Hernias - MColey

8/8/2019 Hernias - MColey

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HERNIASHERNIASMarcelyn Coley Marcelyn Coley

Mount Sinai School of MedicineMount Sinai School of MedicineBasic Science LectureBasic Science Lecture



Historical PerspectiveHistorical Perspective

1515thth century century -- CastrationCastration with wound cauterization with wound cauterizationor hernia sacor hernia sac

debridementdebridement

recommended a trussrecommended a truss



Father of Modern Inguinal HerniaFather of Modern Inguinal Hernia

RepairRepair

EDUARDO B ASSINI



HerniaHernia

Latin forLatin for rupture rupture

an abnormal protrusion of an organ or tissuean abnormal protrusion of an organ or tissuethrough a defect in its surrounding wallsthrough a defect in its surrounding walls

Occur at sites where aponeurosis and fascia areOccur at sites where aponeurosis and fascia arenot covered by striated musclenot covered by striated muscle



Which of the following statements is/are true Which of the following statements is/are true

regarding incidence of the abdominal wall hernia?regarding incidence of the abdominal wall hernia?

A. A. T wo T wo--thrirds of all inguinal hernias arethrirds of all inguinal hernias areclassified as indirect.classified as indirect.

B.B. Femoral hernias are more common in femalesFemoral hernias are more common in femalesthan in males.than in males.

C.C. Direct hernias are common in females.Direct hernias are common in females.

D.D. Hernias generally occur with equal frequency Hernias generally occur with equal frequency

in males and femalesin males and femalesE.E. Premature babies have a 10% incidence of Premature babies have a 10% incidence of

having inguinal hernia.having inguinal hernia.



EpidemiologyEpidemiology

700,000 hernia repairs year700,000 hernia repairs year

Inguinal herniasInguinal hernias --75% of all hernias75% of all hernias

2/3 Indirect, remainder are direct2/3 Indirect, remainder are direct Incisional herniasIncisional hernias ² ² 15 to 20%15 to 20%

Umbilical and epigastricUmbilical and epigastric ² ² 10%10%

FemoralFemoral ² ² 5%5%



EpidemiologyEpidemiology

Prevelance of hernias increases with agePrevelance of hernias increases with age

Most serious complicationMost serious complication ² ² strangulationstrangulation

1 to 3% of groin hernias1 to 3% of groin hernias FemoralFemoral ² ² highest rate of highest rate of complicationscomplications 15% to15% to

20% 20%

recommended all be repaired at time of discovery recommended all be repaired at time of discovery



Abdominal Wall Abdominal Wall

Anatomy Anatomy







Anatomy Anatomy Inguinal ligamentInguinal ligament( Poupart·s)( Poupart·s) ² ² inferior edgeinferior edge

of of external obliqueexternal oblique

Lacunar ligamentLacunar ligament ² ² triangular extension of thetriangular extension of theinguinal ligamentinguinal ligament beforebeforeits insertion upon the pubicits insertion upon the pubictubercletubercle

conjoined tendonconjoined tendon ( 5( 5--10% )10% )--Internal oblique fuses withInternal oblique fuses withtransversus abdoministransversus abdominis

aponeurosisaponeurosis Cooper·s LigamentCooper·s Ligament --

formed by the periosteumformed by the periosteumand fascia along theand fascia along thesuperior ramus of the pubis. superior ramus of the pubis.



Inguinal CanalInguinal Canal

Between deep and superficialBetween deep and superficialinguinal ringsinguinal rings

BoundariesBoundaries SuperificalSuperifical ² ² external obliqueexternal oblique

aponeurosisaponeurosis

SuperiorSuperior ² ² internal andinternal andtransversustransversus

InferiorInferior ² ² shelving edge of shelving edge of inguinal ligamentinguinal ligament and lacunarand lacunar

ligamentligament Posterior (floor)Posterior (floor) ² ²

transversalis fasciatransversalis fascia andandaponeurosis of transversusaponeurosis of transversusabdominis muscleabdominis muscle



