Download Inguinal hernia

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1 Hernias
1.1 A few statistics
HerniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes.s are a widespread phenomenon. Accordingly, around 27 % of men and 3% of
women will suffer from an inguinal herniaThe most common type of hernia with hernial orifice above the inguinal
ligament in the region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. at some stage of their
life. Based on estimates released by international hernia societies, some 20 million people worldwide underwent
inguinal hernia surgery in 2007. In Germany around 275,000 inguinal hernia procedures and just under
100,000 abdominal wall herniaLatin term: hernia ventralis. Hernia of the abdominal wall. operations are carried out
each year. Both children and adults of any gender or age can be affected by this condition.
In abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle layers)
enclosing the abdominal cavity. surgery there is a disease-induced gap in the abdominal wall through which the
peritoneumA smooth layer of connective tissue that lines the abdominal cavity and covers most of the internal
organs., and possibly internal abdominal organs, can protrude. In inguinal hernias the opening is situated in the
region of the inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal
region through the abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring.
The lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the female, the round
ligament of the uterus pass through the inguinal canal., while in diaphragmatic herniaHernia in the region of the
diaphragm. See also hiatal hernia.s it is located within the diaphragmDome-shaped muscle plate protruding into the
chest cavity, which is secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition
between the chest cavity and abdominal cavity. It is the most important respiratory muscle; its muscle fibres
contract when breathing in and relax when breathing out.. Every type of hernia poses a risk of constriction and
life-threatening strangulation of organs, in particular of the large intestine. The risk of strangulation is around 1–3 %
per year.
Hernias should always be operated on since the congenital (present at birth) or acquired gap in the abdominal wall
will not close on its own. If a hernia is operated on at any early stage, it generally poses no danger. Hence, in
principle surgery can be equated with a cure for the disease.
Hernia operations are routine procedures that are performed very often and for many years now. In recent years
the surgical techniques have been continually improved, hence there is an optimal form of treatment available for
each individual case.
1.2 A look at the anatomy
In order to understand why herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with
congenital or acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum
(hernial sac), possibly together with parts of the intestines, protrudes.s occur, we need to take a closer look at the
anatomical structures of the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as
well as muscle layers) enclosing the abdominal cavity., inguinal canalLatin term: canalis inguinalis. A canal
measuring 4 to 5 cm long, running in the inguinal region through the abdominal wall. It originates at the internal
inguinal ring and leads into the external inguinal ring. The lymph vessels and, in the male, the spermatic cord with
the seminal duct and, in the female, the round ligament of the uterus pass through the inguinal canal. and
diaphragmDome-shaped muscle plate protruding into the chest cavity, which is secured to the sternum, costal
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arches and lumbar spine. The diaphragm forms a partition between the chest cavity and abdominal cavity. It is the
most important respiratory muscle; its muscle fibres contract when breathing in and relax when breathing out..
1.2.1 The abdominal wall
The anterior abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle
layers) enclosing the abdominal cavity. is bordered at the upper end by the rib cage and at the lower end by the
inguinal ligamentLatin term: ligamentum inguinale. Reinforcement of a fascia in the lumbar region, which, inter alia,
is fused with the aponeuroses of the oblique abdominal muscles and the transverse fascia.. It is composed of
different layers of tissue lying on top of each other and enclosed on the outside by the skin. Situated immediately
beneath the skin is fat tissue (subcutaneous adipose tissue), beneath that various muscle layers with associated
tendon plates (also called "aponeuroses"). The abdominal wall musculature includes the three lateral abdominal
muscles which, with their wide and flattened tendons providing elastic support, like a corset, to the abdominal
contents. There is also the anterior rectus abdominis muscleLatin term: musculus rectus abdominis. The rectus
muscle runs in two straight lines from the chest to the pelvis. It is subdivided by several intermediate tendons.
