External Hernia

Affiliated Hospital of Jining Medical College
What’s these???
Affiliated Hospital of Jining Medical Colleg
External Hernia
Affiliated Hospital of Jining

Medical College
Department of Gastrointestinal
Surgery
Wang Ailiang
Objectives of Course
 Definition of hernia
 Grasp anatomy of inguinal
canal
 Categories of common
inguinal hernias
 Principle of treatment for
inguinal hernias
Abdominal wall hernias

 general consideration
 inguinal hernias
 femoral hernia
 incisional hernia
 umbilial hernia
 hernia of linea alba
1.GENERAL
CONSIDERATIONS
DEFINITION:
 A sprout and
protrusion of tissue or
viscus through a
weakness or abnormal
opening in an
enclosing layer
 an external abdominal
wall hernia is an
abnormal protrusion
of intra-abdominal
tissue or viscus, whole
or part, through an
opening or defect of
Inguinal hernias
 90% of external abdominal

hernias
 occur in the groin
 include indirect inguinal hernias
and direct inguinal hernais
All Kinds of Hernias:
Affiliated Hospital of Jining Medical Coll
Type of Abdominal Hernia

 femoral hernia
Affiliated Hospital of Jining Medical Colle

 umbilical hernia

 inguinal hernia
ETIOLOGY:
 Weakness of
abdominal wall
 increased intra- A balloon with a
abdominal pressure protrusion
 Etiology
1. intensity of abdominal wall decreased

(common factors):
1) site that some tissues pass through the
abdominal wall: Spermatic cord, round
ligament of uterus
2) bad development of abdominal white line
3) incision, trauma, infection et al.
defect in collagen synthesis or turnover
2. any condition which increases intra-
abdominal pressure
Hernia:
 Clinical types
1. reducible hernia
2. irreducible hernia
3. incarcerated hernia
4. strangulated hernia
Clinical classification
 Reducible hernia: Contained viscus can be
returned from the hernia to its normal
domain spontaneously or with manual
pressure when the patient is recumbent
 Irreducible hernia: Contained viscus
cannot be returned from the hernia to its
normal domain, usually it is due to the
adhesions between the contents of hernia
sac and the wall of hernia sac
Sliding
hernia
Huge hernia
irreducible hernia
Sliding hernia:
 A portion of the wall of the
hernia sac is composed of an
organ such as the cecum on
the right side and the sigmoid
colon on the left side.
Occasionally, bladder is
involved. The development of
a sliding hernia is related to
the variable degree of
posterior fixation of the large
Incarcerated hernia:
 If the neck of hernia is very
narrow, protruded part of
intra-abdominal viscus in
the hernia sac may be
trapped by the narrow
neck, and the lumen of a
segment of bowel within
the hernia sac, if it exists,
may become obstructed.
 In which there is no
interference with blood
supply.
Strangulated hernia:
 If, in addition to incarceration, there is a
compromise of the blood supply of the
contained organ
 Gangrene of the hernia contents and the

hernia sac usually occur after long time of
incarceration
Gangren
e of
incarcer
ated
intestine
strangulated hernia
Special types of hernias

 Richter’s hernia: only part of
circumference of the bowel becomes
incarcerated or strangulated at the narrow
neck of hernia.
 Littre’s hernia: when the incarcerated or

strangulated part is a diverticulum of the
small intestine, usually Meckel’s
diverticulum.
Richter’s hernia
Pathological anatomy:
 The external abdominal hernia

consists of hernia ring, hernia
sac, hernia content, and hernia
covering.
 Pathological anatomy
 covering tissue: skin, subcutaneous

tissue
 hernial sac: protrusion of peritoneum,
 neck of the sac: is narrow where the sac
emerges from the abdomen body of the
sac
 hernial contents: small intestine, major
omentum
Different parts of a hernia:
Inguinal Hernia
Anatomical layers of inguinal
region
 Skin and subcutaneous fat
 External oblique abdominal
muscle
 Internal oblique abdominal
muscle and transverse
abdominal muscle
 Transverse abdominal fascia
 Fat out of peritoneum
 Peritoneum
Internal oblique abdominal muscle

