External Hernia

8/14/2019 External Hernia

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Affiliated Hospital of Jining Medical Colleg


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Whats these??


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External HerniaExternal Hernia

Affiliated Hospital of JiningMedical College

Department of GastrointestinalDepartment of Gastrointestinal

SurgerySurgery

Wang AiliangWang Ailiang

Affiliated Hospital of Jining Medical Colle


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Objectives of CourseObjectives of Course Definition of herniaDefinition of hernia

Grasp anatomy of inguinalGrasp anatomy of inguinalcanalcanal Categories of commonCategories of common

inguinal herniasinguinal hernias

Principle of treatment forPrinciple of treatment foringuinal herniasinguinal hernias



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Abdominal wall herniasAbdominal wall hernias

general considerationgeneral consideration inguinal herniasinguinal hernias

femoral herniafemoral hernia incisional herniaincisional hernia

umbilial herniaumbilial hernia

hernia of linea albahernia of linea alba



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1.GENERAL1.GENERAL

CONSIDERATIONSCONSIDERATIONS



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DEFINITION:DEFINITION:

AA sprout andsprout andprotrusionprotrusion of tissue orof tissue orviscus through aviscus through a

weakness or abnormalweakness or abnormalopening in anopening in anenclosing layerenclosing layer

an external abdominalan external abdominal

wall herniawall hernia is anis anabnormalabnormal protrusionprotrusionof intra-abdominalof intra-abdominaltissue or viscus, wholetissue or viscus, wholeor part, through anor part, through anopening or defect ofopening or defect of



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Inguinal herniasInguinal hernias

90%90% of external abdominalof external abdominalherniashernias

occur in theoccur in the groingroin

includeinclude indirect inguinal herniasindirect inguinal herniasandand direct inguinal hernaisdirect inguinal hernais



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All Kinds of Hernias:All Kinds of Hernias:


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Type of Abdominal HerniaType of Abdominal Hernia femoral hernia

Affiliated Hospital of Jining Medical Col


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Type of Abdominal HerniaType of Abdominal Hernia umbilical hernia

Affiliated Hospital of Jining Medical Coll


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Type of Abdominal HerniaType of Abdominal Hernia

inguinal herniainguinal hernia



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ETIOLOGY:ETIOLOGY:

Weakness ofWeakness of

abdominal wallabdominal wall

increased intra-increased intra-abdominal pressureabdominal pressure

A balloon with a

protrusion



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EtiologyEtiology 1.1.intensity of abdominal wall decreasedintensity of abdominal wall decreased

((common factors):common factors):

1) site that some tissues pass through the1) site that some tissues pass through the

abdominal wall: Spermatic cord, roundabdominal wall: Spermatic cord, round

ligament of uterusligament of uterus

2) bad development of abdominal white line2) bad development of abdominal white line

3) incision, trauma, infection et al.3) incision, trauma, infection et al.

defect in collagen synthesis or turnoverdefect in collagen synthesis or turnover

2.2. any condition which increases intra-any condition which increases intra-

abdominal pressureabdominal pressure



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Hernia:Affiliated Hospital of Jining Medical Colle


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Clinical typesClinical types 1.1. reducible herniareducible hernia

2.2. irreducible herniairreducible hernia

3. incarcerated hernia3. incarcerated hernia4. strangulated hernia4. strangulated hernia



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Clinical classificationClinical classification Reducible herniaReducible hernia: Contained viscus: Contained viscus can becan be

returnedreturned from the hernia to its normalfrom the hernia to its normal

domain spontaneously or with manualdomain spontaneously or with manualpressure when the patient is recumbentpressure when the patient is recumbent

Irreducible herniaIrreducible hernia: Contained viscus: Contained viscus

cannot be returnedcannot be returned from the hernia to itsfrom the hernia to its

normal domain, usually it is due to thenormal domain, usually it is due to theadhesions between the contents of herniaadhesions between the contents of hernia

sac and the wall of hernia sacsac and the wall of hernia sac



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irreducible herniairreducible hernia

Huge herniaHuge hernia

SlidingSliding

herniahernia



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Sliding hernia:Sliding hernia:

A portion ofA portion ofthe wall of thethe wall of the

herniahernia sacsac is composed ofis composed ofanan

organorgan such as the cecum onsuch as the cecum on

the right side and the sigmoidthe right side and the sigmoid

colon on the left side.colon on the left side.

Occasionally, bladder isOccasionally, bladder isinvolved. The development ofinvolved. The development of

a sliding hernia is related toa sliding hernia is related to

the variable degree ofthe variable degree of

posterior fixation of the largeposterior fixation of the large



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Incarcerated herniaIncarcerated hernia::

If the neck of hernia is veryIf the neck of hernia is verynarrow, protruded part ofnarrow, protruded part ofintra-abdominal viscus inintra-abdominal viscus inthe hernia sac may bethe hernia sac may betrapped by the narrowtrapped by the narrowneck, and the lumen of aneck, and the lumen of asegment of bowel withinsegment of bowel within

the hernia sac, if it exists,the hernia sac, if it exists,may become obstructed.may become obstructed.

