HERNIAHERNIAdr sigid djuniawan

dr sigid djuniawan

Introduction Introduction Protrusion of the peritoneum or preperitoneal fat through an abnormal Protrusion of the peritoneum or preperitoneal fat through an abnormal

opening in the abdominal wallopening in the abdominal wall Presents as a bulgePresents as a bulge Peritoneal contents may be trapped in “sac”Peritoneal contents may be trapped in “sac”

Asymptomatic bulge most commonAsymptomatic bulge most common SymptomsSymptoms

Physical effects of sac and contents on surrounding tissuesPhysical effects of sac and contents on surrounding tissues Obstruction and/or strangulation of hernia sac contentsObstruction and/or strangulation of hernia sac contents

EpidemiologyEpidemiology

700,000 hernia repairs year700,000 hernia repairs year Inguinal hernias -75% of all herniasInguinal hernias -75% of all hernias

2/3 Indirect, remainder are direct2/3 Indirect, remainder are direct Incisional hernias – 15 to 20%Incisional hernias – 15 to 20% Umbilical and epigastric – 10%Umbilical and epigastric – 10% Femoral – 5%Femoral – 5%

EpidemiologyEpidemiology

Prevelance of hernias increases with agePrevelance of hernias increases with age Most serious complication – Most serious complication –

strangulationstrangulation 1 to 3% of groin hernias 1 to 3% of groin hernias

Femoral – Femoral – highest rate ofhighest rate of complicationscomplications 15% to 20% 15% to 20% recommended all be repaired at time of recommended all be repaired at time of

discoverydiscovery

Anatomy Anatomy

Areas of Natural WeaknessAreas of Natural Weakness

Used with permission from the American College of Surgeons

AnatomyAnatomy Inguinal ligamentInguinal ligament

(Poupart’s) – inferior (Poupart’s) – inferior edge of edge of external external obliqueoblique

Lacunar ligamentLacunar ligament – – triangular extension of triangular extension of the the inguinal ligamentinguinal ligament before its insertion before its insertion upon the pubic tubercle upon the pubic tubercle

conjoined tendonconjoined tendon (5- (5-10%)- Internal oblique 10%)- Internal oblique fuses with transversus fuses with transversus abdominis aponeurosisabdominis aponeurosis

Cooper’s LigamentCooper’s Ligament - - formed by the formed by the periosteum and fascia periosteum and fascia along the superior along the superior ramus of the pubis. ramus of the pubis.

Inguinal CanalInguinal Canal

Between deep and Between deep and superficial inguinal ringssuperficial inguinal rings

BoundariesBoundaries Superifical – Superifical – external external

oblique aponeurosisoblique aponeurosis Superior – Superior – internal and internal and

transversustransversus Inferior – shelving edge of Inferior – shelving edge of

inguinal ligamentinguinal ligament and and lacunar ligamentlacunar ligament

Posterior (floor) – Posterior (floor) – transversalis fasciatransversalis fascia and and aponeurosis of aponeurosis of transversus abdominis transversus abdominis musclemuscle

Components of Hesselbach’s triangle include Components of Hesselbach’s triangle include which of the following anatomic landmarks?which 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 ligament

D.D. Inguinal ligamentInguinal ligament

E.E. Inferior epigastric vesselsInferior epigastric vessels

Hernia DiathesisHernia Diathesis

Varies with ageVaries with age Pediatric: congenital remnantPediatric: congenital remnant AdultAdult

Tissue weaknessTissue weakness Burst strength < abdominal wall tension Burst strength < abdominal wall tension

Varies with gender Varies with gender

Hernia DiathesisHernia Diathesis

Pediatric: major risk is premature Pediatric: major risk is premature birthbirth

AdultAdult ObesityObesity Previous abdominal surgery Previous abdominal surgery PregnancyPregnancy Abrupt abdominal wall exertionAbrupt abdominal wall exertion

What is a Hernia composed of?What is a Hernia composed of?1.1. Sac: Sac: a folding of a folding of

peritoneum consisting of a peritoneum consisting of a mouth, neck, body and mouth, neck, body and fundus.fundus.

2.2. BodyBody: : which varies in which varies in size and is not necessarily size and is not necessarily occupied.occupied.

3.3. Coverings: Coverings: derived derived from layers of the from layers of the abdominal wall.abdominal wall.

4.4. Contents: Contents: which could which could be anything from the be anything from the omentum, intestines, omentum, intestines, ovary or urinary bladder.ovary or urinary bladder.

A sliding inguinal hernia on the left side is A sliding inguinal hernia on the left side is likely to involve which of the following?likely to involve which of the following?

