Hernia

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Hernia

By: Zaid Hayder


Lecturer: Dr. Bassem Rassam
Hernia:
Definition:
A bulging of part of the contents of the abdominal
cavity through a weakness in the abdominal wall.

Etiology:
There are 2 main etiological factors that are required
for the development of a hernia:
1) Weakness
2) Excessive intra-abdominal pressure
In turn, this weakness could be due to:

• Basic design weakness (e.g: inguinal hernia)


• Weakness due to structures entering and leaving the
abdomen (e.g: the esophagus in hiatus hernia)
• Developmental failure (e.g: congenital diaphragmatic
hernia)
• Genetic weakness of collagen
• Sharp and blunt trauma
• Weakness due to ageing and pregnancy
• Primary neurological and muscle diseases
Pathology:

Any hernia consists of:


I. Defect in the abdominal wall: through which the sac
bulges out.
II. Sac: It is a peritoneal pouch protruding through the
defect & containing the protruded viscus. It consists of the
fundus, body and neck.
III. Content: almost any of the abdominal viscera can
herniate, but the most common contents are bowel
(referred to as enterocele) or omentum (referred to as
omentocele)
Omentocele vs Enterocele?
Omentocele Enterocele

1. Doughy or firm & slippery 1. Soft.


‫قرقرة‬
2. No gurgling on reduction 2. Gurgling on reduction .
3. Percussion → dull 3. Percussion → resonant
4. Easy reduction at first but 4. Difficult reduction at first
difficult at the end. but easy at the end.
Basic anatomy of the abdominal wall:
The roof of the abdomen is formed by: the diaphragm
separating the thoracic from the abdominal cavity.
Weakness of the diaphragm can lead to herniation of
bowel from the area of positive pressure (abdominal
cavity) to the area of negative pressure (thoracic cavity).

The bony pelvis forms the floor of the cavity but a


muscular central portion, the perineum, may also weaken
and allow rectum, bladder and gynaecological organs to
bulge downwards, a condition called prolapse.
Posteriorly the muscles are strong, but there are
two areas of weakness which can lead to rare
lumbar hernias. These two areas are the two
posterior lumbar triangles.
Anteriorly the two powerful rectus abdominus
muscles extend vertically from ribs to pelvis.
Herniation through these strong muscles does
not occur naturally but their central join, the
linea alba, is an area of weakness resulting in
epigastric and paraumbilical hernias.
Classifications of hernia:
Hernias can be classified according to:

I. Site:
External hernia vs Internal hernia
II. According to Complexity:

• Occult – not detectable clinically; may cause severe


pain
• Reducible – a swelling which appears and disappears
• Irreducible – a swelling which cannot be replaced in
the abdomen, high risk of complications
• Strangulated – painful swelling with vascular
compromise, requires urgent surgery
• Infarcted – when contents of the hernia have become
gangrenous, high mortality!
Key point…

The difference between Irreducible


hernia and strangulated hernia is that in
irreducible hernias, the blood supply is
NOT compromised, unlike strangulated
hernias, where the interruption in blood
supply may even lead to infarction!
Lecturer’s Notes:

1) To diagnose hernia, Two physical exam findings are characterstic:


• Reducibility
• A positive cough impulse, which is defined as expansion of a mass
in all directions when the patient is asked to cough. This finding is
typical of hernias.

2) However, not all hernias have a positive cough impulse (e.g: In


cases where the neck is tight and the hernia irreducible there may be
no cough impulse). And vice versa, not every cough impulse = hernia!
(Cough impulse can also occur in a saphena varix)

3) Small hernias can be more dangerous than large ones.


Diagnosis of hernia:

The diagnosis is CLINCAL. Signs that should be sought for in


clinical exam include:

• Reducibility
• Cough impulse
• Tenderness
• Overlying skin colour changes
• Multiple defects/contralateral side
• Signs of previous repair
• Scrotal content for groin hernia
• Associated pathology
Investigations:

For most hernias, no specific investigation is required. Only in


certain cases are investigations necessary:

Plain x-ray – of little value


US
CT – good for incisional hernias and obturator hernias.
MRI – good in sportsman’s groin with pain
Contrast radiology – especially for inguinal hernia
Laparoscopy – useful to identify occult contra-lateral inguinal
hernia
Management:
Like in neunate umbilical hernia that resolves spontaneously
after 2 years need only assurance

Not all hernias require surgical repair. Management of hernias


includes either expectant or surgical management, and the
choice of this treatment will depend on the type of hernia. This
will be discussed in detail later on.