and transverse abdominal muscle:
 The lower arcing free edges of these two
muscles fuse together to form the
conjointed tendon.
 But this condition occurs only in 5% of
persons.
 Thus, falx inguinalis, which forms the
superior wall of the inguinal canal, refer to
the lower arcing free edge of transverse
abdominal muscle rather than two
muscles.
Transvers abdominal
fascia:
 Internal inguinal ring is a partial

interruption in the transverse
fascia, which is located at the
halfway of the inguinal ligament
and up 2 cm to it.
The anatomy of the groin:
Inguinal canal:
 Inguinal canal passes through the lower
anterior abdominal wall from the external
inguinal ring to the internal inguinal ring,
which is about 4-5 cm long in the adults.
 In the male, the testis and the spermatic
cord pass through the inguinal canal from
the abdomen to the scrotum.
 In the female, the round ligament of the
uterus passes it to the major labia.
The four walls of the inguinal

canal
 Are formed by the muscular, aponeurotic,
and fascial layers of the abdominal wall.
 The anterior wall is formed by the external

oblique aponeurosis and the fibers of the
internal oblique muscle.
 The superior wall(roof of the

inguinal canal) is formed by the
falx inguinalis, which is the
arcing free edge of the
transverse abdominal muscle(or
the conjointed tendon which is
the arcing free edge of the
fusing of the internal oblique
abdominal muscle and the
transverse abdominal muscle).
 The inferior wall(floor of the

inguinal canal) is formed by the
inguinal ligament and the
lacunas ligament.
 The posterior wall is formed by
the transverse fascia.
Inguinal canal,
showing
arrangement
of (1)external
oblique
muscle,
(2)internal
oblique
muscle,
(3)transversus
muscle,
(4)fascia
transversalis.
(1)the external oblique abdominal muscle
(2)the internal oblique abdominal
(3)the transverse abdominal muscle
(4)testicular veins
(5)the efferent duct of the testes
(6)the iliac vessels
(7)the inferior epigastic artery and vein
(8)the aponeurosis of the transverse
transversalis fascia
(9)the public tubercle
Spermatic cord:
 When the testicle descents into the
scrotum, it passes through the abdominal
wall in the inguinal region.
 The spermatic cord passes obliquely

downward through the inguinal canal from
the internal inguinal ring, then it emerges
through the external inguinal ring to pass
into the scrotum.
Nerves of inguinal region:
 Include: iliohypogastric nerve,

ilioinguinal nerve, and
genitofemoral nerve.
 During operation: we should not
damage these nerves.
Inguinal triangle:
 The inguinal triangle lies in the
inferomedial inguinal region,
which is an area of potential
weakness and thus often the site
of a direct inguinal hernia.
 The medial border of it is the

linea semilunaris(the lateral
edge of the rictus sheath)
 The inferolateral border is the
inguinal ligament
 The lateral border is the inferior
epigastric artery
Pathological mechanism:
 The mechanism of indirect and

direct inguinal hernia is
different.
Indirect inguinal hernia:
 The processus vaginalis may close

before birth. If that don’t happen, a
persistent processus vaginalis may
predispose to congenital indirect
hernia during the early years of life.
 A weakened area of abdominal wall
associated with an enlargement of
the internal ring may cause an
acquired indirect inguinal hernia.
 As a result, an indirect inguinal

hernia leaves the abdominal
cavity at the internal ring and
passes with the structures of the
spermatic cord either a variable
distance down the inguinal canal
or all the way into the scrotum
through the superficial inguinal
ring directed by the spermatic
cord.
 Therefore, the neck of hernia

must be located lateral to the
inferior epigastric artery to enter
the inguinal canal, and the sac of
hernia must lie within the fibers
of the cremaster muscle.
Direct inguinal hernia:

 Direct inguinal hernias are
always acquired.
 A direct hernia protrudes
through the posterior wall of the
inguinal canal in the inguinal
triangle, and pushes the
peritoneum and transversalis
fascia.
 Normally, the posterior wall of

inguinal canal in the area of the
inguinal triangle is reinforced by
aponeurotic fibers from the
transverser abdominis and the falx
inguinalis.
 However, this kind of reinforcement
may be incomplete because the
supporting extent of falx inguinalis
varies among different persons.
 Thus, the inguinal triangle is a
potential site of weakness to some
Conclusions of indirect and direct

hernia:
 1)The direct hernia projects

through the inguinal triangle
instead of the internal inguinal
ring
 (2)Therefore, the neck of hernia
passes medial to the inferior
epigastric artery
 (3)and the sac of hernia lies

adjacent to(not within) the
spermatic cord. So, this type of
hernia is not through the
external inguinal ring and is
seldom enter the scrotum
 (4) Sliding hernia is more
common in the indirect hernia
than in the direct hernia..
 (5)The risk of strangulation in

indirect is more than in direct,
because the indirect hernia
passes through the internal
inguinal ring and have a narrow
neck, and the direct hernia
usually protrudes through the
inguinal triangle without a
narrow neck.
Clinical manifestations:
 Symptoms: The most important

symptom is a lump or swelling in
the inguinal region which may be
discovered by a routine physical
examination or by the patient
himself. Occasionally, the
patient may have the feeling of
the discomfort or slight pain.
 Signs: The typical clinical feature

is a swelling or a lump in the
inguinal region, which may be
reducible or irreducible with the
patient supine and relaxed.
 When the patient is requested to
strain or cough, the hernia may
become apparent because of
raising intra-abdominal
pressure.
Differences of two kinds of

hernia
 Usually an indirect inguinal
hernia appears as an elliptic
swelling coming down the
inguinal canal and frequently
entering the scrotum.
 A direct inguinal hernia appears
as a symmetric swelling at
external ring.
 Both of them should be located
 The physical signs of an hernia

vary with the contents of the
sac. For example, if a bowel
enters the hernia sac, crepitaion
will be noted on palpation
because of the presence of gas
and fluid within the lumen.
Methods of examination:
 When examining, patient should
be standing in a relaxed
position.
 The finger should be introduced
through the external ring into
the inguinal canal.
 The presence of a dilated
external inguinal canal would be
 When the examining finger has

been advanced well into the
inguinal canal and the patient is
requested to cough or strain, the
indirect hernia should strike the
fingertip and the direct hernia
should strike the ball of the
finger.
 A thumb placed over the internal

inguinal ring should keep an
indirect hernia reduced when the
patient strains while permitting
a direct hernia to appear; again,
it is not always possible to locate
the internal ring accurately
enough to make this technique
foolproof.
7. The differences between the
indirect and the direct inguinal
hernia:
feature indirect direct
age children, young aged people
pathway of people
coming down the pass through
protrusion inguinal canal, may Hesselbach’s
enter the scrotum triangle, rarely
contours of sac elliptic, pear- enter the scrotum
semispheric, wide
compress the shaped
controlled base
controlled
internal ring after
reduced
Relationship of Posterior to the sac Anterior and lateral
spermatic cord with to the sac
sac
Relationship of sac Sac neck is lateral Sac neck is medial
neck with inferior to it to it
epigastric artery
Incarcerated high low
Incarcerated or strangulated
hernia:
 They can often be seen in
emergency conditions, which are
common in the indirect inguinal
hernia, but seldom in the direct
hernia.
 The small intestine is the organ

most frequently affected, and
small bowel obstruction may
happen.
 The patient suffers the sudden
onset of abdominal pain,
vomiting, and distension.
 In that case, we should doubt
the acute incarceration or
strangulation of the bowel.
Differential diagnosis:
1. Indirect, direct, femoral
hernia: They have different
characters.
2. Hydrocele of the spermatic
cord.
3. An undescended testis: The
testis cannot be felt in the
scrotum.
4. Lymphadenopathy or
Hydrocele of the scrotum:

