HERNIA

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HERNIA

• Done by D1 group

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objectives

• Definition
• Anatomy
• Precipitating factors
• Types
• Clinical features
• Preoperative assessment
• Management and repair

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Definition

• A hernia is a protrusion of a viscus or part of a
  viscus through an abnormal opening in the walls
  of its containing cavity .

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Anatomy

• The inguinal canal -
• The inguinal canal is approximately 4 cm long and
  is directed obliquely
• inferomedially through the inferior part of the
  anterolateral abdominal wall. The canal lies
  parallel and 2-4 cm superior to the medial half
  of the inguinal ligament.This ligament extends
  from the anterior superior iliac spine to the
  pubic tubercle.
• The inguinal canal has openings at either end
• The deep (internal) inguinal ring is the entrance
  to the inguinal canal. It is thesite of an
  outpouching of the transversalis fascia. This is
  approximately 1.25 cm superior to the middle of
  the inguinal ligament
• The superficial, or external inguinal ring is the
  exit from the inguinal canal. It is a slitlke
  opening between the diagonal fibres of the
  aponeurosis of the external oblique

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Inguinal canal

• walls of The inguinal canal -
• The anterior wall is formed mainly by the
  aponeurosis of the external Oblique
•  
• . The posterior wall is formed mainly by
  transversalis fascia
•  
• The roof is formed by the arching fibres of the
  internal oblique and
• transverse abdominal muscles.
•  
• The floor is formed by the inguinal ligament,
  which forms a shallow trough. It is
  reinforced in its most medial
  part by the lacunar ligament.

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• Content -
• Spermatic cord ( round ligament of the uterus in
  female )
• The Cord Itself.The contents of the spermatic
  cord are
• (a) the ductus (vas) deferens and its artery .
• (b) the testicular artery and venous
  (pampiniform) plexus.
• (c) the genital branch of the genitofemoral
  nerve.
• (d) lymphatic vessels and sympathetic nerve
  fibers.
• (e) fat and connective tissue surrounding the
  cord and its coverings in various amounts
• Ilioinguinal nerve .
• Ilioinguinal lymph node .

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Femoral Canal

• The major feature of the femoral canal is the
  femoral sheath. This sheath is a condensation of
  the deep fascia (fascia lata) of the thigh and
  contains, from lateral to medial, the femoral
  artery, femoral vein, and femoral canal. The
  femoral canal is a space medial to the vein that
  allows for venous expansion and contains a lymph
  node (node of Cloquet). Other features of the
  femoral triangle include the femoral nerve, which
  lies lateral to the sheath,
•  
• Wall of The Femoral canal
• anterior is the inguinal ligament
• posterior is the iliopsoas, pectineal, and long
  adductor muscles (floor).
• Medial is lacunar ligament
• Lateral is femoral vessle

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Predisposing

• All hernias occur at the site of WEAKNESS OF THE
  ABDOMINAL WALL which are acted on by repeated
  INCREASE in abdominal pressure

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repeated INCREASE in abdominal pressure is
usually due to

• Chronic cough
• Straining
• Bladder neck or urethral obstruction
• Pregnancy
• Vomiting
• Sever muscular effort
• Ascetic fluid

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Types

• Inguinal
• Femoral
• Epigastric
• Para umbilical
• Umbilical
• Obturator
• Superior lumbar
• Inferioer lumbar
• Gluteal
• Sciatic
• Incisional

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• Indirect Inguinal Hernia
• Hernia through the inguinal canal
• Direct Inguinal Hernia
• The sac passes through a weakness or defect of
  the transversalis fascia in the posterior wall of
  the inguinal canal
• Femoral Hernia
• Hernia medial to femoral vessels under inguinal
  ligament
• Umbilical Hernia
• Hernia through the umbilical ring
• Paraumbilical Hernia
• A protrusion through the linea alba just above or
  sometimes just below the umbilicus
• Epigastric Hernia
• Protrusion of extraperitoneal fat through the
  linea alba anywhere between the xiphoid process
  and the umbilicus
• Incisional Hernia
• Hernia through an incisional site
• Lumber Hernia
• occur through the inferior lumber triangle of
  Petit

