Hernia. Hernia A hernia is a protrusion of a viscus or other structure beyond the normal coverings of the cavity in which it is contained. A hernia is.

HerniaHernia

HerniaHernia

A hernia is a protrusion of a viscus or A hernia is a protrusion of a viscus or other structure beyond the normal other structure beyond the normal coverings of the cavity in which it is coverings of the cavity in which it is contained. contained.

Epidemiology Epidemiology

The first record of a hernia is in the The first record of a hernia is in the Egyptian Papyrus Ebers (1550 BC) Egyptian Papyrus Ebers (1550 BC) when it was regarded as a social when it was regarded as a social stigma. stigma.

Abdominal hernias are common. They Abdominal hernias are common. They occur at all ages and in both sexes occur at all ages and in both sexes and account for approximately 10% and account for approximately 10% of the general surgical workload. of the general surgical workload.

Classification Classification Congenital Congenital

In congenital hernias, there is a pre-In congenital hernias, there is a pre-formed sac patent processus vaginalis is formed sac patent processus vaginalis is a good example. a good example.

Acquired Acquired Primary herniasPrimary hernias

occur at natural weak points, such as femoral occur at natural weak points, such as femoral canal, lumbar region, umbilicus.canal, lumbar region, umbilicus.

Secondary herniasSecondary hernias develop at sites of surgical or other injury to develop at sites of surgical or other injury to

the wall e.g. after laparotomy or penetrating the wall e.g. after laparotomy or penetrating injury injury

AetiologyAetiology

The two main factors predisposing to hernia are The two main factors predisposing to hernia are increased intracavity pressureincreased intracavity pressure a weakened abdominal wall. a weakened abdominal wall.

In the abdomen, the raised pressure occurs as a In the abdomen, the raised pressure occurs as a result of: result of: heavy liftingheavy lifting cough-chronic obstructive cough-chronic obstructive airways diseaseairways disease straining to passstraining to pass urine urine-benign prostatic hyperplasia or -benign prostatic hyperplasia or

carcinoma carcinoma straining to pass straining to pass faecesfaeces-constipation or large-bowel -constipation or large-bowel

obstruction obstruction abdominal distension-which may indicate the presence abdominal distension-which may indicate the presence

of an intra-abdominal disorder of an intra-abdominal disorder change in change in abdominal contents-abdominal contents- e.g. ascites, encysted e.g. ascites, encysted

fluid, benign or malignant tumour, pregnancy, fat. fluid, benign or malignant tumour, pregnancy, fat.

AetiologyAetiology A weakened abdominal wall occurs in: A weakened abdominal wall occurs in:

advancing advancing ageage malnutritionmalnutrition-either of -either of

macronutrients (protein, calorie) or macronutrients (protein, calorie) or micronutrients (e.g. vitamin C) micronutrients (e.g. vitamin C)

damage to, or paralysis of, damage to, or paralysis of, motor nervesmotor nerves abnormal abnormal collagen metabolismcollagen metabolism. .

Often, multiple factors are involved. For example, Often, multiple factors are involved. For example, the presence of a patent, congenitally formed sac the presence of a patent, congenitally formed sac may not cause a hernia until an acquired may not cause a hernia until an acquired abdominal wall weakness or raised intra-abdominal wall weakness or raised intra-abdominal pressure allows abdominal contents to abdominal pressure allows abdominal contents to enter the sac. enter the sac.

Inguinal hernia Inguinal hernia

Inguinal hernias account for 80% of Inguinal hernias account for 80% of all external abdominal hernias. all external abdominal hernias.

They occur at all ages, but are most They occur at all ages, but are most common in infants and the elderly. common in infants and the elderly.

Inguinal hernias are 20 times more Inguinal hernias are 20 times more common in men than in women, and common in men than in women, and more frequently occur on the right more frequently occur on the right side. side.