Inguinal CanalInguinal Canal

Contains the spermaticContains the spermaticcord and round ligamentcord and round ligamentof the uterusof the uterus

Spermatic cordSpermatic cord Cremasteric muscle fibersCremasteric muscle fibers

Testicular vessels Testicular vessels

Genital branch of Genital branch of genitofemoral nervegenitofemoral nerve

Vas deferens Vas deferens

Cremasteric vesselsCremasteric vessels



Components of Hesselbach·s triangle include whichComponents of Hesselbach·s triangle include which

of the following anatomic landmarks?of the following anatomic landmarks?

A. A. Pectineal ligamentPectineal ligament

B.B. Lateral border of the rectus sheathLateral border of the rectus sheath

C.C. Cooper·s ligamentCooper·s ligamentD.D. Inguinal ligamentInguinal ligament

E.E. Inferior epigastric vesselsInferior epigastric vessels





Terminology Terminology

ReducibleReducible ² ² can be replaced withincan be replaced within

surrounding musculaturesurrounding musculature

IncarceratedIncarcerated ² ² cannot be reducedcannot be reduced

StrangulatedStrangulated ² ² compromised blood supply tocompromised blood supply toits contentsits contents



Sends sensory branches to the inner thigh andSends sensory branches to the inner thigh and

medial aspect of the scrotummedial aspect of the scrotum

A. A. Ileoinguinal nerveIleoinguinal nerve

B.B. Genitofemoral nerveGenitofemoral nerve

C.C. BothBothD.D. NeitherNeither



A sliding inguinal hernia on the left side is likely to A sliding inguinal hernia on the left side is likely to

involve which of the following?involve which of the following?

A. A. Jejunum composing the posterior wall of the Jejunum composing the posterior wall of thesacsac

B.B. O vary and fallopian tube in a female infantO vary and fallopian tube in a female infant

C.C. OmentumOmentum

D.D. Sigmoid colon composing the posterior wall of Sigmoid colon composing the posterior wall of the sacthe sac

E.E. Cecum composing the anteromedial wall of Cecum composing the anteromedial wall of the sacthe sac



Terminology Terminology

PantaloonPantaloon ² ² di rect an d i n di rect di rect an d i n di rect componentscomponents

R ichter·sR ichter·s ² ² containscontains ant im esenter i c port i on ant im esenter i c port i on of smallof small

bowelbowel Sliding Sliding ² ² involvesinvolves v i sceral per i toneu m v i sceral per i toneu m of an organ , of an organ ,

i.e. bladder, ovary i.e. bladder, ovary

Littre·sLittre·s ² ² hernia containshernia contains M

eckel·s di v

ert i culu

m M eckel·s

di v ert

i culu

m

PetitPetit ² ² hernia athernia at i nfer i or i nfer i or lumbar trianglelumbar triangle

GrynfeltGrynfelt ² ² hernia athernia at super i or super i or lumbar trianglelumbar triangle



Groin HerniasGroin Hernias

IndirectIndirect

DirectDirect

FemoralFemoral



Inguinal HerniaInguinal Hernia

Classified as congenital vs. acquiredClassified as congenital vs. acquired

commonly thought that repeated increases incommonly thought that repeated increases inintraintra--abdominal pressure contribute to herniaabdominal pressure contribute to herniaformationformation

collagen formation and structure deterioratescollagen formation and structure deteriorates with age, and thus hernia formation is more with age, and thus hernia formation is morecommon in the older individual. common in the older individual.





