HERNIAHERNIADone by D1 group

objectivesobjectivesDefinitionAnatomyPrecipitating factors Types Clinical features Preoperative assessment Management and repair

DefinitionDefinition

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

AnatomyAnatomy The inguinal canal :-

The inguinal canal is approximately 4 cm long and is directed obliquely

inferomedially through the inferior part of the anterolateral abdominal wall. The canal lies parallel and 2-4 cm superior to the medial half of the inguinal ligament.This ligament extends from the anterior superior iliac spine to the pubic tubercle.

The inguinal canal has openings at either end : –

The deep (internal) inguinal ring is the entrance to the inguinal canal. It is thesite of an outpouching of the transversalis fascia. This is approximately 1.25 cm superior to the middle of the inguinal ligament

The superficial, or external inguinal ring is the exit from the inguinal canal. It is a slitlke opening between the diagonal fibres of the aponeurosis of the external oblique

Inguinal canalInguinal canal walls of The inguinal canal :- The anterior wall is formed mainly by the aponeurosis of the

external Oblique   . The posterior wall is formed mainly by transversalis fascia   The roof is formed by the arching fibres of the internal

oblique and transverse abdominal muscles.   The floor is formed by the inguinal ligament, which forms a

shallow trough. It is reinforced in its most medial part by the lacunar ligament.

Content :-

1. Spermatic cord ( round ligament of the uterus in female )

The Cord Itself.—The contents of the spermatic cord are

(a) the ductus (vas) deferens and its artery .

(b) the testicular artery and venous (pampiniform) plexus.

(c) the genital branch of the genitofemoral nerve.

(d) lymphatic vessels and sympathetic nerve fibers.

(e) fat and connective tissue surrounding the cord and its coverings in various amounts

2. Ilioinguinal nerve .

3. Ilioinguinal lymph node .

Femoral CanalFemoral CanalThe major feature of the femoral canal is the femoral

sheath. This sheath is a condensation of the deep fascia (fascia lata) of the thigh and contains, from lateral to medial, the femoral artery, femoral vein, and femoral canal. The femoral canal is a space medial to the vein that allows for venous expansion and contains a lymph node (node of Cloquet). Other features of the femoral triangle include the femoral nerve, which lies lateral to the sheath,

  Wall of The Femoral canal

anterior is the inguinal ligament

posterior is the iliopsoas, pectineal, and long adductor muscles (floor).

Medial is lacunar ligament

Lateral is femoral vessle

Predisposing:Predisposing:

All hernias occur at the site of WEAKNESS OF THE ABDOMINAL WALL which are acted on by repeated INCREASE in abdominal pressure

repeated INCREASE in repeated INCREASE in abdominal pressure is abdominal pressure is usually due to usually due to Chronic coughStraining Bladder neck or urethral

obstructionPregnancy Vomiting Sever muscular effortAscetic fluid

Types Types Inguinal FemoralEpigastric Para umbilicalUmbilicalObturatorSuperior lumbarInferioer lumbarGlutealSciaticIncisional

• Indirect Inguinal HerniaHernia through the inguinal canal• Direct Inguinal HerniaThe sac passes through a weakness or defect of the

transversalis fascia in the posterior wall of the inguinal canal

• Femoral HerniaHernia medial to femoral vessels under inguinal ligament• Umbilical HerniaHernia through the umbilical ring• Paraumbilical HerniaA protrusion through the linea alba just above or sometimes

just below the umbilicus• Epigastric HerniaProtrusion of extraperitoneal fat through the linea alba

anywhere between the xiphoid process and the umbilicus• Incisional HerniaHernia through an incisional site• Lumber Herniaoccur through the inferior lumber triangle of Petit

Inguinal hernia Inguinal hernia History: 1.Age ( young vs. old)2.Occupation ( nature ?? )3.Local symptoms: Swelling,

discomfort and pain4.Systemic symptoms: if there is

obstruction or strangulation 5.Precipitating factors

Inguinal hernia Inguinal hernia Examination:1.Inspection for site, size, shape and

color.2.Palpation for surface, temp,

tenderness, composition and reducibility.

3.Expansible cough impulse.4.General exam: for common causes

of increase intra abdominal pressure

Indirect Versus Direct inguinal Indirect Versus Direct inguinal hernias hernias

Indirect is the most common form of hernia and its usually congenital due to patent processus viginalis

Direct usually acquired occur in

old men with weak abdominal muscles.

Indirect Versus Direct inguinal hernias Indirect Inguinal Hernia Direct Inguinal Hernia

Pass through inguinal canal. Bulge from the posterior wall of the inguinal canal

Can descend into the scrotum. Cannot descent into the scrotum.

