Hernia Chapter - King Salman International University PDF

King Salman International University Faculty of Medicine Department of Clinical Medical Sciences...

King Salman International University Faculty of Medicine Department of Clinical Medical Sciences CHAPTER 1: Hernia Surgery ▪ Body is thin in infants, children and in indirect sac By Dr/Emad Sarhan, MD but is thick in direct and long standing hernia. Asst. Professor of Surgery ▪ Hernia without neck: Those hernias with larger HERNIA mouth lack neck, e.g. direct hernia, incisional ▪ Hernia means—’To bud’ or ‘to protrude’, ‘off hernia. shoot’ (Greek) ‘rupture’ (Latin). ▪ Hernia without sac, Epigastric hernia: it is ▪ It is defined as an abnormal protrusion of a protrusion of extra-peritoneal pad of fat. viscous or a part of a viscous within the peritoneal Contents sac through a defect (weak part) and maybe ▪ Omentum: Omentocele (Epiplocele). o External ▪ Intestine: Enterocele, commonly small bowel, but o Internal sometimes even large bowel. o Interstitial ▪ Richter’s hernia: A portion of circumference of ▪ 15% of males and 5% of females will develop groin bowel is the content. hernia. ▪ Urinary bladder may be the content or part of the Incidence posterior wall of the sac: (sliding) ▪ ▪ Ovary, often with fallopian tube. Because the muscular anatomy in the inguinal region is weak and also ▪ Meckel’s diverticulum: Littre’s hernia. due to the presence of natural weakness like deep ring and cord ▪ Fluid: Fluid is secreted from congested bowel or structures. omentum. ▪ Femoral is 17% ▪ Maydl’s Hernia: W-shaped loop ▪ Umbilical is 8.5% ▪ Others are 1.5% (Excluding incisional hernia). CLASSIFICATION OF HERNIA In general, incisional hernia is next to inguinal hernia in occurrence. Classification I (Clinical) 1. Reducible hernia Aetiology 2. Irreducible hernia A. Congenital: preformed sac (patent processus 3. Obstructed hernia vaginalis) 4. Inflamed hernia B. Acquired : chronic increase in IAP and week 5. Strangulated hernia. musculature. Classification II ▪ Straining, Lifting of heavy weight, Obesity, 1. Congenital. Pregnancy, Smoking, Ascites. 2. Acquired. ▪ Chronic cough and Chronic constipation III: According to the contents. ▪ Urinary causes ▪ Omentocele o Old age: BPH, carcinoma prostate. ▪ Enterocele o Young age: stricture urethra. ▪ Cystocele o Very young age: phimosis, meatal ▪ Littre’s hernia (Note: Littre described Meckel’s stenosis. diverticulum in a hernial sac 81 years before Meckel was ▪ Post Appendicectomy: Injury to the ilioinguinal born) nerve ▪ Maydl’s hernia. ▪ Familial-collagen disorder—Prune Belly ▪ Sliding hernia. syndrome. ▪ Richter’s hernia Parts of hernia Hernia is composed of: 1. Defect 2. Covering. layers of the abdominal wall through which the sac passes 3. Sac. 4. Content. ▪ Sac is a diverticulum of peritoneum with mouth, neck, body and fundus. ▪ Neck is narrow in indirect sac but wide in direct Classification IV: Based on sites ▪ Inguinal hernia—occurring in inguinal canal. sac.  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences ▪ Femoral hernia—occurring in femoral canal. ▪ Round ligament in females ▪ Obturator hernia. ▪ Ilio-inguinal nerve ▪ Diaphragmatic hernia. Coverings of Spermatic Cord ▪ Lumbar hernia. ▪ Internal spermatic fascia from fascia transversalis ▪ Spigelian hernia. ▪ Cremasteric fascia. ▪ Umbilical hernia. ▪ External spermatic fascia from external oblique ▪ Epigastric hernia. aponeurosis. Contents of spermatic cord INGUINAL HERNIA ▪ Vas deferens Surgical anatomy of inguinal canal ▪ Artery to vas ▪ Testicular and cremasteric artery ▪ Genital branch of genitofemoral nerve ▪ Pampiniform plexus of veins ▪ Remains of processus vaginalis ▪ Sympathetic plexus around the artery to vas Defence mechanism of inguinal canal ▪ Weak areas are covered by strong structures ▪ Obliquity of inguinal canal ▪ Inguinal canal: It is an oblique passage in lower ▪ Arching of conjoint tendon part of abdominal wall, 4 cm long, situated above ▪ ‘Shutter mechanism’ of internal oblique the medial ½ of inguinal ligament, extending from ▪ ‘Ball valve mechanism’ due to contraction of deep inguinal ring to superficial inguinal ring. cremaster muscle which plugs to superficial ring ▪ Inguinal (Poupart’s) ligament: It is formed by the ▪ When external oblique muscle contracts , lower border of the external oblique aponeurosis intercrural fibres of superficial ring appose causing which is thickened and folded backwards on itself, ‘slit valve mechanism’ extending from anterior superior iliac spine to pubic tubercle. CLASSIFICATION OF INGUINAL HERNIA ▪ Superficial inguinal ring is a triangular opening in I. Anatomical