HERNIAS

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HERNIAS

• Marcelyn Coley
• Mount Sinai School of Medicine
• Basic Science Lecture

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Historical Perspective

• 15th century - Castration with wound
  cauterization or hernia sac debridement
• recommended a truss

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Father of Modern Inguinal Hernia Repair
EDUARDO BASSINI
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Hernia

• Latin for rupture
• an abnormal protrusion of an organ or tissue
  through a defect in its surrounding walls
• Occur at sites where aponeurosis and fascia are
  not covered by striated muscle

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Which of the following statements is/are true
regarding incidence of the abdominal wall hernia?

• Two-thrirds of all inguinal hernias are
  classified as indirect.
• Femoral hernias are more common in females than
  in males.
• Direct hernias are common in females.
• Hernias generally occur with equal frequency in
  males and females
• Premature babies have a 10 incidence of having
  inguinal hernia.

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Epidemiology

• 700,000 hernia repairs year
• Inguinal hernias -75 of all hernias
• 2/3 Indirect, remainder are direct
• Incisional hernias 15 to 20
• Umbilical and epigastric 10
• Femoral 5

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Epidemiology

• Prevelance of hernias increases with age
• Most serious complication strangulation
• 1 to 3 of groin hernias
• Femoral highest rate of complications 15 to
  20
• recommended all be repaired at time of discovery

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Abdominal Wall Anatomy
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Anatomy

• Inguinal ligament (Pouparts) inferior edge of
  external oblique
• Lacunar ligament triangular extension of the
  inguinal ligament before its insertion upon the
  pubic tubercle
• conjoined tendon (5-10)- Internal oblique fuses
  with transversus abdominis aponeurosis
• Coopers Ligament - formed by the periosteum and
  fascia along the superior ramus of the pubis.

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Inguinal Canal

• Between deep and superficial inguinal rings
• Boundaries
• Superifical external oblique aponeurosis
• Superior internal and transversus
• Inferior shelving edge of inguinal ligament and
  lacunar ligament
• Posterior (floor) transversalis fascia and
  aponeurosis of transversus abdominis muscle

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Inguinal Canal

• Contains the spermatic cord and round ligament of
  the uterus
• Spermatic cord
• Cremasteric muscle fibers
• Testicular vessels
• Genital branch of genitofemoral nerve
• Vas deferens
• Cremasteric vessels

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Components of Hesselbachs triangle include which
of the following anatomic landmarks?

• Pectineal ligament
• Lateral border of the rectus sheath
• Coopers ligament
• Inguinal ligament
• Inferior epigastric vessels

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Terminology

• Reducible can be replaced within surrounding
  musculature
• Incarcerated cannot be reduced
• Strangulated compromised blood supply to its
  contents

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• Sends sensory branches to the inner thigh and
  medial aspect of the scrotum
• Ileoinguinal nerve
• Genitofemoral nerve
• Both
• Neither

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

• Jejunum composing the posterior wall of the sac
• Ovary and fallopian tube in a female infant
• Omentum
• Sigmoid colon composing the posterior wall of the
  sac
• Cecum composing the anteromedial wall of the sac

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Terminology

• Pantaloon direct and indirect components
• Richters contains antimesenteric portion of
  small bowel
• Sliding involves visceral peritoneum of an
  organ , i.e. bladder, ovary
• Littres hernia contains Meckels diverticulum
• Petit hernia at inferior lumbar triangle
• Grynfelt hernia at superior lumbar triangle

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Groin Hernias

• Indirect
• Direct
• Femoral

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Inguinal Hernia

• Classified as congenital vs. acquired
• commonly thought that repeated increases in
  intra-abdominal pressure contribute to hernia
  formation
• collagen formation and structure deteriorates
  with age, and thus hernia formation is more
  common in the older individual.