A.A. Jejunum composing the posterior wall Jejunum composing the posterior wall of the sacof the sac

B.B. Ovary and fallopian tube in a female Ovary and fallopian tube in a female infantinfant

C.C. OmentumOmentumD.D. Sigmoid colon composing the Sigmoid colon composing the

posterior wall of the sacposterior wall of the sacE.E. Cecum composing the anteromedial Cecum composing the anteromedial

wall of the sacwall of the sac

TerminologyTerminology

Pantaloon – Pantaloon – direct and indirectdirect and indirect components components Richter’s – contains Richter’s – contains antimesenteric portionantimesenteric portion of of

small bowelsmall bowel Sliding – involves Sliding – involves visceral peritoneumvisceral peritoneum of an organ of an organ

, i.e. bladder, ovary, i.e. bladder, ovary Littre’s – hernia contains Littre’s – hernia contains Meckel’s diverticulumMeckel’s diverticulum Petit – hernia at Petit – hernia at inferiorinferior lumbar triangle lumbar triangle Grynfelt – hernia at Grynfelt – hernia at superiorsuperior lumbar triangle lumbar triangle

Clinical Evaluation: HistoryClinical Evaluation: History DemographicsDemographics

AgeAge GenderGender

Presentation of bulgePresentation of bulge When, where, howWhen, where, how Activities that make it better or worseActivities that make it better or worse Discomfort vs. painDiscomfort vs. pain Signs/symptoms of bowel obstructionSigns/symptoms of bowel obstruction

Clinical Evaluation: HistoryClinical Evaluation: History

Surgery: Surgery: previous repairs/operationsprevious repairs/operations

Review of factors related to increased Review of factors related to increased intra-abdominal pressureintra-abdominal pressure Chronic coughChronic cough ConstipationConstipation Straining to urinateStraining to urinate

Clinical Evaluation: LocationClinical Evaluation: Location

Groin: 75% Groin: 75% InguinalInguinal FemoralFemoral

Anterior abdominal wall: 25%Anterior abdominal wall: 25% UmbilicalUmbilical EpigastricEpigastric SpigelianSpigelian Incisional Incisional

Hernia PathologyHernia Pathology Contents of hernia sacContents of hernia sac

Bowel (small and large, appendix)Bowel (small and large, appendix) Incarceration of portion of bowel wall: Richter’s Incarceration of portion of bowel wall: Richter’s

hernia: Strangulation occurs without hernia: Strangulation occurs without obstructionobstruction

Omentum, bladder, ovary, fallopian tubesOmentum, bladder, ovary, fallopian tubes

Sac wall may be formed by large bowel, Sac wall may be formed by large bowel, bladder, or the ovary/tube: Sliding herniabladder, or the ovary/tube: Sliding hernia

Hernia PathologyHernia Pathology

Fascial defect may exist without Fascial defect may exist without peritoneal hernia sacperitoneal hernia sac

Preperitoneal abdominal wall contents Preperitoneal abdominal wall contents may protrude through fascial defectmay protrude through fascial defect

Preperitoneal fatPreperitoneal fat Lymph nodeLymph node

Hernia PathologyHernia Pathology

Incarceration:Incarceration: contents of hernia sac not contents of hernia sac not reducible into peritoneal cavityreducible into peritoneal cavity Acute: fascial margins trap contentsAcute: fascial margins trap contents Chronic: contents adhesed in sacChronic: contents adhesed in sac

Strangulation:Strangulation: incarceration with incarceration with compromise of blood supplycompromise of blood supply Narrow neck at greatest risk: indirect Narrow neck at greatest risk: indirect

inguinal, femoral, and umbilicalinguinal, femoral, and umbilical

Hernia Repair IndicationsHernia Repair Indications Asymptomatic Asymptomatic

prevent visceral incarceration and/or prevent visceral incarceration and/or strangulationstrangulation

Symptomatic, non-obstructedSymptomatic, non-obstructed Treat discomfort from bulgeTreat discomfort from bulge Prevent incarceration/strangulationPrevent incarceration/strangulation

Visceral obstruction/strangulationVisceral obstruction/strangulation Release obstruction/manage visceraRelease obstruction/manage viscera Prevent recurrencePrevent recurrence

Groin HerniaGroin Hernia Men Men : : WomenWomen 25 25 : : 1 1

Right Right : : LeftLeft 2 2 : : 11

FemoralFemoral Women > MenWomen > Men Strangulation risk > inguinalStrangulation risk > inguinal

InguinalInguinal Indirect Indirect : : Direct 2 Direct 2 : : 11 Most common in men and womenMost common in men and women

Groin HerniaGroin Hernia Inguinal: relationship of sac to inguinal Inguinal: relationship of sac to inguinal

canal determines external bulgecanal determines external bulge

Movement from internal ring to scrotumMovement from internal ring to scrotum Bilateral hernias: direct 4x indirect Bilateral hernias: direct 4x indirect Indirect vs. direct hernia is Indirect vs. direct hernia is

intraoperative diagnosis, not clinical intraoperative diagnosis, not clinical diagnosisdiagnosis

Femoral: relationship of sac to inguinal Femoral: relationship of sac to inguinal ligament determines external bulgeligament determines external bulge