In which there is noIn which there is nointerference with bloodinterference with blood

supply.supply.



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Strangulated hernia:Strangulated hernia:

If, in addition to incarceration, there is aIf, in addition to incarceration, there is a

compromise of the blood supply of thecompromise of the blood supply of thecontained organcontained organ

Gangrene of the hernia contents and theGangrene of the hernia contents and the

hernia sac usually occur after long time ofhernia sac usually occur after long time of

incarcerationincarceration



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GangrenGangrene ofe of

incarcerincarcer

atedated

intestineintestine

strangulated herniastrangulated hernia



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Special types of herniasSpecial types of hernias

Richters hernia:Richters hernia: only part ofonly part of

circumference of the bowel becomescircumference of the bowel becomesincarcerated or strangulated at the narrowincarcerated or strangulated at the narrow

neck of hernia.neck of hernia.

Littres hernia:Littres hernia: when the incarcerated orwhen the incarcerated or

strangulated part is a diverticulum of thestrangulated part is a diverticulum of the

small intestine, usually Meckelssmall intestine, usually Meckels

diverticulum.diverticulum.



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Richters herniaRichters hernia



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Pathological anatomy:Pathological anatomy:

The external abdominal herniaThe external abdominal herniaconsists ofconsists ofhernia ring, herniahernia ring, hernia

sac, hernia content, and herniasac, hernia content, and hernia

covering.covering.



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Pathological anatomyPathological anatomy

covering tissuecovering tissue: skin, subcutaneous: skin, subcutaneous

tissuetissue

hernial sachernial sac: protrusion of peritoneum,: protrusion of peritoneum, neck of the sac: is narrow where the sacneck of the sac: is narrow where the sac

emerges from the abdomen body of theemerges from the abdomen body of the

sacsac

hernial contentshernial contents: small intestine, major: small intestine, major

omentumomentum



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Different parts of a hernia:Different parts of a hernia:


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Inguinal HerniaInguinal Hernia



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Anatomical layers of inguinalAnatomical layers of inguinal

regionregion Skin and subcutaneous fatSkin and subcutaneous fat External oblique abdominalExternal oblique abdominal

musclemuscle

Internal oblique abdominalInternal oblique abdominal

muscle and transversemuscle and transverse

abdominal muscleabdominal muscle

Transverse abdominal fasciaTransverse abdominal fascia

Fat out of peritoneumFat out of peritoneum

PeritoneumPeritoneum



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Internal oblique abdominal muscleInternal oblique abdominal muscle

and transverse abdominal muscle:and transverse abdominal muscle:

The lower arcing free edges of these twoThe lower arcing free edges of these two

muscles fuse together to form themuscles fuse together to form theconjointed tendonconjointed tendon.. But this condition occurs only in 5% ofBut this condition occurs only in 5% of

persons.persons.

Thus,Thus, falx inguinalisfalx inguinalis, which forms the, which forms thesuperior wall of the inguinal canal, refer tosuperior wall of the inguinal canal, refer tothe lower arcing free edge of transversethe lower arcing free edge of transverseabdominal muscle rather than twoabdominal muscle rather than two

muscles.muscles.



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Transvers abdominalTransvers abdominalfascia:fascia:

Internal inguinal ringInternal inguinal ring is a partialis a partial

interruption in the transverseinterruption in the transverse

fascia, which is located at thefascia, which is located at the

halfway of the inguinal ligamenthalfway of the inguinal ligamentand up 2 cm to it.and up 2 cm to it.



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The anatomy of the groin:The anatomy of the groin:


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Inguinal canal:Inguinal canal: Inguinal canal passes through the lowerInguinal canal passes through the lower

anterior abdominal wallanterior abdominal wall from the externalfrom the externalinguinal ring to the internal inguinal ringinguinal ring to the internal inguinal ring,,which is about 4-5 cm long in the adults.which is about 4-5 cm long in the adults.

In the male,In the male, the testis and the spermaticthe testis and the spermaticcordcord pass through the inguinal canal frompass through the inguinal canal fromthe abdomen to the scrotum.the abdomen to the scrotum.

In the female,In the female,

the round ligament of thethe round ligament of the

uterusuterus passes it to the major labia.passes it to the major labia.



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The four walls of the inguinalThe four walls of the inguinalcanalcanal

Are formed by the muscular, aponeurotic,Are formed by the muscular, aponeurotic,

and fascial layers of the abdominal wall.and fascial layers of the abdominal wall.

The anterior wallThe anterior wall is formed byis formed by the externalthe external

oblique aponeurosisoblique aponeurosis and the fibers of theand the fibers of theinternal oblique muscle.internal oblique muscle.



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The superior wallThe superior wall(roof of the(roof of the

inguinal canal) is formed byinguinal canal) is formed by thethe

falx inguinalisfalx inguinalis, which is the, which is the

arcing free edge of thearcing free edge of thetransverse abdominal muscle(transverse abdominal muscle(oror

the conjointed tendonthe conjointed tendon which iswhich is

the arcing free edge of thethe arcing free edge of thefusing of the internal obliquefusing of the internal oblique

abdominal muscle and theabdominal muscle and the

transverse abdominal muscle).transverse abdominal muscle).