(rectus muscle) running down the midline of the body and containing a tendinous cover called the rectus sheathA
covering, composed of the tendinous plates of the anterior abdominal muscles, of the rectus abdominis muscle
(Latin term: musculus rectus abdominis) which runs down the midline of the body.. This, too, is closely intertwined
with connective tissue structures of the abdominal wall and helps retain the abdominal contents in position.
Beneath the muscle layers is, in addition to connective and adipose tissue, the peritoneumA smooth layer of
connective tissue that lines the abdominal cavity and covers most of the internal organs.. It serves as a smooth
lining covering the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk situated between the
diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the peritoneum. and
enclosing the majority of internal organs. [Fig. 1]
Fig 1: The anatomy of the abdominal wall
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1.2.2 The inguinal canal
The inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region
through the abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring. The
lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament of
the uterus pass through the inguinal canal. is a canal measuring around 4 to 5 cm in length and traversing the
abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle layers)
enclosing the abdominal cavity. from the top to the bottom in the inguinal region. Within it are nerves and lymph
vessels as well as, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament
(one of the ligaments serving to secure the uterus within the pelvis). In terms of anatomy, the inguinal region is a
weak point of the abdominal wall since in some parts of it the muscle-tendon layer is very thin. [Fig. 2]
Fig. 2: The anatomy of the inguinal canal
1.2.3 The diaphragm
The diaphragmDome-shaped muscle plate protruding into the chest cavity, which is secured to the sternum, costal
arches and lumbar spine. The diaphragm forms a partition between the chest cavity and abdominal cavity. It is the
most important respiratory muscle; its muscle fibres contract when breathing in and relax when breathing out. is a
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muscular plate that separates the chest and abdominal cavities from each other. It is secured to the breast bone
(sternum), rib cage and lumbar spine, projecting into the chest cavity in the form of two domes. In addition to a
number of smaller gaps, the diaphragm has three large openings: oesophageal hiatusLatin term: hiatus
oesophageus. Opening in the diaphragm through which the oesophagus passes. for the oesophagusGullet.
(gullet), aortic hiatusOpening in the diaphragm through which the aorta as well as lymph (lymphatic) vessels run.
for the aortaLargest artery in the body. (the main blood vessel in the body) and, finally, the opening for the inferior
vena cavaLatin term: vena cava inferior. Large blood vessel running through the vena cava orifice of the diaphragm
from the abdominal cavity into the chest cavity.. These natural openings are potential sources of herniaDerived
from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal
wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with parts of the
intestines, protrudes.s through which, in the event of disease, organs or structures can be displaced from the
abdominal cavityLatin term: cavitas abdominalis. The region of the trunk situated between the diaphragm and
pelvis containing the abdominal organs. The abdominal cavity is lined with the peritoneum. into the chest. Hernias
passing through the oesophageal hiatus are also called hiatal herniaDiaphragmatic hernia protruding through the
oesophageal hiatus.s. [Fig. 3]
Fig. 3: The anatomy of the diaphragm
1.3 What is a hernia?
1.3.1 Structure
Derived from the Greek word “hernos” (bud, sprout, protrusion), the term herniaDerived from the Greek word
“hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in the abdominal wall or diaphragm
(hernial orifice) through which the peritoneum (hernial sac), possibly together with parts of the intestines, protrudes.
means an opening, for example in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose
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tissue as well as muscle layers) enclosing the abdominal cavity., through which the peritoneumA smooth layer of
connective tissue that lines the abdominal cavity and covers most of the internal organs., possibly together with
parts of the intestines, can protrude. This opening can be of congenital or acquired origin. The medical designation
for this opening is hiatal orifice and the protruding peritoneum is called the hiatal sac, and any organ structure
contained therein is called the hernia contentsThe components of the abdominal cavity, such as intestines or
greater omentum, contained within the hernial sac.. The hernial openings can be situated in the abdominal wall, in
the vicinity of surgical scars, in the diaphragmDome-shaped muscle plate protruding into the chest cavity, which is
secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition between the chest cavity
and abdominal cavity. It is the most important respiratory muscle; its muscle fibres contract when breathing in and
relax when breathing out., inguinal region, floor of the pelvis, abdominal cavityLatin term: cavitas abdominalis. The
region of the trunk situated between the diaphragm and pelvis containing the abdominal organs. The abdominal
cavity is lined with the peritoneum. and even in the muscles of the back.
