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5-year DDS Program
General Surgery
Department of Surgery
University School of Medical Science
POZNAN, POLAND
Chairman: prof. Dr hab. n.med. Waclaw Majewski
Hernias
NMS Surgery: Bruce
E.Jarrell, R.Anthony Carabasi, Lippincott
Williams & Wilkins
Suggested textbook:
Historical Perspective
• 15th century Castration with wound
cauterization or
hernia sac
debridement
• recommended a truss
Father of Modern Inguinal Hernia
Repair
EDUARDO BASSI NI
1844-1924
Nuovo metodo operativo per la cura dell'ernia inguinale, 1889
Hernia
• latin for rupture
• an abnormal protrusion of an
organ or tissue through a defect
in its surrounding walls
• the most common herniae develop in the abdomen when a weakness in the abdominal wall evolves into
a localized hole, or "defect", through which adipose
tissue, or abdominal organs covered with peritoneum,
may protrude
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
Epidemiology
• 600,000 hernia repairs yearly in the USA
• Inguinal hernias – 75-80% of all hernias
– 4/5 Indirect, remainder are direct
• Incisional hernias – 8-10%
• Umbilical and epigastric – 3-5%
• Femoral – 5%
Epidemiology
• Prevelance of hernias
increases with age
• Most serious complication
– strangulation – 1-3% of
groin hernias
• Femoral – highest rate of
complications
(strangulation) 15% to 20%
– recommended all be
repaired at time of discovery
Anatomy
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
Anatomy
The inguinal canal contains:
• the spermatic cord (M) and round ligament of the
uterus (F)
• Spermatic cord
–
–
–
–
–
–
–
Cremasteric muscle fibers
Testicular vessels
Genital branch of genitofemoral nerve
Vas deferens
Cremasteric vessels
Veins: pampiniform plexus
Processus vaginalis: an evagination of peritoneum
Anatomy
Hesselbach's triangle
Boundaries:
Medial:
Rectus abdominis muscle
medially
Inferiorly:
Inguinal ligament
Laterally:
Inf. Epigastrics
Anatomy
• Inguinal ligament
(Poupart’s) – inferior
edge of external
oblique
• lacunar ligament
(Gimbernat’s) –
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.
Terminology
• Reducible – can be replaced within
surrounding musculature
• Incarcerated – cannot be reduced
• Strangulated – compromised blood supply to its
contents
Terminology
• Pantaloon – direct and
indirect inguinal hernia
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
• Grynfeltt – hernia at
superior lumbar triangle
Groin Hernias
• Indirect Inguinal
• Direct Inguinal
• Femoral
Inguinal Hernia
• classified as congenital vs.
acquired
• commonly thought that repeated
increases in intra-abdominal
pressure contribute to hernia
formation
• collagen formation and structure
deteriorates with age, and thus
hernia formation is more common
in the older individual
Clinical Presentation
• Groin bulge
• Often asymptomatic
• Dull feeling of
discomfort or
heaviness in the groin
• Focal pain – raise
suspicion for
incarceration or
strangulation
• Symptoms of bowel
obstruction
Diagnosis
• Physical Exam
• 74.5% sensitive and
96.3% specific
• examine the patient in
the standing and
supine positions
• difficult to distinguish
direct and indirect on
exam on alone
Diagnosis
• Radiologic Investigations
– Herniography
• Suspected hernia, but clinical
dx unclear
• Procedure done under
flouroscopy following injection
of contrast medium
• Frontal and oblique
radiographs are taken with and
without increased intraabdominal pressure
– Ultrasonography
– MRI
– CT
Right direct inguinal hernia
Left indirect 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
• Abdominal contents
protrude through
internal inguinal ring
• 5 to 10 times more
common in men
Indirect Inguinal Hernia
• 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
• 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
• Requires palpation of the
femoral canal just below
the inguinal ligament in
the upper thigh
Treatment
• Non-Operative
– Observation
– Trusses can provide symptomatic relief
• Hernia control in ~30% of patients
Operative
•
•
•
•
•
•
Bassini
Shouldice
McVay
Lichtenstein
Preperitoneal
Laparoscopic
• Bassini (early 20th Century)
– Transversus abdominis to Thompson’s
ligament and internal oblique
musculoaponeurotic arches or conjoined
tendon to the inguinal ligament
• Shouldice (1930s) - multilayer imbricated repair of
the posterior wall of the inguinal canal
uses the transversalis fascia, which is divided longitudinally and imbricated
upon itself in two layers; the internal oblique muscle and conjoint tendon are
then sutured to the reflection of the inguinal ligament in two layers (total four
suture lines).
• McVay (1948) - Edge of the transversus abdominis
aponeurosis to Cooper’s ligament; incorporate Cooper’s ligament
and the iliopubic tract (transition suture)
• Lichtenstein
• First pure prosthestic, tension-free repair
to achieve low recurrence rates
• Lichtenstein
• The mesh is sutured to the aponeurotic tissue
overlying the pubic bone medially, continuing
superiorly along the transversus abdominis or
conjoined tendon. The inferolateral edge of the
mesh is sutured to the iliopubic tract or the
shelving edge of the inguinal ligament to a point
lateral to the internal inguinal ring. Neo-ring
created. The ilioinguinal nerve and genital
branch of the genitofemoral nerve are placed
with the cord structures and are passed through
this newly fashioned internal inguinal ring.
Prosthetic Repair
• Polypropylene mesh most common and
preferred
– allows for a fibrotic reaction to occur between
the inguinal floor and the posterior surface of
the mesh, thereby forming scar and
strengthening the closure of the hernia defect
• Polytetrafluoroethylene (PTFE) mesh
– often used for repair of ventral or incision
hernias in which the fibrotic reaction with the
underlying serosal surface of the bowel is
best avoided
Laparoscopic repair
Surgical Complications
•
•
•
•
•
•
Recurrence
Infection
Neuralgia
Bladder injury
Testicular injury
Vas Deferens injury
Other Hernias
Umbilical
Incidence
• Reported 3-8%
• several times greater in Black children
• more common in premature children all
races
• Most close spontaneously by age 2 or 3
• Acquired rather than congenital in adults
• Female to male ratio 10:1
Epigastric
• 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
• Clinical
– Often asymptomatic, incidental finding
– If symptomatic, vague abdominal pain above the umbilicus
exacerbated by standing or coughing; relieved in supine position
– Severe pain secondary to incarceration/strangulation o
preperitoneal fat (often no peritoneal sac) or omentum
– Exam: palpate small, soft, reducible mass superior to the
umbilicus
– RARE to have strangulated bowel
• Treatment – like umbilical hernia
– Excise fat and sac, close primarily
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%) – pain along the
obturator nerve (mid-anterior thigh)
• Palpable mass (20%)
– Treatment - Sugical Repair
Spigelian Hernia
• occurs along the
semilunar line, which
traverses a vertical space
along the lateral rectus
border
Spigelian Hernia
• Clinical
– Swelling in middle to
lower abdomen lateral
to rectus muscle
– Usually reducible
– Up to 20% present
with incarceration
• Treatment: surgical
– Mesh not required
– Recurrence is
uncommon
Lumbar
• Acquired lumbar hernias
– back or flank trauma,
poliomyelitis, back surgery,
and the use of the iliac crest as
a donor site for bone grafts
• Contains to anatomic
triangles, inferior and
superior lumbar triangles
– Grynfeltt’s
– Petit’s
• Strangulation is rare
• Soft swelling in lower
posterior abdomen
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%
Ventral wall (Incisional)
•
•
•
•
Highest incidence in midline
and transverse incisions
Up to 20% 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)