Principles of treatment:
 All inguinal hernias should be
managed by operative treatment
in the adult patient except that
the strong contraindications
exist.
 Emergency operation should be
done when the complications of
incarceration, obstruction, and
strangulation in the indirect
hernia happen
 Although direct hernia seldom occurs

incarceration, operation is also
needed because it is difficult to
distinguish indirect hernia from direct
hernia.
• The congenital inguinal hernia
may spontaneously cure,
operation can be delayed until
the child is more than one
year old.
Non-operative
management:
 The doctor can use some external
support device or truss to maintain
hernia reduction.
 The patient can take off it at night
and put on it in the morning before
he arises.
 However, this method are
recommended to be appllied only in
the patients with strong
contraindications of surgical
operation because it isn’t a
 When an acutely incarcerated

hernia occurs, manual
reduction may be used.
 The patient is placed in hips
elevated position. After
applying an appropriate dose
of analgesics and sedation,
gentle sustained pressure over
the mass may effect reduction
in 30 minutes.
 If that effort fails or
Treatment of inguinal
 Principleshernias
 Review relative anatomy
 Operative methods
 Include new progress in hernia
surgery
Principles of treatment:
 Adult: operative
treatment
 Child under 1: the
congenital inguinal
hernia may
spontaneously cure
 Patient with strong
contraindications:
non-operative
Non-operative
management:
 Using some
external support
device or truss
to maintain
hernia reduction
 Only in the
patients with
strong
contraindications
of surgical
operation
Operative
treatment
Before operation:
 Any problems which could
increase intra-abdominal
pressure, should be solved to
prevent a recurrent hernia.
 Chronic cough
 Constipation
 Prostatic hyperplasia
Aim of Operation
Review: Anatomy of inguinal
canal
 From the internal inguinal ring to the

external inguinal ring, 4-5 cm long
 Inside the canal
 Male: the spermatic cord
 Female: the round ligament of the uterus
Review: Roof ： The conjoint tendon
Anatomy of The anterior wall: The posterior wall:
inguinal canal
the external oblique aponeurosis the transverse fascia
The spermatic cord Floor ： The inguinal ligament

 The superior wall(roof)
 Conjoint tendon
(the arcing edge of the fusing
of the internal oblique
transverse abdominal muscle)
 The inferior wall(floor)
 The inguinal ligament
 The anterior wall
 The external oblique
aponeurosis
 Skin and superficial fascia
 The posterior wall
 The transverse fascia

canal
External oblique aponeurosis Conjoint tendon


canal
The transverse fascia Site for inguinal hernia

Operative techniques
A. Simple high ligation of the
sac
used for child
B. Repair of hernia
C. Tension free Mesh repair
D. Laparoscopic Repair
Operative techniques:
sac:
 anatomically isolate hernia
sac, ligate at the neck of
hernia sac, and removal of the
sac.
 If simple high ligation of the
sac is combined with a
tightening of the internal ring,
sac:
 Cut exteral oblique  Isolate hernia

aponeurosis
sac
 Ligate neck of  Removal of the

B.Repair of hernia: There are three

steps.
(a)The management of the hernia

sac and its contents, that
includes high ligation of the sac
and excision of sac.
(b)The repair of the transverse
fascial defect.
 Closing or decreasing the size of

internal ring by the suture is
required in the most indirect
hernia.
 In the direct hernia, it is usually
a broadbased bulge, reinforced
of weakened area in inguinal
triangle by the fascial repair is
required.
(c)The repair and reinforcement

of the inguinal canal wall.
 The first two essential steps are
the same in any repair of hernia
for the most patient with
inguinal hernia
 The main difference is how to
repair and reinforce the wall of
the inguinal canal.
Roof ： Conjoint tendon
Bassini repair: The anterior wall:

the external oblique aponeurosis
The posterior wall:
the transverse fascia
 Approximates
and sutures the
arcing edge of
the conjointed
tendon to the
inguinal ligament
beneath the
spermatic cord
 Leaves the
spermatic cord
between the
internal oblique
B. Repair of hernia:
herniorrhaphy
 High ligation of the sac
 Repair and reinforcement the
inguinal canal wall
 reinforce the posterior wall of the
inguinal canal :
Bassini Shouldice
Halsted Mcvay
 reinforce the anterior wall of the
inguinal canal:
Ferguson
Shouldice repair: The anterior wall:

The posterior wall:
 Before Bassini
repair, cut
transvers
abdominal
fascia and
suture it
overlaply
 Decrease
recurrent
hernia
Halsted
repair:
The posterior wall:
The anterior wall: the transverse fascia
 Place the
external oblique
aponeurosis
beneath the cord
, but otherwise
resembles the
Bassini repair.
 Leaves the
spermatic cord
under the skin
and
McVay repair: The anterior wall:

The posterior wall:

 Brings the arcing The cooper’s ligament
edge of the
conjointed
tendon
posteriorly and
inferiorly to
Cooper’s
ligament and
suture them
 For big hernia,
recurrent hernia,
femoral hernia
Ferguson
repair:
The anterior wall: The posterior wall:
the external oblique aponeurosis the transverse fascia
 Approximate and
suture the arcing
edge of the
conjointed tendon
to the inguinal
ligament above the
spermatic cord
 Leave the
spermatic cord
beneath the
internal oblique
muscle and the
C. Tension free Mesh

repair
 Use artificial materials
 Tesion free
 Low recurrent rate
Tension free Mesh
repair:
 Shorter recovery time and less post-

operative discomfort
 Used for bilateral hernias, recurrent
Conclusion
Operative techniques
A. Simple high ligation of the sac
B. Repair of hernia
 reinforce the posterior wall of the
inguinal canal :
Bassini Shouldice
Halsted Mcvay
 reinforce the anterior wall of the
inguinal canal:
Ferguson
C. Tension free Mesh repair
Management of incarcerated or
strangulated hernias:
 The most incarcerated hernias
need emergency operation.
 During the operation, it is vital
to inspect whether strangulation
has occurred or not before
reduction.
 If operation has been done early

enough and no strangulation
occur, you can replace the
content and carry out a routine
repair.
 If gangrene has already
developed, all gangrenous tissue
must be resected and you can
not do a repair.
Management of sliding
hernia:
 Management of the sac is
complicated when a sliding hernia
is present.
 The failure to recognize a sliding
hernia may lead to injury involved
organs or their blood supply.
 During operation, the hernia sac is
identified and opened anteriorly
away from the involved organ
which makes up its posterior wall.
 The entire anterior portion of the

sac is removed. Posteriorly as
much sac as possible is removed
without injuring the sliding
organ. Then the involved organ
is reduced into its original
position and the defect in
peritoneum is closed. Finally, a
routine repair can be carried out.
 After hernia repair, patient may need

bed rest for 2-3 days and return to
everyday home activities within one
week.
 But patient should be advised
against heavy lifting and other
vigorous effort for 4-8 weeks.
 The anesthetic may be general,
spinal, or local.
“Hernia today,
gone
tomorrow”
The history of HERNIA

OPERATION
is the history of
SURGERY
OTHER TYPES OF ABDOMINAL

WALL HERNIAS
FEMORAL HERNIA
 A femoral hernia protrudes

through the femoral ring
beneath the inguinal ligament,
which is common in women.
 Because it has a narrow neck, it
is easy to incarceration and
strangulation.
Anatomy:
 The lateral border of the
femoral ring is the femoral
vein
 The anterior border is the
inguinal ligament
 The medial border is the
lacunar ligament
 The posterior border is the
perineal ligament(Cooper's
ligament)
Pathological mechanism:
 Mainly due to the defect in the
transverse fascia in the direct
triangle.
 A peritoneal sac passes under
the inguinal ligament(the
femoral ring) into the femoral
canal.
 The inguinal ligament is a tight
band and beneath it the femoral
 Medial to the femoral vein is a

