Hernia. Definition : Definition : A hernia is a protrusion of a viscus or a part of viscus through an abnormal opening in the walls of its containing.

HerniaHernia

Definition :Definition : A hernia is a protrusion of a viscus or a part of A hernia is a protrusion of a viscus or a part of

viscus through an abnormal opening in the walls of its viscus through an abnormal opening in the walls of its containing cavity.containing cavity.

The external abdominal hernia is the most common The external abdominal hernia is the most common form. The most frequent varieties are the inguinal, form. The most frequent varieties are the inguinal, femoral and umbilical. femoral and umbilical.

General features common to all hernias :General features common to all hernias : Aetiology:Aetiology:

Any condition that increase the intra – abdominal Any condition that increase the intra – abdominal pressure such as a powerful muscular effort may produce a pressure such as a powerful muscular effort may produce a hernia.hernia.

Whooping cough is a predisposing cause in childhood, Whooping cough is a predisposing cause in childhood, whereas a chronic cough, straining on micturition or whereas a chronic cough, straining on micturition or straining on defecation may precipitate a hernia in an adult.straining on defecation may precipitate a hernia in an adult.

It should be remembered that appearance of hernia in an It should be remembered that appearance of hernia in an adult can be a sign of intra – abdominal malignancy. adult can be a sign of intra – abdominal malignancy.

Obesity is an another factor, fat acts to separate muscle Obesity is an another factor, fat acts to separate muscle bundles and layers, weakens apponeurosis and leads to bundles and layers, weakens apponeurosis and leads to appearance of hernia ( para-umbilical, direct inguinal and appearance of hernia ( para-umbilical, direct inguinal and hiatus hernia ).hiatus hernia ).

Hernia is more common in smokers which is due to Hernia is more common in smokers which is due to acquired collagen deficiency increasing the risk of herniaacquired collagen deficiency increasing the risk of hernia

Compisition of a hernia:Compisition of a hernia: Hernia consists of three parts : sac, coverings and the Hernia consists of three parts : sac, coverings and the

contents.contents.

Sac : Sac : It is a diverticulum of peritoneum consisting of :It is a diverticulum of peritoneum consisting of : 1 – 1 – Mouth. Mouth. 2 – 2 – Neck. Neck. 3 – 3 – Body. Body. 4 - 4 - Fundus.Fundus. The neck is usually well defined but in some direct inguinal The neck is usually well defined but in some direct inguinal

hernias and in many incisional hernias there is no actual hernias and in many incisional hernias there is no actual neck. The diameter of the neck is important because neck. The diameter of the neck is important because strangulation of bowel is a likely complication when the neck strangulation of bowel is a likely complication when the neck is narrow as in femoral hernia and para-umbilical hernias.is narrow as in femoral hernia and para-umbilical hernias.

Covering :Covering : Derived from the layers of the abdominal wall through which Derived from the layers of the abdominal wall through which

the sac passes. the sac passes.

Contents :Contents :

These can be : These can be :

– – Omentum = omentocele.Omentum = omentocele.

– – Intestine = interocele ( maily the small bowel but Intestine = interocele ( maily the small bowel but may be the large bowel ).may be the large bowel ).

–– A portion of the circumference of the bowel = A portion of the circumference of the bowel = Richter’s hernia.Richter’s hernia.

–– A portion of the bladder.A portion of the bladder.

–– Ovary with or without the corresponding tube.Ovary with or without the corresponding tube.

–– A Meckel’s diverticulum = Littre’s hernia.A Meckel’s diverticulum = Littre’s hernia.

– – Fluid.Fluid.

Classification :Classification :

Irrespective of site, a hernia can be classified into 5 Irrespective of site, a hernia can be classified into 5 different types :different types :

1 – 1 – Reducible. Reducible. 2 – 2 – Irreducible.Irreducible. 3 – 3 – Obstructed.Obstructed.

4 – 4 – Strangulated.Strangulated. 5 – 5 – Inflammed.Inflammed.

Reducible hernia : Reducible hernia : hernia either reduce itself when the hernia either reduce itself when the patient lies down or can be reduced by the patient or patient lies down or can be reduced by the patient or the surgeon. Such a hernia ( reducible ) gives an the surgeon. Such a hernia ( reducible ) gives an expansible impulse on coughing.expansible impulse on coughing.

Irreducible hernia : Irreducible hernia : in case the contents cannot be in case the contents cannot be returned to the abdomen but there is no evidence of returned to the abdomen but there is no evidence of other complications. It is usually due to adhesions other complications. It is usually due to adhesions between the sac and the contents or overcrowding between the sac and the contents or overcrowding within the sac. Any degree of irreducibility predisposes within the sac. Any degree of irreducibility predisposes to strangulation.to strangulation.