Groin Hernia: Inguinal Groin Hernia: Inguinal AdultsAdults

Weakness of transversalis fasciaWeakness of transversalis fascia Indirect: sac is lateral to inferior Indirect: sac is lateral to inferior

epigastric vesselsepigastric vessels Direct: sac is medial to inferior Direct: sac is medial to inferior

epigastric vesselsepigastric vessels Pantaloon: both indirect and directPantaloon: both indirect and direct

Pediatric: patent processus vaginalisPediatric: patent processus vaginalis

Inguinal herniaInguinal hernia

Male inguinal hernia Female inguinal hernia

Groin Hernia: Differential Groin Hernia: Differential DiagnosisDiagnosis

TendonitisTendonitis Muscle tearMuscle tear Lymph nodeLymph node LipomaLipoma Varicose veinVaricose vein HydroceleHydrocele EpididymitisEpididymitis SpermatoceleSpermatocele

Groin Hernia ManagementGroin Hernia Management

Most hernias: ambulatory ORMost hernias: ambulatory OR

Local/regional/general anesthesiaLocal/regional/general anesthesia

Prohibitive operative risk: trussProhibitive operative risk: truss

Groin Hernia ManagementGroin Hernia Management Acute incarcerationAcute incarceration

Reduction (taxis)Reduction (taxis) Distal traction and gentle milkingDistal traction and gentle milking Caution: reduction en masseCaution: reduction en masse Successful reduction shows visuallySuccessful reduction shows visually

Urgent elective repair if reducedUrgent elective repair if reduced

Groin Hernia ManagementGroin Hernia Management

Emergent repairEmergent repair Irreducible acute incarcerationIrreducible acute incarceration StrangulationStrangulation

Fluid, electrolyte resuscitation Fluid, electrolyte resuscitation

Groin Hernia Groin Hernia Surgical Classification (Nyhus)Surgical Classification (Nyhus)

I: Indirect hernia w/normal internal ringI: Indirect hernia w/normal internal ring

2: Indirect hernia w/enlarged internal ring2: Indirect hernia w/enlarged internal ring

3a: Direct inguinal hernia3a: Direct inguinal hernia

3b: Indirect hernia with weak floor3b: Indirect hernia with weak floor

3c: Femoral hernia3c: Femoral hernia

4: All recurrent hernias4: All recurrent hernias

Direct Inguinal HerniaDirect Inguinal Hernia

Direct Inguinal HerniaDirect Inguinal Hernia

MedialMedial to the to the inferior epigastric inferior epigastric artery and veinartery and vein, , and within and within Hesselbach's Hesselbach's triangle triangle

acquired weakness acquired weakness in the inguinal floor in the inguinal floor

Indirect Inguinal HerniaIndirect Inguinal Hernia Accepted hypothesisAccepted hypothesis: :

incomplete or incomplete or defective obliteration defective obliteration of the of the processus processus vaginalisvaginalis during the during the fetal period fetal period

remnant layer of remnant layer of peritoneum forms a peritoneum forms a sac at the internal sac at the internal ring ring

more frequently on more frequently on the right the right

FemoralFemoral

More common in females More common in females Up to 40% present as Up to 40% present as

emergencies with hernia emergencies with hernia incarceration or incarceration or strangulation strangulation

Passes medial to the Passes medial to the femoral vessels and femoral vessels and nerve in the femoral nerve in the femoral canal through the empty canal through the empty space space

Inguinal ligament forms Inguinal ligament forms the superior borderthe superior border

Groin Hernia Surgery: OpenGroin Hernia Surgery: Open

Indirect sac: high ligationIndirect sac: high ligation

Men: ligation at internal ringMen: ligation at internal ring

Women: ligation/excision of round Women: ligation/excision of round ligament with closure of internal ringligament with closure of internal ring

Cord lipoma: excisionCord lipoma: excision

OperativeOperative

BassiniBassini ShouldiceShouldice McVayMcVay LichtensteinLichtenstein PreperitonealPreperitoneal LaparoscopicLaparoscopic

Bassini (early 20Bassini (early 20thth Century) Century) Transversus abdominis to Thompson’s ligament and Transversus abdominis to Thompson’s 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 the Multilayer imbricated repair of the posterior wall of the

inguinal canalinguinal canal McVay (1948)McVay (1948)

Edge of the transversus abdominis aponeurosis to Edge of the transversus abdominis aponeurosis to Cooper’s ligament; incorporate Cooper’s ligament and Cooper’s ligament; incorporate Cooper’s ligament and the iliopubic tract (transition suture) the iliopubic tract (transition suture)

BASSINI

SHOULDICE

MCVAY

Lichtenstein Lichtenstein First pure prosthestic, tension-free First pure prosthestic, tension-free

repair to achieve low recurrence repair to achieve low recurrence ratesrates

Groin Hernia Surgery: OpenGroin Hernia Surgery: Open

Inguinal floor: tension-free repair with Inguinal floor: tension-free repair with mesh mesh

Anterior plug and patchAnterior plug and patch Anterior patchAnterior patch Posterior patch (Stoppa)Posterior patch (Stoppa)

