Inguinal hernias and abdominal wall defects

Murad Nuserat & Abd AL-Rahman Alhelw

Definition

• A hernia is the protrusion of an organ (intra-abdominal contents) through a defect in its containing wall.

Composition of a hernia

1. The sac

2. The covering of the sac

3. The content of the sac

Composition of a hernia

1. The sac : It is a diverticulum of

peritoneum and is made up of three parts : The mouth, The neck and The body of the sac.

Composition of a hernia

2. The covering:

Coverings are derived from the layers of abdominal wall through which the sac pass

3. Contents:

can be Omentum = omentocle Intestine = enterocele Portion of circumference of intestine = Richter’s hernia Portion of the bladder Ovary(with or without oviduct) Meckel’s diverteculum =Littre’s hernia

EtiologyAny condition that raises intra-abdominal pressure, such as a powerful muscular effort, may produce a hernia.

1. Whooping cough is a predisposing cause in childhood

2. Chronic cough, straining on micturition or straining on defecation, heavy lifting may precipitate a hernia in an adult.

3. Smoking and aging, leading to acquired collagen deficiency.

4. intra-abdominal malignancy, ascites

5. Obesity

6. Multiparity, for femoral hernias

7. Congenital defect, as indirect inguinal hernia (processus vaginalis)

TypesA hernia at any site may be:

1. Reducible

This is the one which the contents of the sac reduced spontaneously or can be pushed back manually. A reducible hernia imparts an expansile impulse on coughing.

2. Irreducible

This one whose contents cannot be returned to the peritoneal cavity either because there are:• adhesions between the sac and contents, or

• because of the narrow neck of the sac.

• Overcorwding within the sac

Irreducible hernia can be :

1. Incarcerated: there are adhesions between the sac and the contents, but there is no obstruction or interference with blood supply. the hernia simply will not reduce

2. Obstructed: a hollow viscus is trapped within the sac and obstruction occurs. The blood supply remains intact. This is a common cause of small bowel obstruction.

3. Strangulated: the arterial blood supply to the contents of the sac is compromised, in such a hernia unless surgical relief is undertaken the contents of the sac will become gangrenous.

Present with local then general abdominal pain and vomiting

tense + tender + no impulse on coughing

Classification continue…A. External hernia

Common hernia

• inguinal

• Femoral

• Umbilical

• incisional Rare hernia

– Spigelian– Gluteal– Obturator– lumbar

Classification continue…

B. Internal hernia

• Diaphragmatic hernia

• Esophogial hernia

• Paraesophogial hernia

Signs and Symptoms

- A lump disappears, reappears, and enlarges on straining and discomfort.

• Physical Signs:• Reduced.• + ve cough impulse, in inspection and palpation

• Investigation:

Hernia is diagnosed clinically. Investigations are rarely indicated or valuable.

Managementhernias should be operatively repaired both to relieve symptoms and to eliminate the complications.

• Surgical techniques:• Herniotomy: removal of sac and closure of its neck.• Herniorrhaphy: involves some sort of reconstruction to:• Restore the anatomy if this is disturbed.• Increase the strength of the abdomenal wall.• Construct a barrier to recurrence.

Inguinal hernia• Epidemiology:

• Male : Female • by 9 to 1 ratio

• young adults mostly have indirect inguinal hernia.

• As age of patient increases, the incidence of direct hernias increases .

Inguinal herniaInguinal Canal Anatomy

• The internal inguinal ring is an opening in the transversalis fascia lateral to the inferior epigastric vessels.

• The external inguinal ring is an opening in the external oblique aponeurosis.

• The inguinal canal is the communication between the internal and external rings.

• Anterior wall: • aponeurosis of external oblique (along entire length),• internal oblique on lateral one third

• Posterior:• fascia transversalis• conjoint tendonon in medial one third

• Roof:• arching lowest fibers of internal oblique , and

transversus abdominis

• Floor (inferior):• inguinal ligament, and • lacunar ligament at the medial end

Inguinal Canal Contents:Male:

• Spermatic cord structures:• vas deferens, • testicular artery • testicular veins (pampiniform plexus), • genital branch of genitofemoral nerve,• artery of the vas deference, • lymphatics, • autonomic nerves,• processus vaginalis.• Ilio inguinal nerve

• Female:

• Round ligament of the uterus,

• genital branch of genitofemoral nerve,

• lymphatics,

• sympathetic plexus.

