HerniaHernia

Complications of herniorrhaphy Complications of herniorrhaphy areare::11 - - wound sepsiswound sepsis

22 - - HaematomaHaematoma

33 - - lymphocele (commoner after operations for femoral lymphocele (commoner after operations for femoral hernia)hernia);;

44 - - wound sinus (especially when foreign tissue is used for wound sinus (especially when foreign tissue is used for the repair)the repair);;

55 - - Division of spermatic cord (especially in infantile Division of spermatic cord (especially in infantile hernia hernia operation)operation)

66 - - Testicular ischaemia (especially after large or recurrent Testicular ischaemia (especially after large or recurrent hernia repairs)hernia repairs)

77 - - Testicular atrophyTesticular atrophy

88 – – HydroceleHydrocele

99 - - Nerve entrapmentNerve entrapment

- - PainPain

- - Parasthesia or numbnessParasthesia or numbness;;

1010 - - Recurrence (especially after operations for largeRecurrence (especially after operations for large . .

hernias in elderly males or sepsishernias in elderly males or sepsis))

- - 50%50% or recurrence happen within 2 yearsor recurrence happen within 2 years

- - False recurrrence ( new hernia )False recurrrence ( new hernia )

1111 – – generalgeneral

a - retention of urinea - retention of urine b - respiratory complications b - respiratory complications

c - thromboembolic complicationsc - thromboembolic complications

Strangulated inguinal hernia :Strangulated inguinal hernia :

Strangulation of inguinal hernia can occurs at any time Strangulation of inguinal hernia can occurs at any time during life and in both sexes. Indirect inguinal hernias during life and in both sexes. Indirect inguinal hernias strangulate more common than the direct hernia due to wide strangulate more common than the direct hernia due to wide neck in direct hernia. Sometimes a hernia strangulates on the neck in direct hernia. Sometimes a hernia strangulates on the first occasion that it descends; more often strangulation occurs first occasion that it descends; more often strangulation occurs in patients who have worn a truss for a long time, and in those in patients who have worn a truss for a long time, and in those with a partially reducible or irreducible hernia.with a partially reducible or irreducible hernia.

In order of frequency, the constricting agent isIn order of frequency, the constricting agent is

11 . .the neck of the sacthe neck of the sac

22 . .the external abdominal ring (in children especially)the external abdominal ring (in children especially)

33 . .rarely adhesions within the sacrarely adhesions within the sac..

ContentsContents :: Usually small intestine is involved in the strangulation; the next Usually small intestine is involved in the strangulation; the next

most frequent content is omentum; sometimes both are implicated. most frequent content is omentum; sometimes both are implicated. For large intestine to become strangulated in an inguinal hernia is of For large intestine to become strangulated in an inguinal hernia is of the utmost rarity.the utmost rarity.

Treatment : Treatment : The treatment of strangulated hernia is by The treatment of strangulated hernia is by emergency operation. emergency operation.

(‘The danger is in the delay, not in the operation)(‘The danger is in the delay, not in the operation) Vigorous resuscitation with intravenous fluids, NG tube aspiration Vigorous resuscitation with intravenous fluids, NG tube aspiration

and antibiotic is essential, also it is important to empty the bladder and antibiotic is essential, also it is important to empty the bladder even by cath if necessary. even by cath if necessary.

Inguinal herniotomy Inguinal herniotomy for strangulationfor strangulation ::

An incision is made over the most prominent part of An incision is made over the most prominent part of the swelling. The external oblique aponeurosis is the swelling. The external oblique aponeurosis is exposed, and the sac, with its coverings, is seen issuing exposed, and the sac, with its coverings, is seen issuing from the superficial inguinal ring. In all but very large from the superficial inguinal ring. In all but very large hernias it is possible to deliver the body and fundus of hernias it is possible to deliver the body and fundus of the sac together with its coverings and (in the male) the sac together with its coverings and (in the male) the testis onto the surface. Each layer covering the the testis onto the surface. Each layer covering the anterior surface of the body of the sac near the fundus anterior surface of the body of the sac near the fundus is incised, and if possible it is stripped off the sac. The is incised, and if possible it is stripped off the sac. The sac is then incised, the fluid there in is mopped up or sac is then incised, the fluid there in is mopped up or aspirated very thoroughly, for it can be highly infected, aspirated very thoroughly, for it can be highly infected, The external oblique aponeurosis and the superficial The external oblique aponeurosis and the superficial inguinal ring are divided. Returning to the sac, a finger inguinal ring are divided. Returning to the sac, a finger is passed into the opening, and employing the finger is passed into the opening, and employing the finger ass guide, the sac is slit along its length.. ass guide, the sac is slit along its length..