Every.mov

Direct Inguinal HerniaDirect Inguinal Hernia

Other causes of groin Other causes of groin swelling swelling

femoral hernia femoral hernia hydrocele hydrocele encysted hydrocele of the cord encysted hydrocele of the cord undescended or ectopic testis undescended or ectopic testis lipoma of the cord lipoma of the cord epididymal cyst. epididymal cyst.

DD of groin swelling(LN)DD of groin swelling(LN)

ComplicationsComplications

IrreducibleIrreducible ObstructedObstructed Strangulated Strangulated Inflamed. Inflamed.

Irreducible herniaIrreducible hernia

The contents cannot be returned to the body cavity The contents cannot be returned to the body cavity in this type of hernia. The causes of irreducibility in this type of hernia. The causes of irreducibility are: are:

narrow neck with rigid margins often in association narrow neck with rigid margins often in association with a capacious sac (e.g. femoral, umbilical) with a capacious sac (e.g. femoral, umbilical)

adhesion formation between the contents and the adhesion formation between the contents and the sac (usually long-standing hernias). sac (usually long-standing hernias).

Irreducible hernias have a greater risk of Irreducible hernias have a greater risk of obstruction and strangulation than reducible ones. obstruction and strangulation than reducible ones.

Obstructed herniaObstructed hernia The obstructed hernia contains intestine in The obstructed hernia contains intestine in

which the lumen has become occluded.which the lumen has become occluded. Obstruction is usually at the neck of the sac Obstruction is usually at the neck of the sac

but may be caused by adhesions within it. but may be caused by adhesions within it. If the obstruction is at both ends of the loop, If the obstruction is at both ends of the loop,

fluid accumulates within it and distension fluid accumulates within it and distension occurs (closed loop obstruction). occurs (closed loop obstruction).

The term 'incarcerated' is sometimes used The term 'incarcerated' is sometimes used to describe a hernia that is irreducible but to describe a hernia that is irreducible but not strangulated. Thus, an irreducible, not strangulated. Thus, an irreducible, obstructed hernia can also be called an obstructed hernia can also be called an incarcerated one. incarcerated one.

Strangulated herniaStrangulated hernia

Ten percent of groin hernias present for the Ten percent of groin hernias present for the first time with strangulation. The blood first time with strangulation. The blood supply to the contents of the hernia is cut off. supply to the contents of the hernia is cut off.

The tissues undergo ischaemic necrosis. The tissues undergo ischaemic necrosis. If the contents of the sac of an abdominal hernia If the contents of the sac of an abdominal hernia

are not bowel, e.g. omentum, the necrosis is are not bowel, e.g. omentum, the necrosis is sterilesterile

Strangulation of bowel is by far the most common Strangulation of bowel is by far the most common and leads to infected necrosis (gangrene). and leads to infected necrosis (gangrene).

Inflamed herniaInflamed hernia

  The contents are inflamed by any process The contents are inflamed by any process that causes this in the tissue or organ that that causes this in the tissue or organ that is not normally herniated, e.g.: is not normally herniated, e.g.: acute appendicitis acute appendicitis Meckel's diverticulitis Meckel's diverticulitis acute salpingitis. acute salpingitis.

It may be impossible to distinguish an It may be impossible to distinguish an inflamed hernia from one that is inflamed hernia from one that is strangulated. strangulated.

InvestigationInvestigation Hernia is a clinical diagnosis. Hernia is a clinical diagnosis.

Investigations are rarely indicated or Investigations are rarely indicated or valuable. valuable.

Imaging Imaging Herniography.Herniography. This technique, which involves This technique, which involves

the injection of contrast medium into the the injection of contrast medium into the peritoneal cavity and subsequent X-ray, is now peritoneal cavity and subsequent X-ray, is now rarely used rarely used

UltrasoundUltrasound is being increasingly used to is being increasingly used to assess hernias that are difficult to define assess hernias that are difficult to define clinically, e.g. a Spigelian hernia. clinically, e.g. a Spigelian hernia.