As such, a hernia is made essentially of the following three parts [Fig. 4]:
·
Hernial orificeGap in the abdominal wall or in the diaphragm through which the peritoneum, possibly
together with parts of the intestines, protrudes.: Disease-induced gap, for example in the abdominal wall.
Depending on its location, it runs through different tissue layers (muscles, tendons, scar tissue, etc.). The location
of the hernial opening determines how the hernia will be designated, for example, one uses the term inguinal
herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the region of the lateral or
medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral
inguinal hernia and medial inguinal hernia., umbilical hernia (close to the navel), incisional herniaHernia occurring
after an abdominal operation in the region of the surgical scar. (in the region of a surgical scar), diaphragmatic
herniaHernia in the region of the diaphragm. See also hiatal hernia., etc.
·
Hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents.: Projection of the peritoneum protruding through the hernial opening. On the outside the hernial
sac is covered by subcutaneous adipose tissue and skin. These layers are called the hernia coveringStructure
enclosing the hernial sac with subcutaneous adipose tissue and skin. .
·
Hernia contents: The hernial sac is either empty or – as in the majority of cases – filled with the hernia
contents. The hernia contents can be made of different components, for example of intestinal loops and/or parts of
the greater omentumLatin term: omentum majus. An adipose and connective tissue layer lined with the peritoneum
and covering the small intestine. The greater omentum is responsible for immune defence in the abdominal
cavity. (this is an apron-like peritoneal structure made of fat and connective tissue which is normally spread across
the intestinal loops). The hernia sac generally contains a fluid called hernia waterFluid contained within the hernial
sac, promoting sliding of the hernia contents., promoting sliding of the hernia contents.
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Fig. 4: Structure of a hernia
1.3.2 Causes
A herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes. can have different causes. Essentially, a distinction is made between congenital
and acquired herniaHernia with hernial orifice and hernial sac situated at a location on the abdominal wall where
there is acquired weakness. The reduction in the strength of the abdominal wall may be due to: impaired collagen
synthesis, raised internal abdominal pressure, overweight, pregnancy.s.
1.3.2.1 Congenital hernias
Here the herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired
gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly
together with parts of the intestines, protrudes. sac is present in some cases at birth as an anlage. In the case of a
congenital inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia., for example, a
finger-shaped protrusion of the peritoneumA smooth layer of connective tissue that lines the abdominal cavity and
covers most of the internal organs., projecting through the internal inguinal ringOrigin of the inguinal canal on the
inside of the abdominal wall situated above the inguinal ligament. into the inguinal canalLatin term: canalis
inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region through the abdominal wall. It originates
at the internal inguinal ring and leads into the external inguinal ring. The lymph vessels and, in the male, the
spermatic cord with the seminal duct and, in the female, the round ligament of the uterus pass through the inguinal
canal., serves as hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents.. In the congenital umbilical herniaHernia protruding in infants or young children through the, as
yet, incompletely closed umbilical ring (congenital hernia), and occurring in adults due to a weakness in the region
of the navel (acquired hernia). the hernial sac projects outwards through the incompletely closed umbilical
ringRing-shaped opening in the tissue around the navel. (a ring-shaped opening in the tissue around the navel). In
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general, congenital herniaHernial orifice and hernial sac are present as an anlage already at birth.s occur already
during infancy or at a young age.
