Hernias

Definition
 A hernia is a protrusion of
a viscus or part of a viscus
through its coverings into
an abnormal situation
 Common Varieties
 Inguinal
 Femoral

 Epigastric

 Umbilical

 Incisional
Common Sites
 Congenitally weak sites
 Penetration sites

 Weak sites

 Damaged nerves with

muscle weakness
Aggravating Factors
 Chronic cough
 Constipation
 Urinary obstruction
 Abdominal distension due to ascites
 Gross obesity
 Cachexia
Classification

 Reducible
 Irreducible

 strangulated
 Inguinal Hernias
 Protrusion of part of the contents of
the abdomen through the inguinal
region of the abdominal wall.
 Common. Precise prevalence and
incidence figures not available
 More common in men
Inguinal Hernias--cont.
 Hernias in the inguinal region
account for 75 % of all forms
of hernias
 Classified as direct, indirect,
and recurrent
 Maybe reducible or irreducible
Clinical Features
History
 Occupation
 Pain or discomfort
 Swelling, disappears on lying down
 Colicky abdominal pain, vomiting,
abdominal distension, and absolute
constipation—classic intestinal
obstruction
 Chronic cough, difficulty in maturation,
and constipation
Inguinal Hernia--Signs
 Reducible lump with
visible and palpable
cough impulse
 Examine with patient

standing and lying supine

 Inguinal hernia—Signs
cont.
 Position, temperature, tenderness,
shape, size, consistency of lump
 Reducibility
 Direct or indirect
 Can you go above it?
 Percussion and auscultation
Indirect Inguinal hernia
 Controlled at internal ring
 Often descends into scrotum

 Defect not palpable

 Appears at mid inguinal

point
Direct Inguinal hernia
 Not controlled at internal ring
 Rarely enters the scrotum
 Reduces upwards and posteriorly
 Defect maybe palpable above the
pubic tubercle
 Appears medial to the mid-inguinal
point, expanding interiorly
 Differential Diagnosis
Diagnosis Distinguishing features

Femoral hernia Below and lateral to the pubic

tubercle
Lymph node No cough impulse
Usually below inguinal ligament
Varicocoele Dilated veins in spermatic cord,
visible with patient standing

Cyst of the canal of Nuck Able to get above the lump

(females)

Hydrocoele of the cord (males) Not reducible

Undescended testis Testis absent from scrotum.

 Surgical Treatment Inguinal
hernia
 Many different techniques
 Meticulous technique essential

 Excision or reduction of hernial

sac
 Repair of the posterior wall of the

inguinal canal
Repair of Posterior Wall
 Approximation
 Bassini’s technique
 Reinforcement
 Darn
 Shouldice repair
 Insertion of prosthetic mesh
 Laparoscopic repair
 Herniotomy
 Prosthesis
 Femoral Hernia
 Protrudes through the femoral canal
 6% of all abdominal wall hernias
 Aetiology unclear—elevated
intrabdominal pressure/laxity groin
tissues
 Common with parity and weight loss
 Maybe reducible, irreducible, and
strangulated
Femoral hernia--clinical
 Asymptomatic lump or
localized intermittent
discomfort
 Richter’s hernia common
 Lies below and lateral to the
pubic tubercle
Femoral Hernia--
treatment
 Conservative—risky and
cannot be controlled with
truss
 High strangulation rate

 Surgery always recommended

Femoral Hernia—treatment
cont.
 Operative
 Excision of sac
 Narrowing of stretched femoral ring

opening
 Approaches
 Low
 Inguinal

 preperitoneal
 Epigastric Hernia
 Protrusion of preperitoneal fat through
linea alba in supraumblical position
 Rare for bowel to herniate but
peritoneal sac and omentum common
 Adult males under 40 years
 Present in 5% of individuals at
autopsy
 Majority asymptomatic
 Epigastric hernia –cont.
 Tender lump
 Gangrene of contents occasionally
 Investigate upper GIT in these
patients
 Surgery indicated in symptomatic
patients
Umbilical Hernia
 Congenital
 Omphalocoele
 Exomphalos

 Infantile umbilical hernia

 Adult Paraumbilical hernia
Adult Paraumbilical Hernia
 Acquired, disruption of linea alba
above or below the umbilical
cicatrix
 Obesity, multiple pregnancies,
and ascites
 Occurs after 35 years and 5 times
more common in the female
Paraumbilical—cont.
 Dragging pain or colicky
 Necrosis of overlying skin in

large hernias
 Usually has a small neck

with danger of strangulation

 Early surgery advisable
Incisional Hernia
 Protrusion of a viscus through
the musculoaponeurotic layers
of a surgical scar
 Dehiscence if it occurs before the
surgical skin wound is healed
 Occurs in about 5%-10% of
patients undergoing surgery
Incisional Hernia—Cont.
 Predisposing factors
 Preoperative condition of patient
 Technique of wound closure
 Postoperative complications
 Surgical treatment
 Direct repair
 Mesh
 Overlap
 Muscle flaps
Rare Hernias
 Obturator
 Spigelian

 Lumbar

 Sciatic

 perineal
Questions?