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The inferior wallThe inferior wall(floor of the(floor of the

inguinal canal) is formed byinguinal canal) is formed by thethe

inguinal ligament and theinguinal ligament and the

lacunas ligamentlacunas ligament.. The posterior wallThe posterior wall is formed byis formed by

the transverse fasciathe transverse fascia..



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Inguinal canal,Inguinal canal,showingshowing

arrangementarrangementof (1)externalof (1)external

obliqueoblique

muscle,muscle,(2)internal(2)internal

obliqueoblique

muscle,muscle,

(3)transversus(3)transversusmuscle,muscle,

(4)fascia(4)fascia

transversalis.transversalis.


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(1)the external oblique abdominal muscle(1)the external oblique abdominal muscle(2)the internal oblique abdominal(2)the internal oblique abdominal(3)the transverse abdominal muscle(3)the transverse abdominal muscle

(4)testicular veins(4)testicular veins(5)the efferent duct of the testes(5)the efferent duct of the testes(6)the iliac vessels(6)the iliac vessels(7)the inferior epigastic artery and vein(7)the inferior epigastic artery and vein(8)the aponeurosis of the transverse(8)the aponeurosis of the transverseabdominal muscle and theabdominal muscle and the

transversalis fasciatransversalis fascia(9)the ublic tubercle(9)the ublic tubercle


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Spermatic cord:Spermatic cord:

When the testicle descents into theWhen the testicle descents into the

scrotum, it passes through the abdominalscrotum, it passes through the abdominalwall in the inguinal region.wall in the inguinal region.

The spermatic cord passes obliquelyThe spermatic cord passes obliquelydownward through the inguinal canal fromdownward through the inguinal canal from

the internal inguinal ring, then it emergesthe internal inguinal ring, then it emerges

through the external inguinal ring to passthrough the external inguinal ring to pass

into the scrotum.into the scrotum.



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Nerves of inguinal region:Nerves of inguinal region:

Include: iliohypogastric nerve,Include: iliohypogastric nerve,ilioinguinal nerve, andilioinguinal nerve, and

genitofemoral nerve.genitofemoral nerve.

During operation: we should notDuring operation: we should notdamage these nerves.damage these nerves.



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Inguinal triangle:Inguinal triangle:

The inguinal triangle lies in theThe inguinal triangle lies in theinferomedial inguinal region,inferomedial inguinal region,

which is an area of potentialwhich is an area of potential

weakness and thus often the siteweakness and thus often the siteof a direct inguinal hernia.of a direct inguinal hernia.



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The medial borderThe medial border of it isof it is thethe

linea semilunarislinea semilunaris(the lateral(the lateral

edge of the rictus sheath)edge of the rictus sheath)

The inferolateral borderThe inferolateral border isis thethe

inguinal ligamentinguinal ligament

The lateral borderThe lateral border isis the inferiorthe inferior

epigastric arteryepigastric artery



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Pathological mechanism:Pathological mechanism:

The mechanism of indirect andThe mechanism of indirect anddirect inguinal hernia isdirect inguinal hernia is

different.different.



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Indirect inguinal hernia:Indirect inguinal hernia:

The processus vaginalis may closeThe processus vaginalis may closebefore birth. If that dont happen, abefore birth. If that dont happen, apersistent processus vaginalis maypersistent processus vaginalis maypredispose topredispose to congenital indirectcongenital indirectherniahernia during the early years of life.during the early years of life.

A weakened area of abdominal wallA weakened area of abdominal wallassociated with an enlargement ofassociated with an enlargement ofthe internal ring may cause anthe internal ring may cause anacquired indirect inguinal herniaacquired indirect inguinal hernia..



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As a result, an indirect inguinalAs a result, an indirect inguinal

hernia leaves the abdominalhernia leaves the abdominal

cavity atcavity at the internal ringthe internal ring andand

passes with the structures ofpasses with the structures ofthethespermatic cordspermatic cord either a variableeither a variable

distance down the inguinal canaldistance down the inguinal canal

or all the way into the scrotumor all the way into the scrotumthroughthrough the superficial inguinalthe superficial inguinal

ringring directed by the spermaticdirected by the spermatic

cord.cord.



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Therefore, the neck of herniaTherefore, the neck of hernia

must be locatedmust be located lateral tolateral to thethe

inferior epigastric artery to enterinferior epigastric artery to enter

the inguinal canal, and the sac ofthe inguinal canal, and the sac ofhernia must liehernia must lie withinwithin the fibersthe fibers

of the cremaster muscle.of the cremaster muscle.



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Direct inguinal hernia:Direct inguinal hernia:

Direct inguinal hernias areDirect inguinal hernias are

always acquired.always acquired. A direct hernia protrudesA direct hernia protrudes

through the posterior wall of thethrough the posterior wall of the

inguinal canalinguinal canal in the inguinalin the inguinaltriangletriangle, and pushes the, and pushes the

peritoneum and transversalisperitoneum and transversalis

fascia.fascia.