1.3.2.2 Acquired hernias
In acquired herniaHernia with hernial orifice and hernial sac situated at a location on the abdominal wall where
there is acquired weakness. The reduction in the strength of the abdominal wall may be due to: impaired collagen
synthesis, raised internal abdominal pressure, overweight, pregnancy.s a hernial orificeGap in the abdominal wall
or in the diaphragm through which the peritoneum, possibly together with parts of the intestines, protrudes. with
hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is
formed at certain weak points of the body, example in the abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. when there is a lack of
abdominal wall strength or in the vicinity of surgical scars because of incomplete scar formation. One important
cause is a defect in collagenStructural protein of the connective tissue. metabolism. Since collagen is responsible
for the connective and supporting tissues of the body, any disruption in its production leads to connective tissue
instability and reduced scar strength. The risk of development of a defect in collagen metabolism, and hence of
connective tissue weakness, increases with age. Hernias can also occur due to a sharp rise in the internal
abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through coughing or pressing.,
as in the case of chronic cough due to lung disease, chronic constipation leading to increased pressing during
bowel movements or if regularly carrying heavy loads. Other risk factors are pregnancy and overweight. In a few
rare cases no reasons can be definitively identified for onset of a hernia.
1.3.3 Complications
HerniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or acquired gap in
the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac), possibly together with
parts of the intestines, protrudes.s can lead to a number of physical and aesthetic defects. Strangulation of the
hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. in
the hernial opening gives rise to a dangerous situation. This is called incarcerationConstriction of tissue, for
example of hernia contents such as greater omentum or intestinal loops in the presence of hernias. Due to swelling
following blood congestion and oedema there is a risk of death (necrosis) of the constricted organs. and results in
local blood congestionLocal accumulation of blood. and leakage of fluid into the tissues (oedemaWater
accumulation in tissue; accompanied by swelling of the tissue.). Tissue swelling leads to virtual strangulation and
impaired blood flow of the organ structure enclosed within the hernial sac. If, because of its size, it is no longer
possible to push back the hernial sac into the body, there is a risk of death (necrosisTissue death due to
irreversible failure of cell functions (cell death).) of its contents, for example strangulated intestinal loops, if surgery
is not promptly carried out. This situation causes the patient severe pain and constitutes an acute emergency
warranting immediate hospitalisation or emergency treatment.
Strangulation of a hernia poses a threat of tissue death and calls for immediate surgery.
1.4 Different types of hernias
A hernia can occur at different body sites. Different types are identified, depending on where the hernia opening is
situated. [Fig. 5]
The most important types of hernias:
Epigastric hernia
Hernia in the midline of the upper abdomenBauch, Unterleib.
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Umbilical hernia
Hernia in the navel region
Incisional hernia
Hernia in the vicinity of a scar left after a previous operation
Inguinal hernia
Hernia in the inguinal region
Femoral hernia
Special form of inguinal hernias descending to the thigh
Parastomal hernia
Hernia in the presence of an artificial intestinal outlet (stoma)
Hiatal hernia
Diaphragmatic hernia at the site where the oesophagus enters the abdomen
Fig. 5: Different types of hernias and their localisation
1.4.1 Epigastric hernia
An epigastric herniaA hernia of the upper abdomen whose hernial orifice is situated in the region of the linea alba.
is a hernia in the midline of the upper abdomenTummy, belly. (between the breast bone (sternum) and navel). The
hernia opening is situated in the region of what is known as the linea alba. This is a tendinous strip formed from the
tendinous skin of the lateral abdominal muscles. The hernial sacEvagination of the peritoneum that protrudes
through a hernial orifice. It may contain hernia contents. may contain components of the greater omentumLatin
term: omentum majus. An adipose and connective tissue layer lined with the peritoneum and covering the small
intestine. The greater omentum is responsible for immune defence in the abdominal cavity., and in rare cases also
parts of the small intestines. Risk factors for onset of an epigastric hernia are connective tissue weakness,
increased internal abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through
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coughing or pressing. (e.g. in the event of chronic cough and strong pressing because of constipation), overweight
and frequent carrying of heavy loads. In general, epigastric hernias can be seen and/or felt. It may, or may not be,
accompanied by pain. If affects men and women equally.
