External Hernias- Diagnosis & Management PDF

By DR DILIBE UC  Introduction.  Incidence.  Types.  Etiology.  Predisposing factors.  Pathogenesis.  Peculiarities of various hernias.  Conclusion.  External Hernia – Protrusion of a viscus or part of it from a cavity in which it is contained and visible on the a...

By DR DILIBE UC  Introduction.  Incidence.  Types.  Etiology.  Predisposing factors.  Pathogenesis.  Peculiarities of various hernias.  Conclusion.  External Hernia – Protrusion of a viscus or part of it from a cavity in which it is contained and visible on the abdominal wall.  -- Protrusion via an opening (congenital/ acquired) in the wall of its cavity.  -- Protrusion via a weakness.  -- Needs a raised intra-compartmental pressure.  Named according to the anatomical site.  Caused by weakness/ opening in the cavity & raised intra-compartmental pressure.  Natural history is progressively increasing swelling.  Mostly have Cough impulse.  Diagnosis mainly clinical; investigation for complicated cases and overall care.  Prognosis is generally good in uncomplicated ones & absence of co-morbidity.  Most common out-patient surgical problem.  About 6% of the population.  In Underdeveloped world, most common cause of Intestinal Obstruction( Ignorance, Poverty, &Lack of Facilities).  Inguinal hernia 80-90% of all hernias. Evenly distributed.  Femoral hernias 2-5%. More among females; Europe, North American >>> Africa.  Umbilical hernias 4%. Via the Linea alba in the umbilical cicatrix. More in developing areas where umbilical sepsis is rife; Genetic disposition.  Paraumbilical hernias- Not common. Within 2cm from the umbilical margin- Superiorly/ Inferiorly/ Laterally.  Epigastric hernia- more than 2cm from the umbilical margin from the Xiphoid to the umblicus.  Lumbar hernia- Superior & Inferior Lumbar Triangles.  Incisional hernia- in scar (Surgical /Traumatic). Advanced community with increased incidence of laparotomy. Wide scar that healed with 2nd intention. Turbulent postoperative state e.g. wound infection.  Defects/ Weakness in the wall with the viscus. CONGENITAL (Internal ring, Femoral ring, External Inguinal ring e.t.c). ACQUIRED- Ageing( Direct Inguinal Hernia) - Infection( Umbilical hernia, Drainage of abscess, Incisional hernia) -Multiple gestation, obesity, intra- abdominal masses.  Nerve Injury( Direct Inguinal hernia following Ilioinguinal nerve injury in appendectomy) Straining / Injury –Tear of muscles / Aponeurosis. Repeated Raised Intra-cavitary / Intra- compartmental pressure. Chronic obstructive airway disease, Chronic Constipation, Chronic urinary obstruction, Heavy manual labor-weight lifting.  Child: Whooping cough.  Adult: Chronic Cough, Smoking(Acquired Collagen Deficiency), Straining.  Defect+ Raised Intracavitary pressure→ Progressive Pouch →Sac →Protrusion via the Defect/ Weakness → Hernia.  Anatomically, Most hernias- Mouth; Neck( Well defined, Narrow in Strangulation, Absent in Direct Inguinal hernia& Incisional hernias); Body(Thin/ Thick); & Fundus.  Exceptions are Epigastric & Incisional hernias.  COVERINGS- From the layers of the abdomen; Thinning out with continuous pressure; Or Thickening in long standing hernia. CONTENTS- Omentum- Omentocele. Intestine- Enterocele. Part of the circumference- Richter’s hernia Bladder- Cystocele. Cecum- Sliding hernia. Appendix- Little’s hernia.  Meckel’s diverticulum- Littre’s hernia  Both Direct & Indirect hernias together- Pantaloon hernia.  Reducibility- Common. Complete return of contents into the abdomen. Irreducibility – Incomplete reduction without any other complications. Incarceration- No reduction at all. Commonly the lumen is loaded with feces. Causes include: Adhesions, Too much content vis a vis the neck, fecal loading of the gut, omentum, sliding hernia.  