Hernia

LECTURE FOR LECTURE FOR MBChB VMBChB V

HERNIA

Definition:

Protrusion of a viscus or part of it from thecavity which it is enclosed through an abnormality or point of weakness in the wall of the cavity.

It is the commonest surgical condition worldwide with a prevalence of 6%.

Commonest cause of intestinal obstruction in the developing world ≈ 75%.

Types of Hernia

1. Inguinal hernia – 80-90% - conformed in all communities.

2. Fermoral – 2-5% - More commoner in females

3. Umbilical Hernia – Common after neonatal sepsis. More in developing countries.

Developmental/genetic factors involved.

Seen more in blacks.

4. Paraumbilical Hernia

5. Epigastric Hernia – 1%

6. Incisional Hernia – 5%

Commonest in poor communities with poor facilities

Cont

7. Spigelian Hernia – Between muscle fibres and apaneurosis of of transverse abdominis.

8. Lumbar Hernia – At the superior or inferior lumbar triangle

9. Obturator herniae

10.Sciatic herniae

Aetiology:

Two main factors

A – Defect or weakness of the wall of the cavity

(i) Embryological/Anatomical Internal inguinal ring Femoral ring Obturator canal

(ii)Acquired factors Ageing – muscle weakness Infection of scar or poor surgical technique Frequent or multiple pregnancies Obesity Nerve injury at operation

Injury to the abdomen

B. Increased Intraabdominal pressure.Chronic coughChronic urinary obstructionChronic constipationHeavy manual workFrequent deliveries

GROIN HERNIAEInguinal/Femoral

Inguinal Canal:Contents Spermatic cord + vessels Ilionguinal nerve Genital bb of genitofemoral nerveIn female – Round ligament

It is a passage for gubernaculum testis to the scrotum in males and to labium majus in the Females.

It is about 4cm long and lies obliquely.

Its boundaries are:

1. Internal Ring: U-shaped and made of transversalis fascie.

Is about 2.5cm above mid-inguinal point width of 0.5 – 1cm.

Usually closes when there is increased abdominal pressure.

2. External Ring:

Is an opening in the ext. oblique apaneurosis

3. Anterior Wall

External oblique apaneurosis

Internal oblique fibres laterally

4. Posterior Wall

Laterally – Transversalis fascie + aparemosis of tranversus abdominis

Medially – Conjoint Tendon

5. Floor of the canal – Inguinal Ligament

6. Roof: Arched fibres of internal oblique

Hasselbach’s Triangle is formed with:

1.Inferior epigastric vessels laterally

2.Conjoint tendon – medially

3.Inguinal ligament – base

Inguinal hernia – Commonest in both sexes

Males - 95%

Females – 50%

M:F 20:1

Direct/Indirect hernia

Indirect – Affects all age groups

- Commonest 20-50 years (60%). Commonest on right than left 2.1 due to late descent of testis.

- About 10% are bilateral

Direct hernia – Right is as common as left. 10% of hernia of those >25 years.

Clinical Fxs:

1.Swelling in the groin – Reducible usually

2.Pain – can occur but is rare

Examination:

1.Visble swelling

2.Palpable cough impulse

3.Is reducible

Complete – Enters scrotum

Bubonocele – Limited to canal

Funicular – Above pubic tubercle

Complications

1.Irreducibility

2.Strengthening/Gangrene formation

3.Fistula formation

4.Rapture of the sac-enviscesation of hernia

Anatomical Complications

1.Ritchers hernia

2.Sliding hernia

3.Hernia en W

Treatment

1.Herniotomy

2.Herniorraphy – Bessinc’s Repair

- Mesh Repair – VIPRO

- Litchensteins procedure

3.Laparoscopy Repair

Complications of Treatment