Clinical PresentationClinical Presentation

Groin bulgeGroin bulge

Often asymptomaticOften asymptomatic

Dull feeling of discomfort or heaviness in theDull feeling of discomfort or heaviness in thegroingroin

Focal painFocal pain ² ² raise suspicion for incarceration orraise suspicion for incarceration or

strangulationstrangulation Symptoms of bowel obstructionSymptoms of bowel obstruction



Inguinal herniaInguinal hernia

Male inguinal hernia Female inguinal hernia



DiagnosisDiagnosis

Physical ExamPhysical Exam

74.5% sensitive and74.5% sensitive and96.3% specific96.3% specific

examine the patient inexamine the patient inthe standing and supinethe standing and supinepositionspositions

difficult to distinguishdifficult to distinguishdirect and indirect ondirect and indirect onexam on aloneexam on alone



DiagnosisDiagnosis

R adiologic InvestigationsR adiologic Investigations Herniography Herniography

Suspected hernia, but clinical dx unclearSuspected hernia, but clinical dx unclear

Procedure done under flouroscopy following injection of Procedure done under flouroscopy following injection of contrast mediumcontrast medium

Frontal and oblique radiographs are taken with andFrontal and oblique radiographs are taken with and without increased intra without increased intra--abdominal pressureabdominal pressure

Ultrasonography Ultrasonography MR IMR I

C TC T



HerniographyHerniography

R ight direct inguinal hernia

Left indirect inguinalhernia



Direct Inguinal HerniaDirect Inguinal Hernia



Direct Inguinal HerniaDirect Inguinal Hernia

M e di al M e di al to theto the inferiorinferiorepigastric artery and veinepigastric artery and vein, , and within Hesselbach'sand within Hesselbach's

triangletriangle

acquired weakness in theacquired weakness in theinguinal flooringuinal floor



Indirect Inguinal herniaIndirect Inguinal hernia

Abdominal contents protrude through internal inguinal Abdominal contents protrude through internal inguinalring ring



Indirect Inguinal HerniaIndirect Inguinal Hernia

Accepted hypothesis Accepted hypothesis::incomplete or defectiveincomplete or defectiveobliteration of theobliteration of the processus v ag i nal i s processus v ag i nal i s during during the fetal periodthe fetal period

remnant layer of remnant layer of peritoneum forms a sacperitoneum forms a sac

at the internal ring at the internal ring more frequently on themore frequently on the

rightright



FemoralFemoral

More common in femalesMore common in females

Up to 40% present asUp to 40% present asemergencies with herniaemergencies with hernia

incarceration or strangulationincarceration or strangulation Passes medial to the femoralPasses medial to the femoral

vessels and nerve in the vessels and nerve in thefemoral canal through thefemoral canal through theempty spaceempty space

Inguinal ligament forms theInguinal ligament forms thesuperior bordersuperior border



FemoralFemoral

palpation of the femoral canal just below thepalpation of the femoral canal just below the

inguinal ligament in the upper thighinguinal ligament in the upper thigh

N A V ELSN A V ELS



T ABLE 1 T ABLE 1Nyhus Classification of Groin HerniasNyhus Classification of Groin Hernias

Type I Type I----indirect inguinal herniaindirect inguinal herniaInternal inguinal ring normal (i.e., pediatric hernia)Internal inguinal ring normal (i.e., pediatric hernia)

Type II Type II----indirect inguinal herniaindirect inguinal hernia

Dilated internal inguinal ring with posterior inguinal wall intactDilated internal inguinal ring with posterior inguinal wall intact

Type III Type III----posterior wall defectsposterior wall defectsDirect inguinal herniaDirect inguinal herniaIndirect inguinal hernia: dilated internal ring with large medial encroachmentIndirect inguinal hernia: dilated internal ring with large medial encroachmenton the transversalis fascia of the Hesselbach's triangle (i.e., massive scrotal, on the transversalis fascia of the Hesselbach's triangle (i.e., massive scrotal,

sliding hernia)sliding hernia)Femoral herniaFemoral hernia

Type IV Type IV----recurrent herniarecurrent hernia



Which of the following statements is/are true Which of the following statements is/are true

regarding direct inguinal hernias?regarding direct inguinal hernias?

A. A. The most likely cause is destruction of connective The most likely cause is destruction of connectivetissue resulting form physical stress.tissue resulting form physical stress.

B.B. Direct hernias should be repaired promptly becauseDirect hernias should be repaired promptly becauseof the risk of incarceration.of the risk of incarceration.

