Download Lecture 8 - UMF IASI 2015

Hernias of the anterolateral wall of the
abdomen
-particular forms-
Inguinal hernias
Anatomy briefing
 Definition: hernias produced through a defect
situated on the posterior wall of the inguinal
canal
 Inguinal canal: a space designed for the passage
of
– Testis – peritoneal diverticula present at birth
– Round ligament – peritoneal diverticula present at
birth (Nuck)
 Major opening in the mucsculo-fascial structure
of the abdominal wall
Inguinal canal
Inguinal canal - structure
 Anatomic structures are dynamic –
description represents a schematic view
– 4 walls (anterior, posterior, superior and
inferior)
– 2 orifices: internal and external
Anterior wall
 Fascia of the
external oblique
muscle
 Fascia ends in 2
pillars
– Spina pubis
– Anterior part of
pubic bone and
rectus sheat
Inferior wall
 Inguinal ligament
 Concavity opened above
 Internally – it reflects fibers towards the
pectineal ridge = the triangular ligament of
Gimbernat and prolonges on the pubic
branch of the iliac bone forming one body
with the ligament of Cooper – solid
strutcture
Inferior wall
Superior wall
 Inferior border of internal oblique and
transversus : the conjoined ligament
 Fusion of the structures is NOT the rule
 The resultant structure is not fibrotic and
sometimes very friable – not suitable for
suturing
Posterior wall
 Fascia transversalis
in it’s way towards
the vascular sheat
 Ligament of
Thompson
(inferiorly)
 2 fibrotic structures
ligaments of Henle
and Hasselbach
Posterior wall
 Weak anatomic region predisposed to hernia
formation
 Muscular structures are supposed to close the
defect during effort
 Inferior eipgastric vessels separate 3 parts
– Profound inguinal orifice (external oblique hernia)
– Middle part (medial to the epigastric vessels)– direct
inguinal hernia
– Internal part (medial to the umbilical artery) inetrnal
oblique hernia
Orifices
 Profund (lateral or internal)
– Situated in fascia transversalis – the external part
– A weak point of the abdominal wall
 Superficial (medial or external)
– Between the pillars of the fascia of the external
oblique muscle
– The place where a hernia engages towards the scrotum
– Place to introduce finger for palpation
Content of the inguinal canal
 Women: round ligament + vessels
 Men: spermatic cord
– cremaster
– vas deferens
– spermatic artery
– deferntial artery
– 2 venous plexuses
– Nervous branches (ilio-hipogastric, ilioininguinal,
genital)
Shall we all develop hernia?
 There is a content passing from the
abdomen to scrotum
 BUT
– The trajectory is oblique through muscles and
during effort the structures are compressed
together
– Oblique muscles work as a curtain and close
the defect
– Internal orrifice is strangulate during effort
External oblique inguinal hernia
 Congenital: persistentce of the peritoneal
diverticula through which the testis
migrated in scrotum. Frequently associated
with abnormal migration of the testis.
– Complete form with totaland free
comunication from the peritoneum till scrotum
– Incomplete forms – vaginala testicularis is
separeted +/- hydrocele or cystic remnants in
the spermatic cord.
External oblique inguinal hernia
 Acuired : migration of
the peritoneal sac
– Herniation point
– Interstitial hernia
– Inguino-pubic hernia
– Inguino-scrotal henria
Clinical signs
 Common signs for all hernia
 Digital exploration through the superficial
orifice
– Evaluation of the defect
– Relations with the epigastric vessels = variety
of hernia
Differential diagnosis
 Uncomplicated interstitial hernia
– Ectopic testis
– Cysts of the spermatic cord
– Solid tumors
 Uncomplicated inguino-pubic hernia
– Crural hernia (line of Malgagine)
– Lypoma of labia major
– Cyst of the Nuck canal
 Inguino-scrotal hernia
– Hydrocel
– Varicocel
– Testicular tumors
Direct inguinal hernia
 A weak point hernia
 The area of weakness is the middle
inguinal area (between the epigastric artery
and remnant of the umbilical artery)
 Sac is completely separated from the
spermatic cord which is pushed away
Particularities
 Frequently in older people, associated with
other hernias
 Frequently bilateral
 Generally small and do not descend in the
scrotum, trajectory being perpendicular on
the inguinal ligament.