If the constriction lies at the superficial inguinal ring or in If the constriction lies at the superficial inguinal ring or in the inguinal canal, it is readily divided by this procedure. the inguinal canal, it is readily divided by this procedure. When the constricting agent is at the deep inguinal ring, When the constricting agent is at the deep inguinal ring, by applying haemostats to the cut edge of the neck of the by applying haemostats to the cut edge of the neck of the sac and drawing them downwards, and at the same time sac and drawing them downwards, and at the same time retracting the internal oblique upwards, it may be possible retracting the internal oblique upwards, it may be possible to continue slitting up the sac over the finger beyond the to continue slitting up the sac over the finger beyond the point of constriction. Then the neck ( deep ring ) of the sac point of constriction. Then the neck ( deep ring ) of the sac is divided with a hernia knife in an upward and inward is divided with a hernia knife in an upward and inward direction, i.e. parallel to the inferior epigastric artery. direction, i.e. parallel to the inferior epigastric artery.

under vision. Once the constricting agent has been under vision. Once the constricting agent has been divided, the strangulated contents can be drawn down. divided, the strangulated contents can be drawn down. Devitalised omentum is excised after being securely Devitalised omentum is excised after being securely ligated. Viable intestine is returned to the peritoneal ligated. Viable intestine is returned to the peritoneal cavity. Doubtfully viable and gangrenous intestine is dealt cavity. Doubtfully viable and gangrenous intestine is dealt with. If the hernial sac is of moderate size and can be with. If the hernial sac is of moderate size and can be separated easily from its coverings, it is excised and dosed separated easily from its coverings, it is excised and dosed by a purse-string sutureby a purse-string suture

Conservative measuresConservative measures: :

These are only indicated in infantsThese are only indicated in infants..

Children are given a sedative and then elevation of bed Children are given a sedative and then elevation of bed foot for no longer than 3 hours. In 75 per cent of cases foot for no longer than 3 hours. In 75 per cent of cases reduction is effected and there appears to be no danger reduction is effected and there appears to be no danger of gangrenous intestine being reduced. Manual of gangrenous intestine being reduced. Manual reduction of irreducible and strangulated hernias under reduction of irreducible and strangulated hernias under sedation is permissible in infants in whom the risk of sedation is permissible in infants in whom the risk of intestinal gangrene appears to be almost nonexistent intestinal gangrene appears to be almost nonexistent for many hours. For all other cases, for many hours. For all other cases, vigorous vigorous manipulation (taxis) has no place in modern surgery, manipulation (taxis) has no place in modern surgery, and and is is mentioned only to be condemned. mentioned only to be condemned. Its dangers Its dangers indudeindude: :

11 - - Contusion or rupture of the intestinal wallContusion or rupture of the intestinal wall..

22 - - Reduction-en-masse. Reduction-en-masse. ‘The sac together with its ‘The sac together with its contents, is pushed forcibly back into the abdomen; contents, is pushed forcibly back into the abdomen; and as the bowel will still be strangulated by the neck and as the bowel will still be strangulated by the neck of the sac, the symptoms are in no way relievedof the sac, the symptoms are in no way relieved..

33 - - Reduction into a loculus of the sacReduction into a loculus of the sac..

44 - - The sac may rupture at its neck and its contents are The sac may rupture at its neck and its contents are reduced, not into the peritoneal cavity, but reduced, not into the peritoneal cavity, but extraperitoneallyextraperitoneally..

. .

