HERNIA

objectives

• Definition
• Anatomy
• Precipitating factors
• Types
• Clinical features
• Preoperative assessment
• Management and repair
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 .
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
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.
•
Content :-
1. 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
2. Ilioinguinal nerve .
3. Ilioinguinal lymph node .
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
Predisposing:

All hernias occur at the site of WEAKNESS OF THE

ABDOMINAL WALL which are acted on by repeated
INCREASE in abdominal pressure
repeated INCREASE in abdominal
pressure is usually due to
• Chronic cough
• Straining
• Bladder neck or urethral obstruction
• Pregnancy
• Vomiting
• Sever muscular effort
• Ascetic fluid
Types

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

 History:
1. Age ( young vs. old)
2. Occupation ( nature ?? )
3. Local symptoms: Swelling, discomfort and pain
4. Systemic symptoms: if there is obstruction or strangulation
5. Precipitating factors
Inguinal hernia

 Examination:
1. Inspection for site, size, shape and color.
2. Palpation for surface, temp, tenderness, composition and
reducibility.
3. Expansible cough impulse.
4. General exam: for common causes of increase intra abdominal
pressure
 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.
 Indirect Versus Direct inguinal hernias
Indirect Inguinal Hernia
Pass through inguinal canal.
Can descend into the scrotum.
Lateral to inferior epigastric vessels.
Reduced: upward, then laterally and
backward.
Controlled: after reduction by pressure over
the internal (deep) inguinal ring.
The defect is not palpable (it is behind the
fibers of the external oblique muscle).
After reduction: the bulge appears in the
middle of inguinal region and then flows
medially before turning down to the scrotum.
Common in children and young adults.
Direct Inguinal Hernia
Bulge from the posterior wall of the inguinal
canal
Cannot descent into the scrotum.
Medial to inferior epigastric vessels.
Reduced: upward, then straight backward.
Not controlled: after reduction by pressure over
the internal (deep) inguinal ring.
The defect may be felt in the abdominal wall
above the pubic tubercle.
After reduction: the bulge reappears exactly
where it was before.
Common in old age.
 Male:

 Female

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
 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 .
 Femoral hernia

History
 Age ; uncommon in children , most common in old age female .
 Sex; women > 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
Femoral hernia versus inguinal hernia

Inguinal hernia Femoral hernia

1- more common in male 1- more common in females

2- pass through the inguinal canal 2- pass through the femoral canal

3- neck of the sac is above and medial 3- neck of the sac is below and lateral
the pubic tubercle the pubic tubercle

4- less common to be strangulated 4- more common to be strangulated

5- can be treated without surgery 5- must be treated surgically

6- the two diagnostic signs of hernia + 6- the two diagnostic signs of hernia -

7- the sac mainly contain ; bowel 7- the sac mainly contains ; omentum
Umbilical hernia

• Signs and symptoms

• Age ; doesn’t 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.
 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 .
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
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
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)
Preoperative assessment

 Investigation data ( pre operative tests ) :

1. Lab :
* CBC : to check hemoglobin level  anemia and WBCs  infections
* U&E : 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
Preoperative assessment

 current medications or allergies

 any major (chronic) illness
 pre op orders :
1. skin preparation
2. diet (NPO)
3. GIT preparation
4. Sedation
5. Preanesthetic medications
6. Other medications
7. Antibiotics
8. Blood transfusion ( if needed )
9. Bladder preparation
Management
and repair
 Inguinal Hernia Repair

Pre op
Evaluation
Reduction
&
preparation

Surgical
TTT
Surgical TTT

Choice of Inguinal floor

TTT of hernial sac
Anesthetic reconstruction
 Pre op evaluation &preparation

Watchful Waiting Surgical TTT

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
2006,295:285)
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.
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.
Surgerical TTT

• 1.choice of anesthetic:
• elective open repair : Local is preferred
• Laproscopic hernia repair: more commonly under GA.
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.
 3.Inguinal Floor
Reconstruction

• Some method of 3.Inguinal

Floor
reconstruction of the Reconstruction
inguinal floor is
necessary in all adult
hernia repairs to prevent
recurrence.
Open tension free Laproscopic &
Primary tissue repair
repair preperitoneal repairs
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.

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

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
 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
 Open surgery
Three approaches have been described for open surgery :
1. Infra-inguinal approach (Lookwood)
2. Supra-inguinal approach ( McEvedy)
3. Trans-inguinal approach ( Lotheissen)
• 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.
Lockwood’s 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.
McEvedy’s 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.
Lotheissen‘s trans-inguinal approach

• The incision is made superior and parallel to inguinal ligament

extending from pubic tubercle to mid inguinal point.
Hernia examination
Thank
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