Download hernias - FK UWKS 2012 C


Introduction

Protrusion of the peritoneum or preperitoneal fat through an abnormal opening in the
abdominal wall



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Presents as a bulge
Peritoneal contents may be trapped in “sac”
Asymptomatic bulge most common
Symptoms
 Physical effects of sac and contents on surrounding tissues
 Obstruction and/or strangulation of hernia sac contents
Epidemiology


700,000 hernia repairs year
Inguinal hernias -75% of all hernias
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2/3 Indirect, remainder are direct
Incisional hernias – 15 to 20%
Umbilical and epigastric – 10%
Femoral – 5%
Epidemiology


Prevelance of hernias increases with age
Most serious complication –
strangulation


1 to 3% of groin hernias
Femoral – highest rate of complications
15% to 20%

recommended all be repaired at time of
discovery
Anatomy
Areas of Natural Weakness
Used with permission from the American College of Surgeons
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Anatomy
Inguinal ligament
(Poupart’s) – inferior
edge of external
oblique
Lacunar ligament –
triangular extension of
the inguinal ligament
before its insertion upon
the pubic tubercle
conjoined tendon (510%)- Internal oblique
fuses with transversus
abdominis aponeurosis
Cooper’s Ligament formed by the
periosteum and fascia
along the superior
ramus of the pubis.
Inguinal Canal

Between deep and
superficial inguinal rings

Boundaries




Superifical – external
oblique aponeurosis
Superior – internal and
transversus
Inferior – shelving edge of
inguinal ligament and
lacunar ligament
Posterior (floor) –
transversalis fascia and
aponeurosis of transversus
abdominis muscle
Components of Hesselbach’s triangle include which
of the following anatomic landmarks?
A.
B.
C.
D.
E.
Pectineal ligament
Lateral border of the rectus sheath
Cooper’s ligament
Inguinal ligament
Inferior epigastric vessels
Hernia Diathesis

Varies with age

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Pediatric: congenital remnant
Adult
Tissue weakness
 Burst strength < abdominal wall tension

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Varies with gender
Hernia Diathesis
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Pediatric: major risk is premature birth
Adult
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Obesity
Previous abdominal surgery
Pregnancy
Abrupt abdominal wall exertion
What is a Hernia composed of?
1.
Sac: a folding of
peritoneum consisting of a
mouth, neck, body and
fundus.
2. Body: which varies in size
and is not necessarily
occupied.
3. Coverings: derived from
layers of the abdominal
wall.
4. Contents: which could be
anything from the
omentum, intestines, ovary
or urinary bladder.
A sliding inguinal hernia on the left side is likely to
involve which of the following?
A.
B.
C.
D.
E.
Jejunum composing the posterior wall of
the sac
Ovary and fallopian tube in a female
infant
Omentum
Sigmoid colon composing the posterior
wall of the sac
Cecum composing the anteromedial wall
of the sac
Terminology

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Pantaloon – direct and indirect components
Richter’s – contains antimesenteric portion of small
bowel
Sliding – involves visceral peritoneum of an organ , i.e.
bladder, ovary
Littre’s – hernia contains Meckel’s diverticulum
Petit – hernia at inferior lumbar triangle
Grynfelt – hernia at superior lumbar triangle
Clinical Evaluation: History


Demographics
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Age

Gender
Presentation of bulge

When, where, how

Activities that make it better or worse

Discomfort vs. pain

Signs/symptoms of bowel obstruction
Clinical Evaluation: History

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Surgery: previous repairs/operations
Review of factors related to increased
intra-abdominal pressure

Chronic cough

Constipation
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Straining to urinate
Clinical Evaluation: Location

Groin: 75%
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Inguinal
Femoral
Anterior abdominal wall: 25%
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Umbilical
Epigastric
Spigelian
Incisional
Hernia Pathology

Contents of hernia sac

Bowel (small and large, appendix)



Incarceration of portion of bowel wall: Richter’s
hernia: Strangulation occurs without obstruction
Omentum, bladder, ovary, fallopian tubes
Sac wall may be formed by large bowel, bladder,
or the ovary/tube: Sliding hernia
Hernia Pathology


Fascial defect may exist without peritoneal
hernia sac
Preperitoneal abdominal wall contents may
protrude through fascial defect

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Preperitoneal fat
Lymph node
Hernia Pathology

Incarceration: contents of hernia sac not
reducible into peritoneal cavity

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Acute: fascial margins trap contents
Chronic: contents adhesed in sac
Strangulation: incarceration with compromise
of blood supply