COMPLICATIONS: Irreducibility; Obstruction; Strangulation- Comprise of blood supply to the contents, sac coverings. In 5% of Inguinal,& 30% of Femoral hernias. Usually at the neck, antimesenteric border. Gangrene supervene in 5-6hrs.  Fistula- Richter’s hernia; Spontaneous perforation( @ convexity or constriction); Incision by Charlattans. Rupture- unrelieved pressure →overlying skin necrosis → rupture →evisceration of the contents. Inflammation- Contents( Appendicitis, Salpingitis) or The coverings- Trophic ulcer. Red, edematous, tender, tense skin/ sac.  ANATOMY OF INGUINAL CANAL- An Oblique canal at the lower abdomen a finger breadth above the Inguinal ligament.  About 4 cm in length in adult & absent in childhood.  Courses downdard &medially from the DEEP( Internal/ Inner) RING to SUPERFICIAL(External/ Outer) RING.  Embyrologically – Route of Descent of the Testis & cord in males / Round ligament of the uterus to the Scrotum& Labium Majora respectively.  WALLS- Anterior wall by the External Oblique Aponeurosis reinforced laterally by Internal Oblique Muscle. Posterior wall by Transversalis fasciae reinforced medially the Conjoint tendon and muscle. Roof by the Arching fibres of Transversus Abdominis & Internal Oblique muscles. Floor by the uprolled Inguinal Ligament.  Openings in the Inguinal Canal- Internal/ Deep ring( U-shaped opening in the Transversalis fascia above the midpoint of the Inguinal ligament. Indirect hernias dilate& weakens the ring en route to the scrotum. External/ Superficial ring- Triangular aperture in the External Oblique aponeurosis above the pubic tubercle. Indirect hernia pass via it to the scrotum & Direct hernia pushes anteriorly via it.  Contents: In Males, Spermatic cord, Ilioinguinal nerve, & genital branch of Genitofemoral nerve. In females the round ligament of the uterus replaces the cord.  Inguinal triangle of Hasselbach- Medially the lateral border of Rectus Sheath; Laterally the Inferior Epigastric vessels; Floor- Inguinal ligament; Direct hernia emerge from the floor with a wide mouth rarely with neck hence no strangulation.  Found in the canal.  16% of the male population.  95% of all male hernias; >50% of all female hernias. M:F = 20-25:1.  65% are Indirect hernias.  55% are Right sided.  12% are Bilateral hernias.  Forms:  Indirect / Oblique hernia enters via the deep ring. Oblique movement of the sac. Usually congenital 90% of the Inguinal hernia. All ages. Right: Left= 2:1 in males. Equal in females. Obstructs &Strangulates more often.  Direct hernia enters via the floor of Inguinal triangle.  Forward movement of the sac via the external ring.  Acquired.  10% of all Inguinal hernias.  Elderly age group. Rarely seen before 30years.  Equal in both sexes.  Rarely strangulates.  Groin swelling- painful/ painless.  Groin discomfort/ Dragging sensation.  Cough Impulse.  Reducible swelling( spontaneously or manually.  Occlusion test.  Irreducible swelling; tenderness.  Complete hernia( Inguinoscrotal hernia) – Reaches the scrotum.  Bubonocele – Within the canal.  Funicular – Just above the pubic tubercle.  Interparietal – Between the anterior abdominal muscles.  Preperitoneal- Between the fascia & peritoneum.  Pantaloon- Occupying the Indirect & Direct positions.  MALES- Femoral hernia; Vaginal hydrocele; Hydrocele of the cord; Undescended/ Ectopic testis; Malgaignes Bulges, Cysts of the Epididymis; Inguinal lymph node, Saphena varix; Lipoma; Spermatocele; Sebaceous cyst.  FEMALES- Femoral hernia, Lipoma of the canal of Knuck, Hydrocele of the canal of Knuck, Inguinal lymph nodes, Saphena varix, Sebaceous cyst.  Diagnosis is clinical.  Abdominal Ultrasound – Intra-abdominal masses.  Chest Xray- COAD; & Elderly.  