HerniaDr. Hatem ElGoharyLecturer of General Surgery

Definition

A hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity.

Aetiology (Congenital)

Congenital preformed sac – the remains of the processus vaginalis.

Aetiology (Aquired)

Any condition that raises intra-abdominal pressure, such as apowerful muscular effort, intra-abdominal malignancy.

Chronic cough, straining on micturition or straining on defaecation mayprecipitate a hernia in an adult.

acquired collagen deficiency increasing an individual’s susceptibility to the development of hernias.

Sites

Composition of a hernia

The sac

The coverings

Contents

The sac

The sac is a diverticulum of peritoneum, consisting of mouth,neck, body and fundus.

The diameter of the neck is important becausestrangulation of bowel is a likely complication when the neck isnarrow, as in femoral and paraumbilical hernias.

The Coverings

Coverings are derived from the layers of the abdominal wallthrough which the sac passes.

Contents •omentum

•intestine •a portion of the circumference of the intestine =

Richter’s hernia

•a portion of the bladder (or a diverticulum) may constitute part of or be the sole content of a direct inguinal, a sliding inguinal or a femoral hernia

•a Meckel’s diverticulum = a Littre’s hernia; •fluid, as part of ascites or as a residuum thereof.

Classification

Reducible

Irreducible

Obstructed

Strangulated

Inflammed

Complications

Irreducible

Obstructed

Strangulated

Inflammed

Reducible hernias

The hernia either reduces itself when the patient lies down or can be reduced by the patient or the surgeon.

Irreducible hernias

contents cannot be returned to the abdomen but there is no evidence of other complications.

It is usually due to adhesions between the sac and its contents or overcrowdingwithin the sac.

Obstructed hernia

This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to theblood supply to the bowel.

Strangulated hernia

A hernia becomes strangulated when the blood supply of its contents is seriously impaired, rendering the contents ischaemic.

Gangrene may occur as early as 5–6 hours after the onset of the first symptoms.

Inflammed Hernia

Inflammation can occur from inflammation of the contents ofthe sac, e.g. acute appendicitis or salpingitis.

or from external causes, e.g. the trophic ulcers that develop in the dependent areas of large umbilical or incisional hernias .

The hernia is usually tender but not tense and the overlying skin red and oedematous.

Inguinal Hernia

Surgical anatomy

Indirect (oblique) inguinal hernia• This is the most common form of hernia

• types of indirect inguinal hernia:

1. Bubonocele. The hernia is limited to the inguinal canal.2. Funicular. The processus vaginalis is closed just above theepididymis. The contents of the sac can be felt separately fromthe testis, which lies below the hernia.3. Complete (synonym: scrotal). The testis appears to lie within the lower part of the hernia.

Direct inguinal hernia

A direct inguinal hernia is always acquired. The sac passesthrough a weakness or defect of the transversalis fascia in theposterior wall of the inguinal canal.

Damage to the ilioinguinal nerve (previousappendicectomy) is another cause, because of the resultingweakness of the conjoined tendon.

They are most common in older men.

Direct hernias do not often attain a large size or descend into the scrotum.

Treatment• Herniotomy (Excision of the sac)• Dissecting out and opening the hernial sac, reducing

any contents and then transfixing the neck of the sac and removing the sac. sufficient for the treatment of hernia in infants.

• Herniorrhaphyhe (Repair of the posterior wall)

repair of the stretched internal inguinal ring and transversalis fascia and further reinforcement of the posterior wall of the inguinal canal and must be achieved without tension.