Narrow neck at greatest risk: indirect inguinal,
femoral, and umbilical
Hernia Repair Indications



Asymptomatic
 prevent visceral incarceration and/or
strangulation
Symptomatic, non-obstructed
 Treat discomfort from bulge
 Prevent incarceration/strangulation
Visceral obstruction/strangulation
 Release obstruction/manage viscera
 Prevent recurrence
Groin Hernia

Men : Women 25 : 1

Right : Left 2 : 1

Femoral



Women > Men
Strangulation risk > inguinal
Inguinal


Indirect : Direct 2 : 1
Most common in men and women
Groin Hernia

Inguinal: relationship of sac to inguinal canal
determines external bulge



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Movement from internal ring to scrotum
Bilateral hernias: direct 4x indirect
Indirect vs. direct hernia is intraoperative
diagnosis, not clinical diagnosis
Femoral: relationship of sac to inguinal ligament
determines external bulge
Groin Hernia: Inguinal


Adults
 Weakness of transversalis fascia
 Indirect: sac is lateral to inferior epigastric
vessels
 Direct: sac is medial to inferior epigastric
vessels
 Pantaloon: both indirect and direct
Pediatric: patent processus vaginalis
Inguinal hernia
Male inguinal hernia
Female inguinal hernia
Groin Hernia: Differential Diagnosis
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Tendonitis
Muscle tear
Lymph node
Lipoma
Varicose vein
Hydrocele
Epididymitis
Spermatocele
Groin Hernia Management

Most hernias: ambulatory OR
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Local/regional/general anesthesia

Prohibitive operative risk: truss
Groin Hernia Management

Acute incarceration

Reduction (taxis)
Distal traction and gentle milking
 Caution: reduction en masse
 Successful reduction shows visually
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Urgent elective repair if reduced
Groin Hernia Management
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Emergent repair
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Irreducible acute incarceration
Strangulation
Fluid, electrolyte resuscitation
Groin Hernia
Surgical Classification (Nyhus)
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I: Indirect hernia w/normal internal ring
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2: Indirect hernia w/enlarged internal ring
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3a: Direct inguinal hernia
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3b: Indirect hernia with weak floor
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3c: Femoral hernia
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4: All recurrent hernias
Direct Inguinal Hernia
Direct Inguinal Hernia

Medial to the inferior
epigastric artery and
vein, and within
Hesselbach's triangle

acquired weakness in
the inguinal floor
Indirect Inguinal Hernia
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

Accepted hypothesis:
incomplete or
defective obliteration
of the processus
vaginalis during the
fetal period
remnant layer of
peritoneum forms a
sac at the internal
ring
more frequently on
the right
Femoral
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More common in females
Up to 40% present as
emergencies with hernia
incarceration or
strangulation
Passes medial to the
femoral vessels and nerve
in the femoral canal
through the empty space
Inguinal ligament forms
the superior border
Groin Hernia Surgery: Open

Indirect sac: high ligation
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Men: ligation at internal ring
Women: ligation/excision of round
ligament with closure of internal ring
Cord lipoma: excision
Operative
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Bassini
Shouldice
McVay
Lichtenstein
Preperitoneal
Laparoscopic
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Bassini (early 20th Century)
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Shouldice (1930s)
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Transversus abdominis to Thompson’s ligament and
internal oblique musculoaponeurotic arches or
conjoined tendon to the inguinal ligament
Multilayer imbricated repair of the posterior wall of the
inguinal canal
McVay (1948)

Edge of the transversus abdominis aponeurosis to
Cooper’s ligament; incorporate Cooper’s ligament and
the iliopubic tract (transition suture)
BASSINI
MCVAY
SHOULDICE
Lichtenstein
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First pure prosthestic, tension-free repair
to achieve low recurrence rates
Groin Hernia Surgery: Open
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Inguinal floor: tension-free repair with mesh
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Anterior plug and patch
Anterior patch
Posterior patch (Stoppa)
Groin Hernia Surgery
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Open tissue repair for risk of infection (example:
strangulated hernia)
Laparoscopic
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Indications
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Recurrent hernia
Bilateral hernias
Must be able to tolerate general anesthesia
More expensive
Groin Hernia Repair
Complications

Recurrence
Tissue
repair: 1.3—25%
Tension-free mesh: 0.5—5%

Greatest risk is repair of previous hernia
at same location
Groin Hernia Repair
Complications

Chronic groin pain: up to 30%
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Numbness over base of scrotum
Groin Hernia Repair
Complications

