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Hernia
Shanghai Jiaotong University Medical School
Renji Hospital
Ni Xingzhi
Hernia
Definition
 A hernia is a swelling caused by the protrusion of
an organ or other tissue through an aperture in
the wall surrounding the space in which it is
situated.
 Such an aperture may be present normal or
abnormal, in which case it can be congenital or
acquired
Hernia
Causes
 Lowered abdominal strength
Abdominal wall where an orifice for an organ or some
tissue go thorough such as inguinal and femoral canal,etc
Or trauma, surgery, infection, obesity, senility etc.

Increased abdominal pressure
Cough, constipation, dysuria, acites, pregnancy, heavylifting
Hernia
Pathological anatomy
 Hernia sac
– Neck of sac

corresponds where the orifice is
– Mouth and body

Contents of sac
– Intra-peritoneal structure: small intestine or omentum

Covering of sac
– Layers of abdominal wall
Hernia
Classification
 Reducible hernia
 Irreducible hernia
– Can not return or completely
– With no severe symptoms

Incarcerated hernia Impaired blood supply
 Strangulated hernia Impaired blood supply till non
Special hernias:
Richter’s, Littre”s (Meckel’s diverticulum)
Hernia

Richter Hernia
Hernia Inguinal hernia
Anatomy
 Inguinal hernia
75% of hernia
– Inferior Inguinal ligament
– Medial Rectus
– superior Ant,sup.iliac spine

Indirect inguinal hernia 60%
– Lateral to inferior epigastric vessel through inguinal canal to
scrotum or not

Direct inguinal hernia
25%
– Through Hesselbach triangle medial to inferior epigastric vessel
Hernia Inguinal hernia

Inguinal
hernia
– Inferior
Inguinal
ligament
– Medial Rectus
– superior
Ant,sup.iliac
spine
Hernia Inguinal hernia

Anatomy of
the inguinal
region from
the internal
aspect, as
seen with the
laparoscopic
approach
Hernia Inguinal hernia
Anatomy
 Skin, fat and fascia(scarpa’s)
 External oblique muscle
–
–
–
–

External oblique muscle aponeurosis
Inguinal ,lacunar and pectineal ligament
External ring Medial and superior to pubic tubercle
Iliogastric and ilioinguinal nerve
External oblique and transversus muscle
– Conjoined tendon
fusion of the aponeuroses of the internal oblique and transversus muscles
where they insert on the pubic tubercle and superior pubic ramus.
Hernia Inguinal hernia


Skin, fat and
fascia(scarpa’s)
External oblique
muscle
– External
oblique muscle
aponeurosis
Hernia Inguinal hernia
• Inguinal
ligament
180-twist of the
external
oblique muscle
aponeurosis
forms a
shelving edge
in the lower
portion of the
ligament
Hernia Inguinal hernia
Anatomy
 Transversalis fascia
– Internal ring




1-2cm above mid-inguinal point
Laterally to inferior epigastric artery
Spermatic cord (vas deferens, testicular vessels), round
ligament
Extra-peritoneal fat
 Peritoneum
Hernia Inguinal hernia
Internal ring
– 1-2cm above
mid-inguinal
point
– Laterally to
inferior
epigastric artery
– Spermatic cord
(vas deferens,
testicular vessels),
round ligament
Hernia Inguinal hernia

inferior
epigastric
artery
Hernia Inguinal hernia
Anatomy of inguinal canal

A canal for passage of spermatic cord in male and round
ligament in female
 Anterior----external oblique aponeurosis,
internal oblique muscle(lateral 1/3)
 Posterior----transversalis fascia and peritoneum
 Superior---- internal oblique muscle and
conjoined tendon
 Inferior----inguinal and lacunar ligament
Hernia Inguinal hernia


Anterior---external oblique
aponeurosis,
internal oblique
muscle(lateral 1/3)
Posterior---transversalis
fascia and
peritoneum
Hernia Inguinal hernia


Anterior---external oblique
aponeurosis,
internal oblique
muscle(lateral 1/3)
Posterior---transversalis
fascia and
peritoneum
Hernia Inguinal hernia

Superior---internal oblique
muscle and
conjoined tendon
 Inferior---inguinal and
lacunar ligament
Hernia Inguinal hernia