1.4.2 Umbilical hernia
Around 5 % of all herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes.s are umbilical herniaHernia protruding in infants or young
children through the, as yet, incompletely closed umbilical ring (congenital hernia), and occurring in adults due to a
weakness in the region of the navel (acquired hernia).s. Often, they are of a congenital nature and thus manifest
already in infancy or at a young age. In adults mainly acquired herniaHernia with hernial orifice and hernial sac
situated at a location on the abdominal wall where there is acquired weakness. The reduction in the strength of the
abdominal wall may be due to: impaired collagen synthesis, raised internal abdominal pressure, overweight,
pregnancy.s are seen, attributable – for example in pregnant women or persons engaging in heavy physical work –
to increased internal abdominal pressureThe pressure prevailing inside the abdomen; this can be raised through
coughing or pressing..
Since the tissue of the abdominal navel is, by nature, less stable than that of the surrounding tissues, the navel
represents a natural weak point in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose
tissue as well as muscle layers) enclosing the abdominal cavity.. In the umbilical hernia, the hernial sacEvagination
of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. protrudes through the
umbilical ringRing-shaped opening in the tissue around the navel.; this is a ring-shaped opening in the tissue
around the navel. The hernia manifests as a swelling in the navel region, and may be painful. The hernial sac may
contain lymphatic or fat tissue from the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum., and in some cases also parts of abdominal organs. Whereas strangulation is virtually never seen in
congenital umbilical hernias, this is by all means possible in the case of acquired umbilical hernias occurring in
adults. Therefore the latter cases should be operated on immediately. In most cases, a congenital umbilical hernia
heals spontaneously, hence surgery is generally not needed.
1.4.3 Incisional hernia
Incisional herniaHernia occurring after an abdominal operation in the region of the surgical scar.s occur after open
surgical procedures on the abdomenTummy, belly. in the region of the surgical scar. This type of hernia is seen
after some 10 % of all abdominal operations. Based on data from the German Federal Statistical Agency, around
50,000 incisional hernia surgical procedures are carried out each year in Germany (!).
Incisional hernias arise because of a lack of strength of the surgical scar. Contributory factors include wound
infection, bleeding, impaired wound healing, patient’s poor general and nutritional status, special diseases such as
diabetes or cancer, overweight, medications (in particular cortisone preparations), long-standing nicotine
consumption as well as defective collagenStructural protein of the connective tissue. metabolism. Incisional hernia
generally presents within one year of abdominal surgery. The main symptom is a visible or palpable protrusion in
the region of a still relatively fresh abdominal surgical scar.
Even if an incisional hernia does not give rise to any complaints, it should nonetheless be operated on since it
could cause dangerous complications, in particular strangulation of intestinal components. However, the original
surgical scar should be first allowed to heal, something that in general takes around six months after the
procedure.
1.4.4 Inguinal hernia
Inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the region of the
lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also
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lateral inguinal hernia and medial inguinal hernia.s account for around 75–80 % of all hernias and are thus the most
common type of hernia. Around 27 % of men and 3 % of women will develop an inguinal hernia at some stage of
their life. Thanks to a narrower inguinal canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long,
running in the inguinal region through the abdominal wall. It originates at the internal inguinal ring and leads into the
external inguinal ring. The lymph vessels and, in the male, the spermatic cord with the seminal duct and, in the
female, the round ligament of the uterus pass through the inguinal canal., women on the whole are less commonly
affected than men.
A distinction is made between medial (= direct) and lateral (= indirect) inguinal hernias.
1.4.4.1 Medial/direct inguinal hernia
This type of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. is always acquired. It
accounts for around 30–40 % of all cases of inguinal hernias and affects in particular men of advanced age. The
hernial opening is situated in the area of what is known as Hesselbach’s triangle, a muscle-free region of the
inguinal fossa. The hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents. runs medially to the blood vessels of the lower abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity. (medial = parallel to the
midline of the body). It protrudes vertically, that is through a direct pathway, through a region of the abdominal body
with acquired tissue weakness.