 Defect is large – unlikely to produce
comlications
Differential diagnostic
 Mostly with the external oblique hernia
Age
Location
Form
Trajectory
Scrotum
Muscular tonus
Epigastric arte.
Complications
Oblique
Direct
Any
Uni/bilateral
Pear shape
Oblique
Yes
Normal
Internal
Frequent
Old
Bilateral 50%
Hemispheric
Perpendicular
No
Weak
External
Rare
Treatment of Inguinal Hernia
 Objectives:
– Resection of the hernia sac
– Treatment of the defect – a solid wall to
prevent hernia recurrence
LARGE VARIETY OF TECHNIQUES
Operative principles
 Incision of superficial
structures and isolation of
spermatic cord.
 Isolate the hernia sac
and the structure
migrated with the
peritoneal layer
(lipomas)
 Open the hernia
sac
 Control de content
 Resction of the sac
and suture the
peritoneal defect
Posterior wall repair
 GOAL – prevent recurrences
 “Anatomical” procedures
– Behind the spermatic cord (Bassini, Shouldice,
McVay)
– In front of the spermatic cord (Kimbarowski, Forgue)
 Procedures that use a synthetic structure (mesh
repair) – respect the principle of tension-free
repair.
Behind the cord repair procedures
Mesh repair
Laparoscopic mesh repair
Orthopedic treatment
 ONLY when the
patient refuses
operations or major
contraindication for
surgical repair
Femoral hernia
 Through the femoral ring in the triangle of
Scarpa
 Femoral ring:
–
–
–
–
Inguinal ligament (ant)
pectineal fascia and ligament of Coopper (post)
lig Gimbernat (internal)
ileo-pectineal ligament (ext)
Anatomy
Variants
– Herniation point – incomplete (under the cribriform
fascia) – complete
 Prevascular, retrovascular, external
 Laugier (through the fibers of the ligament of
Gimbernat)
 Femuro-pectineal (under the pectineal fascia)
 Multi-divericular
 In combination with inguinal hernia – distension
of the groin
Higher incidence in women
 4x more frequent in women
 Diameter of the pelvic girdle is larger
 Accentuated lordosis in lumbar area
 Pregnancies: weakens the abdominal wall
+ sustained increase in intraabdominal
pressure
Pathological particularities
 Small sac, pear-like, well delimitated
neck which is fibrotic
 DIFFERENCES from other hernia:
multiple layers like the onion skins
(skin, subcutaneous tissue, cribriform
fascia, properitoneal tissue, fascia
transversalis)
 Content: any organ, including caecum,
apendix, colon, urinary baldder)
 Major risk for complications,
especially the strangulation – lateral
pinch
Clinical signs - particularities
 Few or no functional signs: little pain or
heaviness in the groin or during extension
of the hip.
 +/- digestive symptoms (colicky pain,
urinary symptoms) more often believed to
have another source
TYPICALLY the signs indicate and
abdominal suffering and the physician does
not explore the groin
Clinical examination
 Small pseudo-tumor in the Scarpa triangle ,
most typical medial to the femoral vessels.
INCONSTANT
 Round or oval shape
 Prolonged under the inguinal ligament – if
the tumor can be felt
 Frequently obese patients with lare
subcutaneous fat layer
Clinical examination
 Consistency is elastic or granular – atypical
for a hernia
 IREDUCIBLE but not associated with a
loud symptomatology in the groin
 IMPULSION AND EXPANSION are
either absent or faint
 High percentage are complicated at
presentation
Differential diagnosis
 REDUCIBLE:
– Inguinal hernia (line
of Malgaigne)
– Varicose vein
– Aneurism of the
superficial femoral
artery
– Tuberculous (cold)
abscess migrated in
the Scarpa triangle
Differential diagnosis
 IREDUCIBLE:
– Strangulated inguinal
–
–
–
–
–
–
hernia
Cyst of the canal of
Nuck
Ectopic testis
Lypoma
Lymphnode
enlargement
Venous thrombosis
Hematoma
Treatment
 Principles same with all hernia
 Access:
– femoral
– inguino-femoral
– inguinal
 Parietal reconstruction:
– Closing the femroal ring by
suturing the inguinal ligament to
Cooper ligament and pectineal
fascia
– Suturing the conjoined tendon to
Cooper ligament
– Mesh prosthesis
Umbilical hernia
A. Congenital
 Failure in the development of the
abdominal wall
– Embryonic form (defect appears before the 3rd
month and organs are not covered by
peritoneum – not real hernia
– Fetal form – covered by peritoneum
Pathology
 Translucent covering (displastic wall)
without vessels and muscles
 You can see abdominal viscera through the
wall. Content can be as much as the whole
abdominal content
Clinical aspects
 Large ventral tumor, present at birth and
surrounded by a skin ring
 Transparent wall: abdominal viscera
EVOLUTION: spontaneous rupture + death
TRATAMENT: surgical
- small defects: as in hernia
- large defects: skin flaps +/- serial operations
B. Umbilical hernias of the child
 Causes:
– Weak umbilical scar
(infection, distension)
– High intraabdominal
pressure (crying,
coughing, fimosis, etc
 Pathology:
– Small sac with a large
neck, little chances of
strangulation
Treatment
 Conservative: if
– Less then 2 years
– Less then 2 cm diameter
• Has to be maintained reduced via a skin fold until
spontaneous closure
 Surgical:
– Resection of the sac
– Parietal repair
C. Umbilical hernias of the adult
 Weak point
 Obese women,
multiple pregnancies,
chronic peritoneal
dyalisis, ascites.
