HERNIAHERNIADone by D1 group
objectivesobjectivesDefinitionAnatomyPrecipitating factors Types Clinical features Preoperative assessment Management and repair
DefinitionDefinition
A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity .
AnatomyAnatomy The inguinal canal :-The inguinal canal is approximately 4 cm long and is directed
obliquelyinferomedially through the inferior part of the anterolateral
abdominal wall. The canal lies parallel and 2-4 cm superior to the medial half of the inguinal ligament.This ligament extends from the anterior superior iliac spine to the pubic tubercle.
The inguinal canal has openings at either end : –The deep (internal) inguinal ring is the entrance to the inguinal
canal. It is thesite of an outpouching of the transversalis fascia. This is approximately 1.25 cm superior to the middle of the inguinal ligament
The superficial, or external inguinal ring is the exit from the inguinal canal. It is a slitlke opening between the diagonal fibres of the aponeurosis of the external oblique
Inguinal canalInguinal canal walls of The inguinal canal :- The anterior wall is formed mainly by the aponeurosis of the
external Oblique . The posterior wall is formed mainly by transversalis fascia The roof is formed by the arching fibres of the internal
oblique and transverse abdominal muscles. The floor is formed by the inguinal ligament, which forms a
shallow trough. It is reinforced in its most medial part by the lacunar ligament.
Content :-1. Spermatic cord ( round ligament of the uterus in
female )The Cord Itself.—The contents of the spermatic cord are (a) the ductus (vas) deferens and its artery . (b) the testicular artery and venous (pampiniform) plexus. (c) the genital branch of the genitofemoral nerve. (d) lymphatic vessels and sympathetic nerve fibers. (e) fat and connective tissue surrounding the cord and its
coverings in various amounts 2. Ilioinguinal nerve .3. Ilioinguinal lymph node .
Femoral CanalFemoral CanalThe major feature of the femoral canal is the femoral
sheath. This sheath is a condensation of the deep fascia (fascia lata) of the thigh and contains, from lateral to medial, the femoral artery, femoral vein, and femoral canal. The femoral canal is a space medial to the vein that allows for venous expansion and contains a lymph node (node of Cloquet). Other features of the femoral triangle include the femoral nerve, which lies lateral to the sheath,
Wall of The Femoral canal anterior is the inguinal ligament posterior is the iliopsoas, pectineal, and long adductor
muscles (floor). Medial is lacunar ligamentLateral is femoral vessle
Predisposing:Predisposing:
All hernias occur at the site of WEAKNESS OF THE ABDOMINAL WALL which are acted on by repeated INCREASE in abdominal pressure
repeated INCREASE in repeated INCREASE in abdominal pressure is abdominal pressure is usually due to usually due to Chronic coughStraining Bladder neck or urethral
obstructionPregnancy Vomiting Sever muscular effortAscetic fluid
Types Types Inguinal FemoralEpigastric Para umbilicalUmbilicalObturatorSuperior lumbarInferioer lumbarGlutealSciaticIncisional
• Indirect Inguinal HerniaHernia through the inguinal canal• Direct Inguinal HerniaThe sac passes through a weakness or defect of the
transversalis fascia in the posterior wall of the inguinal canal
• Femoral HerniaHernia medial to femoral vessels under inguinal ligament• Umbilical HerniaHernia through the umbilical ring• Paraumbilical HerniaA protrusion through the linea alba just above or sometimes
just below the umbilicus• Epigastric HerniaProtrusion of extraperitoneal fat through the linea alba
anywhere between the xiphoid process and the umbilicus• Incisional HerniaHernia through an incisional site• Lumber Herniaoccur through the inferior lumber triangle of Petit
Inguinal hernia Inguinal hernia History: 1.Age ( young vs. old)2.Occupation ( nature ?? )3.Local symptoms: Swelling,
discomfort and pain4.Systemic symptoms: if there is
obstruction or strangulation 5.Precipitating factors
Inguinal hernia Inguinal hernia Examination:1.Inspection for site, size, shape and
color.2.Palpation for surface, temp,
tenderness, composition and reducibility.
3.Expansible cough impulse.4.General exam: for common causes
of increase intra abdominal pressure
Indirect Versus Direct inguinal Indirect Versus Direct inguinal hernias hernias
Indirect is the most common form of hernia and its usually congenital due to patent processus viginalis
Direct usually acquired occur in
old men with weak abdominal muscles.
Indirect Versus Direct inguinal hernias Indirect Inguinal Hernia Direct Inguinal HerniaPass through inguinal canal. Bulge from the posterior wall of the
inguinal canalCan descend into the scrotum. Cannot descent into the scrotum.Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.Reduced: upward, then laterally and backward.