Wound
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Infertility
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Hematoma: 1.0%
Infection: 1.3%
Seroma
Injury to vas deferens
Ischemic orchitis is uncommon
Urinary retention
Other Hernias
Umbilical Hernia

Fascial defect at the umbilicus with peritoneal
sac covered by skin


External bulge at the umbilicus or
periumbilically depending on
subcutaneous migration of sac
Exam: External bulge at or adjacent to the
umbilicus
Pediatric Umbilical Hernia

Present in 10-30% of babies

80% close spontaneously by age 2
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Indications for primary suture repair
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Hernia present after ages 2-4
Large (5 cm) defect at age 1
Adult Umbilical Hernia
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Increased intra-abdominal pressure
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Pregnancy
Obesity
Ascites
Differential diagnosis (rare)

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Embryologic remnants
Metastatic cancer
Adult Umbilical Hernia

Symptoms relate to cosmesis, traction
on the sac, or trapped contents
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Omentum
Small or transverse colon
Acute incarceration: reduction en
masse problematic
Adult Umbilical Hernia Repair
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Assess contents and manage appropriately
based on viability
Open hernia repair
 < 1 cm defect: primary suture repair
 > 1 cm defect: mesh repair lowers
recurrence
Laparoscopic hernia repair: size of access
ports often > hernia incision
Adult Umbilical Hernia Repair

Risks
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Recurrence
Umbilical necrosis
Injury to sac contents
Hematoma
Infection
Epigastric Hernia
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Fascial defect in supraumbilical linea
alba
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Most < 1 cm
20% with multiple defects
Beware diastasis recti
Men: Women 2:1
Epigastric
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midline junction of the
aponeuroses (linea alba)
between the xiphoid
process and umbilicus
Paraumbilical hernia epigastric hernia that
borders the umbilicus
Estimated frequency 35%
More common in Males
3:1
20% may be multiple
Epigastric Hernia


Contents
 Incarcerated preperitoneal fat or falciform
ligament
 Peritoneal sac
Repair
 Open repair similar as for umbilical hernia
 Must palpate or visualize entire supraumbilical
linea alba
 Laparoscopic approach is suboptimal
Spigelian Hernia

Defect through transversus abdominus and
internal oblique muscles
 Occurs at junction of arcuate line and linea
semilunaris
 Fascial defect 1-2 cm
 Covered by external oblique aponeurosis
Spigelian Hernia


occurs along the
semilunar line, which
traverses a vertical space
along the lateral rectus
border
where more than 90% of
spigelian hernias are
found
Spigelian Hernia

Clinical



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Swelling in middle to
lower abdomen lateral
to rectus muscle
Usually reducible
Up to 20% present
with incarceration
Tx: surgical


Mesh not required
Recurrence is
uncommon
Spigelian Hernia
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Presentation
 Lower abdominal swelling lateral to rectus
 Focal discomfort/pain
May require imaging studies for diagnosis
 Ultrasound or CT
Repair: open or laparoscopic, on-lay mesh
Incisional Hernia



Bulge in region of scar from surgery or
penetrating trauma
Chronic wound failure
 Up to 20% of abdominal incisions
Subcutaneous sac may be more complex
 Multi-loculated
 Contents adhesed within sac
Incisional Hernia: Risk Factors
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Previous incisional hernia repair
Obesity
Smoking
Chronic lung disease
Diabetes
Malnutrition
Wound infection
Incisional Hernia Repair


Fix conditions that promoted hernia
occurrence
Open repair

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Primary suture: < 52% recurrence
Mesh: < 24% recurrence
Incisional Hernia Repair
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Complex open repairs
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Stoppa mesh repair
Component separations repair
Laparoscopic repair
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Multiple fascial defects detected
Large on-lay intraperitoneal mesh
5 cm marginal overlap
Incisional Hernia
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Complications of repair
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Recurrence
Seromas
Injury to sac contents
Bleeding
Infection
Review

Pediatric hernias
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Inguinal
Umbilical

Adult hernias

Groin
Inguinal
 Femoral
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Umbilical
Epigastric
Spigelian
Incisional
Points to Remember
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
Hernias represent fascial defects with protrusion
of a peritoneal sac or preperitoneal fat
Asymptomatic bulge most common
Hernia risk is related to visceral obstruction or
strangulation
Tension-free repair with mesh produces lowest
recurrence rates
Summary