Inguinal hernia

Signs & symptoms:• Bulge that enlarges when stand or strain, but often asymptomatic.

• In general direct hernias produce fewer symptoms than indirect hernias and are less likely to complicate.

• On examination:

• Palpable defect or swelling may be present .

• Indirect Hernia usually bulge at Internal Inguinal Ring.

• Direct Hernia usually bulge at External Inguinal Ring.

Inguinal herniaThere are two types

of inguinal hernia:

• Direct inguinal hernia

• Indirect inguinal hernia

Indirect inguinal hernias are the most common type of hernia in both men and women. They are 5 to 10 times more common in men than in women.

Differences between direct and indirect hernias1. Origin and coarse:• Direct: Develops in the area of Hasselbach's triangle. The origin is medially to

the inferior epigastric vessels.

• Indirect: Develops at the internal ring. The origin is lateral to the inferior

epigastric artery.

2. Content:• Direct: Retroperitoneal fat. less commonly, peritoneal sac containing bowel .

• Indirect: Sac of peritoneum coming through internal ring, through which

omentum or bowel can enter.

3. Etiology:• Direct: weakness of the posterior floor of the inguinal canal (acquired).

• Indirect: patent processus vaginalis (Congenital) .

Diagnosis

• The patient usually presents (for groin hernia) with the complaint of a bulge in the inguinal region

• They may describe minor pain or vague discomfort associated with the bulge

• Extreme pain usually represents incarceration with intestinal vascular compromise

• Paresthesias may be present if inguinal nerves are compressed

Diagnosis• Physical exam• The patient should be standing and facing the examiner• Visual inspection may reveal a loss of symmetry in the

inguinal area or bulge• Having the patient perform valsalva’s maneuver or

cough may accentuate the bulge• A fingertip is then placed in the inguinal canal; Valsalva

maneuver is repeated• Differentiation between indirect and direct hernias at

the time of examination is not essential

Hernia Exam

Diagnosis

• Physical exam• Incarcerated hernias sometimes can be reduced manually

• Gentle continuous pressure on the hernial mass towards the inguinal ring is generally effective (Trendelenburg)

Inguinal hernia

• Differential diagnosis:1. Tendonitis

2. Muscle tear

3. Lymphadenopathy

4. Lipoma

5. Varicose vein

6. Hydrocele

7. Epididymitis

8. Spermatocele

Inguinal hernia

• Complications:• Irreducibility, but without signs of obstruction or strangulation

• Small Bowel Obstruction, Usually urgent surgical repair

• Strangulation, Surgical emergency 50% indirect, 3-10% direct.

Inguinal hernia

• Both types (direct and indirect inguinal hernia) may occur at the same time and straddle the inferior epigastric artery.

the hernia sac passes both medially and laterally to the epigastric vessels

• This is called:

Pantaloon hernia

Management:• Inguinal hernias should always be repaired ( herniotomy,

herniorrhaphy ) unless there are specific contraindications.

• Types of operations:

1. a permanent sutures, as in Shouldice repair (layered suture).

2. a permanent mesh to decrease tension.

• The basic operation is inguinal herniotomy, which entails dissecting out and opening the hernial sac, reducing any contents and then transfixing the neck of the sac and removing the remainder. It is employed either by itself or as the first step in a repair procedure (herniorrhaphy)

• Herniotomy and repair (herniorrhaphy) consists of: (1) excision of the hernial sac; plus (2) repair of the stretched internal inguinal ring and the transversalis fascia; and (3) further reinforcement of the posterior wall of the inguinal canal. (2) and (3) must be achieved without tension resulting in the wound and various techniques exist to achieve this, e.g. Shouldice operation, fascial flaps or mesh implants.

Inguinal hernia management

• Treatment of aggravating factors (chronic cough, prostatic obstruction, etc).

• Use of truss (appliance to prevent hernia from protruding) when a patient refuses operative repair or when there are absolute contraindications to operation

Specific Surgical Procedures

These are for repair of the floor of the inguinal canal (herniorrhaphy)

• Lichenstein (Tension Free) Repair

• McVay (Cooper’s Ligament) Repair

• Shouldice (Canadian) Repair

• Laproscopic Hernia Repair

• Bassini Repair

Lichtenstein Repair

AKA: Tension-Free Repair

One of the most commonly performed procedures

A mesh patch is sutured over the defect with a slit to allow passage of the spermatic cord

Lichtenstein Repair

Note:

Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

Femoral hernia• The defect is in the transversalis

fascia overlying the femoral ring at the entry to the femoral canal.