Reduced: upward, then straight backward.
Controlled: after reduction by pressure over the internal (deep) inguinal ring.
Not controlled: after reduction by pressure over the internal (deep) inguinal ring.
The defect is not palpable (it is behind the fibers of the external oblique muscle).
The defect may be felt in the abdominal wall above the pubic tubercle.
After reduction: the bulge appears in the middle of inguinal region and then flows medially before turning down to the scrotum.
After reduction: the bulge reappears exactly where it was before.
Common in children and young adults.
Common in old age.
Note that examination using finger and thumb across the neck of the scrotum will help to distinguish a swelling of inguinal origin and one
that is entirely intrascrotal
Femoral hernia Femoral hernia
Small femoral hernia may be unnoticed by the patient or disregarded for years perhaps until the day it strangulates. Adherence of the greater omentum sometimes causes a dragging pain. Rarely a large sac is present .
Femoral hernia Femoral hernia HistoryAge ; uncommon in children , most
common in old age female .Sex; women > men (but still commonest
hernia in women the inguinal hernia )The patient came with local symptoms 1- discomfort and pain2- swelling in the groinGeneral ; femoral hernia is more likely to
be strangulated than the inguinal herniaMultiplicity ; often bilateral
Femoral hernia versus inguinal Femoral hernia versus inguinal herniahernia
Inguinal hernia Femoral hernia1 -more common in male 1 -more common in females
2 -pass through the inguinal canal
2 -pass through the femoral canal
3 -neck of the sac is above and medial the pubic tubercle
3 -neck of the sac is below and lateral the pubic tubercle
4 -less common to be strangulated
4 -more common to be strangulated
5 -can be treated without surgery
5 -must be treated surgically
6 -the two diagnostic signs of hernia+
6 -the two diagnostic signs of hernia-
7 -the sac mainly contain ; bowel 7 -the sac mainly contains ; omentum
Umbilical herniaUmbilical herniaSigns and symptomsAge ; doesn’t appear until the
umbilical cord has separated and healed .
No specific symptomsHave wide neck and reduce easily ,
rarely give intestinal obstruction.Nature history ; 90 % disappear
spontaneously during the first year.
Examination Inspection Site ; in the center of the umbilicusSize and shape ; size can vary from vary
small to very large . Shape is usually hemispherical.
Palpation Composition ; contain bowel , which makes
it resonant to percussion . They reduce spontaneously when the child lies down .
Reducibility ; easyCough impulse; invariably present .
Acquired umbilical herniaAcquired umbilical herniaHernia through the umbilical scar , so
it is a true umbilical hernia. Not common and is usually secondary
to increase intra abdominal pressure. The most common causes1- pregnancy2- ascitis3- ovarian cyst4- fibrodis5- bowel distention
Incision herniaIncision hernia Signs and symptoms Previous operation or accidental trauma Age ; all ages , but more common in old age. Symptom ; lump ,pain ,intestinal obstruction
( distention ,colic, vomiting ,constipation , sever pain in the lump )
Examination 1- reducible lump 2- expansile cough impulse 3- if the lump dose not reduse and dose not have cough
impulse , than it may be not a hernia Ddx Tumor Chronic abscess Hematoma Foreign body granuloma
Preoperative assessment Preoperative assessment proper history and examinationidentify high risk patientsprepare the preoperative notes :consent..pre op Dxprocedure plannedsurgeonsAnasthesia anticipated (general ,
local, spinal)
Preoperative assessment Preoperative assessment Investigation data ( pre operative tests ) :1. Lab :* CBC : to check hemoglobin level anemia and
WBCs infections* U&E : to check for any electrolyte imbalance* LFTs : indicated in jaundiced patients and
suspected hepatitis or any clotting problems* PT & PTT* ABG* grouping and cross matching 2. Imaging :* Chest X ray : for all patients 3. ECG : for any patient who is more than 40 years
of age
Preoperative assessment Preoperative assessment current medications or allergies any major (chronic) illness pre op orders : 1. skin preparation2. diet (NPO)3. GIT preparation 4. Sedation5. Preanesthetic medications6. Other medications7. Antibiotics8. Blood transfusion ( if needed )9. Bladder preparation
ManagemeManagement and nt and repair repair
Inguinal Hernia Repair
Reduction
SurgicalTTT
Pre op Evaluation
&preparation
Surgical TTT
Choice of Anesthetic TTT of hernial sac Inguinal floor
reconstruction
Pre op evaluation Pre op evaluation &preparation&preparation
Watchful Waiting Surgical TTT
May be appropriate for pt with asymptomatic hernia or elderly pt with minimal symptoms or easily reduced inguinal hernia.
