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HERNIAS BY Dr. Raid Maayah General Surgeon Jordanian Board Historical Perspective 15th century Castration with wound cauterization or hernia sac debridement recommended a truss Father of Modern Inguinal Hernia Repair EDUARDO BASSINI Hernia Latin for rupture an abnormal protrusion of an organ or tissue through a defect in its surrounding walls Occur at sites where aponeurosis and fascia are not covered by striated muscle Which of the following statements is/are true regarding incidence of the abdominal wall hernia? A. B. C. D. E. Two-thrirds of all inguinal hernias are classified as indirect. Femoral hernias are more common in females than in males. Direct hernias are common in females. Hernias generally occur with equal frequency in males and females Premature babies have a 10% incidence of having inguinal hernia. Epidemiology 700,000 hernia repairs year Inguinal hernias -75% of all hernias ◦ 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 Abdominal Wall Anatomy 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 Inguinal Canal Contains the spermatic cord and round ligament of the uterus Spermatic cord ◦ Cremasteric muscle fibers ◦ Testicular vessels ◦ Genital branch of genitofemoral nerve ◦ Vas deferens ◦ Cremasteric vessels 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 Terminology Reducible – can be replaced within surrounding musculature Incarcerated – cannot be reduced Strangulated – compromised blood supply to its contents Sends sensory branches to the inner thigh and medial aspect of the scrotum A. B. C. D. Ileoinguinal nerve Genitofemoral nerve Both Neither 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 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 Groin Hernias Indirect Direct 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 Inguinal hernia Male inguinal hernia Female inguinal hernia 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 intra-abdominal pressure ◦ Ultrasonography ◦ MRI ◦ CT Herniography Left indirect inguinal hernia Right direct inguinal hernia 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 Abdominal contents protrude through internal inguinal ring 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 Femoral palpation of the femoral canal just below the inguinal ligament in the upper thigh NAVELS Which of the following statements is/are true regarding direct inguinal hernias? The most likely cause is destruction of connective tissue resulting form physical stress. B. Direct hernias should be repaired promptly because of the risk of incarceration. C. A direct hernia may be a sliding hernia involving a portion of the bladder wall. D. A direct hernia may pass through the external inguinal ring. E. Colon carcinoma is a known cause of direct inguinal hernias. A. 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 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 First pure prosthestic, tension-free repair to achieve low recurrence rates 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 Prospective study Danish Hernia database of over 13,000 hernia repairs Compared reoperations for recurrent hernia Results: After 5 years significantly lower (1/4 less) recurrence with mesh vs. sutured repair Laparoscopic The cause of neuropathic postherniorrhaphy inguinodynia includes which of the following? A. B. C. D. E. Formation of scar tissue Transection of the ilioinguinal, iliohypogastric, or the genitofemoral nerves Suture entrapment of nerves Staple entrapment of nerves Periosteal reaction Surgical Complications Recurrence Infection Neuralgia Bladder injury Testicular injury Vas Deferens injury Other Hernias Which of the following is/are true statements regarding umbilical hernias? They are embryonic equivalent of a small omphalocele B. Repair in infants is usually deferred until approximately 4 years of age C. Repair in adults is usually indicated D. The “vest-over-pants” type of repair is stronger than simple approximation of fascial margins E. They are most common in Caucasian infants A. Umbilical Incidence Reported ~10% 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 3:1 Epigastric midline junction of the aponeuroses (linea alba) between the xiphoid process and umbilicus Paraumbilical hernia epigastric hernia that borders the umbilicus Estimated frequency 3-5% 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 of preperitoneal fat (often no peritoneal sac) or omentum ◦ Exam: palpate small, soft, reducible mass superior to the umbilicus ◦ RARE to have strangulated bowel Tx ◦ Excise fat and sac, close primarily An 82-year-old previously healthy woman has a 12-hour history of severe epigastric pain associated with nausea and vomiting. She has had no previous abdominal operations. Her WBC count is 21,000/cu mm. The plain films and abdominal CT shown are obtained. Which of the following best describes this patient’s diagnosis? A. B. C. D. E. Pain in the medial thigh and knee is uncommonly associated with this condition It is unusual in women It is unusual in elderly patients It is seldom associated with intestinal necrosis It is usually unilateral 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 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 ◦ 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 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 ◦ Grynfelt’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% Which of the following hernias is most likely to recur after primary repair? A. B. C. D. E. Epigastric hernia Spigelian hernia Indirect hernia Femoral hernia Incisional hernia 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) Which of the following hernias represent an incarceration of a limited portion of small bowel? A. B. C. D. E. Spigelian hernia Grynfelt’s hernia Petit’s hernia Richter’s hernia Littre’s hernia
