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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 Thank you very much!