1.4.4.2 Lateral/indirect inguinal hernia
This type of inguinal herniaThe most common type of hernia with hernial orifice above the inguinal ligament in the
region of the lateral or medial inguinal fossa (Latin term: [no-glossary]fossa inguinalis
lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal hernia. can be either of
congenital or acquired origin. It accounts for around 60–70% of all cases of inguinal hernias and affects men in
particular. It occurs mainly on the right side of the body (49 %), less commonly on the left side (36 %) or on both
sides (15 %). Lateral inguinal herniaAlso called indirect inguinal hernia. A lateral inguinal hernia can be either of
congenital or acquired origin. It runs through the inguinal canal, with the internal inguinal ring as hernial orifice.s do
not project directly through the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as
well as muscle layers) enclosing the abdominal cavity., running instead – indirectly – through the inguinal
canalLatin term: canalis inguinalis. A canal measuring 4 to 5 cm long, running in the inguinal region through the
abdominal wall. It originates at the internal inguinal ring and leads into the external inguinal ring. The lymph vessels
and, in the male, the spermatic cord with the seminal duct and, in the female, the round ligament of the uterus pass
through the inguinal canal.. The internal inguinal ringOrigin of the inguinal canal on the inside of the abdominal wall
situated above the inguinal ligament., which is the entrance to the inguinal canal in the region of the lateral inguinal
fossaExternal inguinal fossa., serves as hernia opening. The hernial sacEvagination of the peritoneum that
protrudes through a hernial orifice. It may contain hernia contents. then protrudes towards the outside at the
external inguinal ringThis is also known as the superficial inguinal ring (Latin term: anulus inguinalis superficalis).
The opening in the inguinal canal on the outside of the abdominal wall above the pubic tubercle, formed by an
opening in the tendon of the external oblique abdominal muscle (Latin term: musculus obliquus externus
abdominis)., which is the outlet of the inguinal ring.
In females, the lateral inguinal hernia can reach as far as the labia majora and, in males, as far as the scrotum. The
terms labial and scrotal herniaLatin term: hernia scrotalis. Lateral inguinal hernia whose hernial sac stretches as far
as the scrotum.s are used, respectively, to denote these conditions.
1.4.5 Femoral hernia
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Around 7 % of all herniaDerived from the Greek word “hérnos” (bud, sprout, protrusion). Hernia with congenital or
acquired gap in the abdominal wall or diaphragm (hernial orifice) through which the peritoneum (hernial sac),
possibly together with parts of the intestines, protrudes.s are femoral herniaLatin term: hernia femoralis. A hernia
passing through the lacuna vasorum.s. This special type of inguinal herniaThe most common type of hernia with
hernial orifice above the inguinal ligament in the region of the lateral or medial inguinal fossa (Latin term:
[no-glossary]fossa inguinalis lateralis[/no-glossary]/medialis). See also lateral inguinal hernia and medial inguinal
hernia. is virtually always acquired and affects mainly women (around 80 % of cases). Risk factors are, in addition
to female gender, advanced age, history of pregnancy / pregnancies as well as overweight. The hernia opening of
femoral hernias is situated beneath the inguinal ligamentLatin term: ligamentum inguinale. Reinforcement of a
fascia in the lumbar region, which, inter alia, is fused with the aponeuroses of the oblique abdominal muscles and
the transverse fascia. in what is known as the lacuna vasorum, which is the entry site for the blood vessels and
nerves supplying the thigh.