classification: (in inguinal hernia) the external oblique aponeurosis and is 1.25 cm ▪ Indirect hernia, Direct hernia or Femoral hernia above the pubic tubercle. The ring is bounded by II. According to the extent. a superomedial and inferolateral crus. Normally ▪ Incomplete: the ring does not admit the tip of little finger. o Bubonocele: Here sac is confined to the ▪ Deep inguinal ring is a U-shaped condensation of inguinal canal. the transversalis fascia, lies 1.25 cm above the o Funicular: Here sac crosses the superficial inguinal ligament midway between the symphysis inguinal ring, but does not reach the bottom of pubis and the anterior superior iliac spine. the scrotum. ▪ In infants both superficial and deep rings are superimposed ▪ Complete: Here sac descends to the bottom of without any obliquity of the inguinal canal. the scrotum. ▪ Inguinal canal in female is called as ‘canal of Nuck III. Gilbert classification Boundaries In front: External oblique aponeurosis and conjoined muscle laterally. Behind: Fascia transversalis and conjoined tendon medially. Above: Conjoined muscle. (Arched fibres of internal oblique). Below: Inguinal ligament. Contents of inguinal canal IV. NYHUS classification ▪ Spermatic cord in males Type I: Indirect hernia with normal deep ring.  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences Type II: Indirect hernia with dilated deep ring. ▪ Contents Type III: Posterior wall defect. ▪ It is usually reducible, but can go for irreducibility, a. Direct. b. Pantaloon hernia. c. Femoral inflammation, obstruction, strangulation. hernia. ▪ Head or leg rising test is done to look for Type IV: Recurrent hernia. abdominal wall muscle tone and Malgaigne bulgings. INDIRECT (OBLIQUE) INGUINAL HERNIA ▪ Special tests ( describe ) ▪ This is the most common type of hernia (65%). o Internal ring occlusion test: ▪ It is more common in younger age group as o External ring test compared to direct inguinal hernia which is more o Zieman’s test common in elderly. o Scrotal neck test ▪ It is more common on right side in 1st decade but ▪ Abdominal, respiratory, urological examination is in 2nd decade the incidence is equal on both done to look for any precipitating factors like sides. chronic bronchitis, ascites, stricture urethra, BPH. ▪ Hernia is bilateral in 30% of cases. ▪ Per rectal examination is a must. ▪ Sac is thin and Neck is narrow and lies lateral to ▪ Percussion and auscultation inferior epigastric vessels. Coverings of indirect hernia (from inside out) 1. Extraperitoneal tissue 2. Internal spermatic fascia 3. Cremasteric fascia 4. External spermatic fascia 5. Skin Precipitating causes for inguinal hernia: As before Types Differential diagnosis ▪ Hydrocele – infantile/encysted/large vaginal/ bilocular ▪ Undescended testis ▪ Femoral hernia ▪ Lipoma of the cord ▪ Hydrocele of the canal of nuck (in females) 1. Bubonocele: Where the hernia is limited to inguinal ▪ Inguinal lymph node enlargement canal. ▪ Groin abscess 2. Funicular: Processus vaginalis is closed just above ▪ Swellinngs with Expansile impulse on coughing the epididymis. Contents of the sac can be felt o Hernia, Laryngocele, Meningocele and separately from testis, which lies below the hernia. Empyema necessitans 3. Complete (Scrotal): Testis appears to lie within the Investigations lower part of hernia. It can occur in any age group. It Chest X-ray to rule out chronic bronchitis. occurs in a congenital preformed sac (processus Ultrasound of abdomen. vaginalis). More commonly contents descend into the Tests relevant for precipitating causes. pre-existing sac, only when there are precipitating Treatment causes which force the content down. In infants: Herniotomy Clinical Features In adults: ▪ It is more common in males (20 : 1 :: Male : o Precipitating causes should be treated first, like Female). TURP for BPH, treatment of chronic bronchitis. ▪ Patient presents with swelling in the groin which Patient is advised to avoid smoking. is better seen while coughing and standing; and ▪ Herniotomy, i.E. Excision of hernial sac felt together with an expansile impulse. ▪ Herniorrhaphy (strengthening of the posterior ▪ In complete type, the content descends down to wall of canal by tissue repair ) the scrotum completely.  