Groin Hernia SurgeryGroin Hernia Surgery Open tissue repair for risk of infection Open tissue repair for risk of infection

(example: strangulated hernia)(example: strangulated hernia)

LaparoscopicLaparoscopic IndicationsIndications

Recurrent herniaRecurrent hernia Bilateral herniasBilateral hernias

Must be able to tolerate general anesthesiaMust be able to tolerate general anesthesia More expensiveMore expensive

Groin Hernia Repair Groin Hernia Repair ComplicationsComplications

RecurrenceRecurrenceTissue repair: 1.3—25%Tissue repair: 1.3—25%Tension-free mesh: 0.5—5%Tension-free mesh: 0.5—5%

Greatest risk is repair of previous Greatest risk is repair of previous hernia at same location hernia at same location

Groin Hernia Repair Groin Hernia Repair ComplicationsComplications

Chronic groin pain: up to 30%Chronic groin pain: up to 30%

Numbness over base of scrotumNumbness over base of scrotum

Groin Hernia Repair Groin Hernia Repair ComplicationsComplications

WoundWound Hematoma: 1.0%Hematoma: 1.0% Infection: 1.3%Infection: 1.3% Seroma Seroma

InfertilityInfertility Injury to vas deferensInjury to vas deferens Ischemic orchitis is uncommonIschemic orchitis is uncommon

Urinary retentionUrinary retention

Other HerniasOther Hernias

Umbilical HerniaUmbilical Hernia Fascial defect at the umbilicus with Fascial defect at the umbilicus with

peritoneal sac covered by skinperitoneal sac covered by skin

External bulge at the umbilicus or External bulge at the umbilicus or periumbilically depending on periumbilically depending on subcutaneous migration of sacsubcutaneous migration of sac

Exam: External bulge at or adjacent to Exam: External bulge at or adjacent to the umbilicusthe umbilicus

Pediatric Umbilical HerniaPediatric Umbilical Hernia

Present in 10-30% of babiesPresent in 10-30% of babies

80% close spontaneously by age 280% close spontaneously by age 2

Indications for primary suture repairIndications for primary suture repair Hernia present after ages 2-4Hernia present after ages 2-4 Large (5 cm) defect at age 1Large (5 cm) defect at age 1

Adult Umbilical HerniaAdult Umbilical Hernia

Increased intra-abdominal Increased intra-abdominal pressurepressure PregnancyPregnancy Obesity Obesity AscitesAscites

Differential diagnosis (rare)Differential diagnosis (rare) Embryologic remnantsEmbryologic remnants Metastatic cancerMetastatic cancer

Adult Umbilical HerniaAdult Umbilical Hernia

Symptoms relate to cosmesis, Symptoms relate to cosmesis, traction on the sac, or trapped traction on the sac, or trapped contentscontents OmentumOmentum Small or transverse colonSmall or transverse colon

Acute incarceration: reduction en Acute incarceration: reduction en masse problematicmasse problematic

Adult Umbilical Hernia RepairAdult Umbilical Hernia Repair Assess contents and manage Assess contents and manage

appropriately based on viabilityappropriately based on viability Open hernia repairOpen hernia repair

< 1 cm defect: primary suture repair< 1 cm defect: primary suture repair >> 1 cm defect: mesh repair lowers 1 cm defect: mesh repair lowers

recurrencerecurrence Laparoscopic hernia repair: size of Laparoscopic hernia repair: size of

access ports often > hernia incisionaccess ports often > hernia incision

Adult Umbilical Hernia RepairAdult Umbilical Hernia Repair

RisksRisks RecurrenceRecurrence Umbilical necrosisUmbilical necrosis Injury to sac contentsInjury to sac contents HematomaHematoma InfectionInfection

Epigastric HerniaEpigastric Hernia

Fascial defect in supraumbilical Fascial defect in supraumbilical linea albalinea alba Most < 1 cmMost < 1 cm 20% with multiple defects20% with multiple defects Beware diastasis rectiBeware diastasis recti

MenMen: : Women Women 22::11

EpigastricEpigastric

midline junction of the midline junction of the aponeuroses (linea alba) aponeuroses (linea alba) betweenbetween the the xiphoid xiphoid processprocess and and umbilicusumbilicus

Paraumbilical hernia - Paraumbilical hernia - epigastric hernia that epigastric hernia that borders the umbilicusborders the umbilicus

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

More common in Males More common in Males 3:13:1

20% may be multiple20% may be multiple

Epigastric HerniaEpigastric Hernia

ContentsContents Incarcerated preperitoneal fat or Incarcerated preperitoneal fat or

falciform ligament falciform ligament Peritoneal sacPeritoneal sac

RepairRepair Open repair similar as for umbilical Open repair similar as for umbilical

herniahernia Must palpate or visualize entire Must palpate or visualize entire

supraumbilical linea albasupraumbilical linea alba Laparoscopic approach is suboptimalLaparoscopic approach is suboptimal

