HERNIAS
CHOMA GEN HOSPITAL
SURGERY DEPARTMENT
PRESENTER: DR. KALALUKA
INTRODUCTION
A hernia is an abnormal protrusion of an
organ or tissue through an opening in the
layer that normally confines it.
a hernia anatomically contains the following
parts
Covering : These are the layers of the
abdominal wall through which the sac
passes.
Sac : a diverticulum of peritoneum with
mouth, neck, body and fundus.
contents : omentum, Intestine,
diverticulum, bladder
RISK FACTORS
Anatomical weakness (Injury to the ilioinguinal nerve
during appendectomy, which innervates the internal
oblique and transversus muscles, surgical scar…)
Developmental failures (failure of the obliteration of
the processus vaginalis)
Genetic weakness of collagen
Sharp and blunt trauma
Weakness due to ageing and pregnancy
Primary neurological and muscle diseases
Increased abdominal pressure [Chronic cough
(tuberculosis, chronic bronchitis, bronchial asthma,
emphysema), Lifting heavy weights, Chronic
constipation, Urinary causes (BPH, prostate
carcinoma, stricture urethra), Ascites]
CLASSIFICATION OF HERNIAS
1) Clinically
i. Reducible Hernia
Hernia gets reduced on its own or by the patient or by the surgeon
Anatomically
ii. Irreducible Hernia
Here contents cannot be returned to the abdomen due to a narrow
neck, adhesions, over crowding. Irreducibility predisposes to
strangulation.
iii. Incarcerated
irreducible hernia that is trapped, risk of strangulation.
iv. Obstructed Hernia
It is an irreducible hernia with obstruction, but blood supply to the
bowel is not interfered. It eventually leads to strangulation.
v. Strangulated Hernia
It is an irreversible hernia with obstruction to blood flow. The
swelling is tense, tender, with no impulse on coughing and some
with features of intestinal obstruction.
CLINICAL CLASSIFICATION
2) According to etiology
i. Congenital
It occurs in a preformed sac/defect. Clinically
may present at a later period due to any of
the precipitating causes like in indirect
inguinal hernia.
ii) Acquired
It is secondary to any causes which raise the
intra-abdominal pressure leading into
weakening of the area like in direct inguinal
hernia.
3) According to the Contents
Omentocele—omentum.
Enterocele—intestine.
Cystocele—urinary bladder.
Littre’s hernia—Meckel’s diverticulum.
Maydl’s hernia — two loops of bowel
Sliding hernia — part of esophagus and
stomach
Richter’s hernia—part of the bowel wall
Amyand hernia— Appendix
4) Anatomical classification (Based on the
Site)
Inguinal hernia—occurring in inguinal canal.
Femoral hernia—occurring in femoral canal.
Obturator hernia.
Diaphragmatic hernia.
Lumbar hernia.
Umbilical hernia.
Epigastric hernia.
INGUINAL HERNIA
These are hernias located in the inguinal
region
Approximatly 75% of all hernias are inguinal
hernias
It is the most common type of hernia
because the muscular anatomy in the
inguinal region is weak and also due to the
presence of natural weakness like deep ring
and cord structures.
A vast majority occur in male
INGUINAL CANAL
Canal located in the inguinal region
In the adult it is approximately 4 cm in length
Is located 2-4 cm cephalad to the inguinal
ligament
it extends between the internal (deep
inguinal) ring and the external (superficial
inguinal) ring opening
The inguinal canal contains either the
spermatic cord or the round ligament of the
uterus
INGUINAL CANAL
Anterior wall: The canal is bounded
superficially by the external oblique
aponeurosis
The cephalad wall (roof) is comprised of the
internal oblique muscle, transverses
abdominis muscle and the aponeuroses of
these muscles
The inferior wall (floor) is formed by the
inguinal ligament and lacunar ligament
The posterior wall is formed by the by the
conjoint tendon
INGUINAL CANAL
Contents of inguinal canal
Spermatic cord in males
Round ligament in females
Ilioinguinal nerve
Contents of spermatic cord
Vas deferens
Artery to vas
Testicular and cremasteric artery
Genital branch of genitofemoral nerve
Pampiniform plexus of veins
Remains of processus vaginalis
Sympathetic plexus around the artery
to vas
CLASSIFICATION OF INGUINAL
HERNIAS
ANATOMICAL CLASSIFICATION
These can be divided as :
Indirect hernia -it comes out through internal
(Deep) ring of the inguinal canal along with the
cord. It is lateral to the inferior epigastric artery.
The inguinal ligament is inferior to hernia.
Direct hernia-it occurs through the posterior
wall of the inguinal canal through Hesselbach’s
triangle (bounded medially by lateral border of
rectus muscle, laterally by inferior epigastric
artery, below by inguinal ligament).
Sac is medial to the inferior epigastric artery.
CLASSIFICATION ACCORDING TO
EXTENT
Incomplete:
Bubonocele: sac is confined to the inguinal
canal
Funicular: here sac crosses the superficial
inguinal ring, but does not reach the bottom
of the scrotum.
Complete: here sac descends to the bottom
of the scrotum.
1) Bubonocele
2) Funicular
3) Complete (pantaloons hernia)
FEMORAL HERNIA
Introduction
Femoral hernia is a protrusion of peritoneum through
the femoral canal.
