Abdominal Wall Hernias. Hernia Definition: A hernia is an abnormal protrusion of a viscus through the wall of a cavity which normally contains it.

Abdominal Wall Hernias

Hernia

Definition: A hernia is an abnormal protrusion of a viscus through the wall of a cavity which normally contains it.

It may be through a congenital/acquired opening

in the presence of continued or repeated intra-abdominal pressure

Types of Hernias

Direct inguinal hernia

Indirect inguinal hernia

Femoral hernia Obturator hernia Sciatic hernia Perineal hernia

Umbilical hernia Paraumbilical

hernia Epigastric hernia Hiatus hernia Diaphragmatic

hernia Incisional hernia Spigelian hernia

Development of a hernia

In young age group: congenital potential space

In old age group: gradual onset and slow enlargement due to weakness in the abdominal wall

Predisposing factors

Congenital defect, e.g. persistence of processus vaginalis incomplete obliteration of umbilicus persistent communication between abd.

and thorax

• Acquired defect, e.g surgical incisions muscle weakness due to ageing/ nerve injury

and wasting/ fatty infiltration/ pregnancy

Precipitating factors

Chronic cough constipation straining at micturition childbirth vomiting severe muscular effort ascites - fluid may increase the size

of an existing sac

Contents in a Hernia

Usual: omentum, small bowel Sliding hernia: content with partial

peritoneal cover such as: sigmoid colon, urinary bladder

Ritcher’s hernia: part of the small bowel wall was in the hernia with perforation but no obstruction

The contents of the sac

Reducible irreducible obstructed, or strangulated

ILIUM

The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle

SACRUMILIUM

Anatomy

Site / Origin

Inguinal Inguino-scrotal Isolated in scrotum

Groin hernias

indirect inguinal direct inguinal femoral

Nyhus Classification

 Type I--indirect inguinal hernia

•Internal inguinal ring normal (i.e. paediatric hernia)

Type II--indirect inguinal hernia •Dilated internal inguinal ring with posterior inguinal wall intact

Type III--posterior wall defects •Direct inguinal hernia •Indirect inguinal hernia: dilated internal ring with large medial encroachment on the transversalis fascia of the Hesselbach's triangle (i.e. massive scrotal, sliding hernia) •Femoral hernia

Type IV--recurrent hernia

Inguinal Hernias - Anatomy

Indirect inguinal hernia

most common in young males enters the inguinal canal through

the deep ring the sac often extends, following the

line of the spermatic cord (over the pubic crest) into the scrotum

the neck of the sac is narrow

Direct inguinal hernia

Common in older men with weak abdominal muscles

Often bilateral the sac bulges forward thro’ the

posterior wall of the inguinal canal, medial to the inferior epigastric vessels

Does not extend into scrotum the neck of the sac is wide

Femoral hernia

Less common than inguinal hernias occur more frequently in females the sac descends thro’ the femoral

ring and canal, thro’ the saphenous opening of the fascia lata.

Blunts the groin crease (both types of inguinal hernia increase

the crease) it has a narrow neck

Main Points in History

Age: young or old? Factors for increase abdominal

pressure Started with a smaller swelling Disappears on lying down Gurgling noise inside the swelling Pain and dragging discomfort Intestinal obstruction

Physical Examination

Three important steps MUST be taken Patient standing for the examination - cough

impulse and cannot get above the swelling Lying down to reduce the hernia by patient Try to hold back the hernia with the thumb

at the internal ring while standing will distinguish direct from indirect inguinal hernia

Anatomical Landmarks

Anterior superior iliac spine Pubic tubercle Inguinal ligament Mid-inguinal point Interrnal inguinal ring To distinguish direct/indirect hernia

Examination of the patient with a hernia

With the patient supine look for signs of systemic toxicity intestinal obstruction or inflammation of the abdominal wall visible bulge, effect on groin crease

and a visible impulse on coughingallow the patient to attempt reduction of

the hernia in the supine position

palpate for cough impulse in the area of abdominal

wall weakness, note any tendernessReducible hernia;

place a finger over the deep ring and allow the patient to stand

ask the patient to hold nose and blow if the hernia appears after release of

your finger, then it is an INDIRECT inguinal hernia

Scrotal Masses

Can you get ABOVE the swelling? Where is the mass arising from? The mass itself cystic/transilluminate? The mass hard and the surface

irregular?