Particularities
 Direct herniation most typically (indirect
machanism is possible if the ring is
asymmetrically positioned)
 Sac initially small may become
multidiverticular + changes generated by
the degenration of the sac by expnasion
 Rigid neck – strangulation factor
 Content: most frequent properitoneal fat,
but viscus can migrate as well
Clinical signs
 Pain on effort +/- digestive symptoms
 Typical signs of hernia with a major
tendency to become irreducible
 If palpation of the ring is possible – large,
round, rigid defect
Complications
 Strangulation (rigid ring, with rapid
progression to necrosis)
 Progressive enlargement – irreducible and
loosing the right to stay in the abdominal
cavity
Treatment
 Surgical:
– Omfalectomy and treatment of hernia
– Techniques that conserve the umbilical scar
(subcutaneous dissection)
– Plastic surgery
Epigastric hernias
Particularities
 Supraumbilical median line
 Frequent multiple hernias
 At the crossing of fibers in the linea alba
 Small, irreducible and containing mostly
properitoneal fat
 One particular form – diastases of the
rectus sheat
 Symptomatic hernia require treatment
Ventro-lateral hernia
Spiegel
Particularities
 Anatomic: defect in the ventro-lateral
abdominal wall where vessels pass
subctaneous. (lateral to the rectus sheat)
 Hernia pushes the fascia of the external
oblique muscle (interstitial form) or
overpasses is (complete form)
Particularities
 Clinical: pain + abdominal deformity
 Dg: in interstitial forms sometimes no
signs. Positive dg by US scan
 Rsik of becoming irreducible or
strangulated
 Surgical treatment like any hernia
UNUSUAL HERNIA
Lumbar hernia
 Pposterior wall (triangle of J.L. Petit – G.
oblique, G. dorsal, iliac bone) or Grynfeld
qudrate space (C12 with small dentate
muscle, paravertebral muscles, small
oblique and lumbar quadrat)
– extraperitoneal
– paraperitoneal
– peritoneal
Other forms
 Obturator
 Perineal
 Hiatus
 Internal
 Ischiatic
Postoperative hernia
Generalities
 HERNIAS = peritoneal diverticulum
under the skin + defect developed
postraumatic
 EVISCERATIONS = posttraumatic wall
defect without a peritoneal covering
Ethiology
 Posttraumatic or postoperative
 Causes that favor postoperative hernia
Old age – scaring abnormalities
Co-morbidities (liver cirrhosis, cancer diabetes)
Obesity
Type of incision
Postoperative infection
Increased intraabdominal pressure developed
postoperative
– Not adequate suture material
–
–
–
–
–
–
Pathology
 Abdominal wall defect – variable in
diameter, frequently multiple, situated
under the skin scar
 Hernia sac: thickened peritoneum,
multidiverticular, frequently under the skin
in contact with it
 Visceral content
Clinical examination
 Pseudo-tumor with all characters of hernia
 Related with the scar
 Diemension and number of parietal defects
 Reducible or irreducible
 Skin overlaying the hernia
Treatment
 Evisceration: urgent, viscus should be
placed back in the abdomen and skin
should be closed
 Postoperative hernia: complex treatment
preferably elective