HERNIAS

Prof. Dr. M. Sphan ERTRK

Definition
A hernia is an abnormal protrusion
of any viscus from its proper
anatomical cavity through:
congenital defect
weakened region in its wall

Frequency
Groin
Indirect inguinal
Direct inguinal
Femoral
Incisional
Ventral
Epigastric
Umbilical
Spigelian
Others
Hiatal
Lumbar
Obturator
Perineal
Sciatic
Peristomal

75-80 %
60-65 %
15 %
5 %
10 %
10 %

5 %

Etiology

Congenital defects
Enlarged foramen
Loss of tissue strength and elasticity
Trauma
Increased intra-abdominal pressure

Descriptive terms
Reducible
Irreducible
Incarcerated
Strangulated
Complete
Incomplete
Sliding
Richters hernia
Maydls hernia
Littres hernia

Inguinal Anatomy.

Surgical Anatomy, Skandalakis

Inguinal Anatomy..

Surg Clin North America

Indirect inguinal hernia.

Indirect inguinal
hernia passes
through the internal
ring and traverses
the inguinal canal.
It may extend into
the scrotum
(complete hernia).
Current Diagn Treatm, Lange

Indirect inguinal hernia..

It occurs as a result of congenitally patent
processus vaginalis.
First clinical evidence may appear at
Childhood
Middle or old age
When incompletely obliterated
Indirect inguinal hernia
Communicating hydrocele
Spermatic cord hydrocele
Hydrocele of testis

Indirect inguinal hernia...

Most common type of hernia in both men and women
5 to 10 times more common in men than in women
More common on the right
60% right
30% left
10% bilateral
A pediatric inguinal hernia is almost always indirect
Potential indirect hernias
Undescended testis
Testis in the inguinal canal
Testicular or spermatic cord hydrocele.

Direct inguinal hernia.

It occurs in the floor of the inguinal
canal because of an acquired weakness
in fascia transversalis.
The incidence therefore increases with
age, and it is often bilateral.
The abdominal structures protrude
through the Hesselbachs triangle into
the posterior wall of the inguinal canal.

Direct inguinal hernia..

The hernia rarely descends into the
scrotum.
The neck of the direct hernia is
wide, so it is less often associated
with strangulation.
Direct hernias are seen almost
exclusively in male patients.

Current Diagn Treatm, Lange

Femoral hernia.
The hernia content
passes beneath the
inguinal ligament
traverses the femoral
canal
seen as a mass at the
level of foramen ovale

Textbook of Surg, Oxford

Femoral herni..
Incarceration* and strangulation* are
frequent (30-40%).
More common in women (1/3 of all groin
hernias) than in men (2% of all groin
hernias).
However, inguinal hernia is more frequent
both in men and in women than femoral
hernia.
Femoral hernias are related to physical
exertion and to pregnancy

Diagnosis.
History
Some patients may describe a sudden pain
and bulge while lifting, coughing or straining
(physical activity).
The mass may be
continiously
intermittantly present
In general, direct hernias
produce fewer symptoms than indirect
inguinal hernias
less likely to become incarcerated or
strangulated.

Diagnosis..
Physical examination
A mass may be

Visible
Tender
Reducible
Bowel sounds may be audible.

A mass may be

Small or nonpalpabl
Palpabl with coughing and straining.

Diagnosis...
Radiology

Plain films
Upper GI series
Contrast medium enema
Herniography
US
CT
MRI

Treatment.
Ideally, all hernias should be
treated surgically.
Because the risk of incarceration,
strangulation and obstruction are
greater than the risk of elective
operation

Treatment..
The principles of repair

Preparation of hernial sac

Opening the sac (herniotomy)
Return of hernia contents into the peritoneal
cavity
Excision or reduction (invagination) of the
hernial sac
Repair of the hernial defect
Tissue approximation
(Bassini, Halsted, McWay, Shouldice)
Prosthetic reinforcement
Open (Lichtenstein, Stoppa, Rives, Kugel)
Laparoscopic

ng Herni, D Uur

ng Herni, D Uur

Umbilical hernia
Umbilical hernias occur at the umbilicus.
10 times more often in women than in men.
The defect is common in children, but is
usually (95%) obliterated spontaneously.
In adults, umbilical hernias are often
associated with increased intra-abdominal
pressure (ascite, pregnancy, obesity, large
intra-abdominal tumor).
Treatment
Simple transverse repair of the fascial defect
(<3 cm).
Prosthetic material (tension-free repair)
(>3 cm / recurrent hernia).

Epigastric hernia
It develops through a
defect in the linea alba
above the umbilicus.
About 20% of epigastric
hernias are multiple
Treatment
Simple repair
10% recurrence rate

Prosthetic repair
For larger hernias

Current Diagn Treatm, Lange

Incisional hernia
Results from poor wound healing in a previous surgical incision
90% are seen during first 3 years
Common etiologic factors:
Poor surgical technique
wound infection
wound hematoma
advanced age
Obesity
Malnutrition
increased postoperative abdominal pressure
(ileus, ascites, pulmonary complication)
Treatment
Primary repair (Recurrence rate is 25%)
Prosthetic repair (Open / laparoscopic)

Diaphragmatic hernias
Potential defects
Single
Esophageal hiatus
Paired
Posterolateral
(Bochdalek)
Anterior
(Morgagni, Larrey)
Treatment
Nissen, Toupet,
Belsey Mark IV
Primary/prosthetic repair

nsan Anat Atlas, Sobotta