Scrotal swellings

Painful + firm Torsion Acute inflammation (orchitis/ epididymitis)

Painless + firm Neoplasm Chronic inflammation haematoma

Soft Varicocele Hydrocele Epididymal cyst

Varicocele

Grade 1 - palpable with Valsalva Grade 2 - palpable without straining Grade 3 - can be seen on inspection Bag of worms in 15% of young man More common on the left side 30% infertile patients have varicocele

Varicocele

Usually cause discomfort after running Spermatogenesis impaired due to

hypoxia, elevated temperature and reflux of metabolites

Treatment by Ligation of the veins Varicocele in older man may indicate

left renal carcinoma with renal vein involvement

Torsion of Testis

To distinguish from Orchitis Both are acute painful swelling of the

testis Treatment is different Age, fever, venereal exposure… Types of torsion - extra-vaginal, intra-

vaginal, Torsion of the undescended testis

Empty Scrotum

Undescended testis Ectopic testis Retractile testis

Hydrocele

Accumulation of fluid in the tunica vaginalis

Short history - thin wall and transilluminate Long history - thick wall and ?previous

trauma Cystic mass, the testis is within the sac

and therefore NOT palpable Can get above the swelling Surgery - Jaboulay’s operation

Trauma to the Scrotum

Haematocele of the testis Rupture of the testis Fracture of the penis Trauma to the bulbous urethra Laceration of the scrotal skin

Testicular Tumour

Hard and irregular swelling of the testis

Spermatic cord normal Types - germ cell, non germ cell,

secondary metastasis, paratesticular tissues

Must palpate the abdomen for central supra-umbilical masses (lymph nodes)

Indication for Surgery

Risk of complications such as strangulation and intestinal obstruction

Pain and mass interfere with function Conservative treatment

Principles of Surgery

Reduction of the contents Excision of the hernial sac Repair of the defect Difficult in case of large hernia

and large defects

Historical developments

1700 BC: Hammurabi (Babylon) – Hernia reduction / bandaging1363 : Guy de Chauliac – Distinguished inguinal from femoral hernia for the first time in

Chirugia Magna

1. Reinforcing the anterior wall and narrowing the external ring Eg Repair by ligation of hernial sac and cicatrization with healing by secondary intention

(Caspar Stromayr, 1559)

2. Reinforcing the posterior wall and narrowing the internal ring 1881 Splitting of external oblique + ligation of sac at internal ring (Lucas-

Championnière) 1889 Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis

fascia) to inguinal ligament (Bassini) 1939 Subcutaneous shift of spermatic cord (Kirschner) 1969 Duplication of transversalis fascia (Shearburn – as per Shouldice) 1987 Application of alloplastic material (Lichtenstein)

3. Reinforcing the posterior wall and narrowing the internal ring from intraabdominally 1891 During laparotomy for other indication (Tait) 1990 Laparoscopic hernia repair (Popp)

Hernien

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

Bassini

Shouldice

Lichtenstein

Robbins-Rutkow

Prolene Hernia System

Open hernia repair

Repair under Tension

1889 Bassini - Suturing of threefold layer (internal oblique, tranversus abdominis + transversalis fascia) to inguinal ligament

Tension created during repair with recurrence rates generally around 10%

Best results reported by Shouldice using his technique in a dedicated hernia hospital – recurrence of only 0.8%

Hernioplastik n. Bassini

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

Bassini

Hernioplastik n. Shouldice

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

Shouldice

Hernioplastik n. Lichtenstein

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

Lichtenstein

Preperitoneal Approach

Originally described by Stoppa Mesh placed between peritoneum and abdominal

wall Precursor to laparoscopic repair techniques

The Lichtenstein Technique

Mesh repair popularised by Lichtenstein – published a series of 1000 patients with no recurrences in 1-5 yr follow-up Mesh repair for ALL hernias Local anaesthetic Day case surgery Same day ambulation

Am J Surg, 1989. 157 (2): 188-93

Lichtenstein Hernia Repair

Local anaesthetic

Prolene Hernia System

Hernien

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

TEP (total extraperitoneal plasty)

TAPP (transabdominal preperitoneal plasty)

Laparoscopic hernia repair

TEP - total extraperitoneale Hernioplastik

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

TEP (mesh between fascia transversalis and peritoneum)

TAPP - transabdominelle praeperitoneale Hernioplastik

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

TAPP (mesh between fascia transversalis and peritoneum)

Hernien

CHIRURGISCHE KLINIK UK BENJAMIN FRANKLIN FU BERLIN

Relapse (no mesh: 10% - 20 %, mesh: ~ 2%)