Routine F/U with health care professional
A Randomized trial concluded that this is an acceptable option for men with minimally symptomatic inguinal hernia and that delaying repair until symptoms increase is safe
due to low rate of incarceration. 23% of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most often hernia-related
pain) , only 1 pt (0.3%) experienced acute hernia incarceration without strangulation within 2years, a second had acute incarceration with
Bowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA 2006,295:285)
Pre op Pre op preparationpreparationMost pt are treated surgically
Increase IAP abnormalities (Chronic cough, Constipation, Bladder outlet
obstruction) should be evaluated and remedied to extent possible before
elective herniorrhaphy.In case of intestinal obstruction and possible strangulation, Broad spectrum
AB,NG suction may be indicated, correction of volume status& elctroyles.
ReductionReductionUncomplicated:Manual Gentle pressure over hernia
Gentle traction over the mass sedation and trendelenburg position.
Complicated (strangulated): no attempt should be made to reduce
the hernia because of potential reduction of gangrenous segment of bowel with the hernial sac.
Surgerical TTTSurgerical TTT1.choice of anesthetic: elective open repair : Local is
preferred Laproscopic hernia repair: more
commonly under GA.
2.TTT OF HERNIAL SAC2.TTT OF HERNIAL SACINDIRECT: sac is dissected free from
the cord structures and creamsteric fibers. Sac should be open away from any herniated contents. Contents are then reduced, and the sac is ligated deep to inguinal ring with an absorbable suture
DIRECT:Too broadly based for ligation and
should not be opened, simple freed from transversalis fibers and inverted.
3.Inguinal Floor 3.Inguinal Floor ReconstructionReconstruction
Some method of reconstruction of
the inguinal floor is necessary in all
adult hernia repairs to prevent recurrence.
3.Inguinal Floor
Reconstruction
Primary tissue repair Open tension free repair
Laproscopic& preperitoneal repairs
1.Primary tissue repair1.Primary tissue repair
Bassini repair: inferior arch of transversalis fascia (TF) or conjoint tendon is approximated to shelving portion of inguinal ligament.
McVay: TF is sutured to cooper ligament.
Shouldice: TF is incised and reapproximated.
2.Open tension free 2.Open tension free repairrepair
Lichtenstein repair &Patch and Plug technique: Mesh is used to
reconstruct inguinal floor
Mesh plug technique : place mesh in the hernial defect
Laproscopic &Laproscopic & preperitoneal repairs preperitoneal repairs TAPP (transabdominal prepeitoneal procedure):
peritoneal space entered by conventional lap at umbilicus and peritoneum overlaying inguinal floor is dissected away as flap.
TEP (Total extraperitoneal repair): preperitoneal space is developed with a balloon inserted between posterior rectus sheath and peritoneum balloon inflated to dissect the peritoneal flaps awau from posterior abdomianl wall and the direct and indirect spaces, other ports inserted into this preperitoneal space without entering peritoneal cavity.
After lap. Dissection and reduction of hernia sac , a large piece of mesh is placed over inguinal floor
Femoral hernia repairFemoral hernia repair• Femoral hernias should be repaired very soon after the diagnosis has been made because of the high risk of strangulation. • There is no place for a truss for a femoral hernia.• Different approaches : Open VS Laparoscopic
Open surgeryOpen surgeryThree approaches have been
described for open surgery :1.Infra-inguinal approach (Lookwood)2.Supra-inguinal approach ( McEvedy)3.Trans-inguinal approach
( Lotheissen)
Each technique has the principle of dissection of the sac with reduction
of its contents, followed by ligation of the sac and closure between the inguinal and pectineal ligaments.
Lockwood’s infra-inguinal Lockwood’s infra-inguinal approachapproach The sac is dissected out below the
inguinal ligament via groin crease incision.
Then the sac is opened and the contents are inspected and reduced into the abdomen.
Then the neck of the sac is pulled down , ligated and allowed to retract through femoral canal.
Then close the femoral canal by mesh plug or non absorbable sutures.
McEvedy’s high approachMcEvedy’s high approachVertical incision is made over the
femoral canal and continued upwards above the inguinal ligament.
This incision provides good access to the preperitoneal space and then to the peritoneum itself.
Use finger dissection to sweep peritoneum from anterior abdominal wall , so the neck of the sac can be identified.
Dissect the sac , reduce the contents and repair the defect by mesh or sutures.
Lotheissen‘s trans-inguinal Lotheissen‘s trans-inguinal approach approach The incision is made superior and
parallel to inguinal ligament extending from pubic tubercle to mid inguinal point.
Hernia examination Hernia examination
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