Etiology, pathology, clinical evaluation, and
treatment of abdominal wall hernias including
inguinal, femoral, umbilical, epigastric, Spigelian,
and incisional hernias
Scenario
Direct Hernia
Indirect inguinal
hernia
Direct inguinal
hernia
Relation to epigastric
vessels
Lataral
medial
Processus vaginalis
Present
Absent
Causes
congenital
Acqiured
Individual hernias
1.
Direct & indirect Inguinal
hernia.
2.
Femoral hernia.
3.
Umbilical hernia &
paraumbilical hernia.
4.
Incisional hernia.
5.
Epigastric hernia.
6.
Rare external Hernias.
Femoral Hernia

Femoral Hernias occur just below the
inguinal ligament, when abdominal
contents pass through a naturally
occurring weakness called the femoral
canal.
The Femoral canal :
 The most medial structure in the
femoral sheath,.
 extending from the femoral ring
to the saphenous opening.
 1.25cm x 1.25cm.
 Contains fat, lymph vessels and
the lymph node of cloquet.
Femoral Hernia (cont..)



Symptoms: Femoral hernias are more common in women, They
typically present as a groin lump. They may or may not be
associated with pain, a femoral hernia has often been found to be
the cause of unexplained small bowel obstruction.
Signs: an absent Cough impulse, with a more globular lump than
the pear shaped lump of the inguinal hernia.
Differential Diagnoses:




Inguinal Hernia.
Femoral Artery Aneurism.
Femoral Lymphadenopathy.
Psoas Abscess.
Umbilical & paraumbilical Hernia
A. Umbilical Hernia:





Seen in infants & children.
Effecting boys more than girls.
tend to resolve without any
treatment by around the age of
5 years.
Obstruction and strangulation
of the hernia is rare.
Babies are prone to this
malformation because of the
process during fetal
development by which the
abdominal organs form outside
the abdominal cavity, later
returning into it through an
opening which will become the
umbilicus.
B. Paraumbilical Hernia:
 Affects adults.
 The defect is either supra or
infraumbilical through the linea
alba.
 The female to male ratio is
20:1.
 May contain omentum, small
intestine or transverse colon.
Etiology:
1.
2.
3.
Obesity.
Flabbiness of the abdominal
muscles.
Multiparity.
Clinical Features:
Clolicky pain and/or irreducibilty
due to omental adhesions.
Incisional Hernia
Definition: An incisional hernia occurs when the area of weakness is the
result of an incompletely healed surgical wound. These can be among the
most frustrating and difficult hernias to treat. It can occur at any incision,
but tend to occur more commonly along a straight line from the sternum
breastbone straight down to the pubis, and are more complex in these
regions. Hernias in this area have a high rate of recurrence.
Causes:
 Any reasons leading to an icrease in intraabdominal pressure
postoperatively such as: chronic cough, vomitting, infection,
malnutrition diabetes, steroid treatment or a tension closure done
during the previous operation.
Clinical Features:
 Swelling at the incisional site +/- pain.
Ventral wall (Incisional)




Highest incidence in midline
and transverse incisions
Up to20% after laparotomy
1/3 present in 5-10 years
postoperatively
Risk factors


obesity, DM, ascites, steroids,
smoking malnutrition, wound
infection
Technical aspects of wound
closure


Type of incision
Excessive tension (prone to
fascial disruption)
Epigastric Hernia


Due to a defectin the linea alba between the
xiphoid process and the umbilicus
Starts as a protrusion of the extraperitoneal fat
at the site where a small vessel pierces the lina
alba and as it enlarges it drags a pouch of
peritoneum after it.
Clinical Features:

Swelling +/- pain similar to a peptic ulcer pain.
Rare external Hernias
Since many organs or parts of organs can herniate through many orifices,
it is very difficult to give an exhaustive list of hernias, with all synonyms
and eponyms. But her are Other hernial types and unusual types of
visceral hernias:
1.
Spiglian Hernia:





Occurs at the spaces of the semilunar line and the lateral edge of
the rectus muscle (inferior to the arcuate line).
The posterior rectus sheath jis weak thus leading to the
protrusion.
Preoperative diagnosis is diffucult & only correct in 50% of the
patients.
u/s & c.t are helpful tools in the diagnosis
Depending on the size of the defect, treatment varies from suture
approximation to using a mesh.
Rare hernias (cont..)
2. Lumbar Hernias:


In the lumbar region, in the form of a broad bulging hernia, that are
not vulnerable to incarceration.
Devided into:
A. Petit’s hernia: which occurs in the inferior lumbar triangle.
B. Grynfeltt’s Hernia: which occurs in the superior lumbar
triangle and is
less common that Petit’s.
Lumbar

