach’s triangle and so cannot normally pass through the external ring.


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DIFFERENCES BETWEEN DIRECT AND

INDIRECT HERNIAS1. Origin and coarse:

Direct: Develops in the area of Hasselbach's triangle. The origin is medially to the inferior epigastric vessels.

Indirect: Develops at the internal ring. The origin is lateral to the

inferior epigastric artery.

2. Content: Direct: Retroperitoneal fat. less commonly, peritoneal sac containing

bowel .

Indirect: Sac of peritoneum coming through internal ring, through which

omentum or bowel can enter.

3. Etiology: Direct: weakness of the posterior floor of the inguinal canal (acquired).

Indirect: patent processus vaginalis (Congenital) .


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INDIRECT INGUINAL HERNIA

• Usually congenital due to persistence in processus.

• May be acquired. May occur at any age in adult life.

▫ TYPES

Vaginal or complete

Incomplete - funicular

- bubonocele


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Vaginal hernia

▫ Also known as complete or scrotal hernia

▫ Processus vaginalis is patent through out

▫ Sac is continuous with the tunica vaginalis

▫ Hernia descends to the bottom of the scrotum

▫ Testis is not felt separately before reduction of hernia.


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Funicular hernia

• Processus vaginalis is closed at the lower end hence sac is separate from the tunica vaginalis

• Testis is felt separately from the content of the sac.

• Most indirect hernia belong to this category and commonly seen in adults.

• Usually acquired but may be congenital

• Appears as inguino-scrotal as in vaginal.


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Bubonocele

▫ Processus is closed at the external ring

▫ Hernia is limited in the inguinal canal hence appear as inguinal swelling.


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COVERINGS OF INDIRECT ING.HERNIA

• Skin

• Superficial fascia; when hernia comes out of external ring. Dartos muscle when in scrotum

• External oblique aponeurosis or external spermatic fascia when of external ring

• Cremasteric muscle

• Internal spermatic fascia

• Processus vaginalis or peritoneum.


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DIRECT INGUINAL HERNIA

• As mentioned above

• Lies outside the cord

• Mostly acquired

• Found predominantly in elderly males

• Seldom comes out through the external ring

• Appears immediately on standing and returns on lying down.

• Rarely strangulates


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COVERINGS OF DIRECT HERNIA

• Skin

• Superficial fascia

• External oblique aponeurosis

• Conjoint tendon when the sac passes medial to the lateral umbilical ligament

• Fascia transversalis

• Peritoneum- sac


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CLINICAL FEATURES

• Symptoms

▫ May be asymptomatic

▫ Swelling in the groin

▫ Pain- due to stretching of the deep ring by the protruding viscous.

NB: severe pain in swelling associated with abdominal pain indicates strangulation.


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CLINICAL FEATURES

• EXAMINATION

▫ Visible cough impulse

▫ Reducibility: unless complicated

▫ Deep ring occlusion test: distinguishes direct from indirect hernia.

▫ Extent: complete or incomplete

NB: pantaloon hernia- direct and indirect inguinal hernia co-exist.


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DIFFERENTIAL DIAG. OF GROIN

SWELLING• In males

▫ Femoral hernia▫ Vaginal hydrocele▫ Encysted hydrocele of the cord ▫ Malgaigne’s bulges▫ Ectopic or undescended testis ▫ Cyst of the epididymis▫ Inguinal lymphadenopathy▫ Saphena varix▫ Sebaceous cyst▫ Lipoma▫ Psoas abscess


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DIFFERENTIAL DIAG. OF GROIN

SWELLING• In female

▫ Femoral hernia

▫ Cyst of canal of nuck

▫ lipoma


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DIFFERENTIALS OF INGUINOSCROTAL

SWELLING• Infantile hydrocele

• Congenital hydrocele

• Encysted hydrocele of the cord

• Varicocele

• Lymph varix or lymphangiectasis of the cord

• funiculitis


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TREATMENT

• Non operative - conservative

• Operative

▫ Open

▫ Laparoscopic

• Post operative complications

• Causes of recurrence


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CONSERVATIVE

1. NO TREATMENT

▫ Severely ill with short life expectancy

2. TRUSS TREATMENT

▫ Prevent descent of content

MODE OF ACTION

Press anterior wall against posterior wall of ing. canal

compresses the deep ring

Causes adhesion of the sac with wall of canal


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CONSERVATIVE

INDICATIONS FOR TRUSS.

1. In infants: Except when associated with undescended testis

2. In old patient: when surgery is contraindicated

3. Those who refuse operative treatment


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CONSERVATIVE

CONTRAINDICATIONS FOR TRUSS

1. Irreducible hernia

2. Patient with source of chronic strain

3. Hernia with huge hydrocele

4. Hernia with undescended testis

5. Patients with poor intelligence and perseverance


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CONSERVATIVE

PROBLEMS OF TRUSS

1. Improper use leads to obstrution and strangulation

2. Improper cleaning leads to unhealthy skin

3. Prolong use leads to muscle atrophy

4. Adhesions


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CONSERVATIVE

TYPES OF TRUSS

1. RAT-TAILED

2. ADDER-HEADED


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CONSERVATIVE

METHOD OF USE

1. Should apply in lying down position after reduction.

2. Use constantly except when patient is in bed. It should be worn before getting off bed

3. The skin cover by pad and the perineum should be kept clean by daily toilet.


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CONSERVATIVE

• TAXIS

It implies vigorous manipulation in an attempt to reduce an acute obstructed hernia of short duration only but without any feature of intestinal obstruction or strangulation.