Spigelian HerniaSpigelian Hernia

Defect through transversus abdominus Defect through transversus abdominus and internal oblique musclesand internal oblique muscles Occurs at junction of arcuate line and Occurs at junction of arcuate line and

linea semilunarislinea semilunaris Fascial defect 1-2 cmFascial defect 1-2 cm Covered by external oblique Covered by external oblique

aponeurosisaponeurosis

Spigelian HerniaSpigelian Hernia

occurs along the occurs along the semilunar line, which semilunar line, which traverses a vertical traverses a vertical space along the lateral space along the lateral rectus border rectus border

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

Spigelian HerniaSpigelian Hernia

ClinicalClinical Swelling in middle to Swelling in middle to

lower abdomen lateral lower abdomen lateral to rectus muscleto rectus muscle

Usually reducibleUsually reducible Up to 20% present Up to 20% present

with incarcerationwith incarceration Tx: surgicalTx: surgical

Mesh not requiredMesh not required Recurrence is Recurrence is

uncommonuncommon

Spigelian HerniaSpigelian Hernia PresentationPresentation

Lower abdominal swelling lateral to Lower abdominal swelling lateral to rectusrectus

Focal discomfort/painFocal discomfort/pain

May require imaging studies for diagnosisMay require imaging studies for diagnosis Ultrasound or CTUltrasound or CT

Repair: open or laparoscopic, on-lay meshRepair: open or laparoscopic, on-lay mesh

Incisional HerniaIncisional Hernia Bulge in region of scar from surgery or Bulge in region of scar from surgery or

penetrating traumapenetrating trauma

Chronic wound failure Chronic wound failure Up to 20% of abdominal incisionsUp to 20% of abdominal incisions

Subcutaneous sac may be more Subcutaneous sac may be more complexcomplex Multi-loculatedMulti-loculated Contents adhesed within sacContents adhesed within sac

Incisional Hernia: Risk Incisional Hernia: Risk FactorsFactors

Previous incisional hernia repairPrevious incisional hernia repair ObesityObesity SmokingSmoking Chronic lung diseaseChronic lung disease DiabetesDiabetes MalnutritionMalnutrition Wound infectionWound infection

Incisional Hernia RepairIncisional Hernia Repair

Fix conditions that promoted Fix conditions that promoted hernia occurrencehernia occurrence

Open repairOpen repair Primary suture: Primary suture: << 52% recurrence 52% recurrence Mesh: Mesh: << 24% recurrence 24% recurrence

Incisional Hernia RepairIncisional Hernia Repair Complex open repairsComplex open repairs

Stoppa mesh repairStoppa mesh repair Component separations repairComponent separations repair

Laparoscopic repairLaparoscopic repair Multiple fascial defects detectedMultiple fascial defects detected Large on-lay intraperitoneal mesh Large on-lay intraperitoneal mesh 5 cm marginal overlap5 cm marginal overlap

Incisional HerniaIncisional Hernia

Complications of repairComplications of repair RecurrenceRecurrence SeromasSeromas Injury to sac contentsInjury to sac contents BleedingBleeding InfectionInfection

ReviewReview Pediatric herniasPediatric hernias

InguinalInguinal UmbilicalUmbilical

Adult herniasAdult hernias GroinGroin

InguinalInguinal FemoralFemoral

UmbilicalUmbilical EpigastricEpigastric SpigelianSpigelian IncisionalIncisional

Points to RememberPoints to Remember

Hernias represent fascial defects with Hernias represent fascial defects with protrusion of a peritoneal sac or protrusion of a peritoneal sac or preperitoneal fatpreperitoneal fat

Asymptomatic bulge most commonAsymptomatic bulge most common Hernia risk is related to visceral Hernia risk is related to visceral

obstruction or strangulationobstruction or strangulation Tension-free repair with mesh produces Tension-free repair with mesh produces

lowest recurrence rateslowest recurrence rates

SummarySummary

Etiology, pathology, clinical evaluation, Etiology, pathology, clinical evaluation,

and treatment of abdominal wall hernias and treatment of abdominal wall hernias

including inguinal, femoral, umbilical, including inguinal, femoral, umbilical,

epigastric, Spigelian, and incisional epigastric, Spigelian, and incisional

herniashernias

Scenario Scenario

Direct HerniaDirect Hernia

Indirect Indirect inguinal hernia inguinal hernia

Direct inguinal Direct inguinal herniahernia

Relation to Relation to epigastric epigastric vessels vessels

Lataral Lataral medialmedial

Processus Processus vaginalis vaginalis

Present Present Absent Absent

Causes Causes congenitalcongenitalAcqiured Acqiured

Individual herniasIndividual hernias

1.1. Direct & indirect Inguinal Direct & indirect Inguinal

hernia.hernia.

2.2. Femoral hernia.Femoral hernia.

3.3. Umbilical hernia & Umbilical hernia &

paraumbilical hernia.paraumbilical hernia.

