HERNIA

Begashaw M (MD)

Introduction

Common surgical problem Adequate knowledge is important Prevent serious complications

Definition

– Is a protrusion of a viscus through an opening in the wall of the cavity

Component

Sac -Out pouch of the peritoneum-

-Four parts-Mouth,Neck,Body&Fundus

Content-viscus/organ inside a sac

- Small bowel and omentum – the commonest

- Large bowel appendix

- Bladder

CLASSIFICATION

Reducible - viscus can be returned back Irreducible - contents can’t be returned backObstructed - intestineis occluded but no

impairment of vascular supplyStrangulated - vascularity of viscus is impairedRichter’s - only one side of wall is herniatedSliding - extra peritoneal structure form part of

wall of the sac

HERNIAS

Risk factors

Increased intra abdominal pressure

- Chronic cough

- Straining at urination or defecation

- Heavy wt lifting

- Abdominal distension

Weakened abdominal wall

- Advanced age

- Malnutrition

- Congenital defect – ppv

- Trauma/surgery

Clinical features

History

- Lump

- Pain, local aching, discomfort

- Factors predisposing to increased intra abdominal pressure

- Symptoms of int. obstruction/strangulation

Physical examination

- Examine Standing & Lying

- Lump – reducible, cough impulse with bowel sound

- Reduced on lying & increases in size _coughing/ straining

- Obstruction – tense, tender, irreducible with absent cough impulse

- Strangulation – more tenderness, with warm indurated, and inflamed overlying skin

Examination

Investigation

a clinical diagnosis investigation is rarely needed

Complications

1. Irreducibility

2. Obstruction

3. Strangulation is a surgical emergencyRisk of obstruction and strangulation is

very high in femoral hernia, paraumblical hernia and indirect inguinal hernia with narrow neck

Principles of management

1. Herniotomy - removal of the sac and closure of the neck

- in infants and children

2. Herniorrhaphy - Herniotomy and repair of the wall to prevent recurrence

Obstruction

Non operative

-Gentle reduction

- Put patient in head down position

- Sedative is given

- Gentle manipulation to reduce the hernia Urgent Surgery

- Failed reduction

- All strangulated hernia

Strangulation

Anatomy-inguinal canal

Boundary

Anteriorly: External oblique apponeurosis

Posteriorly: Fascia transversalis

Inferiorly: Inguinal ligament

Superiorly: Conjoined tendon and internal oblique M Runs in antero inferior (InternalExternal ring)

_Internal ring -2cm above & 2cm medial to mid inguinal ligament

_External ring -just above pubic crest & tubercle

Anatomy

Anatomical site of groin hernia

Contents of inguinal canal

Male Spermatic vessels Vas deference Ileo inguinal nerve Genito femoral nerve

Female Round ligament

Anatomy of Femoral canal

Is a narrow rigid space Boundary

- Inguinal ligamentsuperiorly- Pectineal posteriorly- Lacunar mediallyF- Femoral veinlaterally prone to obstruction & strangulation

Inguinal hernia

- accounts for 80%

- commonest is all ages & sexes

- 20 x more common is males than women

- more common on right side

Classification

1-Indirect_passes through internal inguinal ring along the inguinal canal

-May extend down to the scrotum

2 -Direct_Bulges through post wall of inguinal canal

Classification

Hernia

Indirect inguinal hernia

- 60% on right- 40% Lt side - 20% bilateral- Due congenital defect

patent processes vaginalis

- 20 times more common in men

Direct inguinal hernia

- due to wear and tear associated - advanced age- increased intra abdominal pressure

Femoral Hernia

- acquired downward protrusion of intestinal contents into the femoral canal

- 4 times more common in females

- rare in children

Clinical features

History

- Elderly or middle aged woman

- lump on anterior and upper thigh

- may present with complaints associated with int. obstruction or strangulation

Physical examination

- Small lump on lower groin, lateral and below pubic tubercle

- Reducible/irreducibility

- Bowel sound/cough impulse – usually absent

Femoral hernia

Management

- surgical repair without delay

Umbilical Hernia

Umbilicus is one of the weak sites of the abdomen A hernia can occur at this potential site Risk factors

Female sex

Multiparity

Obesity

Ascites Complications

Obstruction

Strangulation

Rupture

Umblical hernia

Treatment

Expectant - Spontaneous closure is expected in 80% cases of umbilical hernia in under five children

SurgeryBeyond five years

Incisional Hernia

Risk Factors

-Wound infection

-Poor surgical technique (

-Chronic cough

-Straining

-Obesity

Clinical features

Risk of obstruction and strangulation is very rare

Local discomfortCosmetic problemsDifficulties with micturation and bowel

movement when very largeTreatment

Hernioplasty

Incisional hernia