Hernia Types

Hernia
• A hernia is an abnormal protrusion of a viscus or part of a viscus through
a defect either in the containing wall of that viscus or within the cavity in
which the viscus normally is situated.
• In abdominal hernias, the ‘wall’ refers to the anterior and posterior
muscle layers of the abdomen, the diaphragm, and the walls of the pelvis.
• Hernias are either external or internal.
• External – common and present as an abnormal lump which can be detected by
clinical examination of the abdomen or groin
• Internal – rare, and occur when the intestine (the ‘viscus’) passes beneath a
constricting band or through a peritoneal window (the ‘defect’) within the
abdominal cavity or in the diaphragm
Types of Abdominal Hernia (external)
• Anterior wall (ventral) hernia
• Epigastric hernia
• Umbillical hernia
• Paraumbilical hernia
• Spighelian hernia
• Posterior wall hernia
• Lumbar hernia
• Groin hernia
• Inguinal hernia
• Femoral hernia
• Pelvic & perineal hernia
• Obturator hernia
• Perineal hernia
• Sciatic & gluteal hernia
 Epigastric hernia
• Protrusion of extraperitoneal fat, with or without a
small sac of peritoneum through a defect in the
linea alba anywhere between the xiphisternum
and the umbilicus.
• The defect is characteristically small, often about 1
cm in diameter. Patients are frequently fit young
males who present with epigastric pain, which may
be confused with peptic ulceration or biliary disease.
• Patients should be examined in both standing and
lying positions. The hernia is usually easier to feel
than to see, and is diagnosed by palpation of a
small, often very tender, lump in the linea alba.
Ultrasound may be helpful when a hernia is
suspected but cannot be palpated.
• Epigastric hernias are usually irreducible and may be
multiple.
 Umbilical hernia
• An umbilical hernia in a child is a congenital defect in
which a peritoneal sac protrudes through a patent
umbilical ring and is covered by normal skin.
• Approximately 5–10% of Caucasian infants have an
umbilical hernia at birth. About one-third of hernias
close within a month of birth, and they rarely persist
beyond the age of 3–4 years.
• The hernia is noticeable whenever the child cries,
coughs or vomits, and is a cause of concern for parents.
Umbilical hernias in children rarely become irreducible
or strangulate.
• Umbilical hernia is a separate entity from exomphalos
(omphalocele). Exomphalos is a rare congenital
condition in which the midgut fails to return to the
abdominal cavity during the first trimester, with
subsequent failure of the abdominal wall to close at the
umbilicus. At birth, the intestine protrudes into the base
of the umbilical cord and is covered by a thin opaque sac
of amnion, not normal skin.
 Paraumbilical hernia
• A para-umbilical hernia in an adult is an acquired
condition and quite distinct from the umbilical hernia of
childhood.
• A para-umbilical hernia protrudes through one side of
the umbilical ring, while the umbilicus still retains its
fibrous character within the linea alba, although it
becomes effaced by the pressure of the hernial contents
and has an eccentric ‘half-moon’ or crescentic furrow.
• Para-umbilical hernias initially contain extraperitoneal
fat but, as the hernial orifice enlarges, omentum enters
the sac. The contents typically adhere to the sac so that
the hernia becomes loculated and irreducible.
• Para-umbilical hernias occasionally become very large
and contain transverse colon and small intestine.
 Spigelian hernia
• Rare
• A Spigelian hernia occurs through the transversus abdominis
aponeurosis of the anterior abdominal wall, usually below
the level of the umbilicus. The vertical curved line at which
the transverse abdominis muscle becomes an aponeurosis is
the semilunar line, and it extends from the costal margin to
the pubic tubercle. The transversus abdominis aponeurosis
extends medially from the semilunar line to the lateral edge
of the rectus sheath.
• A Spigelian hernia usually occurs at the widest and weakest
point of the aponeurosis, which is about halfway between the
umbilicus and the inguinal ligament.
• Clinically, the diagnosis of a Spigelian hernia may be difficult.