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Inguinal hernia

• History
• Age ( young vs. old)
• Occupation ( nature ?? )
• Local symptoms Swelling, discomfort and pain
• Systemic symptoms if there is obstruction or
  strangulation
• Precipitating factors

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Inguinal hernia

• Examination
• Inspection for site, size, shape and color.
• Palpation for surface, temp, tenderness,
  composition and reducibility.
• Expansible cough impulse.
• General exam for common causes of increase intra
  abdominal pressure

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Indirect Versus Direct inguinal hernias

• Indirect is the most common form of hernia and
  its usually congenital due to patent processus
  viginalis
• Direct usually acquired occur in old men with
  weak abdominal muscles.

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• Indirect Versus Direct inguinal hernias

Direct Inguinal Hernia Indirect Inguinal Hernia
Bulge from the posterior wall of the inguinal canal Pass through inguinal canal.
Cannot descent into the scrotum. Can descend into the scrotum.
Medial to inferior epigastric vessels. Lateral to inferior epigastric vessels.
Reduced upward, then straight backward. Reduced upward, then laterally and backward.
Not controlled after reduction by pressure over the internal (deep) inguinal ring. Controlled after reduction by pressure over the internal (deep) inguinal ring.
The defect may be felt in the abdominal wall above the pubic tubercle. The defect is not palpable (it is behind the fibers of the external oblique muscle).
After reduction the bulge reappears exactly where it was before. After reduction the bulge appears in the middle of inguinal region and then flows medially before turning down to the scrotum.
Common in old age. Common in children and young adults.
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Differential diagnosis of inguinal hernias

• Male
• 1 ) Femoral hernia
• 2 ) Vaginal hydrocele
• 3 ) Spermatocele
• 4 ) Encysted hydrocele of the cord
• 5 ) Un-descended testis
• 6 ) Lipoma of the cord
• Female
• 1 ) Hydrocele of the canal of nuck
• Is a fluid filled distal part of the sac of an
  indirct hernia with narrow proximal part it
  present with a smoth fluctuant swelling with out
  a cough impulse which will transilluminate
• 2 ) Femoral hernia

Note that examination using finger and thumb
across the neck of the scrotum will help to
distinguish a swelling of inguinal origin and one
that is entirely intrascrotal
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Femoral hernia

• Small femoral hernia may be unnoticed by the
  patient or disregarded for years perhaps until
  the day it strangulates. Adherence of the greater
  omentum sometimes causes a dragging pain. Rarely
  a large sac is present .

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Femoral hernia

• History
• Age uncommon in children , most common in old
  age female .
• Sex women gt men (but still commonest hernia in
  women the inguinal hernia )
• The patient came with local symptoms
• 1- discomfort and pain
• 2- swelling in the groin
• General femoral hernia is more likely to be
  strangulated than the inguinal hernia
• Multiplicity often bilateral

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Femoral hernia versus inguinal hernia
Femoral hernia Inguinal hernia
1- more common in females 1- more common in male
2- pass through the femoral canal 2- pass through the inguinal canal
3- neck of the sac is below and lateral the pubic tubercle 3- neck of the sac is above and medial the pubic tubercle
4- more common to be strangulated 4- less common to be strangulated
5- must be treated surgically 5- can be treated without surgery
6- the two diagnostic signs of hernia - 6- the two diagnostic signs of hernia
7- the sac mainly contains omentum 7- the sac mainly contain bowel
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Differential diagnosis of femoral hernia

