abdominal wall hernia essentials ma murphy frcsi back to department of surgery trinity college...
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Abdominal Wall HerniaEssentials
MA MURPHY FRCSI
Back to Department of Surgery Trinity College Dublin
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Objectives
Understand the term hernia Basic anatomical knowledge Clinical features of common hernia Complications of hernias Examination of a hernia Differential diagnoses of a lump in the
groin Management of hernia
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Hernia
A protrusion of an organ or tissue
outside its’ normal compartment
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Common External Hernias
ABDOMINAL WALL & GROIN Midline
• Umbilical
• Para- umbilical
• Epigastric Inguinal
• Direct/ Indirect/ Combined Femoral Incisional
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Common Presentations
A lump Comes and goes Appears on straining /coughing
A pain Dragging pain/ Pain on exertion
Incidental finding on examination/ imaging Presenting as a complication
Incarceration/ Intestinal obstruction
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Inguinal Hernia
Commonest external hernia Male preponderance Infant / adult Direct / indirect / combined Weakness / increased pressure Cause pain / discomfort Carry risk of complications Treated surgically
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Inguinal Hernia - History
OBJECTIVES
Establish differential diagnoses
Identify risk factors and significant co-
morbid pathologies
(e.g. increased intra-abdominal
pressure due to ascites or
chronic airways disease)
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Inguinal Hernia - History
Onset Duration Symptoms Other hernia(e) Irreducibility Gastrointestinal system Respiratory system Surgery / anaesthesia
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Inguinal Hernia - Examination
Surface markings
Anterior superior iliac spine
Pubic tubercle
Midpoint of inguinal ligament
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asis
pubic tubercle
midpoint of inguinal liagament
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Inguinal Hernia - Examination
OBJECTIVES
Confirm diagnoses
Out rule differentials
Establish type
Determine contents
Reducibility
Identify co-morbid pathologies
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Direct V’s Indirect
Direct Post wall Less common Older Smaller Hesselbachs Medial Lower risk
Indirect Deep ring 70% Congenital Scrotal Deep ring Lateral Strangulate
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Inguinal Hernia
Examination
Standing / Lying Supine
Cough impulse
Reducibility
Contents
Bowel sounds
Scrotal contents
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Differential
Direct /Indirect/Combined
Femoral hernia
Hydrocele
Lipoma
Lymph node
Testicular tumour
Saphenous varix
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Inguinal Anatomy
The inguinal canal represents the
oblique passage through the anterior
abdominal wall of the vas deferens
(round ligament)
It is 5cm long and lies directly above the
medial half of the inguinal ligament
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Inguinal Anatomy
Floor• Transversalis fascia• Medially the conjoint tendon
Roof• External oblique aponeurosis• Laterally the conjoint tendon• Skin and superficial fascia
Above • Conjoint tendon
Below• The inguinal ligament
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Inguinal Anatomy
Three nerves
• Ilio-inguinal (on not in)
• Sympathetic fibers
• Genitofemoral Three layers of fascia
• Internal spermatic (transversalis f.)
• Cremasteric (conjoint tendon)
• External spermatic (ext. oblique)
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Inguinal Anatomy
Three arteries
• Testicular (from the aorta)
• Artery of the vas (external iliac)
• Cremasteric (inferior epigastric) Three other structures
• The vas deferens
• The pampniform plexus of veins
• Lymphatics (to aortic nodes)
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TESTIS CORD STRUCTURES
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Inguinal Anatomy
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Hernia Anatomy
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Indirect Hernia
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Direct Inguinal Hernia
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Hernia Complications
Incarceration
Strangulation
Intestinal obstruction
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Varieties of Hernias
Maydls
• W loop of intestine Richters
• Partial inclusion of intestinal wall
Sliding hernia
• Bladder
• Sigmoid colon/ appendix
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Richters’ Hernia
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Maydls’ Hernia
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Hernia Management
Investigations None required for routine
uncomplicated case Plain X-ray for suspected bowel
obstruction Ultrasound in case of diagnostic
uncertainty Herniogram rarely used Routine pre-op investigations
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Hernia Treatment
Surgery To relieve symptoms To prevent complications
Operations Open hernia repair Laparoscopic hernia repair
Pre-peritoneal Intra- abdominal
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Open Hernia Repair
Day-case surgery Anaesthesia
General Local
Operations Tension free Mesh repair
(Lichtenstien) Darn repairs (Shouldice, Bassini)
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Open Hernia Repair
Incision above medial half of inguinal ligament
External oblique opened from external ring to expose the cord and overlying ilioinguinal nerve
Internal (deep) ring exposed Hernial sac identified and reduced Prolene mesh inserted to reinforce
posterior wall and deep ring
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Open Hernia Repair
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Open Hernia Repair
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Open Hernia Repair
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Open Hernia Repair
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Open Hernia Repair
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Laparoscopic Repair
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Laparoscopic Repair
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Laparoscopic Repair
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Surgery Complications
Trauma• Nerve
• Artery (testicular atrophy)
• Intestine Haemorrhage
• Haematoma (infection) Infection
• Wound infection
• Chest Infection
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Femoral Hernia
Herniation through femoral canal Appears below and lateral to pubic
tubercle Relatively uncommon Commoner in females Contains omentum or small intestine High risk of strangulation Repaired surgically
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Femoral Hernia
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Femoral Hernia Repair
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Summary
Inguinal hernia is the commonest
external hernia
Indirect hernias have a higher risk of
strangulation
Hernias are treated by surgery, to relieve
symptoms and prevent complications
Femoral hernias have a high risk of
strangulation
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Recommended Reading
Ellis H. Clinical Anatomy
www.vesalius.com