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Clinical Presentation

• Groin bulge
• Often asymptomatic
• Dull feeling of discomfort or heaviness in the
  groin
• Focal pain raise suspicion for incarceration or
  strangulation
• Symptoms of bowel obstruction

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Inguinal hernia
Female inguinal hernia
Male inguinal hernia
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Diagnosis

• Physical Exam
• 74.5 sensitive and 96.3 specific
• examine the patient in the standing and supine
  positions
• difficult to distinguish direct and indirect on
  exam on alone

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Diagnosis

• Radiologic Investigations
• Herniography
• Suspected hernia, but clinical dx unclear
• Procedure done under flouroscopy following
  injection of contrast medium
• Frontal and oblique radiographs are taken with
  and without increased intra-abdominal pressure
• Ultrasonography
• MRI
• CT

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Herniography
Left indirect inguinal hernia
Right direct inguinal hernia
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Direct Inguinal Hernia
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Direct Inguinal Hernia

• Medial to the inferior epigastric artery and
  vein, and within Hesselbach's triangle
• acquired weakness in the inguinal floor

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Indirect Inguinal hernia

• Abdominal contents protrude through internal
  inguinal ring

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Indirect Inguinal Hernia

• Accepted hypothesis incomplete or defective
  obliteration of the processus vaginalis during
  the fetal period
• remnant layer of peritoneum forms a sac at the
  internal ring
• more frequently on the right

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Femoral

• More common in females
• Up to 40 present as emergencies with hernia
  incarceration or strangulation
• Passes medial to the femoral vessels and nerve in
  the femoral canal through the empty space
• Inguinal ligament forms the superior border

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Femoral

• palpation of the femoral canal just below the
  inguinal ligament in the upper thigh
• NAVELS

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Which of the following statements is/are true
regarding direct inguinal hernias?

• The most likely cause is destruction of
  connective tissue resulting form physical stress.
• Direct hernias should be repaired promptly
  because of the risk of incarceration.
• A direct hernia may be a sliding hernia involving
  a portion of the bladder wall.
• A direct hernia may pass through the external
  inguinal ring.
• Colon carcinoma is a known cause of direct
  inguinal hernias.

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Treatment

• Non-Operative
• Observation
• Trusses can provide symptomatic relief
• Hernia control in 30 of patients

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Operative

• Bassini
• Shouldice
• McVay
• Lichtenstein
• Preperitoneal
• Laparoscopic

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• Bassini (early 20th Century)
• Transversus abdominis to Thompsons ligament and
  internal oblique musculoaponeurotic arches or
  conjoined tendon 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
  Coopers ligament incorporate Coopers ligament
  and the iliopubic tract (transition suture)

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BASSINI
MCVAY
SHOULDICE
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Lichtenstein

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

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Prosthetic Repair

• Polypropylene mesh most common and preferred
• allows for a fibrotic reaction to occur between
  the inguinal floor and the posterior surface of
  the mesh, thereby forming scar and strengthening
  the closure of the hernia defect
• Polytetrafluoroethylene (PTFE) mesh
• often used for repair of ventral or incision
  hernias in which the fibrotic reaction with the
  underlying serosal surface of the bowel is best
  avoided

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• Prospective study
• Danish Hernia database of over 13,000 hernia
  repairs
• Compared re-operations for recurrent hernia
• Results After 5 years significantly lower (1/4
  less) recurrence with mesh vs. sutured repair

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Laparoscopic
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The cause of neuropathic postherniorrhaphy
inguinodynia includes which of the following?

• Formation of scar tissue
• Transection of the ilioinguinal, iliohypogastric,
  or the genitofemoral nerves
• Suture entrapment of nerves
• Staple entrapment of nerves
• Periosteal reaction

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Surgical Complications

• Recurrence
• Infection
• Neuralgia
• Bladder injury
• Testicular injury
• Vas Deferens injury

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Other Hernias
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Which of the following is/are true statements
regarding umbilical hernias?