Sliding herniaSliding hernia: :

As a result of slipping of the posterior parietal As a result of slipping of the posterior parietal peritoneum on the underlying retroperitoneal structures, peritoneum on the underlying retroperitoneal structures, the posterior wall of the sac is not formed of peritoneum the posterior wall of the sac is not formed of peritoneum alone, but by the sigmoid colon and its mesentery on alone, but by the sigmoid colon and its mesentery on the left, the caecum on the right and, sometimes, on the left, the caecum on the right and, sometimes, on either side by a portion of the bladder. It should be either side by a portion of the bladder. It should be clearly understood that the caecum, appendix, or a clearly understood that the caecum, appendix, or a portion of the colon portion of the colon wholly within wholly within a hernial sac does not a hernial sac does not constitute a sliding hernia. A small-bowel sliding hernia constitute a sliding hernia. A small-bowel sliding hernia occurs once in 2000 cases; a sacless sliding hernia once occurs once in 2000 cases; a sacless sliding hernia once in 8000 casesin 8000 cases..

Clinical featuresClinical features : :

A sliding hernia occurs almost exclusively in males. Five A sliding hernia occurs almost exclusively in males. Five out of six sliding hernias are situated on the left side; out of six sliding hernias are situated on the left side; bilateral sliding hernias are exceedingly rare. The patient bilateral sliding hernias are exceedingly rare. The patient is nearly always over 40, the incidence rising with the is nearly always over 40, the incidence rising with the weight of years. There are no clinical findings that are weight of years. There are no clinical findings that are pathognomonic of a sliding hernia, but it should be pathognomonic of a sliding hernia, but it should be suspected in every large globular inguinal hernia suspected in every large globular inguinal hernia descending well into the scrotum. Large intestine is descending well into the scrotum. Large intestine is commonly present in a sliding hernia (or caecum and commonly present in a sliding hernia (or caecum and appendix in a right-sided case)appendix in a right-sided case)..

Occasionally large intestine is strangulated in a sliding Occasionally large intestine is strangulated in a sliding hernia; more often non strangulated large intestine is hernia; more often non strangulated large intestine is present behind the sac containing strangulated small present behind the sac containing strangulated small intestineintestine..

TreatmentTreatment: :

AA sliding hernia is impossible to control with a truss, sliding hernia is impossible to control with a truss, and as a rule the hernia is a cause of considerable and as a rule the hernia is a cause of considerable discomfort. Consequently operation is indicated, and discomfort. Consequently operation is indicated, and the results generally are goodthe results generally are good..

OperationOperation. . It is unnecessary to remove any of the It is unnecessary to remove any of the sliding hernial sac provided it is freed completely from sliding hernial sac provided it is freed completely from the cord and the abdominal wall, and that it is replaced the cord and the abdominal wall, and that it is replaced deep to the repaired fascia transversalis, In many deep to the repaired fascia transversalis, In many instances it is desirable to perform orchiectomy in order instances it is desirable to perform orchiectomy in order to effect a secure repair. No attempt should be made to to effect a secure repair. No attempt should be made to dissect the caecum or colon free from the peritoneum dissect the caecum or colon free from the peritoneum under the impression that these are adhesions, in under the impression that these are adhesions, in which case peritonitis or a faecal flstula resulting from which case peritonitis or a faecal flstula resulting from necrosis of a devascularised portion of the bowel may necrosis of a devascularised portion of the bowel may occur. his is specially liable to occur on the left side, as occur. his is specially liable to occur on the left side, as vessels in the mesocolon may be injuredvessels in the mesocolon may be injured..

Femoral herniaFemoral hernia

Femoral hernia is the third most common type of Femoral hernia is the third most common type of hernia (incisional hernia comes second). It accounts for hernia (incisional hernia comes second). It accounts for about 20 per cent of hernias in women, and 5 per cent about 20 per cent of hernias in women, and 5 per cent in men. The overriding importance of femoral hernia in men. The overriding importance of femoral hernia lies in the facts that it cannot be controlled by a truss, lies in the facts that it cannot be controlled by a truss, and that of all hernias it is the most liable to become and that of all hernias it is the most liable to become strangulated mainly because of the narrowness of the strangulated mainly because of the narrowness of the neck of the sac and the rigidity of theneck of the sac and the rigidity of the femoral ringfemoral ring..