Obstructed hernia : Obstructed hernia : It is irreducible hernia containing It is irreducible hernia containing intestine that is obstructed from without or within but intestine that is obstructed from without or within but there is no interference to the blood supply to the there is no interference to the blood supply to the bowel. The symptoms (colicky abdominal pain and bowel. The symptoms (colicky abdominal pain and tenderness over the hernia site) but less severe and tenderness over the hernia site) but less severe and onset is more gradual than in strangulated hernias. onset is more gradual than in strangulated hernias. Usually there is no clear distinction clinically between Usually there is no clear distinction clinically between obstruction and strangulation and the safe course is to obstruction and strangulation and the safe course is to assume that strangulation is imminent and treat assume that strangulation is imminent and treat accordingly. accordingly.

Incarcerated herniaIncarcerated hernia

The term ‘incarceration’ is often used loosely as an The term ‘incarceration’ is often used loosely as an alternative toalternative to

obstruction or strangulation but is correctly employed obstruction or strangulation but is correctly employed only whenonly when

it is considered that the lumen of that portion of the colonit is considered that the lumen of that portion of the colon

occupying a hernial sac is blocked with faeces. In this occupying a hernial sac is blocked with faeces. In this case, thecase, the

scybalous contents of the bowel should be capable of scybalous contents of the bowel should be capable of beingbeing

indented with the finger, like puttyindented with the finger, like putty..

Strangulated hernia :Strangulated hernia :

A hernia becomes strangulated when the blood supply of A hernia becomes strangulated when the blood supply of its content is seriously impaired, rendering the contents its content is seriously impaired, rendering the contents ischaemic. Gangrene may occur as early as 5-6 hours after ischaemic. Gangrene may occur as early as 5-6 hours after the onset of the first symptoms. Although inguinal hernia is the onset of the first symptoms. Although inguinal hernia is more common than femoral hernia, a femoral hernia is more common than femoral hernia, a femoral hernia is more likely to strangulate because of the narrowness of more likely to strangulate because of the narrowness of the neck and its rigid surrounds.the neck and its rigid surrounds.

Pathology : Pathology : The intestinal blood supply is impaired. Initially, The intestinal blood supply is impaired. Initially, only the venous return is impeded, the wall of the intestine only the venous return is impeded, the wall of the intestine becomes congested and bright red with the transudation of becomes congested and bright red with the transudation of serous fluid into the sac. As congestion increases the wall serous fluid into the sac. As congestion increases the wall of the intestine becomes purple in color. The intestinal of the intestine becomes purple in color. The intestinal pressure increases, distending the intestinal lop and pressure increases, distending the intestinal lop and impairing venous return further. As venous stasis impairing venous return further. As venous stasis increases, the arterial supply becomes more and more increases, the arterial supply becomes more and more impaired. Blood is extravasataed under the serosa and is impaired. Blood is extravasataed under the serosa and is effused into the lumen. effused into the lumen.

The fluid in the sac becomes blood stained and shining The fluid in the sac becomes blood stained and shining serosa dull because of a fibrinous, sticky exudate. At serosa dull because of a fibrinous, sticky exudate. At this stage the walls of the intestine have lost their tone this stage the walls of the intestine have lost their tone and become friable. Bacterial transudation occurs and become friable. Bacterial transudation occurs secondary to the lowered intestinal viability and the secondary to the lowered intestinal viability and the sac fluid becomes infected. Gangrened appears at the sac fluid becomes infected. Gangrened appears at the rings of constriction, which becomes deeply indented rings of constriction, which becomes deeply indented and grey in color. The gangrene then then develops in and grey in color. The gangrene then then develops in the ant mesenteric border, the color varying from black the ant mesenteric border, the color varying from black to green depending on the decomposition of the blood to green depending on the decomposition of the blood in the subserosa. The mesentery involved by the in the subserosa. The mesentery involved by the strangulation also becomes gangerenous. If the strangulation also becomes gangerenous. If the strangulation is unrelieved, perforation of the wall of strangulation is unrelieved, perforation of the wall of the intestine occurs, either at the convexity of the loop the intestine occurs, either at the convexity of the loop or at the seat of constriction. Peritonitis spreads from or at the seat of constriction. Peritonitis spreads from the sac to the peritoneal cavity. the sac to the peritoneal cavity.

