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HERNIAS
MOSTAFA ABOU ALI
PROFFESSOR OF SURGERY
QASSIM UNIVERSITY
FACULTY OF MEDICINE
HERNIAS..DEFENITIONS
• Hernia is a protrusion of an organ through the wall
that normally contains it
• The wall can be the abdominal wall, muscle fascia,
diaphragm or foramen magnum.
• Hernias can be congenital or acquired
• Abdominal wall hernias are common
• Account for approximately 10% of general surgical
workload
• Types Inguinal 73% femoral 17% umblical 8.5 % rare
forms 1.5% ( incisional hernia is excluded.)
A HERNIA CONSISTS OF :
• A sac
• Its coverings
• Its contents ( all abdominal viscera
except liver and pancreas).
ABDOMINAL
REGIONS
WHERE
HERNIAS
OCCUR
HERNIAS…ETIOLOGICAL FACTORS
Acquired hernias:
• Increased intra-abdominal pressure
(e.g. straining or lifting )
• Abdominal weakness (e.g. advancing
age or malnutrition)
ANATOMY OF THE INGUINAL CANAL
• Anterior border is the external oblique
aponeurosis
• Posterior border is the transversalis
fascia
• Inferior border is the inguinal ligament
• Superior border is the conjoint tendon the lower fibers of internal oblique and
transversus abdominis
ANATOMY OF INGUINAL CANAL
Inguinal canal lies between the superficial
and deep inguinal rings
Deep ring lies deep to the mid-inguinal point
Mid-inguinal point is half way between
symphysis pubis and anterior superior iliac spine
Not the midpoint of the inguinal ligament
In men it contains vas deferens and testicular
artery and veins
In women it contains the round ligament
INGUINAL HERNIAS…INCIDENCE.
• 3 %adults will require operation for
inguinal hernia
• Male : female ratio is 12:1
• Elective : emergency operation 12:1
• Peak incidence is in the 6th decade
• 65 %inguinal hernias are indirect
• In females inguinal hernias are as
common as femoral hernias
OBLIQE INGUINAL HERNIA
(I) Congenital theory :
Due to persistence of all or part of
processes vaginalis .
(II) Acquired theory :
Due to deficiency of factors (shutter
mechanism) which prevent herniation.
What is an Indirect Hernia?
Deep ring
• Congenital or acquired
weaknesses in TF
• Location: lateral to deep
epigastric vessels
• Protrude through deep
inguinal ring; may
descend into the scrotum
• Men
DIRECT INGUINAL HERNIA
– Acquired weaknesses in TF
– Location: Hesselbach’s
– Emerge between the deep
epig. artery and rectus abd.
muscle and protrude into
the ingu. canal but not into
the SC.
– More difficult to repair?!
– Men
FACTORS PREVENTING HERNIATION
1- Oblique coarse of the inguinal canal .
2- Contraction of conjoint tendon during
coughing or straining (shutter mechanism) .
3- Contraction of cremasteric muscle :
Plugging of inguinal canal
CLINICAL FEATURES
• Irreducible hernias have either a
narrow neck or the contents adhere to
the sac wall
• Obstructed hernias contain obstructed
but viable intestine
• Strangulated hernias when the venous
drainage from the sac contents is
compromised
CLINICAL FEATURES
• Lump at an appropriate anatomical
site
 Increases in size on coughing or
straining.
 It reduces in size or disappears when
relaxed or supine position.
• Examination may show it to have a
cough impulse and to be reducible
QUESTIONS MUST BE ANSWERED AT THE
END OF GENERAL AND LOCAL
EXAMINATION
1- Hernia or not ?
2- Rt or Lt ?
3- Is it inguinal or femoral ?
4- Is it direct or oblique ?
5- What is the content ?
6- Recurrent or not ?
7- Complicated or not ?
8- what is the predisposing factors ?
HERNIAS…COMPLICATIONS
•
•
•
•
Reducible
Irreducible
Obstructed or incarcerated
Strangulated
D.DIAGNOSIS of OIH
1- Other hernia direct inguinal hernia
2- Hydrocele
femoral hernia
congenital & infantile
encysted hydrocele of the cord
3- Ectopic or undescended testicle
4- Psoas abscess
5- Inguinal adenitis
6- Endemic funiculitis
7- Lipoma of the cord
COMPLICATIONS
Obstruction
• Irreducible
• abdominal pain,
• distension and vomiting may occur
• The hernia will be tense tender and irreducible
Strangulation
• become red and tender,
• Irreducible
• No impulse on cough.
• If contains bowel signs of obstruction.
Rt. INDIRECT ING. HERNIA
Ex. Ring Test?
INTERNAL RING TEST
HUGE LONG STANDING IDIH
COMPLETE
INDIRECT
INGUINAL
HERNIA
INGUINAL HERNIA REPAIR
RATIONALE
TENTION FREE REPAIR
MESH REPAIR
HERNIA…REPAIR
Irrespective of approach used
the following will be achieved
•
•
•
•
Dissection of the sac
Reduction / inspection of the contents
Ligation of the sac
Approximation of the inguinal and
pectineal ligaments
INGUINAL HERNIA.TYPES OF REPAIR
• Bassini repair : Suturing conjoined tendon to
inguinal ligament behind the cord .
• Lytle repair: Plication of the fascia transversalis .
• Shouldice repair : incision of the fascia &
double breasting of it .
• Halsted ‘s repair Bassini repair plus reinforced
by suturing the 2 leaflets of external oblique
together behind the cord
INGUINAL HERNIA.TYPES OF REPAIR
Tanner’s repair: add to the repair a
releasing incision in the rectus sheath to in
avoid tension suture line
Blood good’s repair: triangular flap of ant
rectus sheath wall is turned downward behind
its lateral border and sutured to the inguinal
ligament .
