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HERNIA
• “Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it”
• Common Hernias– INGUINAL– UMBILICAL– FEMORAL– EPIGASTRIC– INCISIONAL
• Rare Hernias– SPIGELIAN– LUMBAR – GLUTEAL– SCIATIC– OBTURATOR
Factors: Weakness of abdominal musculature
• Congenital– Persistence of
processus vaginalis– Patent canal of Tuck– Incomplete
obliteration of umbilicus
• Acquired – Fat– Pregnancy– Incision– Infection– Connective tissue –
smoking, aging, CTD, systemic illness
Increased abdominal pressure
• Chronic constipation• Chronic cough• Bladder outlet obstruction – stricture,
prostrate• Straining – weight lifting• Intra-abdominal malignancy• Vomiting• Repeated pregnancy
• Sac• Covering • Contents– Omentocoele– Enterocoele– Cystocoele – Ovary
• Richter’s• Littre’s• Maydl’s
Classification
• Reducible• Irreducible• Obstructed/ Incarcerated• Strangulated
Reducible Hernia
• Characteristic signs– Reducibility– Cough impulse
Irreducible Hernia
• Due to– Adhesions– Narrowing of neck– Incarceration– Massive hernia inside scrotum
Obstructed Hernia
• Irreducibility + Intestinal obstruction• Features– No cough impulse– Irreducible– Painless– Non tender– Features of intestinal obstruction
Strangulated Hernia
• Blood supply of its contents impaired• Intestinal obstruction ±• Pathology– Intestinal obstruction– Dilation of hernial contents– Impairment of venous return– Stasis --------- Arterial impairment
• Appearance– Congested and bright red– Ecchymosis– Extravasation of blood into lumen/ sac– loss of tone– Translocation of gut bacteria – peritonitis/ sepsis– Gangrene
• Symptoms – Pain, vomiting– Ceases with onset of gangrene, ileus
• Signs – Ill looking– Tense, tender– Irreducible, no cough impulse– Acute intestinal obstruction– Peritonitis
Strangulated Omentocele
• No features of intestinal obstruction• Gangrene onset delayed
Strangulated Richter’s Hernia
• Features mimic gastroenteritis• Obstruction > 50 % of circumference• Colic, diarrhoes• Constipation - ileus
Maydl’s Hernia
• Retrograde strangulation• On opening sac – contents appear normal• Generalized peritonitis may set in early
Inflamed Hernia
• Outside– Abrasion, ill fitting truss
• Inside– Diverticulitis, appendicitis
• Signs of inflammation +• Not associated with intestinal obstruction
INGUINAL HERNIA
Anatomy
Inguinal canal
• Triangular slit 3.75 cm long• Above the inner half of inguinal ligament• Deep to superficial inguinal ring• Developed due to the descent of testis in
embryonic life
Deep Inguinal Ring• Opening in the fascia transversalis• 1.25 cm above mid inguinal point• Medially – inferior epigastric artery• Spermatic cord in males; round ligament in
females
Superficial Inguinal Ring
• Aponeurosis of external oblique – crurae• Above and lateral to pubic crest• Spermatic cord/ round ligament and illio-
inguinal nerves
• Anteriorly – skin, fascia, EO aponeurosis, lateral third – IO aponeurosis
• Posteriorly – transversalis fascia, medial ½ - conjoint tendon
• Above – transversus abdominins and internal oblique fibres
• Below – inguinal ligamnet
Contents
• Illioinguinal nerves• Spermatic cord– Vas defrens– Testicular artery, art to vas defrens, cremasteric– Pampiniform plexus of veins– Lymph vessels– Testicular plexus of sympathetic nerves, genital
branch of genitofemoral
Hassenbach’s Triangle
• Site of direct hernia• Medially – lateral border rectus abdominis • Laterally – inferior epigastric vessel• Inferiorly – inguinal ligament• Floor – fascia transversalis• Umbilical fold – obliterated umbilical artery
Mechanisms for preventing hernia
• Obliquity of inguinal canal• Shutter mechanism of fibres of IO, TA• Sphincter action of TA, IO at deep inguinal ring• Ball valve action of cremasteric• Fibres of internal oblique over deep inguinal
ring• Conjoint tendon
INDIRECT INGUINAL HERNIA
• More common• Young individuals• More common on the right side• On basis of extent– Bubonocele– Funicular hernia– Complete hernia
• Coverings– Peritoneum– Extraperitoneal fat– Internal spermatic fascia– Cremasteric fascia– External spermatic fascia– Superficial fascia– skin
DIRECT INGUINAL HERNIA
• Directly through the hasselbach’s triangle• Acquired (ex- Oglive hernia)• More common in elderly, malgaigne bulgings• Rarely gets strangulated
• Symptoms – Pain/ discomfort– Lump– Systemic symptoms – obstruction, strangulation– Predisposing factors – constipation, chronic
bronchitis, urinary obstruction– Past history
• Signs– REDUCIBILITY– COUGH IMPULSE– Position – d/f femoral hernia– Get above the swelling– Invagination test– Ring occlusion test
Rare Varieties
• Interstitial hernia– Between muscle layers of abdominal wall– Commonly associated with undescended testis– Preperitoneal– Intraperitoneal– Extraperitoneal
Rare Varieties
• Sliding hernia– Older men– Extraperitoneal bowel with sac of peritoneum– Caecum, pelvic colon, bladder– Strangulation of intestine within and outside the
peritoneum• Richter’s • Maydl’s• Littre’s
TREATMENT
• Conservative management• Surgical management
Conservative management : No Treatment
• Indications– Severe ill health– Short life expectency– Refuse operation
Conservative management : Truss
• Indications– Refuse operation– Old patients with severe co morbidities– Children ( c/I – undescended testis)