Clinical features : Clinical features : Sudden pain at first situated over the Sudden pain at first situated over the hernia, is followed by generalized abdominal pain, hernia, is followed by generalized abdominal pain, colicky in character and often located mainly at the colicky in character and often located mainly at the umbilicus. Nausea and subsequently vomiting. The umbilicus. Nausea and subsequently vomiting. The patient may complain of an increase in hernia size.patient may complain of an increase in hernia size.

On examination the hernia is tense, extremely tender On examination the hernia is tense, extremely tender and irreducible and no expansile cough impulse. and irreducible and no expansile cough impulse.

Unless the strangulation is relieved by operation, the Unless the strangulation is relieved by operation, the spasms of pain continue until peristaltic contractions spasms of pain continue until peristaltic contractions cease with the onset of ischemia, when paralytic ileus cease with the onset of ischemia, when paralytic ileus ( often the result of peritonitis ) and septicaemia ( often the result of peritonitis ) and septicaemia develops. Spontaneous cessation of pain must be develops. Spontaneous cessation of pain must be viewed with caution, as this may be a sign of viewed with caution, as this may be a sign of perforation perforation

Strangulated herniaStrangulated hernia

■ ■Present with local then general abdominal pain Present with local then general abdominal pain and vomitingand vomiting

■ ■A normal hernia can strangulate at any timeA normal hernia can strangulate at any time

■ ■Most common in hernias with narrow necks such Most common in hernias with narrow necks such asas

femoral herniasfemoral hernias

■ ■Require urgent surgeryRequire urgent surgery

Imflammed hernia : Imflammed hernia : inflammation can occur from inflammation can occur from inflammation of the contents of the sac as eg. acute inflammation of the contents of the sac as eg. acute appendicitis or salpingitis.appendicitis or salpingitis.

Inflammation can happen from external causes eg. Inflammation can happen from external causes eg. Trophic ulcers that developes in the depending areas Trophic ulcers that developes in the depending areas of large umbilical or incisional hernias. of large umbilical or incisional hernias.

The hernia is usually tender but not tense and the The hernia is usually tender but not tense and the overlying skin red and oedematous. Treatment is overlying skin red and oedematous. Treatment is based on treatment of the inderlying cause. based on treatment of the inderlying cause.

Inguinal HerniaInguinal Hernia

Surgical anatomy :Surgical anatomy :

The superficial inguinal ring is a triangular aperature in The superficial inguinal ring is a triangular aperature in the aponeurosis of the external oblique muscle lies 1.25 the aponeurosis of the external oblique muscle lies 1.25 cm above the pubic tubercle. cm above the pubic tubercle.

The deep inguinal ring is a U shaped condesation of The deep inguinal ring is a U shaped condesation of the transervalis fascia and it lies 1.25 cm above the the transervalis fascia and it lies 1.25 cm above the inguinal ligamentinguinal ligament

An indirect hernia travels down the canal on the outer An indirect hernia travels down the canal on the outer side of the spermatic cord. A direct hernia comes out side of the spermatic cord. A direct hernia comes out directly forwards through the posterior wall of the directly forwards through the posterior wall of the inguinal canal. Whereas the neck of the indirect hernia inguinal canal. Whereas the neck of the indirect hernia is lateral to the inferior epigastric artery, the neck of is lateral to the inferior epigastric artery, the neck of the direct hernia is medial to the artery. the direct hernia is medial to the artery.

An inguinal hernia can be differentiated from femoral An inguinal hernia can be differentiated from femoral hernia by the ascertaining the relation of the neck of hernia by the ascertaining the relation of the neck of the sac to the medial end of the inguinal ligament and the sac to the medial end of the inguinal ligament and the pubic tubercle. In the case of an inguinal hernia, the the pubic tubercle. In the case of an inguinal hernia, the neck is above and medial, whereas that of a femoral neck is above and medial, whereas that of a femoral hernia is below and lateral hernia is below and lateral

Indirect inguinal hernia Indirect inguinal hernia It is the most common type of hernia. It is more common It is the most common type of hernia. It is more common

in the young while the direct type is more common in the in the young while the direct type is more common in the old. In the first decade of life, inguinal hernia is more old. In the first decade of life, inguinal hernia is more common on the right side in the male. This is associated common on the right side in the male. This is associated with the later descent of the right testis and a higher with the later descent of the right testis and a higher incidence of failure of closure of the process vaginalis. incidence of failure of closure of the process vaginalis.

Clinical features :Clinical features :

We start examining the patient in standing position with We start examining the patient in standing position with asking the patient to cough and feel the cough impulse. asking the patient to cough and feel the cough impulse. Then examiner should now :Then examiner should now :

* Is the hernia is right, left or bilateral.* Is the hernia is right, left or bilateral.