Acquired lumbar hernias
–


Contains to anatomic
triangles, inferior and
superior lumbar triangles




back or flank trauma,
poliomyelitis, back surgery,
and the use of the iliac
crest as a donor site for
bone grafts
Grynfelt’s
Petit’s
Strangulation is rare
Soft swelling in lower
posterior abdomen
Rare hernias (cont..)
3. Obturator Hernia:




The obturator canal is covered by a
membrane pierced by the obturator
nerve and vessels. Any enlargement
in the canal or weakness in the
membrane may lead to herniation of
the intetines.
Because of differences in anatomy, it
is much more common in women
than in men.
It often presents with bowel
obstruction.
The Howship-Romberg sign is
suggestive of an obturator hernia,
exacerbated by thigh extension,
medial rotation and adduction. It is
characterized by lancilating pain in
the medial thigh/obturator
distribution, extending to the knee;
caused by hernia compression of the
obturator nerve.
Obturator






Rare form of hernia
Protrusion of intra-abdominal
contents through obturator
foramen
F:M ratio 6:1
The obturator foramen is
formed by the ischial and
pubic rami
obturator vessels and nerve lie
posterolateral to the hernia sac
in the canal
Small bowel is the most
likely intraabdominal
organ to be found in an
obturator hernia
Obturator

4 cardinal signs :
intestinal obstruction (80%)
 Howship-Romberg sign (50%) –History of
repeated episodes of bowel obstruction that
resolve quickly and without intervention
 Palpable mass (20%)


Tx: Sugical Repair
Sciatic





Via greater or lesser
sciatic notch
greater sciatic notch is
traversed by the
piriformis muscle, and
hernia sacs can protrude
either superior or inferior
to this muscle
suprapiriform defect 60%
Infrapiriform 30%
subspinous (through the
lesser sciatic foramen)
10%
EXAMINATION:
Hernias must be examined with the patient standing and in
supine
Always examine both groins.
INSPECTION:
Visible swelling. (site, size and shape)
Visible cough impulse.
Easily reducible
Reappear on straining, standing or coughing
Elucidate Fothergill and Carnet signs.
PALPATION:
Examine as a mass and then
Palpable cough impulse
Reduce
Occlusion test
Three Finger test ( Zimman’s test)
Examination
also asses the following:
Position
Temperature
Tenderness
Shape
Size
Tension
Composition
Expansile cough impulse
Reducible.
PERCUSSION AND AUSCULTATION:
Bowel sound.
Treatment
Most abdominal hernias can be surgically
repaired.
Uncomplicated hernias are principally repaired
by herniorrhaphy.
a Herniorrhaphy (Hernioplasty) is a surgical
procedure for correcting hernia, which can be
devided into four techniques:
Groups 1 and 2: open "tension" repair:

in which the edges of the defect are sewn back

together without any reinforcement or prosthesis. In
the Bassini technique, the conjoint tendon (formed
by the distal ends of the transversus abdominis
muscle and the internal oblique muscle) is
approximated to the inguinal canal and closed. [4]
Although tension repairs are no longer the standard
of care due to the high rate of recurrence of the
hernia, long recovery period, and post-operative
pain, a few tension repairs are still in use today.
Treatment (cont..)
Group 3: open "tension-free" repair:



Almost all repairs done today are open
"tension-free" repairs that involve the
placement of a synthetic mesh to strengthen
the inguinal region.
This operation is called a 'hernioplasty'. The
meshes used are typically made from
polypropylene or polyester. The operation is
typically performed under local anesthesia, and
patients go home within a few hours of
surgery, often requiring no medication beyond
aspirin or acetaminophen.
Recurrence rates are very low - one percent or
less, compared with over 10% for a tension
repair
Treatment (cont..)
Group 4: laparoscopic repair

"Lap" repairs are also tension-free, although the
mesh is placed within the preperitoneal space behind
the defect as opposed to in or over it.

It is further sub-devided into:
 T.A.P.P repair (transabdominal
preperitoneal)
 T.E.P repair (totally extraperitoneal)


It has no proven superiority to the open method
other than a faster recovery time and a slightly
lower post-operative pain score.
laparoscopic surgery, though, requires general
anesthesia, more expensive and consumes more
O.R. time than open repair and carries a higher risk
of complications, and has equivalent or higher rates
of recurrence compared to the open tension-free
repairs.