Hematoma (10%)

Wound infection (< 5%)

Chronic pain (< 5%)

Scrotal edema with or w/o orchitis (< 2%)

Complications

Plug and mesh

Claimed advantages: Decreased operating time Smaller incisions Low recurrence rates

Evidence from trials: Little difference in operating times Recurrence rates 0 – 2% No difference in post-op pain / rehab

Review (ANZ J Surg, 2002, 72: 573-9): No strong evidence for benefits over traditional mesh

repair

Preperitoneal Approach

Advantages:Recurrent hernia – different approach avoids operating on distorted anatomy / scar tissue

May repair bilateral hernias through Pfannenstiel or midline incisions

Complications of Inguinal Hernia Repair

Chronic pain Infections Others

Chronic pain

Persistent pain is the most troublesome complication following inguinal hernia repair

Postulated mechanisms: Nerve injury Tension Infection Suture placement

Chronic Pain

Operative strategies to minimise chronic pain: Avoid placing periosteal sutures on the pubic

tubercle Avoid undue tension on the inguinal ligament Careful preservation of ilioinguinal and

genitofemoral nerves

Strategies to treat chronic post-op pain: Division of ilioinguinal or genitofemoral nerve Removal of mesh / sutures Pain service referral - Tricyclics / anti-depressants

Infections

Infection rate in inguinal hernia wounds 1-2% Superficial infections more common than deep

infections involving prosthesis

Operative techniques to avoid infection: Meticulous asepsis Minimise necrotic tissue / diathermy / desiccation Wound lavage Monofilament sutures Perioperative antibiotics ? Topical antibiotics

Hiatal Hernia Overview

Chronic relapsing condition Significant morbidity Estimated lifetime prevalence of 25-

35 % 44% have heartburn once a month 14% have weekly symptoms 7 % have daily symptoms

Gastroesophageal Reflux

Diagnosis

History Response to a PPI Radiologic findings Endoscopy Ambulatory pH monitoring

History

Heartburn, regurgitation

High specificity, low sensitivity

Atypical Symptoms

Atypical chest pain Hoarseness Nausea Cough Odynophagia Asthma

Globus sensation Onset after age 45 Recurrent

laryngitis Recurrent sore

throat Subglottic stenosis Dental enamel loss

Complications of Gerd

Dysphagia Odynophagia Early satiety GI bleeding Iron deficiency anemia Vomiting Weight loss

Response To PPI

Omeprazole 40 mg BID X 14 days as specific and sensitive for diagnosis as 24 hour pH monitoring

Failure to respond warrants further investigation into patients symptoms

Radiologic Findings

Only 1/3 of patients have radiologic findings Hiatal hernia Erosions Ulcerations Strictures Thickening of mucosal folds

Not the test of choice for diagnosis

Endoscopy

Useful for diagnosing complications of GERD Barrett’s Esophagitis Strictures

Not sensitive for GERD itself Only 50% of patients manifest

evidence on endoscopy

EGD

EGD

EGD

Ambulatory pH Monitoring

Diagnostic gold standard pH monitor placed in esophagus

above sphincter Patient symptom log Correlate symptoms with low pH

Treatment

Lifestyle modifications Antacids Histamine H2 receptor antagonists Prokinetic Agents Proton Pump inhibitors Anti-reflux surgery Newer endoscopic treatments

Lifestyle Modification

Head of bed elevated six inches Decreased fat intake Smoking cessation Weight loss Avoidance of recumbency for 3 hours

post-prandially Avoidance of large meals and trigger

foods Avoidance of exacerbating medications

Dietary Factors

Caffeine

Peppermint

Fatty foods

Chocolate

Spicy foods

Citrus fruits

Tomato products

Alcohol

Antacids

Antacids are appropriate initial tx

1/3 of patients use twice weekly

More effective than placebo

Adverse Effects Of Antacids

Aluminum: constipation, hypophosphatemia, osteomalacia

Calcium: constipation, milk-alkali syndrome, rebound hyperacidity

Magnesium: diarrhea, accumulation in pts. with renal impairment

Sodium bicarb: milk-alkali in high doses

Mag-Aluminum: minor changes in bowel function

H2 Blockers

70% with reported relief within 2 weeks of initiating treatment

faster healing rates in patients with erosive esophagitis compared with placebo

Higher dosages increase effectiveness

Prokinetic Agents

Do not neutralize acid Increase both gastric emptying,

improve peristalsis and increase lower esophageal sphincter pressure

Side-effects: abdominal cramping, diarrhea, prolonged QT and fatal arrhythmias

Proton Pump Inhibitors

Failure of twice daily H2 blockers 83% of patients showed improvement

with PPI vs 50% with H2 blocker For erosive esophagitis, faster healing

rates than H2 blocker At one year, pts tx’d with daily PPI

less likely to relapse No significant difference between the

PPIs

Potential Long-term Complications

Hypergastrinemia, gastric carcinoid tumors in rats

Atrophic gastritis with use of prilosec > 5 years—potential development of gastric CA