Lateral to inferior epigastric vessels. Medial to inferior epigastric vessels.

Reduced: upward, then laterally and backward.

Reduced: upward, then straight backward.

Controlled: after reduction by pressure over the internal (deep) inguinal ring.

Not controlled: after reduction by pressure over the internal (deep) inguinal ring.

The defect is not palpable (it is behind the fibers of the external oblique muscle).

The defect may be felt in the abdominal wall above the pubic tubercle.

After reduction: the bulge appears in the middle of inguinal region and then flows medially before turning down to the scrotum.

After reduction: the bulge reappears exactly where it was before.

Common in children and young adults.

Common in old age.

Note that examination using finger and thumb across the neck of the scrotum will help to distinguish a swelling of inguinal origin and one

that is entirely intrascrotal

Femoral hernia Femoral hernia

Small femoral hernia may be unnoticed by the patient or disregarded for years perhaps until the day it strangulates. Adherence of the greater omentum sometimes causes a dragging pain. Rarely a large sac is present .

Femoral hernia Femoral hernia HistoryAge ; uncommon in children , most

common in old age female .Sex; women > men (but still

commonest hernia in women the inguinal hernia )

The patient came with local symptoms 1- discomfort and pain2- swelling in the groinGeneral ; femoral hernia is more likely

to be strangulated than the inguinal hernia

Multiplicity ; often bilateral

Femoral hernia versus inguinal Femoral hernia versus inguinal herniahernia

Inguinal hernia Femoral hernia

1 -more common in male 1 -more common in females

2 -pass through the inguinal canal

2 -pass through the femoral canal

3 -neck of the sac is above and medial the pubic tubercle

3 -neck of the sac is below and lateral the pubic tubercle

4 -less common to be strangulated

4 -more common to be strangulated

5 -can be treated without surgery

5 -must be treated surgically

6 -the two diagnostic signs of hernia+

6 -the two diagnostic signs of hernia-

7 -the sac mainly contain ; bowel 7 -the sac mainly contains ; omentum

Umbilical herniaUmbilical herniaSigns and symptomsAge ; doesn’t appear until the

umbilical cord has separated and healed .

No specific symptomsHave wide neck and reduce easily ,

rarely give intestinal obstruction.Nature history ; 90 % disappear

spontaneously during the first year.

Examination Inspection Site ; in the center of the umbilicusSize and shape ; size can vary from vary

small to very large . Shape is usually hemispherical.

Palpation Composition ; contain bowel , which makes

it resonant to percussion . They reduce spontaneously when the child lies down .

Reducibility ; easyCough impulse; invariably present .

Acquired umbilical herniaAcquired umbilical hernia

Hernia through the umbilical scar , so it is a true umbilical hernia.

Not common and is usually secondary to increase intra abdominal pressure.

The most common causes1- pregnancy2- ascitis3- ovarian cyst4- fibrodis5- bowel distention

Incision herniaIncision hernia

Signs and symptoms Previous operation or accidental trauma Age ; all ages , but more common in old age. Symptom ; lump ,pain ,intestinal obstruction

( distention ,colic, vomiting ,constipation , sever pain in the lump )

Examination 1- reducible lump 2- expansile cough impulse 3- if the lump dose not reduse and dose not have

cough impulse , than it may be not a hernia Ddx Tumor Chronic abscess Hematoma Foreign body granuloma

Preoperative assessment Preoperative assessment

proper history and examinationidentify high risk patientsprepare the preoperative notes :consent..pre op Dxprocedure plannedsurgeonsAnasthesia anticipated (general ,

local, spinal)

Preoperative assessment Preoperative assessment

Investigation data ( pre operative tests ) :1. Lab :* CBC : to check hemoglobin level anemia and

WBCs infections* U&E : to check for any electrolyte imbalance* LFTs : indicated in jaundiced patients and

suspected hepatitis or any clotting problems* PT & PTT* ABG* grouping and cross matching 2. Imaging :* Chest X ray : for all patients 3. ECG : for any patient who is more than 40 years

of age

Preoperative assessment Preoperative assessment

  current medications or allergies any major (chronic) illness pre op orders : 1. skin preparation2. diet (NPO)3. GIT preparation 4. Sedation5. Preanesthetic medications6. Other medications7. Antibiotics8. Blood transfusion ( if needed )9. Bladder preparation

ManagemeManagement and nt and repair repair

Inguinal Hernia Repair

Reduction

SurgicalTTT

Pre op Evaluation

&preparation

Surgical TTT

Choice of Anesthetic

TTT of hernial sacInguinal floor

reconstruction

Pre op evaluation Pre op evaluation &preparation&preparation

Watchful Waiting Surgical TTT

May be appropriate for pt with asymptomatic hernia or elderly pt with minimal symptoms or easily reduced inguinal hernia.