In general, there are 3 types of surgical methods used in the Tx


of hernia:
The defect is exist it commonly for children not for adults

Herniotomy: Excision of the sac only.


Herniorhaphy: Excision of the sac + Edges of healthy muscle are
sutured to close the defect.

Hernioplasty: Excision of the sac + Re-enforcement by mesh.

(the use of propylene


mesh in Hernioplasty)
All surgical repairs follow the same basic principles:

1) Identification of the sac


2) reduction of the hernia content into the abdominal cavity
with removal of any non-viable tissue and bowel repair If
necessary
3) excision and closure of a peritoneal sac if present or
replacing it deep to the muscles
4) re-approximation of the walls of the neck of the hernia if
possible
5) permanent reinforcement of the abdominal wall defect with
sutures or mesh.
Strangulated hernias:

Definition: Interruption of the blood supply of the contents of


hernia.

• It is the most serious complication of hernias!!

• The commonest hernia seen strangulated is indirect inguinal


hernia as it is the commonest hernia, but the most liable hernias
to be strangulated are femoral and paraumbilical hernias, due to
their narrow neck.
Clinical features:

• Painful, tender, irreducible, tense mass.


• Absence of cough impulse
• Fever, N&V.
• Changes in the overlying skin (erythema, warmth,
edema)
• Features of shock!
• Features of intestinal obstruction
Diagnosis:

CLINICAL!!! There is no investigation that can reliably Dx


strangulation.

Treatment:

URGENT TREATMENT PLEASE! Treatment includes:


1) Resuscitation: Hospitalization, IV fluid, ABs, NG
decompression, foley catheter
2) Surgery
Viable bowel Non-viable bowel
Specific Hernia Types
Inguinal
Hernia
Anatomy of the inguinal canal:

The inguinal canal is a passage that starts from the


deep inguinal ring, extends medially and inferiorly
through the abdominal wall and ends in the superficial
inguinal ring.
As the testis descends from the abdominal cavity to the
scrotum in males, it firsts passes through the deep
inguinal ring into the inguinal canal.
With its descent, the testis will pull a tube of
peritoneum along with it. This peritoneal tube should
obliterate, possibly under hormonal control, but it
commonly fails to obliterate, either in part or totally.
This is known as persistent processus vaginalis, and it
explains the pathophysiology of indirect inguinal
hernia.
Walls of the inguinal canal:

• Anteriorly: skin, superficial fascia and external oblique


aponeurosis cover the full length of the canal; the internal
oblique covers its lateral third.
• Posteriorly: the conjoint tendon (representing the fused
common aponeurotic insertion of the internal oblique and
transversus abdominis muscles into the pubic crest) forms the
posterior wall of the canal medially; the transversalis fascia lies
laterally .
• Above (roof): the lowest fibers of the internal oblique and
transversus abdominis.
• Below (floor) : the inguinal ligament.
Important anatomical landmarks:

 Bony landmarks: ASIS, Pubic symphysis, pubic tubercle (2-3


cm lateral to symphysis)
 Mid-point of Inguinal Ligament lies midway between ASIS
and pubic tubercle. It serves as a landmark for the deep
inguinal ring.
 Mid-inguinal point: midway between ASIS and pubic
symphysis. Site of femoral artery pulsation
 Superficial inguinal ring: 1.25 cm above and medial to
pubic tubercle
 Deep inguinal ring: 1.25 cm above and medial to mid-point
of inguinal ligament
 Femoral ring: 1.25 cm below and lateral to pubic tubercle
Contents of the inguinal canal:

In males: spermatic cord


in females: round ligament of uterus

Types of inguinal hernias:

There are two main types of inguinal hernias; direct (aka medial)
and indirect (aka lateral) inguinal hernias, and are best explained
by the following table:
Indirect inguinal hernia Direct inguinal hernia

Incidence The commonest hernia Less common

Age Mostly pediatrics but any age Mostly elderly, never in children
group could be affected
Sex Males are more affected Only males

Passage Passes through inguinal canal Does not pass through inguinal canal.

Shape pyriform hemispherical

Descent Forwards, medially and downwards. Directly forwards. Cannot descend into
Can descend into scrotum. scrotum.

Reduction Upwards, laterally and Directly backwards


backwards.
Defect Deep inguinal ring, lateral to Hasselbach's triangle, medial to
inferior epigastric vessels inferior epigastric vessels.