• The hernia passes through the femoral canal and presents in the groin, below and lateral to the pubic tubercle.

• It is more common in females and carries a higher risk of strangulation.

• Femoral canal-ant.by inguinal ligament,post by fascia over pectineus muscle and cooper’s ligament, lat. by femoral vein and medial by lacunar ligament

Signs & symptoms:• A lump occurs below and lateral to the

pubic tubercle. It may be reducible.

• It may not be noticed until it becomes tender and painful.

• This type of hernia should be carefully sought in the obese patient who presents with signs of intestinal obstruction without an obvious cause.

• DD’s-saphena varix,enlarged inguinal LN,femoral artery aneurysm,rare femoral abscess.

Surgical repair:• An incision is made directly over the swelling.

• The sac is opened and the contents reduced and the sac removed.

• Femoral canal obliterated with 3 interrupted non absorbable suture.

• Treatment of strangulation or obstruction, if present.

• There is no place for a truss in the treatment of femoral hernia.

Femoral hernia

Umbilical hernia

• This occurs in children because of incomplete closure of the umbilical orifice.

• The majority close spontaneously during the first year of life.

• Surgical repair should only be carried out if the hernia has not disappeared by the age of 2 and the fascial defect is greater than 1.5cm in diameter.

Para-Umbilical hernia

• the hernia does not occur through the umbilical scar but is a protrusion through the linea alba

• It occurs just above or just below the umbilicus, and is more common in obese females.

• Predisposing factors • multiple pregnancies and

• obesity.

Para-Umbilical hernia• The neck of the sac is usually narrow and therefore

there is a high risk of strangulation.

• The most common content is• omentum ,then

• transverse colon and small intestine.

• Treatment: is by • Contents of sac freed from it’s wall,excision of the sac,

and fascial defect repaired by

• Upper flap overlapping the lower, a two layer overlapping repair thereby doubling the strength of repair (Mayo repair)

• >4 cm,recurrent-polypropylene mesh

Paraumbilical Hernia, creascent shaped

Epigastric hernia

• This is usually a small protrusion through the linea Alba in the upper part of the abdomen.

• It consists of :• extraperitoneal fat only, but• May contain omentum or

small bowel.

Epigastric hernia

• It may be extremely painful, probably because of trapping and ischaemia of extraperitoneal fat.

• Treatment• is by enlaging the defect,excising the fat, simple suture of the defect with non-

absorbable sutures .

• >4 cm propylene mesh placed retromuscular plane

Incisional hernia

• This occurs through a defect in the scar of a previous abdominal incision.

Incisional hernia

• Etiology :• Age: Wound healing is poor in the older patient.

• Obesity.

• Postoperative wound infection.

• Postoperative wound haematoma.

• Raised intra-abdominal pressure postoperatively, e.g. coughing, straining, constipation, ileus.

• Steroid therapy.

• Type of incision: Midline vertical wounds have a higher incidence than transverse incisions.

• Poor suturing technique: Rarely does a suture break

Incisional hernia• Sign & symptoms :

• A swelling protrudes through the wound.

• It May occur up to 5 years postoperatively.

• Many are large and involve the whole incision and consequently the neck of the sac is wide and the risk of strangulation rare.

• If the defect is small there is a greater risk of strangulation .

• Treatment-palliative-abd.belt

• - preoperative measures-reduce weight,treat cough,improve nutritional status.stop smoking.

• -surgery:excision of sac,identification and apposition,

• -large hernia-poly propylene mesh

Richter’s hernia• Part of the wall of the

intestine becomes trapped in the defect.

• This is usually the antimesenteric border of the small bowel.

• The lumen is intact

( no obstruction )

Some other hernias• Spigelian hernia: • This is a hernia through the linea semilunaris at the lateral border of the rectus

sheath.

• Littre's hernia: • A hernia that contains a Meckel's diverticulum in the sac.

• Obturator hernia:• This hernia occurs through the obturator foramen. It is commoner in elderly

females.

• Lumbar herniae: • These occur in the lumbar region (below the 12th rib & above the iliac crest).

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