ABDOMINAL HERNIAE

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ABDOMINAL HERNIAE

• LIDIA IONESCU
• 3rd.Surgical Unit

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DEFINITION

• HERNIA a protrusion of an organ through its
  containing wall
• Herniation of the muscle through its fascial
  covering
• Herniation of the brain through a fracture of the
  skull
• Herniation of an intra-abdominal organ through a
  defect in the abdominal wall, pelvis or
  diaphragm-the term hernia is used to describe
  an abnormal opening in a patients muscle that
  will allow tissue or organs to pass through the
  opening in the muscle

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Abdominal herniae

• Before an organ can herniate through its
  retaining wall there must be a weakness in that
  wall
• Normal- related to the anatomical configuration
• Abnormal weakness - congenital abnormality
• -
  acquired as a result of trauma or disease

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Types of hernias

• Common types
• Inguinal
• Umbilical
• Femoral
• Incisional hernia
• Less common types
• Epigastric
• Spigelian
• Obturator

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Types of abdominal hernia
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BE AWARE

• FAILURE TO DIAGNOSE ANY TYPE OF STRANGULATED
  HERNIA
• COMMON OR RARE
• MAY LEAD TO THE PATIENTS DEATH

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Complications

• Irreducibility- bowel obstruction- incarcerated
  bowel
• Strangulation bowel obstruction necrotic
  bowel  

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Relation to gender

• Inguinal hernia is common in men
• Femoral hernia is more common in women

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Certain physical signs

• Occur at weak spots in the abdominal wall
• Reduce on lying down or with direct manual
  pressure
• Expansive cough impulse

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Etiology

• Defects in the abdo wall
• Structures pass through indirect inquinal,
  epigastric
• Muscles fail to overlap spigelian, lumbar
• No muscles, only scar tissue umbilical hernia
• Loss of tissue strength
• Direct inquinal hernia
• Increased intra-abdo pressure
• Trauma

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He had his hernia repaired
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Inguinal hernia

• This type of hernia accounts for the vast
  majority of hernia surgical repairs.
• An inguinal hernia is located in the inguinal
  region of the body where the thigh meets our
  pelvis.
• The most common types of inguinal hernias are
  either direct or indirect hernias and these are
  found more often by far in men rather than women.

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Inguinal hernia
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Inguinal and femoral hernia

• It is possible to develop three types of hernia
  in, or close to the inguinal region direct
  inguinal indirect inguinal femoral.
• Each opening (the deep and superficial inguinal
  rings) is visible and protected by two of the
  muscle layers.
• The muscles and their aponeuroses were clearly
  defined and two of them (internal oblique and
  transversus abdominis) could be seen arching over
  the canal to form its roof and then its posterior
  wall (conjoint tendon).

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Inguinal hernia
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Inguinal herniaPre and post-op. aspect
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Descriptive terms

• Reducible hernia- hernia content can be pushed
  back into the abdomen
• Irreducible hernia-incarcerated hernia- hernia
  content cannot be pushed back
• Obstructing hernia- hernia containing a loop of
  bowel that is kinked and therefore obstructed
• Strangulated hernia-the tissue contained in the
  hernia is ischemic due to interruption of the
  blood supply
• Sliding hernia-when the wall of the hernia sac in
  part formed by the wall of another
  intra-abdominal organ( colon, bladder)
• Richters hernia-one side of the bowel wall is
  trapped in the hernia

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Complications

• Intestinal obstruction- a loop of bowel passes
  through the abdo. wall defect and becomes
  mechanically obstructed.
• Intestinal strangulation with gangrene/perforation
  vascular pedicle to the herniated loop of
  bowel is also interrupted

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Inguinal herniaAnatomy of the inguinal region

• Superficial inguinal ring- triangular defect in
  the aponeurosis of the EOM and the pubic crest
• Deep inguinal ring- an oval opening in the fascia
  transversalis, 1,3 cm. above the mid-inguinal
  ligament.
• Medially- inf. epigastric vessels
• Inguinal canal- oblique passage through the lower
  part of the anterior abdominal wall
• Spermatic cord
• Round ligament

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Inguinal canal

• 1. Inguinal canal
• 2. Spermatic cord
• 3. Testis
• 4. Uterus
• 5. Round ligament
• 6. Lymph vessels
• 7. Superficial inguinal nodes
• 8. Deep inguinal ring
• 9. Superficial inguinal ring

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Inguinal canal

• 4 cm. long, between deep and superficial rings
• Anterior wall- EOM aponeurosis
• Inferior wall- inguinal ligament
• Superior wall- conjoint tendon
• Posterior wall- transversalis fascia
• Hesselbachs triangle- within the posterior
  wall inf.epi.art.- inguinal lig.-lateral border
  of the rectus sheath