CT and MRICT and MRI have an occasional role in rare have an occasional role in rare pelvic hernias (e.g. obturator hernia). pelvic hernias (e.g. obturator hernia).

InvestigationInvestigation Laparoscopy Laparoscopy

Unexpected hernias are sometimes Unexpected hernias are sometimes discovered at the time of laparoscopy discovered at the time of laparoscopy for undiagnosed abdominal pain. for undiagnosed abdominal pain.

Exploratory operation Exploratory operation In some infants with a convincing history In some infants with a convincing history

from the mother, a hernia is not found from the mother, a hernia is not found on clinical examination. Exploratory on clinical examination. Exploratory operation can then be justified. operation can then be justified.

Principles of management Principles of management

There is a particularly strong There is a particularly strong argument in favour of operation in argument in favour of operation in those hernias that have a high those hernias that have a high incidence of complication, incidence of complication, inguinal hernia with a narrow neck inguinal hernia with a narrow neck femoral hernia femoral hernia those that have become irreducible. those that have become irreducible.

preoperative preparation preoperative preparation

Presenting or predisposing conditions Presenting or predisposing conditions such as such as Benign prostatic hyperplasia Benign prostatic hyperplasia Obstructive airways disease may need Obstructive airways disease may need

treatment before the hernia is dealt treatment before the hernia is dealt with. with.

preoperative preparationpreoperative preparation

Large hernias that warrant repair require Large hernias that warrant repair require particularly diligent preoperative particularly diligent preoperative preparation in order to minimise the risk of preparation in order to minimise the risk of the operation and to ensure a favourable the operation and to ensure a favourable long-term outcome. long-term outcome.

Weight reduction should be encouraged. Weight reduction should be encouraged. Smoking is discouraged. Smoking is discouraged. Treatment of intercurrent disease (e.g. Treatment of intercurrent disease (e.g.

hypertension, diabetes) is essential. hypertension, diabetes) is essential.

preoperative preparationpreoperative preparation

Therapeutic pneumoperitoneumTherapeutic pneumoperitoneum is very is very occasionally necessary for giant hernias-when occasionally necessary for giant hernias-when viscera are in a hernia sac for long periods of viscera are in a hernia sac for long periods of time, they lose the 'right of domicile' in the time, they lose the 'right of domicile' in the abdominal cavity; replacing them suddenly into abdominal cavity; replacing them suddenly into the abdomen is associated with the dangers of the abdomen is associated with the dangers of respiratory embarrassmentrespiratory embarrassment compression of the inferior vena cava compression of the inferior vena cava paralytic ileus. paralytic ileus.

These complications can be averted by preparing These complications can be averted by preparing the patient and the abdominal cavity by repeated the patient and the abdominal cavity by repeated intraperitoneal injections of air over the 2 weeks intraperitoneal injections of air over the 2 weeks before operation, up to a total of 2.5 L. before operation, up to a total of 2.5 L.

Surgical techniquesSurgical techniques

HerniotomyHerniotomy is the removal of the sac and is the removal of the sac and closure of its neck. It is the first step in closure of its neck. It is the first step in nearly every hernia repair and in some nearly every hernia repair and in some instances (e.g. infant inguinal hernia-see instances (e.g. infant inguinal hernia-see below) may be all that is required. below) may be all that is required.

HerniorrhaphyHerniorrhaphy involves some sort of involves some sort of reconstruction to: reconstruction to: restore the anatomy if this is disturbed restore the anatomy if this is disturbed increase the strength of the abdominal wall increase the strength of the abdominal wall construct a barrier to recurrence. construct a barrier to recurrence.

