Hernia

1
Hernia
2

• Definition
• A hernia is a protrusion of a viscus or
  a part of viscus through an abnormal opening in
  the walls of its containing cavity.
• The external abdominal hernia is the
  most common form. The most frequent varieties are
  the inguinal, femoral and umbilical.

3

• General features common to all hernias
• Aetiology
• Any condition that increase the intra
  abdominal pressure such as a powerful muscular
  effort may produce a hernia.
• Whooping cough is a predisposing cause
  in childhood, whereas a chronic cough, straining
  on micturition or straining on defecation may
  precipitate a hernia in an adult.
• It should be remembered that appearance
  of hernia in an adult can be a sign of intra
  abdominal malignancy.
• Obesity is an another factor, fat acts
  to separate muscle bundles and layers, weakens
  apponeurosis and leads to appearance of hernia (
  para-umbilical, direct inguinal and hiatus hernia
  ).
• Hernia is more common in smokers which
  is due to acquired collagen deficiency increasing
  the risk of hernia

4

• Compisition of a hernia
• Hernia consists of three parts sac,
  coverings and the contents.
• Sac
• It is a diverticulum of peritoneum consisting
  of
• 1 Mouth. 2 Neck. 3 Body.
  4 - Fundus.
• The neck is usually well defined but in some
  direct inguinal hernias and in many incisional
  hernias there is no actual neck. The diameter of
  the neck is important because strangulation of
  bowel is a likely complication when the neck is
  narrow as in femoral hernia and para-umbilical
  hernias.
• Covering
• Derived from the layers of the abdominal
  wall through which the sac passes.

5

• Contents
• These can be
• Omentum omentocele.
• Intestine interocele ( maily the small
  bowel but may be the large bowel ).
• A portion of the circumference of the
  bowel Richters hernia.
• A portion of the bladder.
• Ovary with or without the corresponding
  tube.
• A Meckels diverticulum Littres hernia.
• Fluid.

6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10

• Classification
• Irrespective of site, a hernia can be
  classified into 5 different types
• 1 Reducible. 2 Irreducible. 3
  Obstructed.
• 4 Strangulated. 5 Inflammed.
• Reducible hernia hernia either reduce itself
  when the patient lies down or can be reduced by
  the patient or the surgeon. Such a hernia (
  reducible ) gives an expansible impulse on
  coughing.
• Irreducible hernia in case the contents cannot
  be returned to the abdomen but there is no
  evidence of other complications. It is usually
  due to adhesions between the sac and the contents
  or overcrowding within the sac. Any degree of
  irreducibility predisposes to strangulation.

11

• Obstructed hernia It is irreducible hernia
  containing intestine that is obstructed from
  without or within but there is no interference
  to the blood supply to the bowel. The symptoms
  (colicky abdominal pain and tenderness over the
  hernia site) but less severe and onset is more
  gradual than in strangulated hernias. Usually
  there is no clear distinction clinically between
  obstruction and strangulation and the safe course
  is to assume that strangulation is imminent and
  treat accordingly.

12

• Incarcerated hernia
• The term incarceration is often used loosely as
  an alternative to
• obstruction or strangulation but is correctly
  employed only when
• it is considered that the lumen of that portion
  of the colon
• occupying a hernial sac is blocked with faeces.
  In this case, the
• scybalous contents of the bowel should be capable
  of being
• indented with the finger, like putty.

13

• Strangulated hernia
• A hernia becomes strangulated when the blood
  supply of its content is seriously impaired,
  rendering the contents ischaemic. Gangrene may
  occur as early as 5-6 hours after the onset of
  the first symptoms. Although inguinal hernia is
  more common than femoral hernia, a femoral hernia
  is more likely to strangulate because of the
  narrowness of the neck and its rigid surrounds.
• Pathology The intestinal blood supply is
  impaired. Initially, only the venous return is
  impeded, the wall of the intestine becomes
  congested and bright red with the transudation of
  serous fluid into the sac. As congestion
  increases the wall of the intestine becomes
  purple in color. The intestinal pressure
  increases, distending the intestinal lop and
  impairing venous return further. As venous stasis
  increases, the arterial supply becomes more and
  more impaired. Blood is extravasataed under the
  serosa and is effused into the lumen.

14

• The fluid in the sac becomes blood stained
  and shining serosa dull because of a fibrinous,
  sticky exudate. At this stage the walls of the
  intestine have lost their tone and become
  friable. Bacterial transudation occurs secondary
  to the lowered intestinal viability and the sac
  fluid becomes infected. Gangrened appears at the
  rings of constriction, which becomes deeply
  indented and grey in color. The gangrene then
  then develops in the ant mesenteric border, the
  color varying from black to green depending on
  the decomposition of the blood in the subserosa.
  The mesentery involved by the strangulation also
  becomes gangerenous. If the strangulation is
  unrelieved, perforation of the wall of the
  intestine occurs, either at the convexity of the
  loop or at the seat of constriction. Peritonitis
  spreads from the sac to the peritoneal cavity.