4.4. Incisional hernia.Incisional hernia.

5.5. Epigastric hernia.Epigastric hernia.

6.6. Rare external Hernias.Rare external Hernias.

Femoral HerniaFemoral Hernia Femoral Hernias occur just below Femoral Hernias occur just below

the inguinal ligament, when the inguinal ligament, when abdominal contents pass through a abdominal contents pass through a naturally occurring weakness called naturally occurring weakness called the femoral canal.the femoral canal.

The Femoral canal : The Femoral canal : The most medial structure in The most medial structure in

the femoral sheath,.the femoral sheath,. extending from the femoral extending from the femoral

ring to the saphenous ring to the saphenous opening.opening.

1.25cm x 1.25cm.1.25cm x 1.25cm. Contains fat, lymph vessels Contains fat, lymph vessels

and the lymph node of and the lymph node of cloquet.cloquet.

Femoral Hernia (cont..)Femoral Hernia (cont..)

Symptoms:Symptoms: Femoral hernias are more common in women, Femoral hernias are more common in women, They typically present as a groin lump. They may or may not be They typically present as a groin lump. They may or may not be associated with pain, a femoral hernia has often been found to associated with pain, a femoral hernia has often been found to be the cause of unexplained small bowel obstruction.be the cause of unexplained small bowel obstruction.

Signs:Signs: an absent Cough impulse, with a more globular lump an absent Cough impulse, with a more globular lump than the pear shaped lump of the inguinal hernia. than the pear shaped lump of the inguinal hernia.

Differential DiagnosesDifferential Diagnoses: : Inguinal Hernia.Inguinal Hernia. Femoral Artery Aneurism.Femoral Artery Aneurism. Femoral Lymphadenopathy.Femoral Lymphadenopathy. Psoas Abscess.Psoas Abscess.

Umbilical & paraumbilical HerniaUmbilical & paraumbilical Hernia

A. Umbilical Hernia:A. Umbilical Hernia:

Seen in infants & children.Seen in infants & children. Effecting boys more than Effecting boys more than

girls.girls. tend to resolve without any tend to resolve without any

treatment by around the age treatment by around the age of 5 years. of 5 years.

Obstruction and strangulation Obstruction and strangulation of the hernia is rare.of the hernia is rare.

Babies are prone to this Babies are prone to this malformation because of the malformation because of the process during fetal process during fetal development by which the development by which the abdominal organs form abdominal organs form outside the abdominal cavity, outside the abdominal cavity, later returning into it through later returning into it through an opening which will become an opening which will become the umbilicus.the umbilicus.

B. Paraumbilical Hernia:B. Paraumbilical Hernia: Affects adults.Affects adults. The defect is either supra or The defect is either supra or

infraumbilical through the infraumbilical through the linea alba.linea alba.

The female to male ratio is The female to male ratio is 20:1.20:1.

May contain omentum, small May contain omentum, small intestine or transverse colon.intestine or transverse colon.

Etiology: Etiology: 1.1. Obesity.Obesity.

2.2. Flabbiness of the abdominal Flabbiness of the abdominal muscles.muscles.

3.3. Multiparity.Multiparity.

Clinical Features:Clinical Features:Clolicky pain and/or Clolicky pain and/or

irreducibilty due to omental irreducibilty due to omental adhesions.adhesions.

Incisional HerniaIncisional Hernia

Definition:Definition: An An incisional herniaincisional hernia occurs when the area of weakness is the occurs when the area of weakness is the result of an incompletely healed surgical wound. These can be among result of an incompletely healed surgical wound. These can be among the most frustrating and difficult hernias to treat. It can occur at any the most frustrating and difficult hernias to treat. It can occur at any incision, but tend to occur more commonly along a straight line from the incision, but tend to occur more commonly along a straight line from the sternum breastbone straight down to the pubis, and are more complex sternum breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence.in these regions. Hernias in this area have a high rate of recurrence.

Causes: Causes: Any reasons leading to an icrease in intraabdominal pressure Any reasons leading to an icrease in intraabdominal pressure

postoperatively such as: chronic cough, vomitting, infection, postoperatively such as: chronic cough, vomitting, infection, malnutrition diabetes, steroid treatment or a tension closure done malnutrition diabetes, steroid treatment or a tension closure done during the previous operation.during the previous operation.

Clinical Features:Clinical Features: Swelling at the incisional site +/- pain.Swelling at the incisional site +/- pain.

Ventral wall (Incisional)Ventral wall (Incisional)

Highest incidence in midline Highest incidence in midline and transverse incisions and transverse incisions

Up to20% after laparotomyUp to20% after laparotomy 1/3 present in 5-10 years 1/3 present in 5-10 years

postoperativelypostoperatively Risk factors Risk factors

obesity, DM, ascites, obesity, DM, ascites, steroids, smoking steroids, smoking malnutrition, wound malnutrition, wound infectioninfection

Technical aspects of wound Technical aspects of wound closureclosure Type of incision Type of incision Excessive tension (prone to Excessive tension (prone to

fascial disruption)fascial disruption)

Epigastric HerniaEpigastric Hernia

Due to a defectin the linea alba between Due to a defectin the linea alba between the xiphoid process and the umbilicusthe xiphoid process and the umbilicus

Starts as a protrusion of the Starts as a protrusion of the extraperitoneal fat at the site where a extraperitoneal fat at the site where a small vessel pierces the lina alba and as small vessel pierces the lina alba and as it enlarges it drags a pouch of it enlarges it drags a pouch of peritoneum after it.peritoneum after it.

