HERNIA

CHINCHU M

Definition

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

repeated INCREASE in
abdominal pressure is
Chronic cough
usually
due to
Straining
Bladder

neck or urethral
obstruction
Pregnancy
Vomiting
Sever muscular effort
Ascetic fluid

Types
Inguinal
Femoral
Epigastric
Para

umbilical
Umbilical
Incisional
Congenital diaphragmatic 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 hernias
Indirect

is the most common

form of hernia and its usually
congenital.

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.

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 versus

inguinal hernia
Inguinal hernia

Femoral hernia

more common in male- 1

more common in females- 1

pass through the inguinal- 2

canal

pass through the femoral- 2

canal

neck of the sac is above and- 3

medial the pubic tubercle

neck of the sac is below and- 3

lateral the pubic tubercle

less common to be- 4

strangulated

more common to be- 4

strangulated

can be treated without surgery- 5 must be treated surgically- 5

the two diagnostic signs of- 6
+hernia

the two diagnostic signs of- 6

-hernia

the sac mainly contain ; bowel- 7

the sac mainly contains ;- 7

omentum

Umbilical hernia
Signs

and symptoms
Age ; doesnt appear until the
umbilical cord has separated and
healed .
No specific symptoms
Have 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
Size and shape ; size can

umbilicus
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 ; easy
Cough impulse; invariably present .

Acquired 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 causes
1- pregnancy
2- ascitis
3- ovarian cyst
4- fibrodis
5- bowel distention

Incision 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 )

Pathophysiology
During fetal development, out pouching
of peritoneum originates at the
inguinal ring
Extends medially down into the
scrotum or labia majora
Failure to close process vaginalis results
in potential sac, and abdominal
contents herniates into the sac

Clinical features
Swelling
Pain
Tenderness
Irritability
Abdominal

distension

Diagnosis
History
Physical

examination
Blood examination
Urine examination
Imaging studies

Manageme
nt and
repair

Preoperative assessment
proper

history and examination

identify high risk patients
prepare the preoperative notes :
consent..
pre op Dx
procedure planned
Anasthesia anticipated (general ,
local, spinal)

Preoperative assessment
Investigation

data ( pre operative tests ) :

1. Lab :
* CBC : to check hemoglobin level anemia
and WBCs infections
* 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

Pre op preparation
Most

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.

Reduction
Uncomplicated:
Manual

Gentle pressure over hernia

Gentle traction over the mass.

Complicated

(strangulated):
no attempt should be made to reduce
the hernia

TREATMENT OF HERNIAL SAC

INDIRECT:

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.

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.

Open tension free

repair
Lichtenstein

repair &Patch and

Plug technique: Mesh is used to
reconstruct inguinal floor
Mesh

plug technique : place

mesh in the hernial defect

Complications
Scrotal

hematoma
Retention of urine
Wound infection
Recurrence

Thank
You