Inguinal hernia
Hernia Inguinal hernia

Anatomy of
Hesselbach’s
triangle
It is bounded
superiorly by
lateral side of
rectus abdominis,
inferiorly by
inguinal ligament
and laterally by
inferior epigastric
vessels.
Hernia Inguinal hernia
Symptoms and Diagnosis of IIH
 Reducible hernia
–
–
–
–

Inguinal protrusion
Dragging discomfort in the groin
Particularly in lifting or strain
Returns after lying down or with help of hands
Irreducible hernia
– Un-retractable inguinal protrusion
– More discomfort
Hernia Inguinal hernia
Symptoms and Diagnosis of IIH
 Incarcerated hernia
– Sudden increased intra-abdominal pressure
– Sudden enlarged herniation with tenderness
– Bowel obstruction manifestations if content is small
intestine

Strangulated hernia
– Relieved pain but herniation persists
– Infarction and perforation of strangulated bowel
– Local and general infection
Hernia

Incarceration
Hernia Inguinal hernia
Symptoms and
Diagnosis
of DIH
 Mostly seen in elders
 Semi-spheres lateral to
pubic tubercle
 Seldom irreducible and
rarely strangulates
 Never goes into
scrotum
Hernia Inguinal hernia
Differentiation
 IIH and DIH
see table 45-1(textbook)
 Other diseases
– Hydrocele
– Undescended testes
– Acute bowel obstruction
Hernia Inguinal hernia
A Normal
B Proximal sac
C Hernia sac extended
to the scrotum
D Proximal and distal
obliteration with
hydrocele of the cord
C Hydrocele of the
scrotum
E Patent processus
with communicating
hydrocele
Hernia Inguinal hernia
Treatment
 Conservative
– Inguinal hernia truss

Surgical
– Dissection of inguinal canal
– Repair of myopectineal orifice
– Closure of inguinal canal
Hernia Inguinal hernia
Treatment
 Surgical
– Hernioplasty





Ferguson
Bassini
Halsted
McVay
Shouldice
Hernia Inguinal hernia-Bassini Operation
Incision of the External Oblique
Aponeurosis
Isolating the spermatic cord
Hernia Inguinal hernia-Bassini Operation
Resection of the Cremaster Muscle
Management of an Indirect Sac
Hernia Inguinal hernia-Bassini Operation
Splitting the Transversalis Fascia
Hernia Inguinal hernia-Bassini Operation
Suture of the Deep Plane
Hernia Inguinal hernia-Bassini Operation
Suture of the Deep Plane
Reconstructing the Anterior Wall of the
Inguinal Canal and the Superficial Planes
Hernia Inguinal hernia-Shoudice Repair
Hernia Inguinal hernia
Treatment
 Surgical
– Tension-free hernioplasty
Hernia Inguinal hernia
Treatment
 Surgical
– Tension-free
hernioplasty
Hernia Inguinal hernia
Treatment
 Surgical
– Laparascopic hernioplsty
Hernia Inguinal hernia

Laparascopic
hernioplsty
– Placement of mesh
internally in inguinal
region
Hernia Inguinal hernia
Treatment
 Irreducible and strangulated hernia
– Maneuver


Within3-4hrs, no tenderness and abdominal irritation
Patient not fit for surgery and without bowel infarction
– Surgery

No hernioplasty after bowel resection
Hernia femoral hernia

A femoral hernia projects through femoral canal
– 3-5% of groin hernia
– Mostly seen in women over 40 or pregnant
 Stretching of pelvic ligament
 Widening of femoral ring during pregnancy

Femoral canal
– Medial to femoral vein
– Opens into abdomen through femoral ring

Femoral canal
–
–
–
–
In front by inguinal ligament
Laterally by femoral vein
Internally by lacunar ligment
Posteriorly by pectineal ligament
Hernia femoral hernia

Femoral
canal
Hernia femoral hernia

Femoral
canal
– In front by
inguinal
ligament
– Laterally by
femoral vein
– Internally by
lacunar
ligment
– Posteriorly
by pectineal
ligament
Hernia femoral hernia

Clinical feature
– A bulge in upper aspect of thigh, beneath inguinal ligament
– Below and lateral the pubic tubercle
– Absence of a cough impulse over inguinal ring
– Liable to strangulate and can not be readily reduced


Differentiation
Surgery
– McVay’s procedure
– Cut inguinal ligament to enlarge the ring to reduce heriation
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