Often, a femoral hernia is diagnosed only at a very late stage, or indeed commonly only when complications are
already present. This is due to the fact that the patients concerned feel only a diffuse pressure pain beneath the
groin, or indeed no pain at all. In obese patients, in particular, it is often difficult to see or feel a femoral hernia in
the form of a swelling below the groin. Hence it is often diagnosed only when the hernial sacEvagination of the
peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is already strangulated within
the hernia opening. By that stage, there is a risk of the hernial sac (for example intestinal loops) not being
adequately supplied with blood, thus posing a risk of necrosisTissue death due to irreversible failure of cell
functions (cell death). (tissue death). For that reason a femoral hernia should always be operated on as early as
possible.
1.4.6 Parastomal hernia
Parastomal herniaA parastomal hernia is an incisional hernia in the vicinity of an artificial intestinal outlet
(endostoma).s are hernias occurring beside (Greek term para = beside) an artificial intestinal outlet (stoma). The
opening in the abdominal wallThe anterior tissue structures (skin, subcutaneous adipose tissue as well as muscle
layers) enclosing the abdominal cavity., which is needed to construct the stoma, serves as the hernia opening
through which the hernial sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain
hernia contents., possibly with parts of the intestines or greater omentumLatin term: omentum majus. An adipose
and connective tissue layer lined with the peritoneum and covering the small intestine. The greater omentum is
responsible for immune defence in the abdominal cavity., protrude outwards. Up to 50 % of all stoma patients are
affected by a parastomal hernia, thus making it the most common complication associated with an artificial
intestinal outlet.
A parastomal hernia occurs if the scar in the region of the stoma (opening) is not sufficiently strong. Contributory
factors are impaired wound healing, bleeding and wound infections, in addition to the patient’s poor general and
nutritional status, special diseases such as diabetes or cancer, overweight, medications (in particular cortisone
preparations), long-standing nicotine consumption as well as defective collagenStructural protein of the connective
tissue. metabolism. The symptoms of a parastomal hernia are palpable defects in the affected tissue or a
protrusion in the region of the artificial intestinal outlet, occurring when coughing or pressing.
1.4.7 Hiatal hernia
If the oesophageal hiatusLatin term: hiatus oesophageus. Opening in the diaphragm through which the
oesophagus passes. is expanded because of a congenital or acquired weakness of the surrounding tissue, a
diaphragmatic herniaHernia in the region of the diaphragm. See also hiatal hernia. can occur at this site. In such a
hiatal herniaDiaphragmatic hernia protruding through the oesophageal hiatus. there is partial or complete
displacement of abdominal organs into the chest cavity. Depending on the size of the hernia, different types are
identified.
The most common type is the axial sliding herniaHiatal hernia, where the stomach is pushed upwards, with
the entrance to the stomach (cardia) being displaced into the chest cavity., where the stomach is pushed
somewhat upwards, resulting in the entrance to the stomach together with the cardiaThe part of the oesophagus
leading into the stomach; entrance to the stomach. (the site where the oesophagusGullet. enters the stomach)
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being displaced into the chest cavity. Often, a sliding hernia causes none, or few, complaints. Hence it is commonly
diagnosed only by chance. However, if the muscular closure mechanism between the oesophagus and stomach
does not function properly because of displacement of the stomach, there can be refluxBackflow of gastric juice
into the oesophagus. (backflow) of stomach acid into the oesophagus. This, in turn, gives rise to irritation of the
oesophageal mucosa causing reflux diseaseIn the presence of an axial sliding hernia, backflow of acidic gastric
juice into the oesophagus with onset of heartburn as well as swallowing disorders. withthe typical symptoms of
heartburn, swallowing disorders and pain in the upper abdomenTummy, belly.. If hiatal hernia causes such
complaints, attempts are made first of all to treat this by means of conservative measures such as weight reduction,
change of diet, change of lifestyle and drug-based treatment. If these prove unsuccessful, the hernia should
definitely be treated surgically as soon as possible.