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Normally, the posterior wall ofNormally, the posterior wall ofinguinal canal in the area of theinguinal canal in the area of theinguinal triangle is reinforced byinguinal triangle is reinforced byaponeurotic fibers from theaponeurotic fibers from the

transverser abdominis and the falxtransverser abdominis and the falxinguinalisinguinalis..

However, this kind of reinforcementHowever, this kind of reinforcement

may be incomplete because themay be incomplete because thesupporting extent of falx inguinalissupporting extent of falx inguinalisvaries among different persons.varies among different persons.

Thus, the inguinal triangle is aThus, the inguinal triangle is aotential site of weakness to someotential site of weakness to some


ffili d i l f i i di l ll


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Conclusions of indirect and directConclusions of indirect and directhernia:hernia:

1)The direct hernia projects1)The direct hernia projectsthrough the inguinal trianglethrough the inguinal triangle

instead of the internal inguinalinstead of the internal inguinal

ringring (2)Therefore, the neck of hernia(2)Therefore, the neck of hernia

passes medial to the inferiorpasses medial to the inferior

epigastric arteryepigastric artery


Affili d H i l f Ji i M di l C ll


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(3)and the sac of hernia lies(3)and the sac of hernia lies

adjacent to(not within) theadjacent to(not within) the

spermatic cord. So, this type ofspermatic cord. So, this type of

hernia is not through thehernia is not through theexternal inguinal ring and isexternal inguinal ring and is

seldom enter the scrotumseldom enter the scrotum

(4) Sliding hernia is more(4) Sliding hernia is morecommon in the indirect herniacommon in the indirect hernia

than in the direct hernia..than in the direct hernia..


Affili t d H it l f Ji i M di l C ll


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(5)The risk of strangulation in(5)The risk of strangulation in

indirect is more than in direct,indirect is more than in direct,

because the indirect herniabecause the indirect hernia

passes through the internalpasses through the internalinguinal ring and have a narrowinguinal ring and have a narrow

neck, and the direct hernianeck, and the direct hernia

usually protrudes through theusually protrudes through theinguinal triangle without ainguinal triangle without a

narrow neck.narrow neck.



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Clinical manifestations:Clinical manifestations:

Symptoms:Symptoms: The most importantThe most important

symptom issymptom is a lumpa lump oror swellingswelling ininthe inguinal region which may bethe inguinal region which may bediscovered by a routine physicaldiscovered by a routine physical

examination or by the patientexamination or by the patienthimself. Occasionally, thehimself. Occasionally, thepatient may have the feeling ofpatient may have the feeling ofthe discomfort or slight pain.the discomfort or slight pain.




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Signs:Signs: The typical clinical featureThe typical clinical feature

isis a swellinga swelling oror a lumpa lump in thein the

inguinal region, which may beinguinal region, which may be

reducible or irreducible with thereducible or irreducible with thepatient supine and relaxed.patient supine and relaxed.

When the patient is requested toWhen the patient is requested to

strain or cough, the hernia maystrain or cough, the hernia maybecome apparent because ofbecome apparent because of

raising intra-abdominalraising intra-abdominal

pressure.pressure.




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Differences of two kinds ofDifferences of two kinds of

herniahernia Usually an indirect inguinalUsually an indirect inguinal

hernia appears as an elliptichernia appears as an ellipticswelling coming down theswelling coming down theinguinal canal and frequentlyinguinal canal and frequentlyentering the scrotum.entering the scrotum.

A direct inguinal hernia appearsA direct inguinal hernia appearsas a symmetric swelling atas a symmetric swelling atexternal ring.external ring.

Both of them should be locatedBoth of them should be located




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The physical signs of an herniaThe physical signs of an hernia

vary with the contents of thevary with the contents of the

sac. For example, if a bowelsac. For example, if a bowel

enters the hernia sac, crepitaionenters the hernia sac, crepitaionwill be noted on palpationwill be noted on palpation

because of the presence of gasbecause of the presence of gas

and fluid within the lumen.and fluid within the lumen.




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Methods of examination:Methods of examination: When examining, patient shouldWhen examining, patient should

be standing in a relaxedbe standing in a relaxedposition.position.

The finger should be introducedThe finger should be introduced

through the external ring intothrough the external ring into

the inguinal canal.the inguinal canal.

The presence of a dilatedThe presence of a dilated

external inguinal canal would beexternal inguinal canal would be




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When the examining finger hasWhen the examining finger has

been advanced well into thebeen advanced well into the

inguinal canal and the patient isinguinal canal and the patient is

requested to cough or strain, therequested to cough or strain, theindirect hernia should strikeindirect hernia should strike thethe

fingertipfingertip and the direct herniaand the direct hernia

should strikeshould strike the ball of thethe ball of thefingerfinger..




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A thumb placed over the internalA thumb placed over the internal

inguinal ring should keep aninguinal ring should keep an

indirect hernia reduced when theindirect hernia reduced when the

patient strains while permittingpatient strains while permittinga direct hernia to appear; again,a direct hernia to appear; again,

it is not always possible to locateit is not always possible to locate

the internal ring accuratelythe internal ring accuratelyenough to make this techniqueenough to make this technique

foolproof.foolproof.