C.C. A direct hernia may be a sliding hernia involving a A direct hernia may be a sliding hernia involving aportion of the bladder wall.portion of the bladder wall.

D.D. A direct hernia may pass through the external inguinal A direct hernia may pass through the external inguinalring .ring .

E.E. Colon carcinoma is a known cause of direct inguinalColon carcinoma is a known cause of direct inguinalhernias.hernias.



Treatment Treatment

NonNon--OperativeOperative

ObservationObservation

Trusses can provide symptomatic relief Trusses can provide symptomatic relief

Hernia control in ~30% of patientsHernia control in ~30% of patients



O perativeO perative

BassiniBassini

ShouldiceShouldice

McVay McVay LichtensteinLichtenstein

PreperitonealPreperitoneal

LaparoscopicLaparoscopic



Bassini (early 20Bassini (early 20thth Century)Century) Transversus abdominis to ThompsonTransversus abdominis to Thompson s ligament ands ligament and

internal oblique musculoaponeurotic arches or internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligamentconjoined tendon to the inguinal ligament

Shouldice (1930s)Shouldice (1930s) Multilayer imbricated repair of the posterior wall of theMultilayer imbricated repair of the posterior wall of the

inguinal canalinguinal canal

McVay (1948)McVay (1948) Edge of the transversus abdominis aponeurosis toEdge of the transversus abdominis aponeurosis to

Cooper Cooper s ligament; incorporate Cooper s ligament; incorporate Cooper s ligament ands ligament andthe iliopubic tract (transition suture)the iliopubic tract (transition suture)



BASSINI

SHOULDICE

MCVAY



LichtensteinLichtenstein

First pure prosthestic, tensionFirst pure prosthestic, tension--free repair tofree repair toachieve low recurrence ratesachieve low recurrence rates



Prosthetic RepairProsthetic Repair

Polypropylene mesh most common andPolypropylene mesh most common andpreferredpreferred allows for a fibrotic reaction to occur between theallows for a fibrotic reaction to occur between the

inguinal floor and the posterior surface of the mesh, inguinal floor and the posterior surface of the mesh, thereby forming scar and strengthening the closurethereby forming scar and strengthening the closureof the hernia defectof the hernia defect

Polytetrafluoroethylene ( PTFE ) meshPolytetrafluoroethylene ( PTFE ) mesh often used for repair of often used for repair of v entral or i nc i s i on hern i as v entral or i nc i s i on hern i as inin

which the fibrotic reaction with the underlying which the fibrotic reaction with the underlying serosal surface of the bowel is best avoidedserosal surface of the bowel is best avoided





Prospective study Prospective study

Danish Hernia databaseDanish Hernia databaseof over 13,000 herniaof over 13,000 hernia

repairsrepairs Compared reCompared re--operationsoperations

for recurrent herniafor recurrent hernia

R esults: After 5 yearsR esults: After 5 years

significantly lower ( 1/4 significantly lower ( 1/4 less) recurrence withless) recurrence withmesh vs. sutured repairmesh vs. sutured repair



LaparoscopicLaparoscopic



The cause of neuropathic postherniorrhaphy The cause of neuropathic postherniorrhaphy

inguinodynia includes which of the following?inguinodynia includes which of the following?

A. A. Formation of scar tissueFormation of scar tissue

B.B. Transection of the ilioinguinal, iliohypogastric, Transection of the ilioinguinal, iliohypogastric,

or the genitofemoral nervesor the genitofemoral nervesC.C. Suture entrapment of nervesSuture entrapment of nerves

D.D. Staple entrapment of nervesStaple entrapment of nerves

E.E. Periosteal reactionPeriosteal reaction



Surgical ComplicationsSurgical Complications

R ecurrenceR ecurrence

InfectionInfection

NeuralgiaNeuralgia Bladder injury Bladder injury

Testicular injury Testicular injury

Vas Deferens injury Vas Deferens injury



Other HerniasOther Hernias



Which of the following is/are true statements Which of the following is/are true statements

regarding umbilical hernias?regarding umbilical hernias?

