Hernia
General Surgery, Renhe Hospital, Three Gorges University,
Zhang-Xianlin
Hernia
Definition :• Protrusion of an organ (intestine ,brain)
or tissue outside its normal body cavity or constricting sheath .
• Abdominal hernia is the protrusion of the abdominal content outside abdominal wall.
Causes of Abdominal Hernia
1. Anatomical defect of the abdominal wall.
2. Acquired weakness of the abdominal wall .
Surgical Anatomy
rectus abdominis(腹直肌 )
Rectus sheath(腹直肌鞘)
External oblique(腹外斜肌 )
pubic symphysiscrural ligament
Surgical Anatomy
脐 bellybutton
chorda spermatica
outer ring
inner ring
腹股沟解剖
inguinal groove
Surgical Anatomy
股管解剖 femoral canal
Surgical Anatomy
Types of Abdominal Hernia
Epigastric
paraumbilical
Umbilical
lumbar
Spigelian(半月疝 )
femoral
inguinal
The Basic Feature Of All Hernias
• They occur at a weak spot .• They reduce on lying down ,or with direct pressure. • The have an expensile cough impulse.
A hernia consist of 3 parts:
1.Sac:
consist of a diverticulum of peritoneum.
2.Contents:
Omentum, small or large intestine, urinary bladder, Omentum, ovaries malignant nodules or ascetic fluid.
3.Coverings:
derived from the layers of abdominal wall.
Complications Of Hernias
• Irreducible
• the hernia contents cannot be manipulated back into the abdominal cavity.
• Incarcerated • the contents of the sac are literally inpresiond in the sac of Hernia.
• Obstruction
• the loop of the bowel become non functioning with normal blood supply .
• Strangulated
• cut off the blood supply to the content sac (tender).
Inguinal Hernia
Protrusion of abdominal contents through the inguinal region
Inguinal Hernia
Differences between indirect and direct hernia
featureindirectdirect
agechildren, young peopleaged people
pathway of protrusioncoming down the inguinal canal, may enter the scrotum
pass through Hesselbach’s triangle, rarely enter the scrotum
contours of sacelliptic, pear-shapedsemispheric, wide base
compress the internal ring after reduced
controlled not controlled
ReducedUpwards, laterally and back ward
Upward and strait backward
Relationship of sac neck with inferior epigastric artery
Sac neck is lateral to it Sac neck is medial to it
Incarcerated incidence
highlow
Inguinal Hernia in Children
Most common is indirect hernia • Patent processes vaginalis
1. Inguinal hernia
2. infantile hydrocele
3. An encysted hydrocele of the cord
• Hydrocele Vs Hernia • More in premature infants
Treatment Notes
• Incarcerated hernia in infancy can almost always be managed by manipulative reduction with subsequent scheduled herniotomy.
• The one exception is In baby girl because the ovaries may be part of the sac content.
Special Varieties of Inguinal Hernia
• Pantaloon Hernia • Maydl’s Hernia • Sliding Hernia • Richter’s Hernia • Litter’s Hernia
Femoral Hernia
Left Femoral Hernia
Femoral Hernia
• Protrusion of abdominal content through the femoral canal .
• More common in females.
• Below and laterally to the pubic tubercle.
• Narrow neck High risk for strangulation.
CASES Case (1) - Asymptomatic, reducible groin swelling in the elderly A 71-year-old man, who has had two myocardial infarcts and
hypertension, presents with a groin bulge, present only when he coughs. It has never been painful.
Case (2) - Asymptomatic reducible groin swelling A fit 34-year-old policeman presents with a three month history of a
progressively enlarging inguino-scrotal swelling. It has not been painful but is becoming more difficult to reduce digitally.
Case (3)- Irreducible groin swelling This otherwise fit 92-year-old lady noticed a groin swelling six
months ago. At first it reduced spontaneously when she lay down but for the past four weeks it has been present constantly, is irreducible, and she now has twinges of pain.
DDx of Lump In The Groin
1. Inguinal Hernia 2. Femoral Hernia3. Enlarged lymph node 4. Sapheno –varix 5. Ectopic testis 6. Psoas abcess7. Psoass bursa 8. Lipoma
Ask in your History
• Lump: duration, first symptoms, associated symptoms, progression, persistent ,other sites ,cause
• Does it reduce on lying down? • Have there been episodes of pain in the swelling? • Have there been episodes of abdominal pain? • Does the patient have any febrile symptoms?• History of rectal bleeding • History of trauma or septic focus in the lower limbs • Causes of increase of intrabdominal pressure • Previous surgeries ?