Complications Common, surgery recommended Rare, surgery not mandatory, esp. in


and Tx early asymptomatic cases
Treatment:
Because defect disappear spontaneously with aging

In infants → herniotomy at 1 year of age

In adults, operation is usually advised. This comprises excision of the


sac and repair of the weakened inguinal canal, commonly performed
either by:
• plicating the transversalis fascia in the posterior wall with a nylon
suture (Shouldice repair)
• or by reinforcing the posterior wall with a nylon or polypropylene
mesh (Lichtenstein repair).
• Or to place a mesh laparoscopically, covering the hernial orifice.
Laparoscopy has particular advantages in the treatment of
recurrent or bilateral hernias.
Complications:

■ Early – pain, bleeding, urinary retention, anaesthetic related


■ Medium – seroma, wound infection
■ Late – chronic pain, testicular atrophy
Femoral
Hernia
Anatomy of Femoral ring:

Borders:

• Anteriorly: the inguinal ligament.


• Medially: lacunar part of the inguinal ligament (Gimbernat's
ligamentł).
• Laterally: the femoral vein.
• Posteriorly: the pectineal ligament (of Astley Cooper), which is
the thickened periosteum along the superior pubic ramus.

Contents: fat + a lymph node (the node of Cloquet).


Femoral hernia:

• Less common than inguinal hernia


• It is more common in females than in males
• However, the most common type of hernia in females is
inguinal hernia!
• Fifty per cent of cases present as an emergency with very high
risk of strangulation!
• Easily missed on examination.
inguinal hernia Femoral hernia

Incidence More common Less common

Sex Males are more affected Females are more affected

Relation to Above and medial to pubic Below and lateral to pubic tubercle
pubic tubercle tubercle

Strangulation Less common More common


Differential diagnosis of femoral hernia:

• Direct inguinal hernia


• Lymph node
• Saphena varix
• Femoral artery aneurysm
• Psoas abscess
• Rupture of adductor longus
with haematoma
Investigations:
In routine cases, no specific investigations are required.
However, if there is uncertainty then US or CT should be
requested.

Treatment:
SURGERY IS MANDATORY! It is wise to treat such cases with
some urgency. There are three open approaches, in addition to a
laparoscopic approach:
• Low approach (Lockwood)
• The inguinal approach (Lotheissen)
• High approach (McEvedy)
• Laparoscopic approach
Ventral
Hernias
Ventral hernias:

This term refers to hernias of the anterior abdominal wall. Inguinal and
femoral hernias are not included even though they are ventral. Lumbar
hernia is included despite being dorsolateral.

Ventral hernias include:

• Umbilical
• Paraumbilical
• Epigastric
• Incisional
• Spigelian
• Parastomal
• Lumbar
• Traumatic
Umbilical hernia:

in children: Common in infants and most resolve spontaneously.


Rarely strangulates.

in adults: Common in overweight men or multiparous women.


Progressively increase in size and may get very large indeed.
Round defect with rigid fibrous margins. Surgery advised
because of risk of strangulation
Para-umbilical hernia:

This is an acquired hernia that occurs just above or below the


umbilicus (usually above). It especially occurs in obese,
multiparous, middle-aged women. The neck is narrow and, like a
femoral hernia, it is particularly prone to become irreducible or
strangulated. The contents are nearly always the omentum, and
often in addition transverse colon and small intestine. A
characteristic feature of paraumbilical hernias on clinical exam is
the “crescent sign”
Paraumbilical hernia Umbilical hernia
Key point…

The main difference between umbilical and


para-umbilical hernias is the location of defect;

• In para-umbilical hernias, the defect is in the


linea alba.

• In umbilical hernias, the defect is in the


umbilical scar itself.
Treatment of para-umbilical hernia:

For defects < 2 cm: The sac is excised and the edges of the rectus
sheath are overlapped above and below the hernia (Mayo's
operation).

For defects > 2 cm: mesh repair is recommended


Epigastric hernia:

• These arise through the midline raphe (linea alba) anywhere


between the xiphoid process and the umbilicus, usually midway.
• When close to the umbilicus they are called supraumbilical
hernias.
• Epigastric hernias begin with a transverse split in the midline
raphe so, in contrast to umbilical hernias, the defect is elliptical.
• It has been hypothesised that the defect occurs at the site
where small blood vessels pierce the linea alba or, more likely,
that it arises at weaknesses due to abnormal decussation of
aponeurotic fibres related to heavy physical activity.
• Epigastric hernia defects are usually less than 1 cm in maximum
diameter
• commonly contain only extraperitoneal fat which gradually
enlarges, spreading in the subcutaneous plane to resemble the
shape of a mushroom.
• When very large they may contain a peritoneal sac but rarely any
bowel.
• More than one hernia may be present. The most common cause
of ‘recurrence’ is failure to identify a second defect at the time
of original repair.
• Peptic ulcers are a DDx!
Incisional hernia:

• Incidence: 10–50 per cent after laparotomy


• Causation due to patient, wound and surgeon factors
• Wide variation in size
• Often multiple defects within the same scar
• Obstruction is common but strangulation is rare
• Open and laparoscopic repairs possible
Treatment:

Both open and laparoscopic options are available. A number of


principles apply, irrespective of the technique used:
1. The repair should cover the whole length of the previous incision.
2. Approximation of the musculo-fascial layers should be done with
minimal tension and prosthetic mesh should be used to reduce the
risk of recurrence.
3. Mesh may be contraindicated in a contaminated field, e.g. bowel
injury during the dissection but, in a clean-contaminated field,
such as after an elective bowel resection, mesh may be used if
placed in a different anatomical plane to the contamination, such
as in the extra-peritoneal/retro-muscular space.
4. Appropriate systemic antibiotics should be used
Spigelian hernia:

• Rare. Often misdiagnosed.


• affects men and women equally
• Can occur at any age, but are most common in elderly.
• They arise through a defect in the Spigelian fascia which is the
aponeurosis of the transversus abdominis muscle.
• High risk of strangulation, so surgery is recommended.
Lumbar hernia:
Most primary lumbar hernias occur through the inferior lumbar
triangle of Petit bounded below by the crest of the ilium,
laterally by the external oblique muscle and medially by the
latissimus dorsi.
Parastomal hernia:
When surgeons create a stoma, they are effectively creating a
hernia by bringing bowel out through the abdominal wall. The
muscle defect created tends to increase in size over time and can
ultimately lead to massive herniation around the stoma.

Traumatic hernia:
These hernias arise through defects caused by injury. They can
be classified into three types:

1. Hernias following abdominal stab wounds.

2. Hernias following blunt trauma.


3. Hernias secondary to muscle atrophy which occurs as a result
of nerve injury or other traumatic denervation. Akin to the
lumbar pseudo-hernia seen after open nephrectomy, these can
arise following chest injury with damage to the intercostal
nerves.

Diagnosis: The key to the aetiology is in the history and the non-
anatomic location of the hernia.

Treatment: Surgery may be justified if the hernia is sufficiently


symptomatic, or if investigations suggest a narrow neck and
hence a risk of obstruction or strangulation. Stab wound
traumatic hernias are straightforward to repair using open or
laparoscopic techiques as for other ventral hernias.
Other hernias/conditions:

Divarification of the recti: It is the condition where the linea alba


stretches laterally as the two rectus muscles separate. It occurs
in the upper abdomen in middle-aged, over- weight men but
also as a result of birth trauma in the female when it occurs
below the umbilicus.
Perineal hernia:
This type of hernia is very rare and includes:
• postoperative hernia through a perineal scar, which may occur after
excision of the rectum
• median sliding perineal hernia, which is a complete prolapse of the
rectum
• anterolateral perineal hernia, which occurs in women and presents
as a swelling of the labium majus
• posterolateral perineal hernia, which passes through the levator ani
to enter the ischiorectal fossa.
Sportsman’s hernia:
This specific entity is well described and presents as severe pain
in the groin area, extending into the scrotum and upper thigh. It
is almost entirely restricted to young men who play contact
sports such as football and rugby. The pain can be debilitating
and prevent the patient from exercising. In most cases, the pain
is due to an orthopaedic injury, such as adductor strain or pubic
symphasis diastasis. However, some believe that it can be due to
muscle tearing (Gilmore’s groin) or stretching of the posterior
wall of the inguinal canal. Other causes of pain should be
excluded, such as hip, pelvic or lumbar spinal disease and
bladder/prostate problems. MRI is the Ix of choice but
ultrasonography, herniography or even laparoscopy may be
used.
Richter hernia:

Richter hernia (partial enterocele) is the protrusion and/or


strangulation of only part of the circumference of the intestine's
antimesenteric border through a rigid small defect of the
abdominal wall.
Obturator hernia:
Obturator hernia, which passes through the obturator canal,
occurs six times more frequently in women than in men. Most
patients are over 60 years of age. These hernias have often
undergone strangulation, frequently of the Richter type, by the
time of presentation. Physical exam may show the Howship-
romberg sign (inner thigh pain on internal rotation of leg).
Diagnosis: CT scan
Treatment: Surgery is indicated.
Amyand hernia:
a hernia that contains appendix.

Littre hernia:
a hernia that contains mickel’s diverticulum.

Pantaloon hernia:
presence of both direct and indirect inguinal hernias in the same
patient.
The Anki deck for this
lecture will be available
on the telegram channel!

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