7. The differences between the7. The differences between the


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indirect and the direct inguinalindirect and the direct inguinal

hernia:hernia:

Sac neck is medialto it

Sac neck is lateralto it

Relationship of sacneck with inferiorepigastric artery

lowhighIncarceratedincidence

Anterior and lateralto the sac

Posterior to the sacRelationship ofspermatic cord withsac

controlledcontrolledcompress theinternal ring afterreduced

semispheric, widebase

elliptic, pear-shaped

contours of sac

pass throughHesselbachstriangle, rarelyenter the scrotum

coming down theinguinal canal, mayenter the scrotum

pathway ofprotrusion

aged peoplechildren, youngpeople

age

directindirectfeature



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Incarcerated or strangulatedIncarcerated or strangulatedherniahernia::

They can often be seen inThey can often be seen inemergency conditions, which areemergency conditions, which are

common in the indirect inguinalcommon in the indirect inguinal

hernia, but seldom in the directhernia, but seldom in the directhernia.hernia.




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The small intestine is the organThe small intestine is the organmost frequently affected, andmost frequently affected, andsmall bowel obstruction maysmall bowel obstruction may

happen.happen. The patient suffers the suddenThe patient suffers the sudden

onset of abdominal pain,onset of abdominal pain,vomiting, and distension.vomiting, and distension.

In that case, we should doubtIn that case, we should doubtthe acute incarceration orthe acute incarceration orstrangulation of the bowel.strangulation of the bowel.




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Differential diagnosis:Differential diagnosis:1.1. Indirect, direct, femoralIndirect, direct, femoral

hernia: They have differenthernia: They have differentcharacters.characters.

2.2. Hydrocele of the spermaticHydrocele of the spermaticcord.cord.

3.3. An undescended testis: TheAn undescended testis: Thetestis cannot be felt in thetestis cannot be felt in thescrotum.scrotum.

4.4. Lymphadenopathy orLymphadenopathy or




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Hydrocele of the scrotum:Hydrocele of the scrotum:




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Principles of treatment:Principles of treatment: All inguinal hernias should beAll inguinal hernias should be

managed by operative treatmentmanaged by operative treatment

in the adult patient except thatin the adult patient except thatthe strong contraindicationsthe strong contraindicationsexist.exist.

Emergency operation should beEmergency operation should bedone when the complications ofdone when the complications ofincarceration, obstruction, andincarceration, obstruction, andstrangulation in the indirectstrangulation in the indirect

hernia happenhernia happen




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Although direct hernia seldom occursAlthough direct hernia seldom occursincarceration, operation is alsoincarceration, operation is also

needed because it is difficult toneeded because it is difficult to

distinguish indirect hernia from directdistinguish indirect hernia from direct

hernia.hernia.

The congenital inguinal herniamay spontaneously cure,

operation can be delayed untilthe child is more than oneyear old.




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Non-operativeNon-operative

management:management: The doctor can use someThe doctor can use some externalexternalsupport device or trusssupport device or truss to maintainto maintain

hernia reduction.hernia reduction.

The patient can take off it at nightThe patient can take off it at nightand put on it in the morning beforeand put on it in the morning before

he arises.he arises.

However, this method areHowever, this method are

recommended to be appllied only inrecommended to be appllied only in

the patients with strongthe patients with strong

contraindications of surgicalcontraindications of surgical

operation because it isnt aoperation because it isnt a




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When an acutely incarceratedWhen an acutely incarceratedhernia occurs,hernia occurs, manualmanualreductionreduction may be used.may be used.

The patient is placed in hipsThe patient is placed in hipselevated position. Afterelevated position. Afterapplying an appropriate doseapplying an appropriate dose

of analgesics and sedation,of analgesics and sedation,gentle sustained pressure overgentle sustained pressure overthe mass may effect reductionthe mass may effect reductionin 30 minutes.in 30 minutes.

If that effort fails orIf that effort fails or




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Treatment of inguinalTreatment of inguinal

herniashernias PrinciplesPrinciples Review relative anatomyReview relative anatomy

Operative methodsOperative methods Include new progress in herniaInclude new progress in hernia

surgerysurgery




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Principles of treatment:Principles of treatment: Adult: operativeAdult: operativetreatmenttreatment

Child under 1: theChild under 1: thecongenital inguinalcongenital inguinal

hernia mayhernia may

spontaneously curespontaneously cure Patient with strongPatient with strong

contraindications:contraindications:

non-operativenon-operative


N tiNon operativeAffiliated Hospital of Jining Medical Colle


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Non-operativeNon-operative

management:management: Using someUsing someexternal supportexternal support

device or trussdevice or truss

to maintainto maintain

hernia reductionhernia reduction

Only in theOnly in the

patients withpatients with

strongstrongcontraindicationscontraindications

of surgicalof surgical

operationoperation




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OperativeOperativetreatmenttreatment

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Before operation:Before operation: Any problems which couldAny problems which could

increase intra-abdominalincrease intra-abdominal

pressure, should be solved topressure, should be solved to

prevent a recurrent hernia.prevent a recurrent hernia. Chronic coughChronic cough

