HERNIA

Learning Objectives
What is a Hernia?
Types of Hernia
Common Presentations
Anatomy of the Abdominal Wall
Anatomy of the Inguinal Region

What is a Hernia?

What is a Hernia?
A protrusion of an organ
or tissue outside its
normal compartment

consists of:
z
z
z

A sac
Its coverings
Its contents

What is a Hernia?

The wall can be the

z
z
z

abdominal wall
muscle fascia
diaphragm

Hernias can be congenital or acquired

Abdominal wall hernias are very common
Account for approximately 10% of general surgical
workload

Common External Hernias

ABDOMINAL WALL &

GROIN
z

Midline
z

Umbilical

Para- umbilical

Epigastric

Inguinal
z

Direct/ Indirect/ Combined

Femoral

Incisional

Common Presentations

A lump
z

Comes and goes

Appears on straining /coughing

A pain
z

Dragging pain/ Pain on exertion

Incidental finding on examination/ imaging

Presenting as a complication
z

Incarceration/ Intestinal obstruction

Complications

If intestinal strangulation occurs, symptoms can

include:
z
z
z
z
z
z

Constipation
Blood in Stools
Fever
Vomiting
Shock
These symptoms indicate the need for emergency
medical attention.

Aetiology
The two main aetiological factors for

acquired hernias are

z

Increased intra-abdominal pressure

e.g. straining or lifting

Abdominal weakness
e.g. advancing age or malnutrition

Anatomy of the
Abdominal Wall

Muscles of the Abdominal Wall

The abdominal wall is composed of four paired muscles

z
z

internal and external obliques,

transversus abdominis, and rectus abdominis

These muscles run at right and oblique angles to one

another, giving the abdominal wall added strength

Fasciae
Aponeuroses
Transversalis Fascia

Aponeuroses

Membranes separating
muscles from each other.
Flat Tendon attaching
muscles to a fixed point
Shiny, whitish-silvery color
Histologically similar to
tendons,
At Umbilicus all 3
aponeuroses pass anteriorally

Rectus Abdominus

Paired muscle running

vertically on each side of the
anterior wall of the abdomen
There are two parallel
muscles, separated by a band
of connective tissue called the
linea alba (white line).
It extends from the pubic
symphysis inferiorly to the
xiphoid and lower costal
cartilages superiorly.
Six Pack

Linea Alba

A fibrous structure that runs down the

midline of the abdomen in humans and
other vertebrates.
The name means white line
Composed mostly of shiny white
collagen connective tissue.
It is formed by the fusion of the
aponeuroses of the abdominal
muscles
Separates the left and right rectus
abdominis muscles.
In muscular individuals its presence
can be seen on the skin, forming the
depression between the left and right
halves of a "six pack."
Only connective tissue, and no
important nerves or blood vessels,
Therefore a median incision through
the linea alba is a common surgical
approach.

Diagram
Xs through Abdominal
Region

Arcuate Line

Horizontal line that demarcates the lower limit of the rectus sheath.
Superior to the arcuate line, the internal oblique aponeurosis splits
to envelope the rectus abdominis muscle.
Inferior to the arcuate line, the inferior oblique and transversus
abdominis aponeuroses merge and pass superficial to the rectus
muscle.
Therefore,
Inferior to the arcuate line, the rectus abdominis rests directly on the
transversalis fascia.
If one dissects the anterolateral abdominal wall, the arcuate line may
be seen, since all the aponeuroses are translucent.

Rectus Sheath: Cross Section Above Arcuate Line

Aponeurosis of external
oblique muscle

Superior epigastric vessels

Aponeurosis of internal
oblique muscle

Anterior layer
of rectus sheath
Rectus
abdominis
muscle

Aponeurosis of transversus
abdominis muscle

External oblique
muscle

Linea alba
Skin

Internal oblique
muscle

Peritoneum
Falciform ligament

Extraperitoneal (fatty) tissue

Transversalis fascia
Posterior layer
of rectus sheath

Transversus abdominis muscle

Subcutaneous fat
(superficial fascia)
(Campers fascia)

Rectus Sheath: Cross Section Below Arcuate Line

Aponeurosis of external
oblique muscle
Aponeurosis of internal
oblique muscle
Aponeurosis of transversus
abdominis muscle

Peritoneum
Extraperitoneal (fatty) tissue
Transversalis fascia

Anterior layer
of rectus sheath
Rectus
abdominis
muscle

Linea alba
Branches of
inferior
epigastric vessels

External oblique
muscle
Internal oblique
muscle

Skin

Umbilical
prevesical
fascia

Urachus
in median
umbilical
fold

Medial
umbilical
ligament
and fold

Subcutaneous fat
(superficial fascia)
(Campers fascia)

Transversus
abdominis
muscle

External Oblique

External Oblique

Lateral and anterior parts of the abdomen

Muscular portion occupies the side,
Aponeurosis of EO forms the anterior wall of the
abdomen.
Only Abdominal Muscle that extends above costal
margin
Attached to Iliac Crest inferiorally
The aponeurosis of the external oblique muscle forms
the inguinal ligament.
The muscle also contributes to the inguinal canal.
Just deep to the external oblique is the internal oblique
muscle.

st
1

Layer
External Obliques

Internal Oblique

Internal Oblique

Fibers run perpendicular to the external oblique

muscle,
The internal oblique performs two major functions.
1.
2.

antagonist (opponent) to the diaphragm,

Its contraction rotates and side-bends the trunk by pulling the rib
cage and midline towards the hip and lower back, of the same
side.
It acts with the external oblique muscle of the opposite side

For example, the right internal oblique and the left external
oblique contract as the torso flexes and rotates to bring the left
shoulder towards the right hip.
For this reason, the internal obliques are referred to as "same
side rotators."