Femoral herniasFemoral hernias

■ ■More common in womenMore common in women

■ ■Cannot be controlled with a trussCannot be controlled with a truss

■ ■Have a high incidence of strangulationHave a high incidence of strangulation

■ ■Should be operated on as soon as possibleShould be operated on as soon as possible

Surgical anatomySurgical anatomy: :

The femoral canal occupies the most medial The femoral canal occupies the most medial compartment of the femoral sheath, and it extends compartment of the femoral sheath, and it extends from the femoral ring above to the saphenous opening from the femoral ring above to the saphenous opening below. It is 1.25cm long, and 1.25 cm wide at its base, below. It is 1.25cm long, and 1.25 cm wide at its base, which is directed upwards. The femoral .canal contains which is directed upwards. The femoral .canal contains fat, lymphatic vessels, and the lymph node of Cloquet. fat, lymphatic vessels, and the lymph node of Cloquet. It is dosed above by the septum cru.rale, a It is dosed above by the septum cru.rale, a condensation of extraperitoneal tissue pierced by condensation of extraperitoneal tissue pierced by lymphatic vessels, and below by the cribriform fascialymphatic vessels, and below by the cribriform fascia . .

The femoral ring is boundedThe femoral ring is bounded::

11 - - anteriorly anteriorly by the inguinal ligamentby the inguinal ligament

22 - - posteriorly posteriorly by Astley Cooper’s (iliopectineal) by Astley Cooper’s (iliopectineal) ligament, the pubic bone, and the fascia over ligament, the pubic bone, and the fascia over the pectineus musclethe pectineus muscle

33 - - medially medially by the concave knife-like edge of by the concave knife-like edge of lacunar ligament, which is also prolonged along lacunar ligament, which is also prolonged along the iliopectineal line as Astley Cooper’s the iliopectineal line as Astley Cooper’s ligamentligament

44 - - laterally laterally by a thin septum separating it from by a thin septum separating it from the femoral veinthe femoral vein..

Sex incidenceSex incidence::

The female to male ratio is about 2:1, but it is interesting that The female to male ratio is about 2:1, but it is interesting that whereas the female patients are frequently elderly, the male patients whereas the female patients are frequently elderly, the male patients are usually between 30 and 45 years. The condition is more prevalent are usually between 30 and 45 years. The condition is more prevalent in women who have borne children than in nulliparas. The broader in women who have borne children than in nulliparas. The broader female pelvis also predisposes female pelvis also predisposes to the conditionto the condition..

PathologyPathology : :

A hernia passing down the femoral canal descends A hernia passing down the femoral canal descends vertically asvertically as far as the saphenous opening. While it is far as the saphenous opening. While it is confined to the inelastic walls of the femoral canal the confined to the inelastic walls of the femoral canal the hernia is necessarily narrow, but once it escapes through hernia is necessarily narrow, but once it escapes through the saphenous opening into the loose areolar tissue of the the saphenous opening into the loose areolar tissue of the groin, it expands. sometimes considerably. A fully groin, it expands. sometimes considerably. A fully distended femoral hernia and its bulbous extremity may distended femoral hernia and its bulbous extremity may be above the inguinal ligament. By the time the contents be above the inguinal ligament. By the time the contents have pursued so tortuous a path they are usually have pursued so tortuous a path they are usually irreducible and apt to strangulate, a circumstance which irreducible and apt to strangulate, a circumstance which is also favoured by the rigidity of the surrounds of the is also favoured by the rigidity of the surrounds of the femoral ringfemoral ring..

Clinical features:Clinical features:

Femoral hernia is rare before puberty. Between 20 Femoral hernia is rare before puberty. Between 20 and 40 years of age the prevalence rises, and and 40 years of age the prevalence rises, and continues to old age. The right side is affected twice as continues to old age. The right side is affected twice as often as the left, and in 20 per cent of cases the often as the left, and in 20 per cent of cases the condition is bilateral. The symptoms to which a femoral condition is bilateral. The symptoms to which a femoral hernia gives rise are less pro nounced than those of an hernia gives rise are less pro nounced than those of an inguinal hernia; indeed, a small femoral hernia may be inguinal hernia; indeed, a small femoral hernia may be unnoticed by the patient or disregarded for years, until unnoticed by the patient or disregarded for years, until perhaps the day it strangulates. Adherence of greater perhaps the day it strangulates. Adherence of greater omentum some times causes a dragging pain. Rarely, a omentum some times causes a dragging pain. Rarely, a large sac is present.large sac is present.