15

• Clinical features Sudden pain at first
  situated over the hernia, is followed by
  generalized abdominal pain, colicky in character
  and often located mainly at the umbilicus. Nausea
  and subsequently vomiting. The patient may
  complain of an increase in hernia size.
• On examination the hernia is tense,
  extremely tender and irreducible and no expansile
  cough impulse.
• Unless the strangulation is relieved by
  operation, the spasms of pain continue until
  peristaltic contractions cease with the onset of
  ischemia, when paralytic ileus ( often the result
  of peritonitis ) and septicaemia develops.
  Spontaneous cessation of pain must be viewed with
  caution, as this may be a sign of perforation

16

• Strangulated hernia
• Present with local then general abdominal pain
  and vomiting
• A normal hernia can strangulate at any time
• Most common in hernias with narrow necks such
  as
• femoral hernias
• Require urgent surgery

17

• Imflammed hernia inflammation can occur from
  inflammation of the contents of the sac as eg.
  acute appendicitis or salpingitis.
• Inflammation can happen from external
  causes eg. Trophic ulcers that developes in the
  depending areas of large umbilical or incisional
  hernias.
• The hernia is usually tender but not tense
  and the overlying skin red and oedematous.
  Treatment is based on treatment of the inderlying
  cause.

18

• Inguinal Hernia
• Surgical anatomy
• The superficial inguinal ring is a
  triangular aperature in the aponeurosis of the
  external oblique muscle lies 1.25 cm above the
  pubic tubercle.
• The deep inguinal ring is a U shaped
  condesation of the transervalis fascia and it
  lies 1.25 cm above the inguinal ligament

19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23

• An indirect hernia travels down the canal on
  the outer side of the spermatic cord. A direct
  hernia comes out directly forwards through the
  posterior wall of the inguinal canal. Whereas the
  neck of the indirect hernia is lateral to the
  inferior epigastric artery, the neck of the
  direct hernia is medial to the artery.
• An inguinal hernia can be differentiated
  from femoral hernia by the ascertaining the
  relation of the neck of the sac to the medial end
  of the inguinal ligament and the pubic tubercle.
  In the case of an inguinal hernia, the neck is
  above and medial, whereas that of a femoral
  hernia is below and lateral

24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27

• Indirect inguinal hernia
• It is the most common type of hernia. It is
  more common in the young while the direct type is
  more common in the old. In the first decade of
  life, inguinal hernia is more common on the right
  side in the male. This is associated with the
  later descent of the right testis and a higher
  incidence of failure of closure of the process
  vaginalis.
• Clinical features
• We start examining the patient in standing
  position with asking the patient to cough and
  feel the cough impulse. Then examiner should now
  
• Is the hernia is right, left or bilateral.
• Is it inguinal or femoral.
• Is it direct or indirect.
• Is it reducible or not.
• Is it complete or not.
• What are the contents

28

• The patient complains of pain in the groin or
  pain referred to the testicles when performing
  heavy wok or taking strenuous exercise. In large
  hernias there is a sensation of weight and
  dragging on the mesentery which may produce
  epigastric pain.
• Differential diagnosis in the male
• 1 Vaginal hydrocele.
• 2 Encysted hydrocele of the cord.
• 3 Spermatocele.
• 4 Femoral hernia.
• 4 Incompletely descended testis.
• 5 Lipoma of the cord.
• Differential diagnosis in the female
• 1 Hydrocele of the canal of Nuck.
• 2 Femoral hernia.

29
(No Transcript)
30
Note that examination using finger and thumb
across the neck of the scrotum will help to
distinguish between a swelling of inguinal origin
and one that is entirely intrascrotal.
31

• Treatment
• Operation is the treatment of choice. (
  Herniotomy Herniorrhaphy )
• Herniotomy means dissecting out and
  opening the hernial sac, reducing any content
  then transfixing the neck of the sac and removing
  the remainder. By itself it is sufficient for the
  treatment of hernia in children and young adults.
• Herniorrhaphy consist of
• 1 repair of the stretches internal ring
  and transversalis fascia.
• 2 further reinforcement of the
  posterior wall of the inguinal canal.

32
(No Transcript)
33

34

• A truss may be used when operation is
  contraindicated or refused. In this condition if
  the truss to be used the hernia should be
  reducible.
• Its use should be mainly historical, as
  there are very few contraindications to surgery
  with todays variety of anaesthetic techniques.

35
(No Transcript)
36

• Direct inguinal hernia
• It is always acquired. The passes through a
  weakness or a defect of the transversalis fascia
  in the posterior wall of the inguinal canal.
  Predisposing factors are smoking and occupations
  that involves straining or heavy lifting. Damage
  to the ilioinguinal nerve (previous
  appendicectomy) is another cause, because of the
  resulting weakness of the conjoined tendon.
  Direct hernia do not often attain a large size or
  reach to the scrotum. In contrast to the indirect
  hernia, the direct lies behind the spermatic
  cord. As the neck is wider than that of indirect
  inguinal hernia, direct inguinal hernia do not
  often strangulate.
• Treatment the principles of repair of direct
  hernia are the same as those of an indirect
  hernia, with the exception that the hernia sac
  can usually be simply inverted after it has been
  dissected free and the transversalis fascia
  reconstructed in front of it. This repair can be
  done also by mesh which is also true for indirect
  hernia repair.

37
THANK YOU