Hernioplasty Hernioplasty

Inguinal hernia

Type 3 inguinal hernia

LOCAL TISSUE REPAIRLOCAL TISSUE REPAIRSholdiceSholdice

Mc vay repairMc vay repair

Tension free hernioplastyTension free hernioplasty

StrangulationStrangulation

Inguinal swellings which may Inguinal swellings which may resemble a femoral herniaresemble a femoral hernia

Inguinal herniaInguinal hernia Swelling is above and medial to the Swelling is above and medial to the public tuberclepublic tubercle

Saphena varixSaphena varix Compressible Palpable thrill on Compressible Palpable thrill on coughingcoughing

Femoral artery aneurysmFemoral artery aneurysm Expanding pulsation Bruit Expanding pulsation Bruit Enlarged lymph nodeEnlarged lymph node Usually multiple Not fixed on Usually multiple Not fixed on

deep aspect and therefore more mobile Seek cause-deep aspect and therefore more mobile Seek cause-infection, tumour, lymphomainfection, tumour, lymphoma

LipomaLipoma Soft but not reducible Soft but not reducible Psoas abscessPsoas abscess Fluctuant Lateral to femoral artery Fluctuant Lateral to femoral artery

Associated swelling in the iliac fossaAssociated swelling in the iliac fossa Ectopic testisEctopic testis Empty scrotum Empty scrotum

Femoral HerniaFemoral Hernia

Umbilical herniaUmbilical hernia Congenital (infantile) umbilical hernia Congenital (infantile) umbilical hernia Adult umbilical hernia Adult umbilical hernia

True umbilical herniaTrue umbilical hernia In this condition, the protrusion is through the In this condition, the protrusion is through the

umbilical scar, everting the umbilicusumbilical scar, everting the umbilicus The cause is often secondary to an increase in the The cause is often secondary to an increase in the

volume of contents of the abdominal cavity-e.g. due volume of contents of the abdominal cavity-e.g. due to obesity, ascites or large benign or malignant intra-to obesity, ascites or large benign or malignant intra-abdominal tumours. abdominal tumours.

Para-umbilical herniaPara-umbilical hernia The weakest area of the umbilical scar is at the The weakest area of the umbilical scar is at the

superior aspect between the umbilical vein and the superior aspect between the umbilical vein and the upper margin of the umbilical ring. upper margin of the umbilical ring.

It is at this point that a para-umbilical hernia It is at this point that a para-umbilical hernia develops. The emerging sac displaces the umbilical develops. The emerging sac displaces the umbilical scar, which lies below and slightly to one side. scar, which lies below and slightly to one side.

Ventral herniaVentral hernia

Epigastric hernia Epigastric hernia

Three-quarters of epigastric hernias Three-quarters of epigastric hernias are asymptomatic and found are asymptomatic and found incidentally on physical examination. incidentally on physical examination. When symptoms are present they are When symptoms are present they are of two types: of two types: local pain-often exacerbated by physical local pain-often exacerbated by physical

exertion exertion ill-defined pain-epigastric in site, often ill-defined pain-epigastric in site, often

worse after mealsworse after meals

Incisional hernia Incisional hernia Aetiology Aetiology Preoperative factors Preoperative factors

AgeAge-the tissues of the elderly do not -the tissues of the elderly do not heal as well as those of the young. heal as well as those of the young.

MalnutritionMalnutrition protein-calorie malnutritionprotein-calorie malnutrition vitamin deficiency (vitamin C is essential for vitamin deficiency (vitamin C is essential for

collagen maturation) collagen maturation) trace metal deficiency (zinc is required for trace metal deficiency (zinc is required for

epithelialisation). epithelialisation).

Incisional hernia Incisional hernia Aetiology Aetiology Preoperative factors Preoperative factors

SepsisSepsis-worsens malnutrition and delays -worsens malnutrition and delays anabolism. anabolism.

UraemiaUraemia-inhibits fibroblast division. -inhibits fibroblast division. JaundiceJaundice-impedes collagen maturation. -impedes collagen maturation. ObesityObesity-predisposes to wound infection, seroma -predisposes to wound infection, seroma

and haematoma. and haematoma. Diabetes mellitusDiabetes mellitus-predisposes to wound -predisposes to wound

infection. infection. SteroidsSteroids-have a generalised proteolytic effect. -have a generalised proteolytic effect. Peritoneal contamination (peritonitis)Peritoneal contamination (peritonitis)--

predisposes to wound infection. predisposes to wound infection.