Differential diagnosis:Differential diagnosis:

A femoral hernia has to be distinguished from the A femoral hernia has to be distinguished from the following.following.

11 - - An inguinal herniaAn inguinal hernia. . An inguinal hernia lies above and An inguinal hernia lies above and medial to the medial end of the inguinal ligament at its medial to the medial end of the inguinal ligament at its attachment to the pubic tubere. The femoral hernia lies attachment to the pubic tubere. The femoral hernia lies below this. Occasionally the fundus of a femoral hernia below this. Occasionally the fundus of a femoral hernia sac overlies the inguinal ligamentsac overlies the inguinal ligament..  

2 - 2 - A saphena varixA saphena varix. . A saphena varix is a saccular A saphena varix is a saccular enlargement of the termination of the long saphenous enlargement of the termination of the long saphenous vein and it is usually accompanied by other signs of vein and it is usually accompanied by other signs of varicose veins. The swelling disappears completely when varicose veins. The swelling disappears completely when the patient lies down, while a femoral hernia sac usually the patient lies down, while a femoral hernia sac usually is still palpable. In both there is an impulse on coughing. is still palpable. In both there is an impulse on coughing. A saphena varix will, however, impart a fluid thrill to the A saphena varix will, however, impart a fluid thrill to the examining fingers when the patient coughs, or when the examining fingers when the patient coughs, or when the saphenous vein below the varix is tapped with the fingers saphenous vein below the varix is tapped with the fingers of the other hand. Sometimes a venous hum can be heard of the other hand. Sometimes a venous hum can be heard when a stethoscope is applied over a saphena varix. when a stethoscope is applied over a saphena varix.

33- - An enlarged femoral lymph nodeAn enlarged femoral lymph node. . If there are other If there are other enlarged lymph nodes in the region the diagnosis is enlarged lymph nodes in the region the diagnosis is tolerably simple, but when Cloquet’s lymph node alone tolerably simple, but when Cloquet’s lymph node alone is affected the diagnosis may be impossible unless is affected the diagnosis may be impossible unless there is a due, such as an infected wound or abrasion there is a due, such as an infected wound or abrasion on the corresponding limb or on the perineum. Doubt on the corresponding limb or on the perineum. Doubt should be removed by immediate surgeryshould be removed by immediate surgery..

44- - LipomaLipoma..

55- - A femoral aneurysmA femoral aneurysm . ...

66- - A psouas absccssA psouas absccss. . There is often a suprainguinal There is often a suprainguinal fluctuating swelling — fluctuating swelling — an iliac an iliac abscess — . Examination abscess — . Examination of the spine and a radiograph will settle the diagnosisof the spine and a radiograph will settle the diagnosis..

77 - - A distended psoas bursaA distended psoas bursa. . The swelling diminishes when The swelling diminishes when the the hip is flexed, and osteoarthrosis of the hip is hip is flexed, and osteoarthrosis of the hip is

presentpresent . .88- - Rupture of the adductor longss Rupture of the adductor longss with haematomawith haematoma..

Strangulated femoral hernia :Strangulated femoral hernia :

A femoral hernia strangulates frequently and A femoral hernia strangulates frequently and gangrene develops rapidly. gangrene develops rapidly. This is accounted for by the This is accounted for by the narrow, unyielding femoral ring. In 40 per cent of cases narrow, unyielding femoral ring. In 40 per cent of cases the obstructing agent is not lacunar ligament but the the obstructing agent is not lacunar ligament but the narrow neck of the femoral sac itself. The frequent narrow neck of the femoral sac itself. The frequent occurrence of a occurrence of a Richter’s hernia Richter’s hernia also must be stressed.also must be stressed.

Treatment of femoral herniaTreatment of femoral hernia::

The constant risk of strangulation is sufficient reason The constant risk of strangulation is sufficient reason for urging operation. A truss is contraindicated because for urging operation. A truss is contraindicated because of this risk.of this risk.

