MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

ESTABLISHMENT OF EDUCATION "VITEBSK STATE ORDER

FRIENDSHIP OF PEOPLES MEDICAL”

REFERATH

Abdominal Hernias , Complications of hernia , Surgical Treatment

TALAL
MOHAMMAD
Group No 52

Teacher of in charge
М.И.КУГАЕВ

Vitebsk 2021
 Contents
Parts of a Hernia

Classification of Hernias

Common Types of Hernias

Predisposing Factors and Causes of Hernias

Common symptoms of an uncomplicated hernia

Sliding Hernia

Strangulated Hernias

Surgical Treatment of Hernias

Hernia Incision for Uncomplicated External Hernias

Features of Hernial Incision for Sliding Hernias

Features of Hernial Incision for Strangulated Hernias

Inguinal Hernias

Layers of the Anterior Abdominal Wall (From superficial to deep):

Folds and Ligaments of the anterior abdominal Wall:

Walls of the inguinal canal

Contents of inguinal canal:

Openings of Inguinal canal:

Types of Inguinal Hernias:

Examination of a patient with an inguinal hernia:

Surgical Treatment of Inguinal Hernias

hernia Incision for Inguinal Hernias

Hernioplasty of Inguinal Hernias with Tension

Hernioplasty by Martinov

Hernioplasty by Jirar-Spasokukovsky with Kimberovsky suture

 Hernias

“A Hernia is the exit of internal organs, together with the parietal peritoneum,
through a natural or artificial foramen”

Parts of a Hernia
A hernia consists of 3 parts:

1) Hernial Covering – Layers of tissue in adjoining region. e.g.: Skin,

Subcutaneous tissue, aponeurosis etc...

2) Hernial Sac – Protruding part of parietal peritoneum. Consists of: i> Body ii>
Neck – At the level of the defect in the abdominal wall where the hernia
emerges

3) Hernial contents – Bowel or the omentum

Eventration (Eviseration / эвентрация) – The protrusion of abdominal contents
through a defect or weakness in the abdominal wall and the peritoneum.
e.g.: When sutures placed on peritoneum and abdominal wall after a surgery
rupture, the intestines protrude out.
 Difference between Eventration and Hernias : The organs which come outside
during eventration are NOT covered by the parietal peritoneum

Eventration

Classification of Hernias
(1) Etiological Classification
a) Congenital Hernias – Present at birth
b) Acquired Hernias – Occurs as a result of predisposing or causative factors. Can
be further classified into: i> Traumatic Hernias ii> Postoperative / Incisional
Hernias iii> Neuropathic Hernias
(2) Classification according to localization
a) External Hernias – Herniation outside a body cavity (e.g.: Inguinal Hernias)
b) Internal Hernias – Herniation inside a body cavity e.g.: Diaphragmatic Hernias)
(3) Classification according to “Anatomical” localization
a) Inguinal Hernias
b) Femoral Hernias
c) Umbilical Hernias
d) Hernias of linea alba (Epigastric Hernias)
e) Hernias of linea semilunaris (Spigelian Hernias)
f) Hernias of Xiphoid process
(4) Classification according to size of the hernia
a) Small Hernia
b) Medium Hernia
c) Large Hernia
d) Giant Hernia
(5) Classification according to the presence of complications
a) Uncomplicated Hernia
b) Complicated Hernia – Hernia which occurs with complications such as
strangulation, inflammation, coprostasis, hernial injury, tumour of hernia, foreign
body in hernial contents, irreducibleness of hernia and skin destruction
(6) Classification by sight:
a) Complete Hernia – Hernial sac and its contents are outside the natural or
artificial foramen
b) Incomplete Hernia – Hernial sac and its contents are not outside the natural or
artificial foramen yet. They are still inside the body cavity.
(7) Clinical Classification
a) Reducible (Free) Hernia – Hernia in which the hernial contents can move freely
from the body cavity to the hernial sac
b) Irreducible Hernia – Hernia in which the hernial contents cannot move freely
due to the formation of adhesive processes (Strangulated Hernia is also a type of
Irreducible Hernia)

Common Types of Hernias

 Predisposing Factors and Causes of Hernias
Predisposing Factors
General Factors are like Hereditary Age Gender Obesity Constitution
Local Characteristics of anatomic construction of individual region
(Inguinal canal, femoral canal, umbilicus, semilunar line injury or wound,
especially postoperative etc.)