A. A. They are embryonic equivalent of a small They are embryonic equivalent of a smallomphaloceleomphalocele

B.B. R epair in infants is usually deferred untilR epair in infants is usually deferred until

approximately 4 years of ageapproximately 4 years of ageC.C. R epair in adults is usually indicatedR epair in adults is usually indicated

D.D. The ´vest The ´vest--overover--pantsµ type of repair is stronger thanpantsµ type of repair is stronger than

simple approximation of fascial marginssimple approximation of fascial marginsE.E. They are most common in Caucasian infants They are most common in Caucasian infants



UmbilicalUmbilical

IncidenceIncidence

R eported ~10%R eported ~10%

several times greater in Black childrenseveral times greater in Black children more common in premature children all racesmore common in premature children all races

Most close spontaneously by age 2 or 3Most close spontaneously by age 2 or 3

Acquired rather than congenital in adults Acquired rather than congenital in adults Female to male ratio 3:1 Female to male ratio 3:1



EpigastricEpigastric

midline junction of themidline junction of theaponeuroses (linea alba)aponeuroses (linea alba)b etween b etween thethe xiphoid processxiphoid processandand umbilicusumbilicus

Paraumbilical herniaParaumbilical hernia --epigastric hernia that bordersepigastric hernia that bordersthe umbilicusthe umbilicus

Estimated frequency 3Estimated frequency 3--5%5%

More common in Males 3:1More common in Males 3:1

20% may be multiple20% may be multiple



EpigastricEpigastric

ClinicalClinical Often asymptomatic, incidental finding Often asymptomatic, incidental finding

If symptomatic, vague abdominal pain above the umbilicus exacerbatedIf symptomatic, vague abdominal pain above the umbilicus exacerbatedby standing or coughing; relieved in supine positionby standing or coughing; relieved in supine position

Severe pain secondary to incarceration/strangulation of preperitoneal fatSevere pain secondary to incarceration/strangulation of preperitoneal fat(often no peritoneal sac) or omentum(often no peritoneal sac) or omentum

Exam: palpate small, soft, reducible mass superior to the umbilicusExam: palpate small, soft, reducible mass superior to the umbilicus

RARERARE to have strangulated bowelto have strangulated bowel

Tx Tx Excise fat and sac, close primarily Excise fat and sac, close primarily



An 82 An 82--year year--old previously healthy woman has a 12old previously healthy woman has a 12--hour history of severe epigastrichour history of severe epigastric

pain associated with nausea and vomiting. She has had no previous abdominal pain associated with nausea and vomiting. She has had no previous abdominal

operations. Her WBC count is 21,000/cu mm. The plain films and abdominal C T operations. Her WBC count is 21,000/cu mm. The plain films and abdominal C T

shown are obtained.shown are obtained.



Which of the following best describes Which of the following best describes

this patient·s diagnosis?this patient·s diagnosis?

A. A. Pain in the medial thigh and knee isPain in the medial thigh and knee is

uncommonly associated with this conditionuncommonly associated with this condition

B.B. It is unusual in womenIt is unusual in women

C.C. It is unusual in elderly patientsIt is unusual in elderly patients

D.D. It is seldom associated with intestinal necrosisIt is seldom associated with intestinal necrosis

E.E. It is usually unilateralIt is usually unilateral



ObturatorObturator

R are form of herniaR are form of hernia

Protrusion of intraProtrusion of intra--abdominalabdominalcontents throughcontents through obturatorobturatorforamenforamen

F:M ratio 6:1F:M ratio 6:1

The obturator foramen is formed The obturator foramen is formedby the ischial and pubic ramiby the ischial and pubic rami

obturator vessels and nerve lieobturator vessels and nerve lieposterolateral to the hernia sac inposterolateral to the hernia sac inthe canalthe canal

