Hernias Presentation

8/8/2019 Hernias Presentation

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Hernias



Hernia

a protrusion of any viscus from its proper

cavity. The protruded parts are generally

contained in a sac-like structure, formed by

the membrane with which the cavity is

naturally lined



Abdominal Hernias

Indirect Inguinal Hernia

Direct Inguinal Hernia

Umbilical

Femoral

Richter

Incisional

Spigelian

Obturator



Hernia - Conditions

Reducible hernia: This term refers to the ability toreturn the contents of the hernia into the abdominalcavity, either spontaneously or manually.

Incarcerated hernia: An incarcerated hernia is nolonger reducible. The vascular supply of the bowel isnot compromised. Bowel obstruction is common.

Strangulated hernia: A strangulated hernia occurswhen the vascular supply of the bowel is compromisedsecondary to incarceration of hernia contents.



What are the symptoms of inguinal

hernia?

Symptoms of inguinal hernia include:

a small bulge in one or both sides of the grointhat may increase in size and disappear when

lying down; in males, it can present as a swollenor enlarged scrotum

discomfort or sharp painespecially whenstraining, lifting, or exercisingthat improveswhen resting

a feeling of weakness or pressure in the groin

a burning, gurgling, or aching feeling at the bulge



Anatomy of inguinal canal



Boundaries of inguinal canal

Ant : External oblique aponeurosisand few fibers of internal oblique

laterally Post : Fascia transversalis andconjoined tendon

Superior : Arched fibres of conjoinedtendon

Inferior : Inguinal ligament



Contents of inguinal canal

Spermatic cord, ilioinguinal nerve, genital

br. of genitofemoral nerve.

Round ligament in females. Vestigial remnant of processes vaginalis.



Inguinal Hernias


± most common type of

hernia

± follows the tract throughthe inguinal canal

± results from a persistent

process vaginalis




The inguinal canal begins inthe intra-abdominal cavity atthe internal inguinal ring,located approximately midwaybetween the pubic symphysis

and the anterior iliac spine.The canal courses down alongthe inguinal ligament to theexternal ring, located medialto the inferior epigastricarteries, subcutaneously and

slightly above the pubictubercle. Contents of thishernia then follow the tract of the testicle down into thescrotal sac



Inguinal Hernias

Direct Inguinal Hernia ± caused by connective tissue degeneration of the abdominal

muscles, which causes weakening of the muscles during theadult years.

± occurs due to a defect or weakness in the transversalis fasciaarea of the Hesselbach triangle The triangle is defined inferiorly by the inguinal ligament, laterally by

the inferior epigastric arteries, and medially by the conjoined tendon

± One or more of the following factors can cause pressure on theabdominal muscles and may worsen the hernia:

sudden twists, pulls, or muscle strains lifting heavy objects

straining on the toilet because of constipation

weight gain

chronic coughing



Direct Inguinal Hernia



Diagnosis

thorough medical history andconducts a physicalexamination.

patient may be asked to standand cough so the doctor can

feel the hernia as it moves intothe groin or scrotum.

check to if the hernia can begently massaged back into itsproper position in theabdomen.

Herniography

US of groin

CT scan of pelvis



Examination

Inguino scrotal swelling

Expansile cough

Reducibility Finger Invagination Test

Deep Ring occlusion Test

(Three finger Test)



Treatment

Surgical

Watchful waiting for elderly pt. with smallasymptomatic hernia

Truss



Surgery

Herniorrhaphy:

± Bassini¶s Repair

± Shouldice Repair

± Mc Vay Hernioplasty : Mesh graft application

Laparoscopic Repair



Types of repair

Bassini (early 20th Century) ± The conjoined tendon of the transversus abdominis and

the internal oblique muscles is sutured to the inguinal

ligament

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

inguinal canal

McVay (1948)

± Edge of the transversus abdominis aponeurosis to

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



Bassini¶s repair

EDUARDO B ASSINI



Shouldice repair



Mc Vay repair



Lichtenstein repair

First pure prosthestic, tensionFirst pure prosthestic, tension--free repair to achieve low recurrence ratesfree repair to achieve low recurrence rates



Types of Prosthesis

Polypropylene mesh most common andpreferred

± allows for a fibrotic reaction to occur betweenthe inguinal floor and the posterior surface of

the mesh, thereby forming scar andstrengthening the closure of the hernia defect

Polytetrafluoroethylene (PTFE) mesh

± often used for repair of ventral or incision

hernias in which the fibrotic reaction with theunderlying serosal surface of the bowel isbest avoided



Hernia mesh



Complications

Hernia recurrence

Bleeding

Wound infection Painful scar

Injury to internal organs



Conservative treatment

Trusses can provide symptomatic relief



Femoral Hernia

follows the tract below theinguinal ligament throughthe femoral canal. The canallies medial to the femoral

vein and lateral to thelacunar (Gimbernat)ligament. Because femoralhernias protrude throughsuch a small defined space,

they frequently becomeincarcerated or strangulated



1-FEMORAL ARTERY(LATERAL COMPARTMENT)

2-FEMORAL VEIN(INTERMEDIATE COMPARTMENT)

3-FEMORAL CANAL(MEDIAL COMPARTMENT)







Pantaloon Hernia

± occurs when both adirect and an indirecthernia develop on the

same side of the groin.The hernia is namedpantaloon because thetwo hernia sacs aredivided by epigastric

vessels, and so they looklike a pair of pants fromthe 17th century



Littres Hernia - a hernia involving a Meckel's diverticulum

Sliding Hernia - a variant that is seen in 3% of hernia cases. It occurswhen the wall of the hernia sac is an organ like the bladder or thecolon

Spigelian hernia

± protrusion of preperitoneal fat, a sac of peritoneum, or an organ,through a congenital defect or weakness in the spigelian fascia

± This is typically a soft reducible mass encountered lateral to the rectus

muscle and below the umbilicus ± It advances through different muscle layers of the abdominal wall andspreadsout like a mushroom between external and internal obliquemuscles



Richters hernia

± occurs when only the antimesenteric border of

the bowel herniates through the fascial defect.

± involves only a portion of the circumference of the

bowel

± the bowel may not be obstructed, even if the

hernia is incarcerated or strangulated, and thepatient may not present with vomiting.



Incisional hernia

± This iatrogenic hernia occurs in 2-10% of all abdominaloperations secondary to breakdown of the fascial closure of prior surgery

± patients present with a bulge at the site of a previous incision

Obturator hernia ± passes through the obturator foramen, following the path of the

obturator nerves and muscles

± Obturator hernias occur with a female-to-male ratio of 6:1,because of a gender-specific larger canal diameter

± Because of its anatomic position, this hernia presents morecommonly as a bowel obstruction than as a protrusion of bowelcontents



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Hernias Presentation