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Types of inguinal herniae

• Indirect inguinal herniae
• Passes through the deep inguinal ring, down the
  inguinal canal
• May extend into the scrotum
• 5 times commoner than direct hernia
• Direct inguinal hernia
• Passes through the Hesselbach triangle
• Posterior to the spematic cord
• Does not pass into the scrotum
• Less often associated with strangulation

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Symptoms and signsInguinal hernia

• Gender- all ages
• Occupation- heavy works
• Local symptoms- dragging sensation in the groin
• Systemic symptoms- obstructive hernia- vomiting,
  distension, colicky abdominal pain, absolute
  constipation

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Inguinal herniaPhysical examination

• Position- above the inguinal ligament
• Tenderness- if strangulated
• Shape- pear-shaped with the stalk at the
  external inguinal ring
• Composition- soft-gut, firm-omentum.
• Cough impulse
• Reducibility

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Inguinal herniaGeneral examination

• Look for causes of a raised intra-abdominal
  pressure
• Chronic bronchitis- caughing
• Chronic retention of urine- difficulty in
  micturition
• Chirrhosis - ascites
• Intra-abdominal masses
• Look for signs of intestinal obstruction
• - Abdominal distention
• - Visible peristalsis
• - High-piched bowel sounds

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Inguinal herniaDifferential diagnosis

• Femoral hernia
• Vaginal hydrocele
• Undescended testis
• Lipoma

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Femoral herniaAnatomy

• Femoral canal space containing lymphatic and
  fat tissue
• Femoral ring inguinal ligament, Coopers
  ligament, pectineal line, femoral vein

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Femoral canal
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Femoral hernia
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Femoral hernia

• Femoral ring is rigid- strangulation more likely
• The bulge can be palpated in inguinal crease,
  below inguinal ligament
• Obese patients- difficult to palpate
• Think to a complicated femoral hernia in an obese
  patient with painful femoral area and bowel
  obstruction symptoms
• More common in women
• Related with physical effort

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Femoral canal
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Symptoms and signsFemoral hernia

• Age - uncommon in kids
• Gender -women more affected
• Position - below and lateral to the pubic
  tubercle
• Tenderness - not tender unless complicated
• Shape and size - spherical, small
• Surface - smooth
• Reducibility- firm pressure
• Cough impulse - tight ring- less likely

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Differential diagnosisFemoral hernia

• Inguinal hernia
• Enlarged lymph nodes
• Sapheno-varix
• Ectopic testis
• Psoas abscess
• Lipoma

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Umbilical hernia
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Umbilical hernia

• This type of hernia occurs at the level of the
  naval and are usually the result of the failure
  of the abdominal wall defect to close after the
  patients umbilical cord falls off as an infant.
  Most of these hernias defects will close in
  childhood by the age of 3-5.
• Remaining umbilical hernias however can enlarge
  over time and require repair in the adult
  patient.

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Congenital umbilical hernia

• 90 of cases, defects are closed by the age of
  one year
• 99 by 2 years of age
• Surgery is contraindicated below the age of 3
  years

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Acquired umbilical hernia

• Adult hernia through the umbilical scar
• Secondary to a raised intra-abdominal pressure

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Umbilical hernia

• Congenital umbilical hernia
• Acquired umbilical hernia
• Para-umbilical hernia

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Para-umbilical hernia

• Acquired umbilical hernia
• Appears through a defect that is adjacent to the
  umbilical scar

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Umbilical hernia
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Marked ascites and an umbilical hernia, which had
ruptured a few days before the photograph, in a
patient with cirrhosis and portal hypertension
secondary to hepatitis C.
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Spigelian hernia

• This type of hernia  is a rare form of hernia
  defect that can occur at the level of the
  umbilicus but actually lateral to it.
• These hernias are often difficult to diagnose

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Epigastric hernia

• Protrusion of extraperitoneal fat through a
  defect in the linea alba
• Between xiphisternum and umbilicus
• More frequent in men
• In obese patients difficult to palpate
• Epigastric pain

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Epigastric hernias occur in the midline in the
upper abdomen between the rib cage and the
umbilicus. They are usually composed of fat and
rarely containing abdominal organs.
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Incisional hernia

• This hernia is the result of a separation of the
  muscle layers at the site of a previous surgical
  incision.
• The hernia defect may appear shortly after a
  surgical procedure or many years after a surgical
  procedure has been performed.
• Several risk factors that are associated with the
  development of an incisional hernia
• wound infection at the time of the original
  surgery,
• obese patient,
• diabetes,
• chronic steroid use,
• resumption of strenuous activity following the
  initial surgical procedure before the muscular
  closure has had time to heal properly.