Small bowel is the most likelySmall bowel is the most likelyintraabdominal organ to beintraabdominal organ to befound in an obturator herniafound in an obturator hernia



ObturatorObturator

4 cardinal signs :4 cardinal signs :

intestinal obstructionintestinal obstruction (80% )(80% )

HowshipHowship--Romberg signRomberg sign ( 50% )( 50% ) ² ² History of History of repeatedrepeated

episodes of bowel obstructionepisodes of bowel obstruction that resolve quickly andthat resolve quickly and without intervention without intervention

Palpable massPalpable mass (20% )(20% )

Tx: Sugical R epair Tx: Sugical R epair



Spigelian HerniaSpigelian Hernia

occurs along the semilunaroccurs along the semilunarline, which traverses aline, which traverses a

vertical space along the vertical space along thelateral rectus borderlateral rectus border

where more than 90% of where more than 90% of spigelian hernias are foundspigelian hernias are found



Spigelian HerniaSpigelian Hernia

ClinicalClinical

Swelling in middle toSwelling in middle tolower abdomen lateral tolower abdomen lateral to

rectus musclerectus muscle Usually reducibleUsually reducible

Up to 20% present withUp to 20% present withincarcerationincarceration

Tx: surgical Tx: surgical Mesh not requiredMesh not required

R ecurrence is uncommonR ecurrence is uncommon



LumbarLumbar

Acquired lumbar hernias Acquired lumbar hernias ² ² back or flank trauma, back or flank trauma,

poliomyelitis, back surgery , andpoliomyelitis, back surgery , and

the use of the iliac crest as athe use of the iliac crest as adonor site for bone graftsdonor site for bone grafts

Contains to anatomicContains to anatomictriangles, inferior andtriangles, inferior andsuperior lumbar trianglessuperior lumbar triangles

Grynfelt·sGrynfelt·s Petit·sPetit·s

Strangulation is rareStrangulation is rare

Soft swelling in lowerSoft swelling in lowerposterior abdomenposterior abdomen



SciaticSciatic

Via greater or lesser sciatic Via greater or lesser sciaticnotchnotch

greater sciatic notch isgreater sciatic notch istraversed by the piriformistraversed by the piriformismuscle, and hernia sacs canmuscle, and hernia sacs can

protrude either superior orprotrude either superior orinferior to this muscleinferior to this muscle

suprapiriform defect 60%suprapiriform defect 60%

Infrapiriform 30% Infrapiriform 30%

subspinous (through thesubspinous (through thelesser sciatic foramen) 10% lesser sciatic foramen) 10%



Which of the following hernias is most likely to recur Which of the following hernias is most likely to recur

after primary repair?after primary repair?

A. A. Epigastric herniaEpigastric hernia

B.B. Spigelian herniaSpigelian hernia

C.C. Indirect herniaIndirect herniaD.D. Femoral herniaFemoral hernia

E.E. Incisional herniaIncisional hernia



Ventral wall (Incisional) Ventral wall (Incisional)

Highest incidence in midline andHighest incidence in midline andtransverse incisionstransverse incisions

Up to20% after laparotomy Up to20% after laparotomy

1/3 present in 51/3 present in 5--10 years10 yearspostoperatively postoperatively

R isk factorsR isk factors

obesity , DM, ascites, steroids, obesity , DM, ascites, steroids, smoking malnutrition, woundsmoking malnutrition, woundinfectioninfection

Technical aspects of wound closure Technical aspects of wound closure

Type of incision Type of incision Excessive tension (prone to fascialExcessive tension (prone to fascial

disruption)disruption)







Which of the following hernias represent an Which of the following hernias represent an

incarceration of a limited portion of small bowel?incarceration of a limited portion of small bowel?

A. A. Spigelian herniaSpigelian hernia

B.B. Grynfelt·s herniaGrynfelt·s hernia

C.C. Petit·s herniaPetit·s herniaD.D. R ichter·s herniaR ichter·s hernia

E.E. Littre·s herniaLittre·s hernia

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Hernias - MColey