: : Umbilical herniaUmbilical hernia

Exomphalos (syn. omphalocele) occurs once in every Exomphalos (syn. omphalocele) occurs once in every 6000 births; it is due to failure of all or part of the midgut to 6000 births; it is due to failure of all or part of the midgut to return to the coelom during early fetal life. Sometimes a return to the coelom during early fetal life. Sometimes a large sac ruptures during birth. When the sac remains large sac ruptures during birth. When the sac remains unruptured, it is semitranslucent and although very thin it unruptured, it is semitranslucent and although very thin it consists of three layers — an outer layer of amniotic consists of three layers — an outer layer of amniotic membrane, a middle layer of Wharton’s jelly, and an inner membrane, a middle layer of Wharton’s jelly, and an inner layer of peritoneum. There arelayer of peritoneum. There are

two varieties of exomphalostwo varieties of exomphalos::

Exomphalos minor:Exomphalos minor: The sac is relatively small and to its The sac is relatively small and to its summit is attached the umbilical cord, Inadvertently sloop summit is attached the umbilical cord, Inadvertently sloop of small intestine or a Meckels diverticulum can be included of small intestine or a Meckels diverticulum can be included in the ligature applied to the base of an umbilical cord in the ligature applied to the base of an umbilical cord containing this protrusioncontaining this protrusion..

Exomphalos major: Exomphalos major: The umbilical cord is attached to the The umbilical cord is attached to the inferior aspect of the swelling, which contains small and inferior aspect of the swelling, which contains small and large intestine, and ,nearly always a portion of the liver, large intestine, and ,nearly always a portion of the liver, Half the cases belong to this groupHalf the cases belong to this group..

TreatmentTreatment:: Exomphalos minor. Exomphalos minor. It is necessary only to twist the It is necessary only to twist the

cord, so as to reduce the contents of the sac through cord, so as to reduce the contents of the sac through the narrow umbilical opening into the peritoneal cavity, the narrow umbilical opening into the peritoneal cavity, and to retain them by firm strapping. Despite a and to retain them by firm strapping. Despite a seropurulent discharge on no account must the seropurulent discharge on no account must the strapping be removed for fourteen daysstrapping be removed for fourteen days..

Exomphalos major. Exomphalos major. Operation within the first few Operation within the first few hours of life is the only hope, otherwise the sac will hours of life is the only hope, otherwise the sac will burst. To prevent further distension of the contents of burst. To prevent further distension of the contents of the sac, the infant should not be fed. A few newborn the sac, the infant should not be fed. A few newborn infants with a ruptured sac have survived following infants with a ruptured sac have survived following immediate operation and antibiotic therapyimmediate operation and antibiotic therapy..

Umbilical hernia of infants and childrenUmbilical hernia of infants and children . .

This is a hernia through a weak umbilical scar. The ratio of This is a hernia through a weak umbilical scar. The ratio of males to females is 2:1. Most do not become obvious until the males to females is 2:1. Most do not become obvious until the infant is several weeks old. The hernia is often symptomless, infant is several weeks old. The hernia is often symptomless, but increase in the size of the hernia on crying causes pain, but increase in the size of the hernia on crying causes pain, which makes the infant cry more. Small hernias are spherical; which makes the infant cry more. Small hernias are spherical; those that increase in size tend to assume a conical shape and those that increase in size tend to assume a conical shape and are present apart from crying. Obstruction or strangulation are present apart from crying. Obstruction or strangulation below the age of three years is extremely uncommonbelow the age of three years is extremely uncommon

TreatmentTreatment::

Conservative treatment Conservative treatment is successful is successful in in about 95 per cent of about 95 per cent of cases. When the hernia is symptomless, reassurances of the cases. When the hernia is symptomless, reassurances of the parents is all that is necessary, for in a very high percentage parents is all that is necessary, for in a very high percentage of cases the hernia will be found to disappear spontaneously of cases the hernia will be found to disappear spontaneously during the first few months of life. Cure may also be hastened during the first few months of life. Cure may also be hastened by pulling the skin and abdominal musculature together by by pulling the skin and abdominal musculature together by adhesive strapping placed across the abdomenadhesive strapping placed across the abdomen..

• ..

  

HenuiorrhaphyHenuiorrhaphy..

If the hernia persists at 2 years of age or older it is If the hernia persists at 2 years of age or older it is unlikely to resolve and herniorrhaphy is indicatedunlikely to resolve and herniorrhaphy is indicated..

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