Increased risk of enteric infections—campylobacter

Vitamin B malabsorption

Antireflux Surgery

Indications Failed medical management Patient preference for surgery despite

successful medical management Complicated GERD Large Hiatal Hernia Atypical symptoms with reflux

documented on 24-hour pH monitoring

Surgical Candidates

Reflux esophagitis documented by EGD

Normal esophageal motility by manometry

Should have at least a partial response to trial of acid suppression therapy

Basic Tenets Of Surgery

Reduction of hiatal hernia Repair of diaphragmatic hiatus Strengthening of the GE junction-

diaphragm attachment Strengthening of antireflux barrier

though gastric wrap around GE junction (fundoplication)

75-90% effective at alleviating heartburn and regurgitation

Surgical options for hiatal hernia

Nissen fundoplication Collis gastroplasty Partial fundoplication Burma gastropexy

Nissen Fundoplication

Collis Gastroplasty

240o Partial fundoplication Belsey Mk IV

Post-surgical Complications

Solid food dysphagia: 10% Gas/bloating: 7-10% Diarrhea, nausea and early satiety:

< 10% Within 3-5 years, 52% of patients

taking antireflux meds again

New Endoscopic Treatments

Stretta procedure: radiofrequency heating of GE junction

Endoscopic gastroplasy (endocinch) Less costly than conventional

surgery Initial studies show decreased or

eliminated use of acid suppressant meds in 50-75% of patients

Incisional Hernia Any laparotomy associated with incisional

hernia rate of 14% Technical failure in closure: tension, bites,

layers Associated factors

Obesity Infected case/wound Diabetes Multiple operations malnourished

Genetically predetermined:collagen defect

Types of Surgery

Onlay Sublay Inlay

„Sublay” Mesh Insertion Technique

Posterior layer of rectus abdominis sheath

Rectus abdominis

Anterior layer of rectus abdominis sheath

Peritoneum

Mesh

„Onlay” Mesh Insertion Technique

Posterior layer of rectus abdominis sheath

Rectus abdominis

Anterior layer of rectus abdominis sheath

Peritoneum

Mesh

„Inlay” Mesh Insertion Technique

Posterior layer of rectus abdominis sheath

Rectus abdominis

Anterior layer of rectus abdominis sheath

PeritoneumMesh

Bibliography

1. ACS Surgery: Principles and Practice by Douglas W., Md. Wilmore (Editor), Laurence Y., Md. Cheung (Editor), Alden H., Md. Harken (Editor), James W., Md. Holcroft (Editor), Jonathan L., Md. Meakins (Editor), Nathaniel J., Md. Soper (Editor), Douglas W. Wilmore, Laurence Y. Cheung, Alden H. Harken, James W. Holcroft, Jonathan L. Meakins, Nathaniel J. Soper Publisher: WebMD Professional Publishing; 2nd edition (February 1, 2003)

2. Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practic. Courtney M. Townsend, Jr., editor-in-chief; associate editors, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox. W.B. Saunders Company 2001

3. Oxford Textbook of Surgery (3-Volume Set) 2nd edition (January 15, 2000): by Peter J. Morris (Editor), William C. Wood (Editor) By Oxford Press

4. Essentials of Surgery: Scientific Principles and Practice 2nd edition (January 15, 1997): by Lazar J., Md. Greenfield (Editor), Michael W. Mulholland (Editor), Keith T. Oldham (Editor), Gerald B. Zelenock (Editor), Keith D. Lillimoe (Editor), Keit Oldham By Lippincott Williams & Wilkins Publishers

5. Current Surgical Diagnosis and Treatment, 11th Ed 2003: Lawrence W. Way, Gerard M. Doherty By McGraw-Hill/Appleton & Lange

6. Principles of Surgery Seventh Edition Editor-in-Chief Seymour I. Schwartz, M.D. The  McGraw-Hill Companies, Inc. 1999