• 1) Inguinal hernia
• 2 ) saphena varix a saccular enlargment of the
  termination of the long saphenous vein The
  swelling disappears completely when the patient
  lies flat there is impulse in
• coughing and fluid thrill and sometimes venous
  hum can be heard over a
• saphena varix
• 3 ) Enlarge lymph node fever other lymph node
  enlargment
• 4 ) Lipoma
• 5 ) Femoral aneurysm expansile pulsation
• 6 ) Psoas abscess
• There is often a fluctuating swelling and
  examination of the spine and a radiograph
• will confirm the diagnosis
• 7 ) A distended psoas bursa
• The swelling diminishes when the hip is flexed
  and osteoarthritis of the hip is present

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Umbilical hernia

• Signs and symptoms
• Age doesnt appear until the umbilical cord has
  separated and healed .
• No specific symptoms
• Have wide neck and reduce easily , rarely give
  intestinal obstruction.
• Nature history 90 disappear spontaneously
  during the first year.

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• Examination
• Inspection
• Site in the center of the umbilicus
• Size and shape size can vary from vary small to
  very large . Shape is usually hemispherical.
• Palpation
• Composition contain bowel , which makes it
  resonant to percussion . They reduce
  spontaneously when the child lies down .
• Reducibility easy
• Cough impulse invariably present .

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Acquired umbilical hernia

• Hernia through the umbilical scar , so it is a
  true umbilical hernia.
• Not common and is usually secondary to increase
  intra abdominal pressure.
• The most common causes
• 1- pregnancy
• 2- ascitis
• 3- ovarian cyst
• 4- fibrodis
• 5- bowel distention

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Incision hernia

• Signs and symptoms
• Previous operation or accidental trauma
• Age all ages , but more common in old age.
• Symptom lump ,pain ,intestinal obstruction (
  distention ,colic, vomiting ,constipation , sever
  pain in the lump )
• Examination
• 1- reducible lump
• 2- expansile cough impulse
• 3- if the lump dose not reduse and dose not have
  cough impulse , than it may be not a hernia
• Ddx
• Tumor
• Chronic abscess
• Hematoma
• Foreign body granuloma

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Preoperative assessment

• proper history and examination
• identify high risk patients
• prepare the preoperative notes
• consent..
• pre op Dx
• procedure planned
• surgeons
• Anasthesia anticipated (general , local, spinal)

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Preoperative assessment

• Investigation data ( pre operative tests )
• 1. Lab
• CBC to check hemoglobin level ? anemia and
  WBCs ? infections
• UE to check for any electrolyte imbalance
• LFTs indicated in jaundiced patients and
  suspected hepatitis or any clotting problems
• PT PTT
• ABG
• grouping and cross matching
• 2. Imaging
• Chest X ray for all patients
• 3. ECG for any patient who is more than 40
  years of age

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Preoperative assessment

•  
• current medications or allergies
• any major (chronic) illness
• pre op orders
• skin preparation
• diet (NPO)
• GIT preparation
• Sedation
• Preanesthetic medications
• Other medications
• Antibiotics
• Blood transfusion ( if needed )
• Bladder preparation

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Management and repair
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Inguinal Hernia Repair
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Pre op evaluation preparation
Surgical TTT
Watchful Waiting
May be appropriate for pt with asymptomatic
hernia or elderly pt with minimal symptoms or
easily reduced inguinal hernia.
Routine F/U with health care professional
A Randomized trial concluded that this is an
acceptable option for men with minimally
symptomatic inguinal hernia and that delaying
repair until symptoms increase is safe due to low
rate of incarceration. 23 of pt initially
treated with watchful waiting crossed over to
surgical ttt due to increase in symptoms (most
often hernia-related pain) , only 1 pt (0.3)
experienced acute hernia incarceration without
strangulation within 2years, a second had acute
incarceration with Bowel obstruction at 4 years,
corresponding to frequency of acute intervention
of 1.8/1000 pt-years (JAMA 2006,295285)
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Pre op preparation

• Most pt are treated surgically
• Increase IAP abnormalities (Chronic cough,
  Constipation, Bladder outlet obstruction) should
  be evaluated and remedied to extent possible
  before elective herniorrhaphy.
• In case of intestinal obstruction and possible
  strangulation, Broad spectrum AB,NG suction may
  be indicated, correction of volume status
  elctroyles.

