hernia

Abdominal Wall HerniaEssentials

MA MURPHY FRCSI

Back to Department of Surgery Trinity College Dublin


Objectives Understand the term hernia Basic anatomical knowledge Clinical features of common hernia Complications of hernias Examination of a hernia Differential diagnoses of a lump in the

groin Management of hernia


Hernia

A protrusion of an organ or tissue outside its’ normal compartment


Common External Hernias ABDOMINAL WALL & GROIN

Midline• Umbilical• Para- umbilical• Epigastric

Inguinal• Direct/ Indirect/ Combined

Femoral Incisional


Common Presentations A lump

Comes and goes Appears on straining /coughing

A pain Dragging pain/ Pain on exertion

Incidental finding on examination/ imaging Presenting as a complication

Incarceration/ Intestinal obstruction


Inguinal Hernia Commonest external hernia Male preponderance Infant / adult Direct / indirect / combined Weakness / increased pressure Cause pain / discomfort Carry risk of complications Treated surgically


Inguinal Hernia - History

OBJECTIVES Establish differential diagnoses Identify risk factors and significant co-

morbid pathologies (e.g. increased intra-abdominal

pressure due to ascites or chronic airways disease)


Inguinal Hernia - History Onset Duration Symptoms Other hernia(e) Irreducibility Gastrointestinal system Respiratory system Surgery / anaesthesia


Inguinal Hernia - Examination Surface markings

Anterior superior iliac spine

Pubic tubercle

Midpoint of inguinal ligament


asis

pubic tubercle

midpoint of inguinal liagament


Inguinal Hernia - Examination

OBJECTIVES Confirm diagnoses Out rule differentials Establish type Determine contents Reducibility Identify co-morbid pathologies


Direct V’s Indirect Direct Post wall Less common Older Smaller Hesselbachs Medial Lower risk

Indirect Deep ring 70% Congenital Scrotal Deep ring Lateral Strangulate


Inguinal Hernia Examination

Standing / Lying Supine Cough impulse Reducibility Contents Bowel sounds Scrotal contents


Differential Direct /Indirect/Combined Femoral hernia Hydrocele Lipoma Lymph node Testicular tumour Saphenous varix


Inguinal Anatomy The inguinal canal represents the

oblique passage through the anterior abdominal wall of the vas deferens (round ligament)

It is 5cm long and lies directly above the medial half of the inguinal ligament


Inguinal Anatomy Floor

• Transversalis fascia• Medially the conjoint tendon

Roof• External oblique aponeurosis• Laterally the conjoint tendon• Skin and superficial fascia

Above • Conjoint tendon

Below• The inguinal ligament


Inguinal Anatomy Three nerves

• Ilio-inguinal (on not in)• Sympathetic fibers• Genitofemoral

Three layers of fascia• Internal spermatic (transversalis f.)• Cremasteric (conjoint tendon)• External spermatic (ext. oblique)


Inguinal Anatomy Three arteries

• Testicular (from the aorta)• Artery of the vas (external iliac)• Cremasteric (inferior epigastric)

Three other structures• The vas deferens• The pampniform plexus of veins• Lymphatics (to aortic nodes)


TESTIS CORD STRUCTURES


Inguinal Anatomy


Hernia Anatomy


Indirect Hernia


Direct Inguinal Hernia


Hernia Complications Incarceration

Strangulation

Intestinal obstruction


Varieties of Hernias Maydls

• W loop of intestine Richters

• Partial inclusion of intestinal wall

Sliding hernia• Bladder• Sigmoid colon/ appendix


Richters’ Hernia


Maydls’ Hernia


Hernia Management Investigations

None required for routine uncomplicated case

Plain X-ray for suspected bowel obstruction

Ultrasound in case of diagnostic uncertainty

Herniogram rarely used Routine pre-op investigations


Hernia Treatment Surgery

To relieve symptoms To prevent complications

Operations Open hernia repair Laparoscopic hernia repair

Pre-peritoneal Intra- abdominal


Open Hernia Repair Day-case surgery Anaesthesia

General Local

Operations Tension free Mesh repair

(Lichtenstien) Darn repairs (Shouldice, Bassini)


Open Hernia Repair Incision above medial half of inguinal

ligament External oblique opened from external

ring to expose the cord and overlying ilioinguinal nerve

Internal (deep) ring exposed Hernial sac identified and reduced Prolene mesh inserted to reinforce

posterior wall and deep ring


Open Hernia Repair


Laparoscopic Repair


Surgery Complications Trauma

• Nerve• Artery (testicular atrophy)• Intestine

Haemorrhage• Haematoma (infection)

Infection• Wound infection• Chest Infection


Femoral Hernia Herniation through femoral canal Appears below and lateral to pubic

tubercle Relatively uncommon Commoner in females Contains omentum or small intestine High risk of strangulation Repaired surgically


Femoral Hernia


Femoral Hernia Repair


Summary Inguinal hernia is the commonest

external hernia Indirect hernias have a higher risk of

strangulation Hernias are treated by surgery, to relieve

symptoms and prevent complications Femoral hernias have a high risk of

strangulation


Recommended Reading Ellis H. Clinical Anatomy www.vesalius.com

http://www.vesalius.com/

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