Clinical Features:Clinical Features:

Swelling +/- pain similar to a peptic ulcer Swelling +/- pain similar to a peptic ulcer pain.pain.

Rare external HerniasRare external Hernias

Since many organs or parts of organs can herniate through many orifices, it Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. But her are Other hernial types and unusual types of visceral eponyms. But her are Other hernial types and unusual types of visceral hernias:hernias:

1.1. Spiglian Hernia:Spiglian Hernia: Occurs at the spaces of the semilunar line and the lateral edge of Occurs at the spaces of the semilunar line and the lateral edge of

the rectus muscle (inferior to the arcuate line).the rectus muscle (inferior to the arcuate line). The posterior rectus sheath jis weak thus leading to the protrusion.The posterior rectus sheath jis weak thus leading to the protrusion. Preoperative diagnosis is diffucult & only correct in 50% of the Preoperative diagnosis is diffucult & only correct in 50% of the

patients.patients. u/s & c.t are helpful tools in the diagnosisu/s & c.t are helpful tools in the diagnosis Depending on the size of the defect, treatment varies from suture Depending on the size of the defect, treatment varies from suture

approximation to using a mesh.approximation to using a mesh.

Rare hernias (cont..)Rare hernias (cont..)2. Lumbar Hernias:2. Lumbar Hernias:

In the lumbar region, in the form of a broad bulging hernia, In the lumbar region, in the form of a broad bulging hernia, that are not vulnerable to incarceration.that are not vulnerable to incarceration.

Devided intoDevided into: :

A. Petit’s hernia: A. Petit’s hernia: which occurs in the inferior lumbar which occurs in the inferior lumbar triangle.triangle.

B. Grynfeltt’s Hernia: B. Grynfeltt’s Hernia: which occurs in the superior which occurs in the superior lumbar lumbar triangle and is triangle and is less common that Petit’s. less common that Petit’s.

LumbarLumbar Acquired lumbar hernias Acquired lumbar hernias

– – back or flank trauma, back or flank trauma,

poliomyelitis, back poliomyelitis, back surgery, and the use of the surgery, and the use of the iliac crest as a donor site iliac crest as a donor site for bone grafts for bone grafts

Contains to anatomic Contains to anatomic triangles, inferior and triangles, inferior and superior lumbar trianglessuperior lumbar triangles Grynfelt’sGrynfelt’s Petit’s Petit’s

Strangulation is rareStrangulation is rare Soft swelling in lower Soft swelling in lower

posterior abdomenposterior abdomen

Rare hernias (cont..)Rare hernias (cont..)3. Obturator Hernia:3. Obturator Hernia:

The obturator canal is covered by The obturator canal is covered by a membrane pierced by the a membrane pierced by the obturator nerve and vessels. Any obturator nerve and vessels. Any enlargement in the canal or enlargement in the canal or weakness in the membrane may weakness in the membrane may lead to herniation of the intetines.lead to herniation of the intetines.

Because of differences in anatomy, Because of differences in anatomy, it is much more common in women it is much more common in women than in men.than in men.

It often presents with bowel It often presents with bowel obstruction.obstruction.

The Howship-Romberg sign is The Howship-Romberg sign is suggestive of an obturator hernia, suggestive of an obturator hernia, exacerbated by thigh extension, exacerbated by thigh extension, medial rotation and adduction. It is medial rotation and adduction. It is characterized by lancilating pain in characterized by lancilating pain in the medial thigh/obturator the medial thigh/obturator distribution, extending to the knee; distribution, extending to the knee; caused by hernia compression of caused by hernia compression of the obturator nerve.the obturator nerve.

ObturatorObturator

Rare form of herniaRare form of hernia Protrusion of intra-abdominal Protrusion of intra-abdominal

contents through contents through obturator obturator foramenforamen

F:M ratio 6:1F:M ratio 6:1 The obturator foramen is The obturator foramen is

formed by the ischial and formed by the ischial and pubic rami pubic rami

obturator vessels and nerve obturator vessels and nerve lie posterolateral to the lie posterolateral to the hernia sac in the canal hernia sac in the canal

Small bowel is the most Small bowel is the most likely intraabdominal likely intraabdominal organ to be found in an organ to be found in an obturator herniaobturator hernia

ObturatorObturator

4 cardinal signs : 4 cardinal signs : intestinal obstructionintestinal obstruction (80%) (80%) Howship-Romberg signHowship-Romberg sign (50%) –History of (50%) –History of

repeated episodes of bowel obstructionrepeated episodes of bowel obstruction that resolve quickly and without intervention that resolve quickly and without intervention

Palpable massPalpable mass (20%) (20%)