Routine F/U with health care professional

A Randomized trial concluded that this is an acceptable option for men with minimally symptomatic inguinal hernia and that delaying repair until symptoms increase is safe

due to low rate of incarceration. 23% of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most often hernia-related

pain) , only 1 pt (0.3%) experienced acute hernia incarceration without strangulation within 2years, a second had acute incarceration with

Bowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA 2006,295:285)

Pre op Pre op preparationpreparationMost pt are treated surgically

Increase IAP abnormalities (Chronic cough, Constipation, Bladder outlet

obstruction) should be evaluated and remedied to extent possible before

elective herniorrhaphy.In case of intestinal obstruction and

possible strangulation, Broad spectrum AB,NG suction may be indicated, correction of volume

status& elctroyles.

ReductionReductionUncomplicated:Manual Gentle pressure over hernia

Gentle traction over the mass sedation and trendelenburg position.

Complicated (strangulated): no attempt should be made to reduce

the hernia because of potential reduction of gangrenous segment of bowel with the hernial sac.

Surgerical TTTSurgerical TTT1.choice of anesthetic: elective open repair : Local is

preferred Laproscopic hernia repair: more

commonly under GA.

2.TTT OF HERNIAL SAC2.TTT OF HERNIAL SACINDIRECT: sac is dissected free from

the cord structures and creamsteric fibers. Sac should be open away from any herniated contents. Contents are then reduced, and the sac is ligated deep to inguinal ring with an absorbable suture

DIRECT:Too broadly based for ligation and

should not be opened, simple freed from transversalis fibers and inverted.

3.Inguinal Floor 3.Inguinal Floor ReconstructionReconstruction

Some method of reconstruction of

the inguinal floor is necessary in all

adult hernia repairs to prevent recurrence.

3.Inguinal Floor

Reconstruction

Primary tissue repairOpen tension free

repairLaproscopic&

preperitoneal repairs

1.Primary tissue repair1.Primary tissue repair

Bassini repair: inferior arch of transversalis fascia (TF) or conjoint tendon is approximated to shelving portion of inguinal ligament.

McVay: TF is sutured to cooper ligament.

Shouldice: TF is incised and reapproximated.

2.Open tension free 2.Open tension free repairrepair

Lichtenstein repair &Patch and Plug technique: Mesh is used to

reconstruct inguinal floor

Mesh plug technique : place mesh in the hernial defect

Laproscopic &Laproscopic & preperitoneal repairs preperitoneal repairs TAPP (transabdominal prepeitoneal procedure):

peritoneal space entered by conventional lap at umbilicus and peritoneum overlaying inguinal floor is dissected away as flap.

TEP (Total extraperitoneal repair): preperitoneal space is developed with a balloon inserted between posterior rectus sheath and peritoneum balloon inflated to dissect the peritoneal flaps awau from posterior abdomianl wall and the direct and indirect spaces, other ports inserted into this preperitoneal space without entering peritoneal cavity.

After lap. Dissection and reduction of hernia sac , a large piece of mesh is placed over inguinal floor

Femoral hernia repairFemoral hernia repair• Femoral hernias should be repaired very soon after the diagnosis has been made because of the high risk of strangulation. • There is no place for a truss for a femoral hernia.• Different approaches : Open VS Laparoscopic

Open surgeryOpen surgeryThree approaches have been

described for open surgery :1.Infra-inguinal approach (Lookwood)2.Supra-inguinal approach ( McEvedy)3.Trans-inguinal approach

( Lotheissen)

Each technique has the principle of dissection of the sac with reduction

of its contents, followed by ligation of the sac and closure between the inguinal and pectineal ligaments.

Lockwood’s infra-inguinal Lockwood’s infra-inguinal approachapproach The sac is dissected out below the

inguinal ligament via groin crease incision.

Then the sac is opened and the contents are inspected and reduced into the abdomen.

Then the neck of the sac is pulled down , ligated and allowed to retract through femoral canal.

Then close the femoral canal by mesh plug or non absorbable sutures.

McEvedy’s high approachMcEvedy’s high approachVertical incision is made over the

femoral canal and continued upwards above the inguinal ligament.

This incision provides good access to the preperitoneal space and then to the peritoneum itself.

Use finger dissection to sweep peritoneum from anterior abdominal wall , so the neck of the sac can be identified.

Dissect the sac , reduce the contents and repair the defect by mesh or sutures.

Lotheissen‘s trans-inguinal Lotheissen‘s trans-inguinal approach approach The incision is made superior and

parallel to inguinal ligament extending from pubic tubercle to mid inguinal point.

Hernia examination Hernia examination

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