Download - Abdominal Wall Hernia
Abdominal Wall HerniaEssentials
MA MURPHY FRCSI
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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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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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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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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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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