Physical Exam• Before Physical Exam,pay attention to: • Introduce your self ,• Take permission,
• Patients privacy ,
• Position standing up
• Exposure bilateral inguinal region and the groin
Physical Exam• From in front :1. Inspection lump: site, shape scrotum: does it extend to the
scrotum 2. Palpation : (decide is it hernia or not)Ask the patient about pain before you palpate • Can you go above it• Can you palpate the testis • If it is a hernia type • Define pubic tubercle
Can you go Above it?
Physical Exam
Physical Exam• Feel from the sides
1. Aim to examine the lump
( tenderness, temperature, size ,shape, site, composition (
2. Reducible?? How?? Ask the pts if you couldn’t
3. Controlled when you pressure over deep inguinal ring ?
4. Expensile cough impulse
5. Direction of reappearance
Physical Exam
Physical Exam• Percussion of the sac
• Auscultation of the sac
• Feel the other side
• Abdominal examination
• Cardiovascular and respiratory assessment
Treatment of groin hernias
Approach• conservative (reassure the patient) • a truss (now a rare treatment option) • OperateTreatment of groin hernias can be summarized: • Direct inguinal hernia - rarely operate unless
there is a specific indication. • Indirect inguinal hernia - usually operate. • Femoral hernia - always operate unless there is
a contraindication.
Treatment of groin hernias
• Direct inguinal hernia Most require no treatment. Patients with pure direct inguinal bulges are at
virtually no risk of complications. Most are elderly and reassurance is usually appropriate.
• Indirect inguinal hernia Most require operative treatment as the risks of irreducibility and obstruction
are higher. Advise repair unless the patient’s general health is such that the risks of operation outweigh the possible benefits.
The operation for inguinal hernia may be: 1. sutured, e.g. Bassini, Shouldice 2. open mesh, e.g. Lichtenstein 3. laparoscopic mesh, e.g. TAPP (transabdominal preperitoneal), TEP (total
extra peritoneal) 4. in babies, simple herniotomy is all that is required.
Femoral hernia repair
Femoral hernia treatment :
1. high approach
2. low approach
3. inguinal approach
Left Femoral Hernia
Direct inguinal Hernia
lump
Right Indirect Inguinal Hernia
www.icareunit.com
包块 lump
Left Indirect Inguinal Hernia
Left Indirect Inguinal Hernia
Bilateral indirect inguinal hernia
Bilateral indirect inguinal hernia
Emergency presentation with small bowel obstruction, tender irreducible groin swelling
A previously fit 58-year-old woman has been aware of a groin hernia for several years. It has recently become irreducible. Today it has become acutely painful and she has colicky abdominal pain, distension and vomiting. She has now become confused, clammy, hypotensive and oliguric
What is you approach?
Epigastric Hernia
• It occurs through the linea alba midway between the xiphisternum & the umbilicus.
• It is a protrusion of extraperitonial fat from the site of entry of a small blood vessel through the linea alba (fatty Hernia of linea alba).
• It is usually small in size, it may drag a pouch of peritoneum to form a true hernia.
Epigastric Hernia
• The neck is usually too small to allow a hollow viscous to enter it, consequently the sac is empty or it contains small part of omentum. (not true hernia )
• It is probably as a result of sudden strain that tears the interlacing fibers of linea alba.
Epigastric Hernia
• Clinically; The patient is usually a manual worker, 30-50y in age, symptom less, incidentally discovered during routine exam
• Pain & tenderness is due to strangulated fat.
• Referred pain & dyspepsia is most probably related to DU, GS etc.
• Treatment: Excision & repair of defect.
Epigastric Hernia
Umbilical Hernia
• True umbilical Common in children.
• Intestinal obstruction extremely rare.
• Surgical repair if persisted after 3rd birthday .
Para-umbilical hernia
• Para umbilical usually middle age women obese or multiparous
• It is a protrusion through the linea alba just above or the umbilicus. As it enlarges it sags downward and can attain a large dimensions
• The neck of the sac is narrow as compared with the size of the sac & it’s contents ( om-entum, small intestine or part of the colon). Usually loculated due to adhesions.
Para-umblical Hernia
• Clinically; more common in women, obese, multiparous & 35-50y of age.
• It becomes irreducible due to adhesions & strang-ulation may occur. Pain colicky or dragging.
• The skin over it becomes reddened, smooth & may become excoriated.
• Treated by division of adhesions. & repair of defect “Mayo’s repair”
Para-umblical Hernia.
Para-umlical Hernia
Paraumlical Hernia
Incisional Hernia
• Protrusion through surgical wound • Occur after 3-5% of abdominal operation • Causes
1. Midline ,vertical incision
2. Poor technique
3. Wound or chest infection
4. Obesity • Strangulation is rare but repair is advisable
Incisional hernia.
Thank You