ConstipationConstipation

Prostatic hyperplasiaProstatic hyperplasia

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Aim of OperationAim of Operation

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Review: Anatomy of inguinalReview: Anatomy of inguinal

canalcanal

From the internal inguinal ring to theFrom the internal inguinal ring to the

external inguinal ring, 4-5 cm longexternal inguinal ring, 4-5 cm long Inside the canalInside the canal

Male:Male: the spermatic cordthe spermatic cord Female:Female: the round ligament of the uterusthe round ligament of the uterus

p J g

Review:Review:A t fA t f

Roof The conjoint tendon


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Anatomy ofAnatomy of

inguinal canalinguinal canal The superior wall(roof)The superior wall(roof)

Conjoint tendonConjoint tendon(the arcing edge of the fusing(the arcing edge of the fusingof the internal obliqueof the internal oblique

abdominal muscle and theabdominal muscle and thetransverse abdominal muscle)transverse abdominal muscle) The inferior wall(floor)The inferior wall(floor)

The inguinal ligamentThe inguinal ligament The anterior wallThe anterior wall

The external obliqueThe external obliqueaponeurosisaponeurosis Skin and superficial fasciaSkin and superficial fascia

The posterior wallThe posterior wall The transverse fasciaThe transverse fascia

The anterior wall:the external oblique aponeurosis

The posterior wall:the transverse fascia

Floor The inguinal ligamentThe spermatic cord



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canalcanal

External oblique aponeurosis Conjoint tendon

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canalcanal

The transverse fascia Site for inguinal hernia



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Operative techniquesOperative techniques

A. Simple high ligation of theA. Simple high ligation of the

sacsac

used for childused for childB. Repair of herniaB. Repair of hernia

C. Tension free Mesh repairC. Tension free Mesh repair

D. Laparoscopic RepairD. Laparoscopic Repair



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Operative techniques:Operative techniques:

A.A. Simple high ligation of theSimple high ligation of the

sac:sac:

anatomically isolate herniaanatomically isolate herniasac, ligate at the neck ofsac, ligate at the neck of

hernia sac, and removal of thehernia sac, and removal of the

sac.sac. If simple high ligation of theIf simple high ligation of the

sac is combined with asac is combined with a

tightening of the internal ring,tightening of the internal ring,

A Si l hi h li ti f thA Si l hi h li ti f th



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A. Simple high ligation of theA. Simple high ligation of the

sac:sac:

Ligate neck ofLigate neck of

Isolate herniasac

Cut exteral obliqueaponeurosis

Removal of the



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B.Repair of hernia: There are threeB.Repair of hernia: There are three

steps.steps.

(a)The management of the hernia(a)The management of the hernia

sac and its contents, thatsac and its contents, thatincludes high ligation of the sacincludes high ligation of the sac

and excision of sac.and excision of sac.

(b)The repair of the transverse(b)The repair of the transversefascial defect.fascial defect.



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Closing or decreasing the size ofClosing or decreasing the size ofinternal ring by the suture isinternal ring by the suture is

required in the most indirectrequired in the most indirect

hernia.hernia. In the direct hernia, it is usuallyIn the direct hernia, it is usually

a broadbased bulge, reinforceda broadbased bulge, reinforced

of weakened area in inguinalof weakened area in inguinaltriangle by the fascial repair istriangle by the fascial repair is

required.required.



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(c)The repair and reinforcement(c)The repair and reinforcementof the inguinal canal wall.of the inguinal canal wall. The first two essential steps areThe first two essential steps are

the same in any repair of herniathe same in any repair of hernia

for the most patient withfor the most patient with

inguinal herniainguinal hernia

The main difference is how toThe main difference is how to

repair and reinforce the wall ofrepair and reinforce the wall of

the inguinal canal.the inguinal canal.

Bassini repair:Bassini

repair:

RoofConjoint tendon


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Bassini repair:Bassini repair:

ApproximatesApproximatesand sutures theand sutures thearcing edge ofarcing edge of

the conjointedthe conjointedtendon to thetendon to theinguinal ligamentinguinal ligamentbeneathbeneath thethe

spermatic cordspermatic cord LeavesLeaves thethe

spermatic cordspermatic cordbetween thebetween the

internal obliqueinternal oblique




i f h iAffiliated Hospital of Jining Medical Colle


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B.B. Repair of herniaRepair of hernia::

herniorrhaphyherniorrhaphy High ligation of the sacHigh ligation of the sac Repair and reinforcement theRepair and reinforcement the

inguinal canal wallinguinal canal wall reinforce the posterior wall of thereinforce the posterior wall of the

inguinal canal :inguinal canal :BassiniBassini ShouldiceShouldice

HalstedHalsted McvayMcvay reinforce the anterior wall of thereinforce the anterior wall of the

inguinal canal:inguinal canal:FergusonFerguson

Shouldice repair:Shouldice re

pair:RoofConjoint tendon


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Shouldice repair:Shouldice repair:

Before BassiniBefore Bassini

repair, cutrepair, cut

transverstransvers

abdominalabdominal

fasciafascia andand

suture itsuture itoverlaplyoverlaply

DecreaseDecrease

recurrentrecurrent

herniahernia





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HalstedHalsted

RoofConjoint tendon


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repair:repair:

Place thePlace the

external obliqueexternal oblique

aponeurosisaponeurosis

beneathbeneath the cordthe cord

, but otherwise, but otherwise

resembles theresembles the

Bassini repair.Bassini repair. LeavesLeaves thethe

spermatic cordspermatic cordunder the skinunder the skin

andand




McVay repair:Mc

Vay repair:RoofConjoint tendon


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McVay repair:McVay repair:

Brings the arcingBrings the arcingedge of theedge of the

conjointedconjointed

tendontendon

posteriorly andposteriorly and

inferiorlyinferiorly toto

CoopersCoopers

ligament andligament andsuture themsuture them

For big hernia,For big hernia,

recurrent hernia,recurrent hernia,

femoral herniafemoral hernia




The coopers ligament

Ferguson

Ferguson

RoofConjoint tendon


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repair:repair:

Approximate andApproximate andsuture the arcingsuture the arcingedge of theedge of the

conjointed tendonconjointed tendonto the inguinalto the inguinalligamentligament aboveabove thethespermatic cordspermatic cord

LeaveLeave thethespermatic cordspermatic cordbeneath thebeneath theinternal obliqueinternal obliquemuscle and themuscle and the






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C. Tension free MeshC. Tension free Meshrepairrepair

Use artificial materialsUse artificial materials Tesion freeTesion free

Low recurrent rateLow recurrent rate

T i f M hTension free MeshAffiliated Hospital of Jining Medical Colle


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Tension free MeshTension free Mesh

repair:repair:


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Shorter recovery time and less post-operative discomfort

Used for bilateral hernias, recurrent


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ConclusionConclusion



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Operative techniquesOperative techniques

A. Simple high ligation of the sacA. Simple high ligation of the sac

B. Repair of herniaB. Repair of hernia reinforce the posterior wall of thereinforce the posterior wall of the

inguinal canal :inguinal canal :BassiniBassini ShouldiceShouldice

HalstedHalsted McvayMcvay

reinforce the anterior wall of thereinforce the anterior wall of the

inguinal canal:inguinal canal:FergusonFerguson

C. Tension free Mesh repairC. Tension free Mesh repair




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Management of incarcerated orManagement of incarcerated orstrangulated hernias:strangulated hernias:

The most incarcerated herniasThe most incarcerated hernias

need emergency operation.need emergency operation. During the operation, it is vitalDuring the operation, it is vital

to inspect whether strangulationto inspect whether strangulation

has occurred or not beforehas occurred or not beforereduction.reduction.



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If operation has been done earlyIf operation has been done earlyenough and no strangulationenough and no strangulation

occur, you can replace theoccur, you can replace the

content and carry out a routinecontent and carry out a routinerepair.repair.

If gangrene has alreadyIf gangrene has already

developed, all gangrenous tissuedeveloped, all gangrenous tissuemust be resected and you canmust be resected and you can

not do a repair.not do a repair.

M t f lidiM t f lidiAffiliated Hospital of Jining Medical Colle


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Management of slidingManagement of sliding

hernia:hernia: Management of the sac isManagement of the sac iscomplicated when a sliding herniacomplicated when a sliding hernia

is present.is present.

The failure to recognize a slidingThe failure to recognize a slidinghernia may lead to injury involvedhernia may lead to injury involved

organs or their blood supply.organs or their blood supply.

During operation, the hernia sac isDuring operation, the hernia sac isidentified and opened anteriorlyidentified and opened anteriorly

away from the involved organaway from the involved organ

which makes up its posterior wall.which makes up its posterior wall.



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The entire anterior portion of theThe entire anterior portion of thesac is removed. Posteriorly assac is removed. Posteriorly as

much sac as possible is removedmuch sac as possible is removed

without injuring the slidingwithout injuring the slidingorgan. Then the involved organorgan. Then the involved organ

is reduced into its originalis reduced into its original

position and the defect inposition and the defect inperitoneum is closed. Finally, aperitoneum is closed. Finally, a

routine repair can be carried out.routine repair can be carried out.



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After hernia repair, patient may needAfter hernia repair, patient may needbed rest for 2-3 days and return tobed rest for 2-3 days and return to

everyday home activities within oneeveryday home activities within one

week.week.

But patient should be advisedBut patient should be advised

against heavy lifting and otheragainst heavy lifting and other

vigorous effort for 4-8 weeks.vigorous effort for 4-8 weeks.

The anesthetic may be general,The anesthetic may be general,spinal, or local.spinal, or local.



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Hernia today,Hernia today,

gonegone

tomorrowtomorrow



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The history ofThe history ofHERNIAHERNIA

OPERATIONOPERATION

is the history ofis the history of

SURGERYSURGERY



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OTHER TYPES OF ABDOMINALOTHER TYPES OF ABDOMINAL

WALL HERNIASWALL HERNIAS



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FEMORAL HERNIAFEMORAL HERNIA



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A femoral hernia protrudesA femoral hernia protrudesthroughthrough the femoral ringthe femoral ringbeneath the inguinal ligament,beneath the inguinal ligament,

which is common in women.which is common in women. Because it has a narrow neck, itBecause it has a narrow neck, it

isis easyeasy to incarceration andto incarceration and

strangulation.strangulation.

