HERNIA

Begashaw M (MD)

Introduction

Common surgical problem Adequate knowledge is important Prevent serious complications

Definition

– Is a protrusion of a viscus through an opening in the wall of the cavity

Component

Sac -Out pouch of the peritoneum- -Four parts-

Mouth,Neck,Body&FundusContent-viscus/organ inside a sac - Small bowel and omentum – the

commonest - Large bowel appendix - Bladder

CLASSIFICATION

Reducible - viscus can be returned back Irreducible - contents can’t be returned backObstructed - intestineis occluded but no

impairment of vascular supplyStrangulated - vascularity of viscus is impairedRichter’s - only one side of wall is herniatedSliding - extra peritoneal structure form part of

wall of the sac

HERNIAS

Risk factors

Increased intra abdominal pressure

- Chronic cough- Straining at urination or

defecation- Heavy wt lifting- Abdominal distension

Weakened abdominal wall

- Advanced age- Malnutrition- Congenital defect – ppv- Trauma/surgery

Clinical features

History- Lump- Pain, local aching, discomfort- Factors predisposing to increased intra

abdominal pressure- Symptoms of int. obstruction/strangulation

Physical examination

- Examine Standing & Lying- Lump – reducible, cough impulse with bowel sound- Reduced on lying & increases in size _coughing/

straining- Obstruction – tense, tender, irreducible with absent

cough impulse- Strangulation – more tenderness, with warm

indurated, and inflamed overlying skin

Examination

Investigation

a clinical diagnosis investigation is rarely needed

Complications

1. Irreducibility2. Obstruction3. Strangulation is a surgical emergencyRisk of obstruction and strangulation is

very high in femoral hernia, paraumblical hernia and indirect inguinal hernia with narrow neck

Principles of management

1. Herniotomy - removal of the sac and closure of the neck

- in infants and children2. Herniorrhaphy - Herniotomy and repair of

the wall to prevent recurrence

Obstruction

Non operative -Gentle reduction - Put patient in head down position - Sedative is given - Gentle manipulation to reduce the hernia Urgent Surgery - Failed reduction - All strangulated hernia

Strangulation

Anatomy-inguinal canal Boundary Anteriorly: External oblique apponeurosis Posteriorly: Fascia transversalis Inferiorly: Inguinal ligament Superiorly: Conjoined tendon and internal oblique M Runs in antero inferior (InternalExternal ring)_Internal ring -2cm above & 2cm medial to mid

inguinal ligament_External ring -just above pubic crest & tubercle

Anatomy

Anatomical site of groin hernia

Contents of inguinal canal

Male Spermatic vessels Vas deference Ileo inguinal nerve Genito femoral nerve

Female Round ligament

Anatomy of Femoral canal

Is a narrow rigid space Boundary- Inguinal ligamentsuperiorly- Pectineal posteriorly- Lacunar mediallyF- Femoral veinlaterally prone to obstruction & strangulation

Inguinal hernia

- accounts for 80%- commonest is all ages & sexes- 20 x more common is males than women- more common on right side

Classification

1-Indirect_passes through internal inguinal ring along the inguinal canal

-May extend down to the scrotum2 -Direct_Bulges through post wall of

inguinal canal

Classification

Hernia

Indirect inguinal hernia

- 60% on right- 40% Lt side - 20% bilateral- Due congenital defect patent processes vaginalis- 20 times more common in men

Direct inguinal hernia

- due to wear and tear associated - advanced age- increased intra abdominal pressure

Femoral Hernia

- acquired downward protrusion of intestinal contents into the femoral canal

- 4 times more common in females- rare in children

Clinical features

History- Elderly or middle aged

woman- lump on anterior and upper

thigh- may present with complaints

associated with int. obstruction or strangulation

Physical examination- Small lump on lower groin,

lateral and below pubic tubercle

- Reducible/irreducibility- Bowel sound/cough impulse

– usually absent

Femoral hernia

Management

- surgical repair without delay

Umbilical Hernia Umbilicus is one of the weak sites of the abdomen A hernia can occur at this potential site Risk factors Female sex Multiparity Obesity Ascites Complications Obstruction Strangulation Rupture

Umblical hernia

Treatment

Expectant - Spontaneous closure is expected in 80% cases of umbilical hernia in under five children

SurgeryBeyond five years

Incisional Hernia

Risk Factors -Wound infection -Poor surgical technique ( -Chronic cough -Straining -Obesity

Clinical features

Risk of obstruction and strangulation is very rare

Local discomfortCosmetic problemsDifficulties with micturation and bowel

movement when very largeTreatment Hernioplasty

Incisional hernia