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Incisional hernia

• Hernia through an acquired scar in the abdominal
  wall
• Caused by a previous surgical operation with
  complicated wound
• Hematoma
• Infection

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Incisional herniaDiagnosis

• Lump at the level of a scar
• Tender lump if complicated irreducibility or
  obstruction
• Non complicated incisional hernia is reducible
  with cough impulse

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Incisional hernia

• This type of hernia is typically a result of the
  muscles of an old incision breaking down.
• An incision in the abdominal wall will always be
  an area of potential weakness
• When the incision breaks down an incisional
  hernia develops.

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Incisional hernia

• An incisional hernia may occur at any site where
  an operation has been perfomed previously.
• The scar represents a weakened area, which if
  stretched over time, may allow the underlying
  intestines to bulge through. Repair is often
  necessary.

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Incisional herniaCT aspects - protrusion of the
colon through the postero-lateral left abdominal
wall
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Rare types of hernias

• Cooper's hernia a femoral hernia with two sacs,
  the first being in the femoral canal, and the
  second passing through a defect in the
  superficial fascia and appearing immediately
  beneath the skin.
• Littre's hernia a hernia involving a Meckels
  diverticulum . It is named after the French
  anatomist Alexis Littre (1658-1726).
• Lumbar hernia a hernia in the lumbar region (not
  to be confused with a lumbar disc hernia),
  contains the following entities
• Petit's hernia a hernia through Petit's triangle
  (inferior lumbar triangle). It is named after
  French surgeon Jean Louis Petit (1674-1750).
• Grynfeltt's hernia a hernia through
  Grynfeltt-Lesshaft triangle (superior lumbar
  triangle). It is named after physician Joseph
  Grynfeltt (1840-1913).
• Obturator hernia hernia through obturator canal
  
• Pantaloon hernia a combined direct and indirect
  hernia, when the hernial sac protrudes on either
  side of the inferior epigastric vessels.
• Amyands hernia- appendix in the inguinal hernia
  sac

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Rare types of hernias

• Properitoneal hernia rare hernia located
  directly above the peritoneum, for example, when
  part of an inguinal hernia projects from the deep
  inguinal ring to the preperitoneal space.
• Richters hernia a hernia involving only one
  sidewall of the bowel, which can result in bowel
  strangulation leading to perforation through
  ischaemia without causing bowel obstruction or
  any of its warning signs. It is named after
  German surgeon August Gottlieb Richter
  (1742-1812).
• Sliding hernia occurs when an organ drags along
  part of the peritoneum, or, in other words, the
  organ is part of the hernia sac. The colon and
  the urinary bladder are often involved.
• Spigelian hernia, also known as spontaneous
  lateral ventral hernia.
• Sports hernia a hernia characterized by chronic
  groin pain in athletes and a dilated superficial
  ring of the inguinal canal.
• Velpeau hernia a hernia in the groin in front of
  the femoral blood vessels

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Case report

• An 85-year-old-male arrived at hospital
  presenting a right groin mass.
• His history included hypertension, coronary
  artery disease, of which all were receiving
  regular medical treatment. Additionally, he had
  recently experienced urinary frequency and
  nocturia.
• A right groin mass had been protruding for 1
  month prior to hospital admission, which
  increased in size when standing and before stool
  passage, but decreased in size after stool
  passage or lying down. Mild tenderness had been
  noted for 1 week. The mass was not reducible.

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Case report

• Impression was inguinal hernia and the patient
  was admitted for surgical intervention.
• Laboratory data were within normal limits. Blood
  pressure was well controlled.
• The patient was scheduled for elective surgery.
• The oblique conventional incision between
  external and internal rings was used to achieve a
  better approach. An appendix was found completely
  within the indirect sliding hernia sac .

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Case report

• The distal end of the appendix was trapped by
  the external ring, leaving a mark on the
  appendix.
• The body and base of the appendix was healthy and
  a moderate amount of clear ascites was found in
  the hernial sac.
• The distal portion of the appendix was attached
  to the distal portion of the hernial sac, which
  lay outside the external ring of the right groin.
  
• The mobilized cecum and ascending colon were far
  away from the paracolic space, apparently sliding
  until occupying the neck of the hernial sac.

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Case report

• Appendectomy was performed and hernioplasty was
  done instantly with Bassinis method.
• The patients postoperative condition was
  uneventful and he was discharged on the next day.
• He was followed up at our OPD one week later and
  the right groin looked good. Pathology revealed
  an acute suppurative appendicitis

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Amyands herniaAppendix in the inguinal hernial
sacSurgical specimen
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Case reportDiscutions

• Amyands hernia is defined as an uninflamed
  appendix in an inguinal hernia.
• This rare condition was named after the first
  surgeon to perform appendectomy, Claudius Amyand,
  an English surgeon of the 18th century who first
  described this condition.
• The incidence of Amyands hernia is estimated to
  occur in approximately one percent of adult
  inguinal hernia repair cases.
• Acute appendicitis occurs much less frequently,
  and perforated appendix and periappendicular
  abscess formation within an inguinal hernia sac
  is an extremely rare clinical entity.