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Reduction

• Uncomplicated
• Manual? Gentle pressure over hernia ?Gentle
  traction over the mass ? sedation and
  trendelenburg position.
• Complicated (strangulated)
• no attempt should be made to reduce the hernia
  because of potential reduction of gangrenous
  segment of bowel with the hernial sac.

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Surgerical TTT

• 1.choice of anesthetic
• elective open repair Local is preferred
• Laproscopic hernia repair more commonly under
  GA.

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2.TTT OF HERNIAL SAC

• INDIRECT sac is dissected free from the cord
  structures and creamsteric fibers. Sac should be
  open away from any herniated contents. Contents
  are then reduced, and the sac is ligated deep to
  inguinal ring with an absorbable suture
• DIRECT
• Too broadly based for ligation and should not be
  opened, simple freed from transversalis fibers
  and inverted.

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3.Inguinal Floor Reconstruction

• Some method of reconstruction of the inguinal
  floor is necessary in all adult hernia repairs to
  prevent recurrence.

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1.Primary tissue repair

• Bassini repair inferior arch of transversalis
  fascia (TF) or conjoint tendon is approximated to
  shelving portion of inguinal ligament.
• McVay TF is sutured to cooper ligament.
• Shouldice TF is incised and reapproximated.

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2.Open tension free repair

• Lichtenstein repair Patch and Plug technique
  Mesh is used to reconstruct inguinal floor
• Mesh plug technique place mesh in the hernial
  defect

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Laproscopic preperitoneal repairs

• TAPP (transabdominal prepeitoneal procedure)
  peritoneal space entered by conventional lap at
  umbilicus and peritoneum overlaying inguinal
  floor is dissected away as flap.
• TEP (Total extraperitoneal repair) preperitoneal
  space is developed with a balloon inserted
  between posterior rectus sheath and peritoneum ?
  balloon inflated to dissect the peritoneal flaps
  awau from posterior abdomianl wall and the direct
  and indirect spaces, other ports inserted into
  this preperitoneal space without entering
  peritoneal cavity.
• After lap. Dissection and reduction of hernia sac
  , a large piece of mesh is placed over inguinal
  floor

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Femoral hernia repair

• Femoral hernias should be repaired very soon
  after the diagnosis has been made because of the
  high risk of strangulation.
• There is no place for a truss for a femoral
  hernia.
• Different approaches
• Open VS Laparoscopic

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Open surgery

• Three approaches have been described for open
  surgery
• Infra-inguinal approach (Lookwood)
• Supra-inguinal approach ( McEvedy)
• Trans-inguinal approach ( Lotheissen)

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• Each technique has the principle of dissection of
  the sac with reduction of its contents, followed
  by ligation of the sac and closure between the
  inguinal and pectineal ligaments.

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Lockwoods infra-inguinal approach

• The sac is dissected out below the inguinal
  ligament via groin crease incision.
• Then the sac is opened and the contents are
  inspected and reduced into the abdomen.
• Then the neck of the sac is pulled down , ligated
  and allowed to retract through femoral canal.
• Then close the femoral canal by mesh plug or non
  absorbable sutures.

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McEvedys high approach

• Vertical incision is made over the femoral canal
  and continued upwards above the inguinal
  ligament.
• This incision provides good access to the
  preperitoneal space and then to the peritoneum
  itself.
• Use finger dissection to sweep peritoneum from
  anterior abdominal wall , so the neck of the sac
  can be identified.
• Dissect the sac , reduce the contents and repair
  the defect by mesh or sutures.

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Lotheissens trans-inguinal approach

• The incision is made superior and parallel to
  inguinal ligament extending from pubic tubercle
  to mid inguinal point.

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Hernia examination
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Thank You