Full Blood Count- Leucocytosis in Strangulation.  Urinalysis.  Fasting Blood Glucose.  Herniotomy in Children.  Herniorrhaphy- Herniotomy + Repair of the Posterior wall+ Tightening of the Deep ring.  Highlights- Preoperative Optimization; Address Co-morbidities; Avoid Truss- Uncomfortable, increases Strangulation. Posterior wall repair- Bassini; Open Mesh( Lichtenstein); Shouldice, Nylon Darn etc.  Open / Closed  Anesthesia- Field Block- plain Local anesthetic agent or with adrenaline avoiding later around the spermatic cord.  Regional anesthesia- Subarachnoid/ spinal or Epidural.  General Anesthesia especially children & in strangulation.  Exposure of the layers.  Separation of the sac from the spermatic cord.  High ligation of the sac.  Posterior wall repair and tightening of the deep ring.  Layered wound closure.  Intra-operative – Anesthetic—  Surgical- Primary hemorrhage, Trauma to Urinary bladder, caecum, ovary ,gut, etc.  Postoperative-Early- Urinary retention; Reactionary hemorrhage; Hematoma; Seroma; Scrotal edema/ Hematoma; Wound infection; Wound Dehiscence etc.  Late- Wound pain, Testicular atrophy/ Infarction, Recurrence(Long standing, Large size, Elderly, repeated straining, poor technique, wound infection).  In obstructed / strangulated hernias, @ neck of the sac, external ring, adhesion within the sac/content or the deep ring.  Management – Resuscitation- Fluids, NG tube, Urethral catheterization, Antibiotics, Analgesia &Emergency Operation.  About 5% of the White population & 2% in Black races.  Of these, 30-35% in White Females & 2% in White Males.  9% in Black Females & 1% in Black Males.  Elderly.  Female multiparous.  A Triangle @ anterior aspect of the upper thigh. The Upper / Superior - Inguinal ligament; Medially - Adductor longus muscle; Laterally - Sartorius muscle. The anterior wall from without skin, superficial fascia, deep fascia. The Floor – Pectineus muscle medially & Iliopsoas muscle laterally  Contents of the femoral triangle- Femoral canal, Femoral vein, Femoral artery, Femoral nerve lymph nodes.  FEMORAL CANAL – Vertical Gap 1.25-3cm length at the upper medial end of the femoral triangle, from the femoral ring -its opening to the saphenous opening inferiorly. Contents of the femoral canal– Femoral hernia, Lymph nodes(Cloquet), Fat.  Femoral ring- weak spot which allows herniation following raised Intra-abdominal pressure.  Has a tight margins except for the femoral vein.  The margins include the Inguinal ligament anteriorly; Pectineal ligament posteriorly; Lacunar ligament medially; & Femoral vein medially.  Repeated raised Intra-abdominal pressure →Stretching, Weakness, Breach of fascia over the femoral ring.  Fascial aggregation and adherence to the lateral edge of the lacunar ligament.  Sac →Ring →Canal → Saphenous Opening upwards into the subcutaneous tissue.  Contents: Small intestine, omentum occasionally adnexia, colon,bladder, extraperitoneal fat, appendix etc.  Complications- Strangulation- constricting / tight ring, sharp medial margin of the lacunar ligament, narrow neck, small sac. -Irreducibility. -Fistula. -Obstruction.  Groin swelling, Discomfort, Acute pain in strangulation.  Sign- Below & lateral to the pubic tubercle.  Cough impulse may be absent due to narrow neck tightly packed with extraperitoneal fat.  Reducible/ Irreducible.  Inguinal hernia;  Saphena varix;  Psoas Abscess;  Lipoma of the femoral triangle;  Femoral lymph node;  Femoral artery aneurysm;  Sebaceous cyst.  Operation- Excision of the Sac; Closure of the ring.  High; Trans-inguinal ; Low approach.  Mostly acquired- Breach/ Weak Scar(Umbilical Sepsis). Poor Obstetric Care.  Congenital – Persistent Extraembryocoelom. Premature Infants.  Clinical Features- Umbilical Swelling mostly painless, Umbilical defect.  