Causes
Increase of Intra-abdominal pressure due to Heavy manual work , Chronic
Constipation, Chronic Cough Injuries , Straining during micturition ,Weight Lifting ,
Difficult Labor , Pregnancy, Tumor of abdominal cavity

weakening of abdominal wall due to Stretching and thinning during repeated

pregnancies , Injuries (including operations), Decreased muscle tone at paralysis ,
Old age

Common symptoms of an uncomplicated hernia

1) Presence of a lump
2) Lump disappears in supine position (It is reducible)
3) Lump is painless (If pain is present, it is a complicated hernia)
4) Expansile cough impulse (Cough push symptom) – When the patient is in
standing position, turn the patient’s head to a side. Keep the fingers over the lump
(as if you are holding a cricket ball). Tell the patient to ‘give a cough’. Fingers will
move apart if there is an expansile cough impulse. Then the patient should be
assessed in the supine position.
 5) If the hernia is big in size, ask patient to flex his head and take a deep breath to
the abdomen when in supine position. The organs will protrude out freely if it is an
uncomplicated hernia.

Sliding Hernias

“A sliding hernia is a hernia in which one of the walls of the hernial sac include a
tubular mesoperitoneal organ (an organ covered by the peritoneum on three
sides)
- Commonly found organs in a sliding hernia : Urinary Bladder and Caecum
- During examination, you can feel that one wall of the peritoneum is thick
- If the bladder is the involved organ, patient may suddenly ask to go to the toilet
during palpation
 Strangulated Hernias

“A strangulated hernia is a hernia in which the blood supply to its

hernial contents (intestines) is cut off due to strangulation of vessels”
- Symptoms include:
(a) Presence of a lump that that doesn’t disappear in supine position (Non-
reducible)
(b) PAIN that gets worse very quickly
(c) Expansile cough impulse absent
(d) Symptoms of ileus present
(e) Necrosis may be seen

- Types of strangulated Hernias:

(1) Elastic Strangulation – Hernia which occurs due to external pressure exerted
on the vessels
(2) Fecal Strangulation – Hernia which occurs due to internal pressure exerted on
the vessels by fecal mass
(3) Parietal (Richter’s) hernia – Hernia in which a portion (one wall) of the bowel is
strangulated
(4) Retrograde (Maydl’s or W-shaped) hernia – Hernia in which some loops of the
bowel are strangulated
(5) Littre’s hernia – Hernia of the Meckel’s diverticulum
 Surgical Treatment of Hernias
Surgical Treatment of Hernias

Hernia Incision Hernioplasty

. With tension
. Without tension

Hernia Incision for Uncomplicated External Hernias

1) Isolate Hernial sac before its neck after cutting the tissue above or near the
hernial sac (skin and subcutaneous tissue)
2) Fix the hernial sac in zone of base with help of anatomical forceps (or
Hemostatic clamp of Billiroth) and cut the hernial sac (For good visualization of
uncomplicated hernias, you may cut until the neck)
3) Examine the hernial content
4) If hernial content is an organ, cut hernial ring and return the organs back to
the abdominal cavity
5) Suture the hernial sac in zone of neck
6) Remove hernial sac distal to the sutured part
- However, hernia may reappear through this place. That is why we need to
perform Hernioplasty. [Discussed later under Inguinal, femoral and umbilical
hernias]
 Features of Hernial Incision for Sliding Hernias
Law of “4 DON’T”s:
1) DO NOT ISOLATE hernial sac in zone of neck
2) DO NOT CUT hernial sac in zone of neck
3) DO NOT SUTURE hernial sac in zone of neck
4) DO NOT REMOVE entire hernial sac before zone of neck