The patient, who typically is a middle-aged female, presents
with diffuse aching pain in the area of the hernia, which is
small and may not be palpable. Pain is often present during
the day but may recede at night if the hernia reduces, and
may be made worse by raising the arm on the affected side. If
a lump is not palpable, the diagnosis may be confirmed by
ultrasound or computed tomography scanning. The hernia
usually contains omentum but may contain small or large
bowel. A Richter’s hernia may occur, and obstruction and
strangulation are well-recognised complications.
 Lumbar hernia
• Rare
• occur typically in individuals with poor muscle tone, either spontaneously, or
following trauma, surgery, or paralysis of paravertebral muscles secondary to
poliomyelitis.
• DDx: a lipoma, lumbar abscess or haematoma.
• Lumbar hernias occur through two triangular sites of weakness in the lumbar
region of the abdominal wall.
1. Inferior lumbar triangle hernia (triangle of Petit) – herniation occurs between
the iliac crest inferiorly, the posterior edge of external oblique muscle
anteriorly, and the anterior edge of latissimus dorsi posteriorly. The ‘floor’ of
the triangle through which the hernia protrudes is formed by the internal
oblique and transversus abdominis muscles.
2. Superior lumbar triangle (triangle of Grynfeltt–Lesshaft) – the hernia occurs
between the lowermost edge of serratus posterior inferior muscle and the
twelfth rib superiorly, the anterior border of internal oblique muscle
anteriorly, and the lateral edge of erector spinae muscle medially. Grynfeltt’s
triangle lies superior to Petit’s triangle, and the ‘floor’ is formed by the
quadratus lumborum muscle. The hernia is covered by the latissimus dorsi.
 Femoral hernia
• occurs when the transversalis fascia
which normally covers the femoral
ring is disrupted, so that a peritoneal
sac and hernial contents pass through
the femoral ring into the femoral
canal.
• 2–3x more common in females than
males, and occur in the older age
group, often after a period of weight
loss. Femoral hernias are never
congenital, and are twice as common
in parous as in non-parous females.
• Approximately 60% of femoral hernias
are on the right, 30% on the left, and
10% bilateral.
• Is the commonest site for a Richter’s
hernia
 Obturatorial hernia
• Rare
• It protrudes through the obturator canal or foramen, which is a
normal anatomical structure between the obturator groove on the
inferior aspect of the superior pubic ramus and superior border of
the obturator membrane.
• The obturator canal carries the obturator nerve and vessels. When
large, the hernial sac passes between the pectineus and adductor
longus muscles and protrudes forwards to produce a diffuse bulge in
the femoral triangle, where it can be mistaken for a femoral hernia.
It is more common on the right side.
• The hernia occurs most often in elderly females, particularly in those
who have become debilitated and lost weight rapidly. Usually, the
patient presents with intestinal obstruction of unknown cause, and
the hernia is diagnosed at laparotomy. Patients may complain of
diffuse pain in the groin together with pain in the medial side of the
thigh and knee because of pressure on the obturator nerve. The
hernia may be felt in the femoral triangle and also on vaginal
examination. A Richter’s hernia may occur with strangulation of the
entrapped part of the intestinal wall.
 Perineal hernia
• Perineal hernias occur in the soft tissues of the
perineum and are very rare. They may be primary or
postoperative.
• Primary perineal hernias occur anteriorly through the
urogenital diaphragm or posteriorly through the levator
ani muscle or between the levator ani and coccygeus
muscles.
• Secondary perineal hernias occur most often after
surgery, such as abdominal-perineal resection, pelvic
exenteration, or hysterectomy. Radiation therapy, wound
infection, and obesity predispose to the development of
secondary perineal hernias.
• Rare.
• Primary perineal hernias are most common in middle-
aged women. Secondary perineal hernias occur after less
than 3% of pelvic exenterations and less than 1% of
abdominal-perineal resections for rectosigmoid cancer
Sciatic Hernia
• Sciatic hernias are very rare and occur
when a peritoneal sac enters the
greater (gluteal hernia) or lesser
sciatic foramina.
• Pain caused by pressure on the sciatic
nerve or a palpable swelling and
tenderness in the buttock suggests
the diagnosis.
• Most commonly, sciatic hernias are
discovered at laparotomy for intestinal
obstruction. The sac is excised, but
attempts to close the defect run the
risk of sciatic nerve damage.