small empty space through
which a femoral hernia may
project with a very narrow neck.
 The contents of the hernia easily
occur incarceration and
strangulation.
Clinical manifestations:
 Symptoms: Normally
asymptomatic until
incarceration or strangulation
occurs. Even with obstruction
or strangulation, the patient
may feel discomfort more in
the abdomen than in the
femoral area.
 Signs: A small bulge in the
Differential diagnosis:
 Inguinal hernia:
 A saphenous varix: without
comfortable
 Lipoma:
 Abscess:
Treatment:
 Because of the high incidence of
incarceration and strangulation,
all femoral hernias should be
managed by operative
treatment.
 If incarceration of femoral hernia
has occurred, manual reduction
is forbidden and emergency
operation is indicated.
 The principles of operation:

complete excision of the hernia
sac, repair and reinforcement of
the defect in the transversalis
fascia, closure of the femoral
canal.
 McVay is the common repairing
method.
Incisional hernia
 Develop in an old operative
incision.
 The incisional wound infection
is the most important factor.
 Age, obesity, other diseases,
poor surgical technique are
other causes.
 The principle of management
is early operative repair.
Umbilical hernia:
 Umbilicus is a weakened area in
the abdominal wall due to the
exist of the umbilical cord of
embryo.
 Congenital umbilical hernia is
common in infants. But most of
these infants spontaneous close
the fascial defect within the first
two years of life.
 The principle of treatment: using

some external support device
when child is less than six
months; and the operative repair
should be delayed until two
years old.
 Umbilical hernia in adults can be
seen in women with multiple
pregnancies, obesity, or patients
with severe ascites.
Epigastric hernia:
 Also called the hernia linea
alba, usually occur above the
level of the umbilicus.
 An area of congenital
weakness in the linea alba with
increased intra-abdominal
pressure is the cause of this
type of hernia.
 More common in men than in
women.
 A small epigastric hernia
谢谢

External Hernia

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Affiliated Hospital of Jining Medical College

Affiliated Hospital of Jining

Abdominal wall hernias

 90% of external abdominal

Type of Abdominal Hernia

Type of Abdominal Hernia

Type of Abdominal Hernia

1. intensity of abdominal wall decreased

 Gangrene of the hernia contents and the

Special types of hernias

 Littre’s hernia: when the incarcerated or

 The external abdominal hernia

 covering tissue: skin, subcutaneous

Internal oblique abdominal muscle

 Internal inguinal ring is a partial

The four walls of the inguinal

 The anterior wall is formed by the external

 The superior wall(roof of the

 The inferior wall(floor of the

 The spermatic cord passes obliquely

Nerves of inguinal region:

 Include: iliohypogastric nerve,

 The medial border of it is the

 The mechanism of indirect and

Indirect inguinal hernia:

 The processus vaginalis may close

 As a result, an indirect inguinal

 Therefore, the neck of hernia

Direct inguinal hernia:

 Normally, the posterior wall of

Conclusions of indirect and direct

 1)The direct hernia projects

 (3)and the sac of hernia lies

 (5)The risk of strangulation in

 Symptoms: The most important

 Signs: The typical clinical feature

Differences of two kinds of

 The physical signs of an hernia

 When the examining finger has

 A thumb placed over the internal

 The small intestine is the organ

Hydrocele of the scrotum:

 Although direct hernia seldom occurs

 When an acutely incarcerated

 From the internal inguinal ring to the

Anatomy of The anterior wall: The posterior wall:

The spermatic cord Floor ： The inguinal ligament

Review: Anatomy of inguinal

External oblique aponeurosis Conjoint tendon

Review: Anatomy of inguinal

The transverse fascia Site for inguinal hernia

 Cut exteral oblique  Isolate hernia

 Ligate neck of  Removal of the

B.Repair of hernia: There are three

(a)The management of the hernia

 Closing or decreasing the size of

(c)The repair and reinforcement

Bassini repair: The anterior wall:

The spermatic cord Floor ： The inguinal ligament

Shouldice repair: The anterior wall:

The spermatic cord Floor ： The inguinal ligament

The spermatic cord Floor ： The inguinal ligament

McVay repair: The anterior wall:

The spermatic cord Floor ： The inguinal ligament