In the less common paraoesophageal herniaWith this type of diaphragmatic hernia the proximal section of
the stomach near the oesophagus protrudes through the oesophageal hiatus into the chest cavity. the first
(proximal) portion of the stomach is displaced through the oesophageal hiatus and along the oesophagus into the
chest cavity (the entrance to the stomach, the cardia, remains within the abdominal cavityLatin term: cavitas
abdominalis. The region of the trunk situated between the diaphragm and pelvis containing the abdominal organs.
The abdominal cavity is lined with the peritoneum., unlike in the case of the axial sliding hernia). In some cases
with this type of hiatal hernia parts of other organs, such as intestinal loops or parts of the greater omentumLatin
term: omentum majus. An adipose and connective tissue layer lined with the peritoneum and covering the small
intestine. The greater omentum is responsible for immune defence in the abdominal cavity. are displaced into the
chest cavity. To begin with, patients have generally no complaints, as only later do symptoms such as a feeling of
fullness, or pressure occur in the chest, swallowing disorders or respiratory distress. Life-threatening complications
can occur because of strangulation of the displaced organs. Therefore the paraoesophageal hernia must always be
surgically treated as soon as possible.
In some cases mixed forms of sliding hernia and paraoesophageal hernia are seen. A rare, but severe form of
paraoesophageal hernia is the upside-down stomach, also known as a thoracic stomachSee Upside-down
stomach.. In such a case two-thirds or more of the stomach (or even the entire stomach) are displaced into the
chest cavity. This causes distortion of the stomach and displacement of the chest cavity organs, in particular of the
lungs and heart. Patients thus often suffer from cardiovascular complaints, respiratory distress or chest pain. Just
like other paraoesophageal hernias, an upside-down stomachAlso called thoracic stomach. A severe form of
paraoesophageal hernia where two-thirds or more of the stomach (or even the entire stomach) are displaced into
the chest cavity. must be operated on as quickly as possible to prevent dangerous complications.
1.4.8 Rare hernias
1.4.8.1 Internal herniaDisplacement of abdominal intestines into enlarged peritoneal pockets within the trunk,
possibly with incarceration. Often, this type of hernia cannot be detected with the naked eye.s
These types of hernias cannot as a rule be detected with the naked eye or be felt, because the hernial
sacEvagination of the peritoneum that protrudes through a hernial orifice. It may contain hernia contents. is situated
within peritoneal pockets inside the abdominal cavityLatin term: cavitas abdominalis. The region of the trunk
situated between the diaphragm and pelvis containing the abdominal organs. The abdominal cavity is lined with the
peritoneum..
1.4.8.2 Spieghel herniaA rare hernia which, in the region of the lateral abdominal wall, penetrates what is known as
Spieghel’s line (muscle-tendon border of the transverse abdominal muscle at the lateral margin of the rectus
abdominis muscle).
This is a hernia which occurs in the region of the lateral abdominal wallThe anterior tissue structures (skin,
subcutaneous adipose tissue as well as muscle layers) enclosing the abdominal cavity.. It penetrates what is
known as Spieghel’s line (muscle-tendon border of the transverse abdominal muscle at the lateral margin of the
anterior rectus abdominis muscleLatin term: musculus rectus abdominis. The rectus muscle runs in two straight
lines from the chest to the pelvis. It is subdivided by several intermediate tendons.).
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1.4.8.3 Morgagni’s hernia
A hernia protrudes through a small gap in the diaphragmDome-shaped muscle plate protruding into the chest
cavity, which is secured to the sternum, costal arches and lumbar spine. The diaphragm forms a partition between
the chest cavity and abdominal cavity. It is the most important respiratory muscle; its muscle fibres contract when
breathing in and relax when breathing out., known as Morgagni’s gap Morgagni’s hernias occur close to the
breast bone.
1.4.8.4 Richter’s hernia
In the case of this hernia, which is also known as an intestinal wall hernia, the hernia contentsThe components of
the abdominal cavity, such as intestines or greater omentum, contained within the hernial sac. within the hernial
sac are composed of only a protruded part of the intestinal wall. Intestinal passage is unaffected since the entire
intestines are not involved.
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