Incisional hernia Incisional hernia Operative factors Operative factors

Type of incisionType of incision-vertical-vertical incisions are more incisions are more prone to hernia than are transverse ones. prone to hernia than are transverse ones.

Technique and materialsTechnique and materials-- tensiontension in the closure impedes blood supply to the in the closure impedes blood supply to the

wound; wound; badly badly tied knotstied knots can work loose; can work loose; closure with rapidly closure with rapidly absorbable sutureabsorbable suture material fails material fails

to support the abdominal wall for a sufficient time to to support the abdominal wall for a sufficient time to permit sound union. permit sound union.

Type of operationType of operation- operations- operations involving the involving the bowel or urinary tract are more likely to bowel or urinary tract are more likely to develop wound infection. develop wound infection.

DrainsDrains-a drain passing through the wound -a drain passing through the wound often results in a hernia. often results in a hernia.

Incisional hernia Incisional hernia

Postoperative factors Postoperative factors Wound infectionWound infection-equal-equal in importance with the in importance with the

wrong choice of suture material: there is wrong choice of suture material: there is enzymatic destruction of healing tissues; enzymatic destruction of healing tissues; inflammatory swelling raises tissue tension and inflammatory swelling raises tissue tension and impedes blood supply; 5-20% of wound infections impedes blood supply; 5-20% of wound infections result in a hernia. result in a hernia.

Abdominal distensionAbdominal distension-postoperative ileus-postoperative ileus increases increases the tension on a wound; stitches may cut out. the tension on a wound; stitches may cut out.

CoughingCoughing-generates wound tension. -generates wound tension. Approximately 40% of incisional hernias occur with Approximately 40% of incisional hernias occur with

a documented episode of wound infection. a documented episode of wound infection.

Interparietal herniaInterparietal hernia

The hernial sac lies between the layers of the The hernial sac lies between the layers of the abdominal wall. abdominal wall.

The cause may be The cause may be congenital, when there is an associated abnormality of congenital, when there is an associated abnormality of

testicular descenttesticular descent acquired in an area of weakness in the lateral aspect of acquired in an area of weakness in the lateral aspect of

the deep inguinal ring and inguinal canal (when the sac the deep inguinal ring and inguinal canal (when the sac usually communicates with a concomitant indirect usually communicates with a concomitant indirect inguinal hernia). inguinal hernia).

The classification of such hernias is based on the The classification of such hernias is based on the anatomical location of the sac: anatomical location of the sac: properitoneal (20%) properitoneal (20%) interstitial (60%) interstitial (60%) superficial (20%). superficial (20%).

Spigelian herniaSpigelian hernia

This is an interparietal hernia in the line of This is an interparietal hernia in the line of the linea semilunaris (the lateral margin of the linea semilunaris (the lateral margin of the rectus sheath, running from the tip of the rectus sheath, running from the tip of the ninth costal cartilage to the pubic the ninth costal cartilage to the pubic crest). crest).

The hernia is usually at the level of the The hernia is usually at the level of the arcuate line, below which all aponeurotic arcuate line, below which all aponeurotic layers are reflected anterior to the rectus layers are reflected anterior to the rectus muscle. muscle.

Spigelian herniaSpigelian hernia

Symptoms are: Symptoms are: local pain that is worse on straining local pain that is worse on straining lump lump non-specific lower-quadrant discomfort which non-specific lower-quadrant discomfort which

needs to be investigated in its own right needs to be investigated in its own right features of obstruction or strangulation. features of obstruction or strangulation.

Signs are: Signs are: tenderness at the site of the hernial orifice tenderness at the site of the hernial orifice lump which may be difficult or even impossible lump which may be difficult or even impossible

to feel. to feel.