Anatomy:Anatomy:



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Anatomy:Anatomy:

The lateral borderThe lateral border of theof thefemoral ring is the femoralfemoral ring is the femoralveinvein

The anterior borderThe anterior border is theis theinguinal ligamentinguinal ligament

The medial borderThe medial border is theis the

lacunar ligamentlacunar ligament The posterior borderThe posterior border is theis theperineal ligament(Cooper'sperineal ligament(Cooper'sligament)ligament)



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Pathological mechanism:Pathological mechanism: Mainly due to the defect in theMainly due to the defect in the

transverse fascia in the directtransverse fascia in the directtriangle.triangle.

A peritoneal sac passes underA peritoneal sac passes underthe inguinal ligament(thethe inguinal ligament(the

femoral ring) into the femoralfemoral ring) into the femoralcanal.canal.

The inguinal ligament is a tightThe inguinal ligament is a tight

band and beneath it the femoralband and beneath it the femoral



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Medial to the femoral vein is aMedial to the femoral vein is asmall empty space throughsmall empty space through

which a femoral hernia maywhich a femoral hernia may

project with a very narrow neck.project with a very narrow neck. The contents of the hernia easilyThe contents of the hernia easily

occur incarceration andoccur incarceration and

strangulation.strangulation.


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Clinical manifestations:Clinical manifestations:

Symptoms:Symptoms: NormallyNormally

asymptomaticasymptomatic untiluntil

incarceration or strangulationincarceration or strangulationoccurs. Even with obstructionoccurs. Even with obstruction

or strangulation, the patientor strangulation, the patient

may feel discomfort more inmay feel discomfort more in

the abdomen than in thethe abdomen than in the

femoral area.femoral area.

Signs:Signs: A smallA small bulgebulge in thein the



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Differential diagnosis:Differential diagnosis: Inguinal hernia:Inguinal hernia:

A saphenous varix: withoutA saphenous varix: without

comfortablecomfortable

Lipoma:Lipoma:

Abscess:Abscess:



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T t tTreatment



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Treatment:Treatment: Because of the high incidence ofBecause of the high incidence of

incarceration and strangulation,incarceration and strangulation,

all femoral hernias should beall femoral hernias should be

managed by operativemanaged by operativetreatment.treatment.

If incarceration of femoral herniaIf incarceration of femoral hernia

has occurred, manual reductionhas occurred, manual reductionis forbidden and emergencyis forbidden and emergency

operation is indicated.operation is indicated.



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TheThe principlesprinciples of operation:of operation:complete excision of the herniacomplete excision of the hernia

sac, repair and reinforcement ofsac, repair and reinforcement of

the defect in the transversalisthe defect in the transversalisfascia, closure of the femoralfascia, closure of the femoral

canal.canal.

McVayMcVay is the common repairingis the common repairingmethod.method.



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Incisional herniaIncisional hernia Develop in an old operativeDevelop in an old operative

incision.incision.

The incisional wound infectionThe incisional wound infectionis the most important factor.is the most important factor.

Age, obesity, other diseases,Age, obesity, other diseases,

poor surgical technique arepoor surgical technique areother causes.other causes.

The principle of managementThe principle of management

is early operative repairis early operative repair

U bili l h iU bili l h i



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Umbilical hernia:Umbilical hernia: Umbilicus is a weakened area inUmbilicus is a weakened area in

the abdominal wall due to thethe abdominal wall due to the

exist of the umbilical cord ofexist of the umbilical cord of

embryo.embryo. Congenital umbilical hernia isCongenital umbilical hernia is

common in infants. But most ofcommon in infants. But most of

these infants spontaneous closethese infants spontaneous closethe fascial defect within the firstthe fascial defect within the first

two years of life.two years of life.



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The principle of treatment: usingThe principle of treatment: usingsome external support devicesome external support device

when child is less than sixwhen child is less than six

months; and the operative repairmonths; and the operative repairshould be delayed until twoshould be delayed until two

years old.years old.

Umbilical hernia in adults can beUmbilical hernia in adults can beseen in women with multipleseen in women with multiple

pregnancies, obesity, or patientspregnancies, obesity, or patients

with severe ascites.with severe ascites.

Epigastric herniaEpigastric hernia:



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Epigastric hernia:Epigastric hernia: Also calledAlso called the hernia lineathe hernia linea

albaalba, usually occur above the, usually occur above thelevel of the umbilicus.level of the umbilicus.

An area of congenitalAn area of congenitalweakness in the linea alba withweakness in the linea alba withincreased intra-abdominalincreased intra-abdominalpressure is the cause of thispressure is the cause of this

type of hernia.type of hernia. More common in men than inMore common in men than in

women.women.

A small e i astric hernia


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Documents

External Hernia