Hernia & PRDr.AbdulWAHID M Salih

M.D. Surgery

Hernia• protrusion of an organ

or the fascia of an organ through the

wall of the cavity that normally contains

• Congenital, acquired • Most have an

expansile cough impulse

a Hernia composed of;

1.Sac: a folding of peritoneum consisting of a mouth, neck, body and fundus.

2.Body: which varies in size and is not necessarily occupied.

3.Coverings: derived from layers of the abdominal wall.

4.Contents: which could be anything from the omentum, intestines, ovary or urinary bladder.

In children,• Specifically in infants, the parents" observation of a swelling or protusionmay be the only positive feature. • In the infancy may beTransilluminable

Inguinal• Superficial inguinal ring—

1.25 cm above and lateral to the pubic tubercle

• Deep inguinal ring—1.25 cm above and medial to the mid point of inguinal ligament

• Length of the inguinal canal—3.25cm

Ingiunal canal BoundariesMALT: 2M 2A, 2L, 2T: Superior wall [roof]: 2 Muscles:• Internal oblique Muscle• Transverse abdominus Muscle Anterior wall: 2 Aponeuroses:• Aponeurosis of external oblique• Aponeurosis of internal oblique Lower wall [floor]: 2 Ligaments:• Inguinal Ligament• Lacunar Ligament Posterior wall: 2Ts:• Transversalis fascia [laterally]• Conjoint Tendon [medially]

Ingiunal canal ContentsIlioinguinal nerve. Spermatic cord, which contains:3 arteries:• Testicular a.• Ductus deferens a.• Cremasteric a.3 nerves:• Cremasteric n.• Genital branch of the genitofemoral n.• Autonomics3 other things:• Ductus deferens• Pampiniform plexus• Lymphatics

Types of indirect inguinal hernia1. Incomplete;    Bubonocele—limited within the inguinal canal    Funicular—limited just above the epididymis2.Complete; traverses to the bottom of the scrotum

• Introduce yourself

• Wash hands

• Chaperone

• Standing up

• Undressed from waist down

• Look for an visible lumps

• Any scars, overlying skin changes.

• The lump extends into the scrotum

position•Pt. stands, exposed area visible. •best performed with the patient

standing and in supine•the physician seated on a stool

prepare• Stand at the side of the patient,

• one hand on the patients back to support him.

• hand and arm should be roughly parallel to the inguinal ligament when palpating the lump.

• Observation of the groin area in oblique light

• Visible swelling. Examine as a mass; (STEM; site,skin,size,shape,…)

Mass

Most important1. Can you get above it?

2. Reducibility test

3. Expansile Cough Impulse;

4. Invagination test

5. Three finger test

Zieman’s technique

6. Ring occlusion test

Also Asses • Intra or extra abdominal

• Tension

• Composition

• Percussion and auscultation;

Bowel Sounds

• Always examine both groins

• Tranillumination

1-Cough Impulse•Pt. coughs to highlight hernia.•May not ;if the neck is blocked by adhesions•Visible & Palpable cough impulse.•Reappear on straining, standing or coughing  

2-Reducibility test• Ask pt. to reduce hernia himselves

• usually done in lying position.

• The thigh of the affected side should be flexed, adducted and internally rotated.

• Finger guard of the inguinal canal by thumb and index finger and then the scrotum is gently squeezed.

Relation to Pubic Tubercle

INGUINAL HERNIA; The neck above and medial to the pubic tubercle

FEMORAL HERNIA; The neck below and lateral to pubic tubercle

3-Get above the swelling test• Done in standing position

• At the root of the scrotum place the thumb in front and the index behind

•Try to reach above the swelling. • Inguinal hernia; cannot get above

• Pure scrotal swelling; will get above

4-Invagination test•The scrotum on each side is inverted with the examining index finger •Entering the inguinal canal along the course of the cord structures.•The size of the external ring. •The finger push up to the superf inguinal ring. •The pulp should feel the ring.•Pat is asked to cough, •A palpable impulse will confirm the hernia; felt on the pulp then direct felt on the tip then indirect hernia.

5-Three finger test / Zieman’s techniqueIndex finger; deep inguinal ring (indirect hernia)

Middle finger; superficial ing. Ring (direct hernia) Ring finger; saphenous opening (femoral hernia)

The patient is asked to cough.

6-Ring occlusion test•Reduce the hernia

•Occlusion of the deep ring by thumb.•Then holding the thumb in position ask

The pt to stand then cough

•If no bulging; indirect

•If bulging; direct .

Beside• Beside; at the level of inguinal region

at the affected side; Notice a small bulge Compare to the other side.• Stand beside the pt; your shoulder

behind the opposite shoulder of pt; Reduce the hernia. Ask the pt to cough

Examine the abdomen;

Causes Of raised intraabd. pressure;

• Enlarged bladder (BPH)

• Ascites

Search; predisposing factors;

describe the hernia1.  Site (inguinal)2.  Right/Left3.  Reducible/Irreducible 4.  Complete/Incomplete 5.  Direct/Indirect

•Any hernia that is tender•Nausea and vomiting; •No attempt to reduce it manually. •An acute surgical emergency.

Strangulation

indirect summary•Relation to epigastric vessels;Relation to epigastric vessels; Lataral Lataral •Processus vaginalis; Processus vaginalis; PresentPresent•congenitalcongenital•Unilateral (usually).•always descends the scrotum •prone to obstruction and strangulation

Direct summary•Bilateral•AcqiuredAcqiured •Processus vaginalis; Processus vaginalis; AbsentAbsent •Rarely strangulate; medial tomedial toepigastric vessels; epigastric vessels;

Femoral Hernia (cont..)Femoral hernias are more common in women, present as a groin lump. the cause of unexplained small bowel obstruction.an absent Cough impulseglobular lump than the pear shaped lump of the inguinal

hernia. • Differential Diagnoses:

Inguinal Hernia.Femoral Artery Aneurism.Femoral Lymphadenopathy.Psoas Abscess.

Umbilical Hernia:• In infants & children.• Boys more than girls.• Tend to resolve without any treatment

by around the age of 5 years.

• Obstruction and strangulation is rare.

Paraumbilical Hernia:• Affects adults.

• either supra or infraumbilical through the linea alba.

• The female to male ratio is 20:1.

• Clolicky pain and/or irreducibilty due to omental adhesions.

Incisional Hernia• weakness is the result of an

incompletely healed surgical wound.

• more along a straight line from the sternum down to the pubis.

• Swelling at the

incisional site +/- pain.

Epigastric Herniaa defectin the linea alba between the

xiphoid process and umbilicusStarts as a protrusion of the

extraperitoneal fat Swelling +/- pain similar to a peptic ulcer pain.

Rare external Hernias1. Spiglian Hernia:

spaces of the semilunar line and the lateral edge of the rectus muscle (inferior to the arcuate line).

The posterior rectus sheath is weak Preoperative diagnosis is diffucult u/s & c.t are helpful tools in the diagnosis

2-Lumbar Hernias:broad bulging hernia

not vulnerable to incarceration.

A. Petit’s hernia: inferior lumbar triangle.

B. Grynfeltt’s Hernia:superior lumbar triangle and is less common than Petit’s.