* Is it inguinal or femoral.* Is it inguinal or femoral.

* Is it direct or indirect.* Is it direct or indirect.

* Is it reducible or not.* Is it reducible or not.

* Is it complete or not.* Is it complete or not.

* What are the contents * What are the contents

The patient complains of pain in the groin or pain referred The patient complains of pain in the groin or pain referred to the testicles when performing heavy wok or taking to the testicles when performing heavy wok or taking strenuous exercise. In large hernias there is a sensation strenuous exercise. In large hernias there is a sensation of weight and dragging on the mesentery which may of weight and dragging on the mesentery which may produce epigastric pain.produce epigastric pain.

Differential diagnosis in the male :Differential diagnosis in the male :

1 – 1 – Vaginal hydrocele.Vaginal hydrocele.

2 – 2 – Encysted hydrocele of the cord.Encysted hydrocele of the cord.

3 – 3 – Spermatocele.Spermatocele.

4 – 4 – Femoral hernia.Femoral hernia.

4 – 4 – Incompletely descended testis.Incompletely descended testis.

5 – 5 – Lipoma of the cord. Lipoma of the cord.

Differential diagnosis in the female :Differential diagnosis in the female :

1 – 1 – Hydrocele of the canal of Nuck.Hydrocele of the canal of Nuck.

2 – 2 – Femoral hernia.Femoral hernia.

Note that examination using finger and thumb across the neck ofthe scrotum will help to distinguish between a swelling of inguinalorigin and one that is entirely intrascrotal.

Treatment :Treatment :

Operation is the treatment of choice. Operation is the treatment of choice. ( Herniotomy ( Herniotomy + + Herniorrhaphy )Herniorrhaphy )

* * Herniotomy : means dissecting out and opening the Herniotomy : means dissecting out and opening the hernial sac, reducing any content then transfixing the hernial sac, reducing any content then transfixing the neck of the sac and removing the remainder. By itself neck of the sac and removing the remainder. By itself it is sufficient for the treatment of hernia in children it is sufficient for the treatment of hernia in children and young adults.and young adults.

* * Herniorrhaphy : consist of : Herniorrhaphy : consist of :

1 – repair of the stretches internal ring and 1 – repair of the stretches internal ring and transversalis fascia.transversalis fascia.

2 – further reinforcement of the posterior wall of 2 – further reinforcement of the posterior wall of the inguinal canal.the inguinal canal.

* A truss may be used when operation is * A truss may be used when operation is contraindicated or refused. In this condition if the truss contraindicated or refused. In this condition if the truss to be used the hernia should be reducible. to be used the hernia should be reducible.

Its use should be mainly historical, as there are very Its use should be mainly historical, as there are very few contraindications to surgery with today’s variety of few contraindications to surgery with today’s variety of anaesthetic techniquesanaesthetic techniques..

Direct inguinal hernia Direct inguinal hernia

It is always acquired. The passes through a weakness or a It is always acquired. The passes through a weakness or a defect of the transversalis fascia in the posterior wall of the defect of the transversalis fascia in the posterior wall of the inguinal canal. Predisposing factors are smoking and inguinal canal. Predisposing factors are smoking and occupations that involves straining or heavy lifting. occupations that involves straining or heavy lifting. Damage to the ilioinguinal nerve (previous Damage to the ilioinguinal nerve (previous appendicectomy) is another cause, because of the appendicectomy) is another cause, because of the resulting weakness of the conjoined tendon. Direct hernia resulting weakness of the conjoined tendon. Direct hernia do not often attain a large size or reach to the scrotum. In do not often attain a large size or reach to the scrotum. In contrast to the indirect hernia, the direct lies behind the contrast to the indirect hernia, the direct lies behind the spermatic cord. As the neck is wider than that of indirect spermatic cord. As the neck is wider than that of indirect inguinal hernia, direct inguinal hernia do not often inguinal hernia, direct inguinal hernia do not often strangulatestrangulate..

Treatment : Treatment : the principles of repair of direct hernia are the the principles of repair of direct hernia are the same as those of an indirect hernia, with the exception same as those of an indirect hernia, with the exception that the hernia sac can usually be simply inverted after it that the hernia sac can usually be simply inverted after it has been dissected free and the transversalis fascia has been dissected free and the transversalis fascia reconstructed in front of it. This repair can be done also by reconstructed in front of it. This repair can be done also by mesh which is also true for indirect hernia repair. mesh which is also true for indirect hernia repair.

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