INGUINAL HERNIA.TYPES OF REPAIR
• Shouldice or Liechtenstein now
regarded as 'gold standard' as judged
by low risk of recurrence
• Laparoscopic hernia repair:
Should be reserved for bilateral or
recurrent hernia
SPERMATIC CORD
STRENTHENING OF THE POSTERIOR WALL OF
TH ING. CANAL
INCESION
INDIRECT INGUINAL HERNIA MESH REPAIR
Hernia Sac
Vas Deference
Hernia Sac Twisted
Spermatic Cord with the Vas
Preparation of the Mesh for Mesh Repair
Right direct inguinal hernia, the sac was coming from the posterior
wall of the inguinal canal. The cord is elevated separate from the
sac.
Left direct inguinal hernia. the sac is separated
from the cord.
direct inguinal hernia, the sac was fully reduced
Spermatic Cord
The superior edge of the mesh was tacked down to the aponeurosis or muscle
of the internal oblique with a few interrupted sutures.
Mesh in place and fixed
Laparoscopic Trans-abdominal pre-peritoneal prosthetic
Fixation.
Mesh in Place
Spermatic Cord
Peritoneal closure on the pre-peritoneal mesh
MORTALITY OF ELECTIVE
HERNIA REPAIR
The mortality of elective hernia
repair increases with age
MORTALITY OF STRANGULATED HERNIA REPAIR
• 10 %patients with strangulation give no previous
history of a hernia
• The peak incidence of hernia strangulation is
approximately 80 years
• In those with acute onset of a hernia the greatest
risk is in the first 3 months
• Risk of strangulation depends on type of hernia
- Femoral is approximately 40%
- Direct inguinal is approximately 3%
MORTALITY OF STRANGULATED HERNIA
REPAIR
• The mortality of surgery for strangulated
hernias has changed little over the past 50
years
• Operative mortality remains at
approximately 10%
• Is ten times greater than that following an
elective repair
• Risk of death is dependent on :
-Age
-Presence of necrotic bowel requiring
resection
COMPLICATIONS OF HERNIA SURGERY
•
•
•
•
•
Urinary retention
Scrotal haematoma
Damage to the ileoinguinal nerve
Ischaemic orchitis
Recurrent hernia
TRUSSES
•
•
•
•
40000 sold annually in UK
20 %purchased prior to seeing a doctor
45 %have no instruction on fitting
75 %fit whilst standing up !
RECURRENT INGUINAL HERNIA
• Recurrence rate varies with
herniorrhaphy technique and duration of
follow up
• With Bassini and darn repairs may be as
high as 20%
• With Shouldice and Lichtenstein repairs
recurrence rates <1% have been reported
RECURRENT INGUINAL HERNIA
Factor involved in recurrence
include :
- Inadequate preoperative
selection
- Type of hernia
- Type of operation
- Postoperative wound infection
RECURRENT HERNIA REPAIR
• Recurrent hernias should be repaired
using a mesh technique
• Can be performed as either an open
or a laparoscopic procedure
• Patients should be consented for a
possible orchidectomy
FEMORAL HERNIAS…INCIDINCE.
• Account for 7% of all abdominal wall
hernia
• Female : male ratio is 4:1
• Commonest in middle aged and
elderly women
• Rare in children
• More common in parous
ANATOMY OF THE FEMORAL CANAL
• Anterior border is the inguinal
ligament
• Posterior border is the pectineal
ligament
• Medial border is the lacunar ligament
• Lateral border is the femoral vein
FEMORAL SHEATH AND CANAL WI TH RELATIONS OF CONTENTS
Pubic Tubercle
Right Femoral Hernia
FEMORAL HERNIA…REPAIR
All uncomplicated femoral hernias should be
repaired as an urgent elective procedure
Three classical approaches to the femoral
canal have been described
– Low (Lockwood)
– Transinguinal (Lotheissen)
– High (McEvedy)
SPECIAL TYPES OF HERNIA
Richter's hernia
• Partial enterocele
• presents with strangulation and
obstruction
SPECIAL TYPES OF HERNIA
• Maydl's hernia
W loop strangulation, Strangulated
bowel within abdominal cavity
• Litter's hernia Strangulated Meckel's
diverticulum Can cause small bowel
fistula
CONGENITAL INGUINAL HERNA
• Presence of an PATENT processes vaginalis .
• The hernia reaches down to the bottom of the
scrotum.
• The testis lies among the contents of the sac
• Although congenital , it may appear in adult
life .
• Herniotomy can be performed at any age
provided a skilled anaesthetist and surgeon are
available.
Incarcerated Congenital Inguinal Hernia
LEFT CONGENITAL INGUINAL HERNIA
SUBCUTANEIUS HERNIOTOMY
DISECTED SAC
VAS DEFRENCE
VD
TRANSFEXSION LIGATION AT THE NECK
Wound Closure With Subcuticulr Fine Sutures
Previous Rt. H Repair
CONGENITAL UMBLICAL HERNIA
OXOMPHALUS MINOR
Infantile Umblical Hernia
• Due to week umblical scar
• Repair is not urgent as it can
close spontaneously
• If persist or became more
wide, repair at 2y age.
• Very rare to be complicated
• Just remove the granuloma
• No truss
ADULT AQUIRED PARAUMBLICAL HERNIA
PATIENT IS STRAINING
HUGE VENTRAL HERNIA
WITH PENDULUS ABDOMEN
HUGE VENTRAL HERNIA
WITH PENDULUS ABDOMEN