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CONSERVATION

• PROCEDUREBy an experience surgeonDone after admission in a hospitalPatient lying supine and foot of bed raised by 9 inch

blockAdequate analgesia: pethidine then wait for 20-30min

then give buscopanWhen well sedated, try to reduce the herniaObserve patient for 24-48hr (for obstruction,

strangulation or recurrence)During observation, patient is allowed plain water and

electrolyte orally onlyPlan for an elective operation.


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CONSERVATIVE

• DANGERS OF TAXIS

Reduction-en-mass

Reduction of content into the loculus of the sac

Contusion or rupture of content

Extra peritoneal reduction (when sac ruptures)


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OPERATIVES

▫ Operative treatment is the treatment of choice as there is risk of complications.

▫ In uncomplicated hernia, the source of strain should be treated first.

▫ In infant of few days old, wait until baby is 3month old.


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OPERATIVES

• Operation is the treatment of choice

▫ INDIRECT INGUINAL HERNIA

▫ The 3 essential requirements;

Herniotomy

Lytle’s repair

herniorrhaphy


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OPERATIVES

• HERNIOTOMY

▫ Separation of sac from cord srtuctures

▫ Reducing the content

▫ Transfixation and ligation of sac

▫ Excise the redundant sac

▫ NB; indirect sac is anteriolateral to the cord▫ It is done for infant and children, adolescent and young

adult with good musculature.


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OPERATIVES

• LYTLE’S REPAIR

• Tightening of the internal inguinal ring around the spermatic cord.

• Use prolene 2.o


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OPERATIVES

• HERNIORRHAPHY▫ Heniotomy +reconstruction of the posterior wall of the

inguinal canalI. LichtensteinII. Bassini repairIII. Shouldice repairIV. Nylon darnV. Mc Vay’sVI. Gilbert’s plugVII. Stoppas repairVIII.Kuntz operation


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OPERATIVES

• Lichtenstein ▫ Mesh repair of posterior wall

• Bassini▫ Suturing the cojoint tendon to the inguinal

ligament behind the cord with non absorbable monofilament preferably nylon

• Shouldice▫ Modification of Bassini▫ Multilayered(4layers) Bassini’s repair▫ 1st 2layers double breasting of transversalis fascia


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OPERATIVES

• Shouldice con’t.▫ 3rd layer is suturing the cojoint tendon to the

inguinal ligament▫ 4th layer involves suturing the anterior rectus

sheath and the cojoined tendon of the inner surface of lower leaf of external oblique muscle

▫ Best anatomical repair, least recurrence

• McVay’s▫ approximation of cojoint tendon with ligament of

cooper▫ Prevent both femoral and inguinal hernia


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POST-OP COMPLICATIONS

• INTRA-OPERATIVE▫ Injury to the external iliac or femoral vessels▫ Injury the vas deferens▫ Injury to the bladder and colon esp in sliding hernia▫ Injury to the inferior epigastric vessel▫ Injury to the content of the sac▫ Injury to the testicular artery

• EARLY POST-OP▫ Retention of urine ▫ Haematoma of cord and scrotum▫ Wound infection


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• LATE POST-OP

▫ Recurrence

▫ Sinuses

▫ Neuralgic pain- ilioinguinal nerve – hyperasthesiaover the medial side of the inguinal canal

▫ Painful scar

▫ Atrophy of the testis due to injury to testicular artery

▫ Ostetis pubis

▫ Mesh extrusion with or without foreign body reaction

▫ Epidermoid cyst


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CAUSES OF RECURRENCE

• Inadequate pre-op preparation▫ Persistent causes of straining ▫ Infection

Intra-operative▫ Tension repair▫ Low ligation of sac ▫ Inadequate lytle’s repair (in huge long standing

hernia)

Treatment of recurrence is via preperitonealrepair(there is fibrosis of the previous site). Can be open or laparoscopic(gold standard).


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Special hernias

• Sliding hernia(Hernia-en-glissade)

▫ The content forms part of the sac.

▫ Part of the posterior wall formed not only by the peritoneum but also by part of retroperitoneal structure. Eg urinary bladder, caecum, sigmoid colon.

▫ Features;

Old age

Long standing case

Left sided more common

Huge scrotal

Appears slowly after reduction


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• Significance of sliding hernia;

▫ Easily strangulated

▫ Failure to recognize the visceral component of the hernia sac during operation leading to injury .

Treatment

hernioplasty


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• Spigelian hernia▫ Hernia through the spigelian fascia; a strip of

fascia that runs parallel to the outerborder of rectus sheath from tip of the 9th costal cartilage to pubic tubercle.

• Richter’s hernia ▫ Only portion of the circumference become

protruded into the hernia sac.▫ Chance of strangulation without complete

obstruction of the lumen.▫ Diarrhea is seen in cases of strangulation


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• Littre’s hernia▫ Meckel’s diverticulum is seen in the sac

• Sacless hernia ▫ Epigastric hernia of the linea alba

• Dual hernia▫ Also known pantaloon/saddle bag hernia▫ Has two sacs direct and indirect hernia▫ Deep ring occlusion test may be confusing▫ One of the causes of recurrence, since the indirect

sac can be missed in repair of the direct.


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• Maydl’s hernia

▫ Also known as Hernia-en-W

▫ Two adjacent loops of bowel remain in the sac(look like W), the connecting portion remains inside the abdomen

▫ The connecting portion of the W is more vulnerable to strangulation


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• Ogilvie hernia

▫ Congenital direct hernia; through a rigid circular orifice in the conjoined tendon just lateral to where it insert into the rectus sheath.


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hernia

Health & Medicine

sac contentthe sac

body of sac

hydrocele of sac

abdominal cavity

anterior abdominal wall

large mouth incisional

external oblique

weak opening