HERNIA (FEMORAL & UMBILICAL)

FEMORAL & UMBILICAL

HERNIANUR HANISAH BINTI ZAINOREN

CONTENTS

Anatomy

Introduction

Causes

Clinical features

Diagnosis

Treatment

SHEATH . CANAL . RINGFEMORAL

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL SHEATH

FEMORAL CANAL

FEMORAL CANAL

FEMORAL RING

FEMORAL RING BOUNDARIES

ANTERIORLY


POSTERIORLY


MEDIALLY


LATERALLY

FEMORAL RING

FEMORAL RING

Lymphatics

Areolar tissue

Boundaries of femoral ring :

•Superoanteriorly inguinal lig.

•Inferoposteriorly iliopectineal lig.

•Medially lacunar ligament (Gimbernat’s ligament)

•Laterally thin septum which separates femoral canal & femoral vein(silver fascia)

INTRODUCTION

Protrusion of extra peritoneal tissue, peritoneum & sometimes abdominal content through the femoral canal

Female: Male = 2:1

Commonly unilateral, right side are more affected

Bilateral, in 15-20 %

RISK FACTORS

1. Female

2. Old ages

3. Low weight, elderly females

4. Previous h/o sutured inguinal hernia

repair

CLINICAL FEATURES

•Gaur sign : dilatation of superficial epigastric/ circumflex iliac veins due to compression

•Right side is more commonly affected

•Small swelling below the inguinal lig. very often unnoticed

•Expansile impulse is often not present due to narrow canal

•Swelling is below and lateral to pubic tubercle

•Strangulation 30-80%

INGUINAL VS FEMORAL HERNIA

INGUINAL FEMORALAbove and medial to

the pubic tubercleBelow and lateral to the

pubic tubercle

Above the crease of the groin

Below the crease of the groin

Can be reduced completely

Cannot be reduced completely

Cough impulse usually present

Many do not have cough impulse

INVESTIGATION

•No specific investigations are required•Ultrasound & CT scan•Emergency patient , small bowel obstruction usually occurs plain X-ray

TREATMENT

3 classical approach :

i. Low approach (Lockwood)

below the inguinal ligament

ii. Inguinal approach

(Lotheissen) through inguinal

canal

iii. High approach (McEvedy)

mainly above the inguinal canal

*some cases can be managed laparoscopically

TREATMENT

1. Low approach (Lockwood)

•An incision is made over 1cm below and parallel to the inguinal lig.

•The sac is opened and the contents are reduced

•Non-absorbable sutures are placed between inguinal ligament & iliopectineal ligament

TREATMENT

2. Inguinal approach (Lotheissen)•Transversalis fascia is opened from deep inguinal ring to pubic tubercle.

•Hernia is reduced by combination of pulling from above and pushing from below.

•Once reduced, neck of hernia is closed with sutures/ mesh plugs

TREATMENT

3. High Approach (McEvedy)

•Horizontal incision is made in lower abdominal

centered at lateral edge of rectus muscle.

•Ant. Rectus sheath is incised and rectus muscle

displaced medially.

•Hernia is reduced and sac is opened for careful

inspection of bowel.

•Femoral defect then is closed with sutures/ mesh

TREATMENT

4. Laparoscopic approach

•TEP and TAPP approach can be used

•A standard mesh is inserted

•Ideal for reducible femoral hernias, not

in emergency cases nor for irreducible

hernia

DIFFERENTIAL DIAGNOSIS

•Direct inguinal hernia

•Lymph node

•Saphena varix

•Lipoma

•Femoral artery aneurysm

•Psoas abscess

•Rupture of adductor longus with haematoma

UMBILICAL HERNIA

UMBILICAL HERNIA

The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually within a week of birth

This process may be delayed, leading to the development of herniation in the neonatal period

The umbilical ring may also stretch and reopen in adult life

UMBILICAL HERNIA IN CHILDREN•10% of infants, higher incidence in premature babies•Hernia appears within a few weeks of birth•Symptomless •Increases in size on crying•Classical conical shape

Incidence:•Boys = Girls•Black infants (8x) > White

Obstruction/strangulation are extremely uncommon in

<3 years of age

TREATMENT• Conservative treatment : < 2 years, symptomless,

parental reassurance

• 95% will resolve spontaneously

• Surgical repair : if the hernia persists > 2 years (unlikely to

resolve)

OPERATION• Small curved incision is made immediately below the

umbilicus

• Neck of the sac is defined, opened and any contents are

returned to the peritoneal cavity

• Sac is closed and redundant sac is excised

• The defect in linea alba is closed

with interrupted sutures.

UMBILICAL HERNIA IN ADULTReopening of umbilical defect caused by conditions that cause thinning and stretching of midline raphe (linea alba)Repeated pregnancies weaken abdominal wall

Obesity flabby abdominal muscle

Ascites, especially in cirrhotic patients

Defect in median raphe is immediately adjacent to

true umbilicus (usually above) PARAUMBILICAL

HERNIA

UMBILICAL HERNIA IN ADULT

•Round with well defined fibrous margin.

•ContentsSmall umbilical hernia often contain extraperitoneal fat

or omentum

Larger hernia contain small or large bowel

Very large hernia have narrow neck of the sac

prone to become irreducible, obstructed and

strangulated.


Clinical features• Swelling in the umbilical region - increase on

coughing/straining

• Cough impulse expansile impulse is present

• Patient may also have inguinal hernia

• Reducibility can be present

• Crescent-shaped appearance of the umbilicus

• Patient complaint of pain due to tissue tension, and

symptom of intermittent bowel obstruction

• Dermatitis in case of large hernia (due to thinned &

stretched of overlying skin)


Treatment•Operation hernia that contain bowel

(higher risk of strangulation)

•Small hernia is left alone if it is asymptomatic (but may enlarge and require surgery at a later date)

•Reduction of weight

*Surgery may be performed open or laparoscopically

OPEN UMBILICAL HERNIA REPAIRVery small defects < 1 cm

•Closed with a simple figure-of-eight suture

•Repaired by darn technique where a non-absorbable,

monofilament suture is criss-crossed across the defect

and anchored firmly to the fascia all around

OPEN UMBILICAL HERNIA REPAIR

Defects up to 2 cm• Sutured primarily with minimal tension

• Classical repair by Mayo :

• A transverse incision is made and the hernia sac is dissected, opened

and its content reduced

• Any non viable tissue is removed

• The peritoneum is closed

• The defect in the anterior rectus sheath is extended laterally on both

sides and elevated to create an upper and lower flap (double

breasted)

OPEN UMBILICAL HERNIA REPAIR

Defects > 2 cm

•Mesh repair; mesh is placed in one of the several

anatomical planes

• Within the peritoneal cavity

• In the retromuscular space

• In the extraperitoneal space

• In the subcutaneous plane

LAPAROSCOPIC UMBILICAL HERNIA REPAIR

•3 ports are placed laterally on the abdominal wall

•The contents of the hernia are reduced by traction and

external pressure

•A disc of non-adherent mesh, is introduced and positioned on

the under surface of the abdominal wall, centered on the

defect

•It is then fixed to the peritoneum and posterior rectus

sheaths using staples, tacks or sutures

REFERENCES

•Short Practice of Surgery, Bailey & Love’s, 26th Edition

•Manipal Manual of Surgery,K Rajagopal Shenoy, 4th edition

•https://www.youtube.com/watch?v=NMXdU4UIu9Y

THANK YOU

Education

HERNIA (FEMORAL & UMBILICAL)