Spigelian herniaSpigelian hernia

Recently, ultrasonography has Recently, ultrasonography has proved useful in the demonstration proved useful in the demonstration of these hernias in patients with of these hernias in patients with convincing histories but who lack convincing histories but who lack clinical signs. clinical signs.

RepairRepair is a simple matter of excising is a simple matter of excising the sac and closing the defect. the sac and closing the defect.

Obturator herniaObturator hernia

In this condition, herniation occurs along the In this condition, herniation occurs along the obturator canal, which carries the obturator nerve obturator canal, which carries the obturator nerve and vessels out of the pelvis. and vessels out of the pelvis.

It is most commonly seen in frail old ladies. The It is most commonly seen in frail old ladies. The hernia starts as a pre-peritoneal plug and hernia starts as a pre-peritoneal plug and gradually enlarges, taking a sac of peritoneum gradually enlarges, taking a sac of peritoneum with it.with it.

A loop of bowel may enter the sac and reduce A loop of bowel may enter the sac and reduce spontaneously. spontaneously.

A Richter's strangulation is common. A Richter's strangulation is common.

Lumbar herniaLumbar hernia

Congenital Congenital Acquired primary Acquired primary Acquired secondary-the result of Acquired secondary-the result of

surgical incision. surgical incision. Acquired hernias through an incision for Acquired hernias through an incision for

lumbar approach to the kidney are not lumbar approach to the kidney are not uncommon; however, with the decline in uncommon; however, with the decline in open renal surgery they are becoming less open renal surgery they are becoming less common. common.

Sciatic herniaSciatic hernia

A sciatic hernia is the protrusion of a pelvic A sciatic hernia is the protrusion of a pelvic peritoneal sac through the greater or lesser sciatic peritoneal sac through the greater or lesser sciatic foramen. foramen.

Clinical features Clinical features Patients present with discomfortPatients present with discomfort a swelling in the buttocka swelling in the buttock there may be symptoms of sciatic nerve compression.there may be symptoms of sciatic nerve compression. If the hernia is large, there is a reducible mass in the If the hernia is large, there is a reducible mass in the

gluteal area, made larger on standing. gluteal area, made larger on standing. Herniation of the ureters can cause urinary symptoms. Herniation of the ureters can cause urinary symptoms.

There is an appreciable risk of strangulation. There is an appreciable risk of strangulation. Management Management

Treatment is by excision of the sac and closure of the Treatment is by excision of the sac and closure of the defect by a transabdominal or transgluteal approach. defect by a transabdominal or transgluteal approach.

Perineal herniaPerineal hernia These may be: These may be:

congenital congenital primary acquired primary acquired incisional. incisional.

Primary acquired perineal hernias occur in Primary acquired perineal hernias occur in middle-aged, multiparous women. middle-aged, multiparous women. Their broad pelvis and the muscle-weakening Their broad pelvis and the muscle-weakening

effect of childbirth result in herniation through effect of childbirth result in herniation through the pelvic floor. the pelvic floor.

Incisional perineal hernia follows 1% of Incisional perineal hernia follows 1% of combined abdominoperineal excisions of combined abdominoperineal excisions of the rectum. the rectum.

Perineal herniaPerineal hernia

Clinical features Clinical features There is usually a perineal swelling and discomfort There is usually a perineal swelling and discomfort

when sitting. when sitting. A soft mass is found in the perineum, which is A soft mass is found in the perineum, which is

usually reducible. The wide neck has elastic usually reducible. The wide neck has elastic margins. margins.

These hernias rarely have dangerous complications. These hernias rarely have dangerous complications. Management Management

Repair is by a combined abdominal and pelvic Repair is by a combined abdominal and pelvic approach. approach.

The hernia is approached from below, the sac The hernia is approached from below, the sac dissected free and reduced into the abdominal dissected free and reduced into the abdominal cavity. cavity.

A laparotomy is performed and the pelvic floor A laparotomy is performed and the pelvic floor repaired from above. repaired from above.