Are demonstrated by a mass below the inguinal
ligament
Usually in women >40 years
due to the wider pelvis in women hence wider
femoral canal and weaker ligamentous support
Anatomy of femoral canal
Anterior: inguinal ligament
Posterior: pectineal ligament
Medial: lacunar ligament
Lateral: femoral vein
A Femoral hernia emerges through the
femoral canal and may be felt as a soft
swelling below and lateral to the pubic
tubercle.
It protrudes through the femoral canal, the
hernial sac descends down vertically up to
the saphenous opening and then escapes out
into the loose areolar tissue to expand out
like a retort.
Because of its irregular pathway and narrow
neck, it is more prone for obstruction and
strangulation.
UMBILICAL HERNIA
Hernia in the umbilical region
Umbilical hernia develops due to either
absence of umbilical fascia or incomplete
closure of umbilical defect.
Can be congenital or acquired; congenital
more common in Africa; more common in
infants
CLINICAL FEATURES
• Visible bulge or lump or intermittent swelling
[most noticeable when standing, coughing,
crying (in children) or straining, may
dissappear when laying down]
• Pain or discomfort (may be painless or may
be accompanied by dull aching, dragging
pain or heavy feeling. Severe pain suggests a
strangulated hernia)
• Symptoms of intestinal obstruction
• Symptoms of a strangulation (severe pain,
nausea, vomiting, fever, irreducibility of the
hernia)
PHYSICAL EXAMINATION
Inspection
Previous surgical scars
site of the hernia
Underlying skin (usually normal but may be
red or purple or with dark discoloration and
swollen in a strangulated hernia)
Cough impulse (Swelling appears or
increases in size when pt coughs)
Labia majora of affected side is larger than
non affected side in femoral hernias
Palpation
Temperature , tenderness?
Consistency [soft (enterocele), doughy
(omentocele), tense, firm..]
Reducibility (attempt to reduce the hernia)
Getting above the swelling (ability to palpate
the spermatic cord structures)
Location (if above inguinal ligament =
inguinal hernia, if below inguinal ligament =
femoral hernia)
Tests to differentiate the different types of
groin hernia
Internal ring occlusion test: Internal ring is
located half inch above the mid-inguinal point
(center point between anterosuperior iliac
spine and pubic symphysis). After reducing the
contents, in lying down position, internal ring
is occluded using the thumb. Patient is asked
to cough. If a swelling appears medial to the
thumb, then it is a direct hernia. If swelling
does not appear and on releasing the thumb
swelling appears during coughing, then it is an
indirect hernia confirmed in standing position.
Ring invagination test: After reduction of
hernia, the little finger/index finger of the
examiner is invaginated from the bottom of
the scrotum, gradually pushed up and
rotated to enter the superficial inguinal ring.
The impulse on coughing is felt at the tip of
the invaginated finger in a direct inguinal
hernia.
Zieman’s test: The examiner places his
index finger on the deep inguinal ring and
middle finger on the superficial inguinal ring,
ring finger over saphenous opening .The
patient is asked to cough or to hold the nose
and blow. If impulse is felt on the index
finger, it is an indirect hernia
DIFFERENTIAL DIAGNOSIS OF GROIN
SWELLINGS
Hydrocele
Undescended testis
Lipoma of the cord
Hydrocele of the canal of nuck (in females)
Inguinal lymph node enlargement
Groin abscess
INVESTIGATIONS
U/S
Computed tomography (CT) is helpful in
complex ventral and incisional hernias
FBC
Group and save
Abdominal X-ray
MANAGEMENT
In infants
Only herniotomy (excision of the sac) is
done through inguinal approach in inguinal
hernias
Observation until age 4-5 in umbilical
hernias (most close spontaneously)
Conservative management with adhesive
strapping in umbilical hernias
In adults
Conservative management
Indications:
elderly patients or with severe systemic
diseases
Truss
Surgical management
- Elective in reducible hernias, emergency in
non reducible and strangulated hernias.
a) herniorrhaphy (strengthening abdominal
wall with sutures) different techniques are
used to achieve this e.g bassini’s stitch in
which Conjoint tendon and inguinal ligament
are approximated using interrupted
nonabsorbable monofilament sutures and the
medial most stitch taken from the
periosteum of the pubic tubercle. Other
techniques include ; Shouldice, MacVay,
darning, Andrew’s, Wilkinson….
c) hernioplasty = repairing using mesh, it's the
gold standard. Indicated for incisional hernias
d) laparoscopy = TAPP (Transabdominal
Preperitoneal) TEP (Totally Extraperitoneal)
methods can be used to repair inguinal hernias
using mesh
TAPP involves entering the abdominal cavity to
place a mesh patch in the preperitoneal space
(the area between the abdominal wall and the
peritoneum).
TEP involves repairing the hernia without entering
the abdominal cavity, placing the mesh in the
preperitoneal space from outside the
peritoneum.
COMPLICATIONS OF HERNIAL REPAIR
Hemorrhage/ haematoma
Infection
Seroma
Injury to the bowel
Injury or irritation of the bladder
Testicular ischemia/ atrophy
Persistant pain (nerve irritation of ilioinguinal
nerve and genitofemoral nerve)
Mesh infections
Mesh migration/ adhesion
Infertility
Recurrence
APPROACH TO STRANGULATED
HERNIAS
NPO
IV fluids
NGT (if vomiting or severe obstruction)
antibiotics
analgesia
emergency surgery
THE
END