Transversus Abdominus

So called from the direction of

its fibers, is
Most internal of the flat
muscles of the abdomen
Immediately beneath the
internal oblique muscle.
From Inguinal Canal to
Diaphragm

2nd and 3rd Layers

Internal Obliques
&
Transverse Abdominus

Transversalis fascia

A thin aponeurotic membrane which

lies between the inner surface of the
Transversus abdominus and the
extraperitoneal fat.
Below, it has the following
attachments:
z

posteriorly, to the whole length of the

iliac crest
between the anterior superior iliac
spine and the femoral vessels it is
connected to the posterior margin of
the inguinal ligament

It descends in front of the femoral

vessels to form the anterior wall of the
femoral sheath.
The spermatic cord in the male and
the round ligament of the uterus in the
female pass through the transversalis
fascia at a spot called the inguinal
ring.
This opening is not visible externally

th
4

Layer
Transversalis Fascia

Summary of Abdominal
Wall Muscles

Muscles of the Abdominal Wall

In addition to forming the abdominal wall, these

muscles:
z

Are involved with lateral flexion and rotation of the

trunk
Help promote urination, defecation, vomiting,
coughing, childbirth and screaming

Muscles of the Abdominal Wall

Muscles of the Abdominal Wall

Inguinal Anatomy

 Inguinal Ligament
Inguinal Canal
Spermatic Cord
Pubic Tubercle

Inguinal Anatomy

Vessels that provide blood to

the testicle exit the abdomen
through a hole in the
abdominal wall (inguinal ring).
In women, this ring is also
present, despite the absence
of testicular vessels.
In normal cases, the inguinal
ring is small enough to prevent
the passage of abdominal
contents outside of the
abdominal cavity.

1.
2.
3.
4.
5.
6.
7.

8.

Inguinal ligament
Transversus abdominis
Muscle
Transversus abdominis
aponeurosis
Internal oblique Muscle
Internal oblique
aponeurosis
Transversalis fascia
Cremasteric fascia
forming middle coating
of spermatic cord
Pubic tubercle

Normal Inguinal Anatomy

Inguinal Anatomy
The inguinal canal represents the oblique

passage through the anterior abdominal

wall of the vas deferens (or round
ligament)
It is 5cm long and lies directly above the

medial half of the inguinal ligament

Testis cord structures

Hernia Anatomy

Inguinal ring enlarges

Bowel/tissue can
pass through it.
Pain and often lump
in the groin.
In most cases, the
bowel is able to reenter the abdomen on
its own. (reducible)

Types of Hernia

Hernia Definition
Severity

Reducible
Irreducible
Obstructed or
incarcerated
Strangulated

Position
Midline
z
z
z

Inguinal
z

Umbilical
Para- umbilical
Epigastric
Direct/ Indirect/
Combined

Femoral
Incisional

Types of Hernia?

Types of Hernia

Reducible Hernia
Irreducible Hernias
z

a narrow neck

or the contents adhere to the sac wall

Types of Hernia

Obstructed or
Incarcerated Hernia
z

Less frequently, the

intestine becomes trapped
outside of the abdomen.
Viable intestine

All inguinal hernias

must be repaired or

Strangulated Hernia.
z

z
z

Intestine passing through

the inguinal ring becomes
trapped
Deprived of blood flow
Venous Drainage
compromised

Positions of Hernias

Inguinal hernia

The most common hernia

Up to 75% of all abdominal hernias
For a thorough understanding of inguinal hernias, much insight is needed in
the anatomy of the inguinal canal.
Inguinal hernias are further divided into
z

Indirect

the more common

(2/3)
the inguinal canal is entered via a congenital weakness at its entrance (the internal
inguinal ring, and

Direct" type
(1/3)
where the hernia contents push through a weak spot in the back wall of the inguinal
canal.

Inguinal hernias are more common in men than women

While femoral hernias are more common in women.

Diagram of an
indirect, scrotal
inguinal hernia
(median view from the
left).

Direct Vs Indirect

Direct

Indirect

Posterior wall

Deep ring

Less common

70%

Older

Congenital

Smaller

Scrotal

Hesselbachs

Deep ring

Medial

Lateral

Lower risk

Strangulate

Femoral hernia

Femoral hernias occur just below

the inguinal ligament
Abdominal contents pass into the
weak area at the posterior wall of
the femoral canal.
Hard to distinguish from the
inguinal type (especially when
ascending cephalad): however
z
z

generally appear more rounded,

strong female preponderance in
femoral hernias.
The incidence of strangulation in
femoral hernias is high.

Repair techniques are similar for

femoral and inguinal hernia.

Umbilical Hernia

Especially common in
infants of African descent
Occur more in boys
Protrusion of intraabdominal contents
through a weakness at
the site of passage of the
umbilical cord through the
abdominal wall
Often resolve
spontaneously
In adults, more frequent
in obese or pregnant
women.

Incisional Hernia

An incisional hernia occurs

when the defect is the result of
an incompletely healed
surgical wound.
In median laparotomy incisions
in the linea alba, they are
termed ventral hernias.
These can be the most
frustrating and difficult to treat,
as the repair utilises already
attenuated tissue.