• Contraindications– Irreducible hernia– Undescended testis– Chronic bronchitits, strenous labour– Associated with large hydrocele– Not intelligent enough to position properly
• Dangers– Pressure atropht of muscles of inguinal region– Ostruction or strangulation– Used with partially reduced hernia – may cause
trauma– Improper cleanliness – unhealthy skin– Adhesions between sac and canal– Chance of strangulation remains
Operative treatment
• Herniotomy– Neck of sac transfixed, ligated and excised– Infants and children; young men with good
musculature• Herniorrhaphy– Herniotomy + repair of postrior wall– Indirect hernias– Adults with good muscle tone
Hernioplasty
• Herniotomy + reinforcement of posterior wall• Autologous– Fascia lata– External oblique aponeurosis– Anterior rectus sheath flap– Skin flap – dermoplasty/ skin ribbon
• Heterogenous – Prolene – Stainless steel
• Indications– Indirect hernia – poor muscle tone– Direct hernia– Recurranthernia– Predisposing factors – chronic cough,etc
Treatment of Strangulated Hernia
• Emergency surgery• Resuscitation• Reduction of hernia– Foot end elevation– Ice pack– NG, IV fluids– Analgesia, antibiotic
• Assess viability – Green/ black color– Flaccid , lustureless appearance– No peristalssis– Blood stained, foul smelling fluid in sac
• Bowel viable - HERNIORRHAPHY
• Bowel nonviable – Linear patch of gangrene – invagination– Loop of bowel – resection and anastomosis if gen
condition permits– Bowel large intestine – exteriorisation
RECURRENT INGUINAL HERNIA
• Types of hernia– Sliding– Large/ long standing– Large direct hernia
• Types of patients – chronic cough• Inadequate preoperative preparation
RECURRENT INGUINAL HERNIA
• Operative faults– Failure to ligate sac– Tension in repair – Use of absorbable sutures– Bleeding – infection– Fault in selection of operation
• Postoperative care– Wound infection– Lifting heaavy weights– Persistence of predisposing factors
• Appearance of new hernia
FEMORAL HERNIA
• Femoral ring – femoral canal – saphenous opening
• More common in– Females– Old age
• Most liable to strangulate
Anatomy
Coverings of the sac of femoral hernia
• Skin• Superficial fascia• Cribriform fascia• Anterior layer of femoral sheath• Fatty contents of femoral canal• Femoral septum• Peritoneum
Rare types of femoral hernia
• Prevascular hernia(Velpeu’s) – ass with posterior dislocation (Narath’s hernia)
• Retrovascular hernia - Serafini
• Pectineal hernia – Cloquet’s• External femoral hernia –
Hesselbach’s• Lacunar hernia – Lingier’s
• Symptoms– Swelling– Pain– Systemic symptoms
• Zeimenns technique• Invagination technique• Ring occlusion test• Position of swelling
Treatment
• No conservative management• Surgery – herniorrhaphy
– High operation(McEvedy’s)
– Lottheissen’s
– Lockwood
UMBILICAL HERNIA
• Three major types– Exomphalos– Umbilical hernia in infants and children– Paraumbilical hernia in adults
Exomphalos
• Minor– Small sac– Summit attached to the umbilical cord– Treatment • twisting of umbilical cord and strapping
Exomphalos
• Major • Umbilical cord attached to inferior
aspect of swelling• Contains intestines, liver• Surgical emergency• Immediate decompression and
reduction
Umbilical hernia in children and infants
• Weak umbilical scar following neonatal sepsis• Usually asymptomatic• 90% cured within 12 – 18 months• > 18 months – surgery
Paraumbilical hernia of adults
• Supraumbilical or infraumbilical• Adhesions - seldom reducible • Predisposing factors –– Women– Obesity– Repeated pregnancy
• Treatment – Mayo’s operation
EPIGASTRIC HERNIA(Fatty Hernia of Linea Alba)
• Through fibres of linea alba• Blood vessels pierce linea alba• Initially extraperitoneal fat only• M.c. – young muscular men with strenous
activity• Usually irreducible, no cough impulse• If symptomatic - surgery
INCISIONAL HERNIA(Ventral Hernia)
• Defect with patient– Obesity– Chronic cough perioperative period– Undue abdominal distention– Malnutrition
• Operative– Injury to nerves– Careless wound closure– Hemorrhage – infection– Tube drainage through laparotomy wound– Midline infraumbilical
• Postoperative– Infection– Postop cough, distention– Postop peritonitis– Early removal of sutures– Postop steroid therapy
Types of incisional hernia
• Type 1– Upper abdomen/ midline lower abdomen– Wide gap in musculature– Low risk of strangulation
• Type 2– Lateral part of abdomen– Small defect– Strangulation risk high
Treatment
• Prevention of incisional hernia– Weight reduction– Correct nutritional defects– Treat chronic cough– Careful closure of abdomen– Prevent post op wound infection
• Conservative management– Reducible type 1
• SURGICAL MANAGEMENT
LUMBAR HERNIA
• Superior lumbar hernia
• Inferior lumbar hernia
Incisional lumbar hernia
• Renal surgery with post op infection• Paralysis of lumbar muscles(phantom hernia)• Treatment– Primary hernia – herniorrhaphy– Incisional hernia
OBTURATOR HERNIA
• Rare; old women• Through obturator
foramen• Thigh flexed, abducted and
externally rotated• Referred pain to knee joint• Strangulation - surgery
SPIGELEAN HERNIA
• Interparietal hernia• At level of arcuate line,
lateral to rectus• Treatment - surgery
• Gluteal hernia
• Sciatic hernia
CONCLUSION
• Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it
• Inguinal hernia most frequent• Usual mode of treatment is surgical
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