• They are embryonic equivalent of a small
  omphalocele
• Repair in infants is usually deferred until
  approximately 4 years of age
• Repair in adults is usually indicated
• The vest-over-pants type of repair is stronger
  than simple approximation of fascial margins
• They are most common in Caucasian infants

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Umbilical

• Incidence
• Reported 10
• several times greater in Black children
• more common in premature children all races
• Most close spontaneously by age 2 or 3
• Acquired rather than congenital in adults
• Female to male ratio 31

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Epigastric

• midline junction of the aponeuroses (linea alba)
  between the xiphoid process and umbilicus
• Paraumbilical hernia - epigastric hernia that
  borders the umbilicus
• Estimated frequency 3-5
• More common in Males 31
• 20 may be multiple

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Epigastric

• Clinical
• Often asymptomatic, incidental finding
• If symptomatic, vague abdominal pain above the
  umbilicus exacerbated by standing or coughing
  relieved in supine position
• Severe pain secondary to incarceration/strangulati
  on of preperitoneal fat (often no peritoneal sac)
  or omentum
• Exam palpate small, soft, reducible mass
  superior to the umbilicus
• RARE to have strangulated bowel
• Tx
• Excise fat and sac, close primarily

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An 82-year-old previously healthy woman has a
12-hour history of severe epigastric 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 CT
shown are obtained.
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Which of the following best describes this
patients diagnosis?

• Pain in the medial thigh and knee is uncommonly
  associated with this condition
• It is unusual in women
• It is unusual in elderly patients
• It is seldom associated with intestinal necrosis
• It is usually unilateral

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Obturator

• Rare form of hernia
• Protrusion of intra-abdominal contents through
  obturator foramen
• FM ratio 61
• The obturator foramen is formed by the ischial
  and pubic rami
• obturator vessels and nerve lie posterolateral to
  the hernia sac in the canal
• Small bowel is the most likely intraabdominal
  organ to be found in an obturator hernia

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Obturator

• 4 cardinal signs
• intestinal obstruction (80)
• Howship-Romberg sign (50) History of repeated
  episodes of bowel obstruction that resolve
  quickly and without intervention
• Palpable mass (20)
• Tx Sugical Repair

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Spigelian Hernia

• occurs along the semilunar line, which traverses
  a vertical space along the lateral rectus border
• where more than 90 of spigelian hernias are
  found

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Spigelian Hernia

• Clinical
• Swelling in middle to lower abdomen lateral to
  rectus muscle
• Usually reducible
• Up to 20 present with incarceration
• Tx surgical
• Mesh not required
• Recurrence is uncommon

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Lumbar

• Acquired lumbar hernias
• back or flank trauma, poliomyelitis, back
  surgery, and the use of the iliac crest as a
  donor site for bone grafts
• Contains to anatomic triangles, inferior and
  superior lumbar triangles
• Grynfelts
• Petits
• Strangulation is rare
• Soft swelling in lower posterior abdomen

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Sciatic

• Via greater or lesser sciatic notch
• greater sciatic notch is traversed by the
  piriformis muscle, and hernia sacs can protrude
  either superior or inferior to this muscle
• suprapiriform defect 60
• Infrapiriform 30
• subspinous (through the lesser sciatic foramen)
  10

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Which of the following hernias is most likely to
recur after primary repair?

• Epigastric hernia
• Spigelian hernia
• Indirect hernia
• Femoral hernia
• Incisional hernia

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Ventral wall (Incisional)

• Highest incidence in midline and transverse
  incisions
• Up to20 after laparotomy
• 1/3 present in 5-10 years postoperatively
• Risk factors
• obesity, DM, ascites, steroids, smoking
  malnutrition, wound infection
• Technical aspects of wound closure
• Type of incision
• Excessive tension (prone to fascial disruption)

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Which of the following hernias represent an
incarceration of a limited portion of small bowel?

• Spigelian hernia
• Grynfelts hernia
• Petits hernia
• Richters hernia
• Littres hernia