Tx: Sugical RepairTx: Sugical Repair

SciaticSciatic Via greater or lesser sciatic Via greater or lesser sciatic

notch notch greater sciatic notch is greater sciatic notch is

traversed by the piriformis traversed by the piriformis muscle, and hernia sacs muscle, and hernia sacs can protrude either can protrude either superior or inferior to this superior or inferior to this muscle muscle

suprapiriform defect 60%suprapiriform defect 60% Infrapiriform 30% Infrapiriform 30% subspinous (through the subspinous (through the

lesser sciatic foramen) 10% lesser sciatic foramen) 10%

EXAMINATION:EXAMINATION:

Hernias must be examined with the patient standing Hernias must be examined with the patient standing and in supineand in supineAlways examine both groins.Always examine both groins.

INSPECTION:INSPECTION:Visible swelling. (site, size and shape)Visible swelling. (site, size and shape)Visible cough impulse.Visible cough impulse.Easily reducibleEasily reducibleReappear on straining, standing or coughing Reappear on straining, standing or coughing Elucidate Fothergill and Carnet signs.Elucidate Fothergill and Carnet signs.

PALPATION:PALPATION:Examine as a mass and then Examine as a mass and then Palpable cough impulsePalpable cough impulseReduceReduceOcclusion testOcclusion testThree Finger test ( Zimman’s test)Three Finger test ( Zimman’s test)

ExaminationExamination

also asses the following:also asses the following:PositionPositionTemperatureTemperatureTendernessTendernessShapeShapeSizeSizeTensionTensionCompositionCompositionExpansile cough impulseExpansile cough impulseReducible.Reducible.

PERCUSSION AND AUSCULTATION:PERCUSSION AND AUSCULTATION:

Bowel sound.Bowel sound.

TreatmentTreatmentMost abdominal hernias can be surgically Most abdominal hernias can be surgically repaired.repaired.

Uncomplicated hernias are principally Uncomplicated hernias are principally repaired by herniorrhaphy.repaired by herniorrhaphy.

aa Herniorrhaphy (Hernioplasty) is a surgical Herniorrhaphy (Hernioplasty) is a surgical procedure for correcting hernia, which can procedure for correcting hernia, which can be devided into four techniques:be devided into four techniques:

Groups 1 and 2: open "tension" repair:Groups 1 and 2: open "tension" repair: in which the edges of the defect are sewn back in which the edges of the defect are sewn back

together without any reinforcement or prosthesis. together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus (formed by the distal ends of the transversus abdominis muscle and the internal oblique abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and muscle) is approximated to the inguinal canal and closed. closed. [4][4]

Although tension repairs are no longer the Although tension repairs are no longer the standard of care due to the high rate of standard of care due to the high rate of recurrence of the hernia, long recovery period, recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are and post-operative pain, a few tension repairs are still in use today.still in use today.

Treatment (cont..)Treatment (cont..)Group 3: open "tension-free" repair:Group 3: open "tension-free" repair:

Almost all repairs done today are open Almost all repairs done today are open "tension-free" repairs that involve the "tension-free" repairs that involve the placement of a synthetic mesh to placement of a synthetic mesh to strengthen the inguinal region.strengthen the inguinal region.

This operation is called a 'hernioplasty'. The This operation is called a 'hernioplasty'. The meshes used are typically made from meshes used are typically made from polypropylene or polyester. The operation polypropylene or polyester. The operation is typically performed under local is typically performed under local anesthesia, and patients go home within a anesthesia, and patients go home within a few hours of surgery, often requiring no few hours of surgery, often requiring no medication beyond aspirin or medication beyond aspirin or acetaminophen.acetaminophen.

Recurrence rates are very low - one Recurrence rates are very low - one percent or less, compared with over 10% percent or less, compared with over 10% for a tension repairfor a tension repair

Treatment (cont..)Treatment (cont..)

Group 4: laparoscopic repairGroup 4: laparoscopic repair "Lap" repairs are also tension-free, although "Lap" repairs are also tension-free, although

the mesh is placed within the preperitoneal the mesh is placed within the preperitoneal space behind the defect as opposed to in or space behind the defect as opposed to in or over it.over it.

It is further sub-devided into:It is further sub-devided into: T.A.P.P repair (transabdominal T.A.P.P repair (transabdominal

preperitoneal)preperitoneal) T.E.P repair (totally T.E.P repair (totally

extraperitoneal)extraperitoneal)

It has no proven superiority to the open It has no proven superiority to the open method other than a faster recovery time and method other than a faster recovery time and a slightly lower post-operative pain score.a slightly lower post-operative pain score.

laparoscopic surgery, though, requires general laparoscopic surgery, though, requires general anesthesia, more expensive and consumes anesthesia, more expensive and consumes more O.R. time than open repair and carries a more O.R. time than open repair and carries a higher risk of complications, and has higher risk of complications, and has equivalent or higher rates of recurrence equivalent or higher rates of recurrence compared to the open tension-free repairs.compared to the open tension-free repairs.