Features of Hernial Incision for Strangulated Hernias

1) Before cutting hernial sac, you must cover operation injury with sterile gauze
2) You must not cut hernial gate before examination of content of hernia
3) Examination of content of Hernia
 Law of “3 P”s You must investigate hernial content for: a) Pink colour
b) Pulse c) Peristalsis
4) If the 3 P’s are present  Usual operation as uncomplicated hernia

5) If the 3 P’s are absent  After fixation of hernia, cut the hernial gate and cover
the content of hernia with sterile gauze containing warm NaCl solution and
wait for 15 minutes
6) Through 15 minutes if you see the 3 P’s  Usual operation as uncomplicated
hernia
7) Through 15 minutes if you don’t see the 3 P’s  Resection of Intestines

Resection of Intestines: - During resection, you must not only remove the
damaged part but also a 40 cm proximally healthy part and a 20 cm distal
healthy part
- This is done because the mucosa is affected first and then the other layers
(submucosa, muscularis and serous layer respectively)
- So, even though the outer appearance looks healthy, the mucosa may be still
damaged beneath
- Hence a part of normal looking intestines must be removed as well

Inguinal Hernias

 Layers of the Anterior Abdominal Wall (From superficial to deep):

1) Skin

2) Subcutaneous Tissue

3) Superficial Fascia i) Superficial Lamina (Camper’s Fascia) – A fatty layer

which continues into the thigh as the fascia lata. It is not attached to the
inguinal ligament
ii) Deep Lamina (Thompson’s or Scarpa’s fascia) – A membranous layer which
continues to form the superficial fascia of the penis and scrotum in males and
the perineal fascia in females. It is attached to the inguinal ligament

4) Muscles (from superficial to deep) i) Pyramidalis muscle ii) Rectus

Abdominis muscle with its covering (Rectus Sheath) iii) External Oblique
muscle iv) Internal Oblique muscle v) Transverse abdominis muscle

5) Transversalis Fascia

6) Preperitoneal fatty space

7) Peritoneum
 Folds and Ligaments of the anterior abdominal Wall:
 Walls of the inguinal canal

 Contents of inguinal canal

: Males : Spermatic Cord and Ilioinguinal Nerve (Genital branch of genitofemoral
nerve is inside the spermatic cord)
Females : Round ligament of the uterus, Ilioinguinal Nerve and Genital branch of
genitofemoral nerve
 Openings of Inguinal canal:

 Types of Inguinal Hernias:

1) Direct / Straight Inguinal Hernias – Hernias which come out through the
medial inguinal fossa, due to a weakened posterior wall of the inguinal canal
and doesn’t descend into the scrotum
2) Indirect / Oblique Inguinal Hernias – Hernias which come out through the
lateral inguinal fossa, due to a weakened anterior wall of the inguinal canal
and may descend into the scrotum. There are three subtypes: a) Bubonocele –
Limited to the inguinal canal b) Funicular – Just above the epididymis c)
Complete – Inguinoscrotal
3) Pantaloon Hernias – Both direct and indirect hernias on the same side of the
groin
Examination of a patient with an inguinal hernia:
1) Patient presents with a lump on Inguinal Area (with or without pain).
Remember! If the lump is above the inguinal ligament, it is an inguinal hernia. If it
is below the inguinal ligament, it is a femoral hernia.
2) Check for the other common symptoms of uncomplicated hernias (absence of
pain, disappearance in supine position / reducible, expansile cough impulse)
3) Investigate for Symptom of block to differentiate between a direct and indirect
inguinal hernia – Insert finger through the external inguinal ring and ask patient to
cough in supine position. If you feel the hernial contents pushing the tip of your
finger, it is an indirect hernia. If not, it is a direct hernia.
4) Identify predisposing factors:
i> Chronic cough
ii> Chronic constipation
iii> Straining during micturition
iv> Cigarette smoking
5) Check the scrotum and penis
6) Check the opposite hernial orifice