Reducible. Irreducibility/ Strangulation rare.  Treatment: Wait till 5years as most will spontaneously close. Mayo’s repair via Smile incision.  More females than males. 3:1 – 10:1.  Etiology: Weak linea alba; Weak posterior Rectus sheath with Raised intra-abdominal pressure( Multiple gestations, Obesity, Chronic cough)  Morphology- Small mouth, Narrow neck, yet large sac, Loculated.  Contents- Omentum; Small intestine, Transverse colon.  Clinical features- Multiparous obese women (40-50years ).  Pain/ Discomfort, Recurrent abdominal pain, Nausea, Chronic constipation( Sub-acute Intestinal Obstruction).  Cough Impulse.  Reducible /Irreducible.  Complications: Irreducibility, Strangulation, Rupture.  Weight Reduction;  Mayo’s Overlapping Repair.  Occurring Midline Anterior Abdominal wall between the Xiphoid process & Umblicus.  1% of all hernias. Majority are asymptomatic.  M:F=1:3. Between 20-50years.  Clinical Features- Symptomless. Sometimes associated deep epigastric pain,  +/- Cough Impulse depending on sac.  Tenderness.  DDx- Peptic ulcer disease.  Treatment; Indication – Persistent Pain; Increasing Size; Tenderness. Simple Repair/ Overlapping Repair.  Occurring via weak Scar. Post laparotomy/ Traumatic scar/ Drainage Scar.  Etiology- Raised Intra-abdominal pressure( Perioperative cough, Straining to urinate/ Defecate, Abdominal Distension).  Poor Wound Healing – Wound Infection, Hematoma, Poor Suture Technique, Poor blood supply, Obesity.  Complications: Strangulation; Skin atrophy; Rupture.  Clinical Features: Swelling in Scar more prominent on cough/ straining; Local Discomfort/ Pain.  Stretched/ Thin Scar, Wide Rough Scar, Visible Intestinal loops, Multiple defects/ Loculations.  Preoperative Care: Quit Smoking; Weight Reduction; Treat Cough & other causes of Raised Intra- abdominal pressure.  Highlights of the Operation: Skin incision to incorporate the previous scar. Dissect to get healthy tissues around. Adhesiolysis. Layered Wound Closure in a Tension-free manner. Overlapping of the fascial edges/ simple apposition if defect 5cm in length- Inlay, Onlay or Sublay. Drainage to avoid hematoma, seroma  In Spigelian zone between the muscular & aponeurotic parts of Transversus Abdominis muscles usual site crossed by the arcuate line.  PATHOLOGY: Muscle Wasting, Multiparity, Obesity, Straining. Crescentic defect with rigid edges. Contents: Omentum, Small intestine. Complications: Irreducibility; Strangulation.  Clinical Features: Elderly; Swelling below the umbilicus & lateral to the rectus sheath; cough impulse. Localized constant/ recurrent pain;  Treatment: Repair.  Protrusion via the Lumbar triangles.  Anatomically; Each Superior Lumbar triangle(GRYNFELTT HERNIA) is bounded Superiorly by 12th Rib, Anteriorly by Internal Oblique Muscle & Posteriorly by the Sacrospinalis. The Floor- Transversus Abdominis muscle.  Each Inferior Lumbar Triangle ( PETIT’S HERNIA)– Anteriorly by External Oblique Muscle, Posteriorly by Latissum dorsi muscle, Inferiorly by the Iliac crest. The Floor by Lumbodorsal fascia& Internal Oblique muscle.  Mostly Acquired. Spontaneously- Repeated Indirect Injury, Ageing, Obesity, Sudden loss of fat. Surgical- Renal operations. Direct Trauma.  Few Congenital- Malformation of muscles, Collagen Disorders.  Contents- Fat; Small gut; Colon: Kidney;Omentum; Appendix.  Male : Female=3:1.  Age 50-70years.  Left: Right=2:1  Soft, Non tender reducible swelling with cough impulse.  DDx- Lipoma, Cold Abscess.  TREATMENT: Repair  Hernia is protrusion of viscus or part of it from its containing cavity.  Tends to increase in size.  Needs weakness/ defect & raised pressure to occur.  Swelling with cough impulse most times.  Diagnosis is clinical.  Treatment is operation- Open/ Laparoscopic.