Surgical Treatment of Inguinal Hernias

Surgical Treatment of Hernias

Hernia Incision Hernioplasty

.With tension
. Without tension
Hernia Incision for Inguinal Hernias
The incision:
a) Leaving a gap of 2 fingers above the inguinal ligament, make an incision parallel
to the inguinal ligament extending laterally from the mid-line to a length of 8-10
cm.
b) Cut skin, sub-cutaneous tissue and superficial fascia.
c) Now you’ll see the aponeurosis of external oblique muscle and the external ring
of the inguinal canal.
d) Insert a grooved probe through the external ring and cut the anterior wall of
the inguinal canal
e) Now you’ll see the hernial sac
f) The next steps depend on whether the hernia is uncomplicated or complicated
(Refer pages 9. – 10. For details)

Hernioplasty of Inguinal Hernias with Tension

- Hernioplasty is necessary to prevent relapsing of a hernia in the future
- In Hernioplasty with tension, we do not use any artificial material
- The body tissues itself are used to strengthen the respective walls of the inguinal
canal
 - Spermatic cord and muscles are in their original places
- When the aponeurosis of external oblique muscle is cut during the hernial
incision, you are left with 2 flaps (a superior one and an inferior one)
- Stitch the superior flap to the inguinal ligament
- Stitch the inferior flap to the superior flap
- Now, you have created a double layered anterior wall for the inguinal canal

Hernioplasty by Jirar-Spasokukovsky with Kimberovsky suture

There are three variants of this method
1) Hernioplasty by Jirar
2) Hernioplasty by Jirar-Spasokukovsky
3) Hernioplasty by Jirar-Spasokukovsky with Kimberovsky suture
 The method by Jirar
- Spermatic cord is in its original place but NOT the muscles
- Stitch the muscles (Internal oblique + Transverse abdominis) to the inguinal
ligament
- Stitch the superior flap to the inguinal ligament
- Stitch the inferior flap to the superior flap
- Now, you have created a three layered anterior wall for the inguinal canal
(Muscles + Superior flap + Inferior flap)

 The method by Jirar-Spasokukovsky

- Spermatic cord is in its original place but NOT the muscles

- Stitch the muscles (Internal oblique + Transverse abdominis) and the superior
flap to the inguinal ligament in one step
- Stitch the inferior flap to the superior flap
- Now, you have created a three layered anterior wall for the inguinal canal
The method by Jirar-Spasokukovsky with Kimberovsky suture

- Spermatic cord is in its original place but NOT the muscles

- Stitch the muscles (Internal oblique + Transverse abdominis) and the superior
flap to the inguinal ligament in one step using the Kimberovsky suture
- Kimberovsky suture : Needle first passes through superior flap towards muscles,
then passes posteriorly through the muscles, then passes anteriorly again through
the superior flap, and finally throught the inguinal ligament
- Stitch the inferior flap to the superior flap
- Now, you have created a three layered anterior wall for the inguinal canal
- When the Kimberovsky suture is used, the muscles are not in direct contact with
the inguinal ligament. Instead, muscles come in contact with the aponeurosis
which now lies above the inguinal ligament
 REFERENCE LIST

https://www.google.by/search?
hl=en&sxsrf=ALeKk03_xV_DN6O-kwbFdnwarUEwMNA3SA
%3A1614257712200&source=hp&ei=MJ43YJ3GCIP8sAfUlI2QD
w&iflsig=AINFCbYAAAAAYDesQAELzuwYrmRe9NMIAai5Js417fq
J&q=hernia&oq=hernia&gs_lcp=Cgdnd3Mtd2l6EAMyBAgjECcyA
ggAMgIIADICCAAyAggAMgIIADICCAAyAggAMgIIADICCAA6Aggu
OggILhDHARCjAjoHCAAQRhD5AToICC4QxwEQrwE6BQguEJMCO
gQILhAKUJrAnwNYreifA2C9658DaAVwAHgCgAG_BIgB7xOSAQs
wLjUuMC4xLjIuMZgBAKABAaoBB2d3cy13aXo&sclient=gws-
wiz&ved=0ahUKEwidnojMioXvAhUDPuwKHVRKA_IQ4dUDCAc&
uact=5

https://en.wikipedia.org/wiki/Hernia
https://www.healthline.com/health/hernia