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences ▪ Hernioplasty is the present choice (ideal) for all inguinal and groin hernias. Polypropylene Mesh is placed either onlay or inlay mesh is used. ▪ TEP (Totally extraperitoneal repair) ▪ TAPP (Transabdominal Preperitoneal Procedure) Repair may be ▪ Pure tissue repair–Shouldice, Mac Vay (Still very useful repairs) and Modified Bassini (not very useful – high recurrence rate as it is repair with tension and nonphysiological) ▪ Prosthetic repair–Lichtenstein, Rives, Gilbert, Stoppa, TEP, TAPP Modified Bassini’s Herniorrhaphy ▪ It is strengthening of the posterior wall of the inguinal canal by approximation of the conjoint tendon to inguinal ligament using monofilament nonabsorbable suture material. ▪ Medial most stitch is taken from the Removal of Cord at Inguinal Region (Hamilton-Bailey periosteum of pubic tubercle (called as key or operation) Bassini’s stitch). External oblique is closed and ▪ Cord is removed from the inguinal canal by other layers are also closed. ligating both at external and internal ring. But Shouldice Repair testis is retained (for psychological reason) ▪ It is a multilayered repair.. After doing and closure of inguinal canal by repair is done. herniotomy, transversalis fascia is incised Hernioplasty along the line of the wound from deep ring to Lichtenstein’s method (tension free mesh repair) pubic tubercle. Conservative treatment: ▪ Lower flap of fascia is sutured to posterior 1. Taxis: Patient is placed in supine position with hip part of the upper flap. and knee flexed and hip internally rotated. Contents ▪ Upper flap is sutured to the inguinal ligament. are pushed with one hand directing with other hand It causes double-breasting of the transversalis 2. Use of Truss: Rat-tailed sprung truss is used. fascia. ▪ Complications are discomfort, ulceration, ▪ Then conjoint tendon and inguinal ligament is strangulation, inflammation approximated by two layers of continuous ▪ It may be used in elderly people, who are not sutures. fit for anaesthesia and surgery ▪ EOA is sutured in two layers (double- ▪ Conservative treatment should be avoided in breasting) in front of the cord. hernia as much as possible Mc Vay Operation – 1940 - (Cooper’s ligament repair) ▪ Truss is absolutely contraindicated in femoral ▪ It is repair by placing interrupted sutures and sliding hernia between transversalis fascia to Copper’s Complications of herniorrhaphy: ligament starting from pubic tubercle medially Haemorrhage, Haematoma or Haematocele towards femoral sheath and later continued Infection–1-5% as suture repair between transversalis fascia Post-herniorrhaphy hydrocele, lymphocele and iliopubic tract laterally up to the entrance Hyperaesthesia over the medial side of inguinal of cord is reached. canal (neuralgia) Lytle’s Repair Recurrence ▪ Often internal ring is narrowed by placing Osteitis pubis interrupted sutures over the medial side of Injury to urinary bladder/bowel the ring to the transversalis fascia using either Testicular atrophy, penile oedema rarely can occur thread or silk. (To narrow the ring and push the cord laterally).  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences Direct hernia Direct hernia rarely descends into the scrotum and strangulation is not as common as in indirect hernia. Clinical picture ▪ Hernia (swelling): describe ▪ Head or leg rising test : Malgaigne bulgings (weak, soft, supple, swellings which signifies poor abdominal muscle tone) ▪ Special tests ( describe ) o Internal ring occlusion test, External ring test, Zieman’s test and Scrotal neck test ▪ Abdominal, respiratory, urological examination ▪ Per rectal examination is a must, Percussion and ▪ 10-15% of the hernias are direct. auscultation. ▪ 50% of direct hernias occur bilaterally. Treatment ▪ 35% of inguinal hernias are direct. Surgery: ▪ It is uncommon in females. ▪ Usually direct sac is not opened. ▪ It is always acquired, due to the weakening ▪ Care should be taken at the medial aspect due to of the posterior wall of the inguinal canal. the presence of bladder (bladder should be ▪ Hernia is medial to the inferior epigastric emptied before surgery). artery with wide neck. ▪ Ideally hernioplasty (mesh repair) is done. ▪ Sac is thick and often the medial wall or ▪ In case of bilateral hernia, mesh repair can be content may be bladder. done on both sides together. ▪ Direct hernia occurs through Hesselbach’s Funicular direct hernia (prevesical hernia) triangle which is bounded ▪ It is a type of direct hernia that is prone for o Inferior epigastric artery laterally strangulation. o Lateral border of rectus medially ▪ It is a narrow-necked hernia with prevesical fat o Inguinal ligament below. and a portion of the bladder, and or intestine ▪ It is divided into medial and lateral halves by that herniates through a small defect in the obliterated umbilical artery (lateral umbilical medial part of the conjoined tendon just above the ligament). So direct hernia is classified as pubic tubercle. medial or lateral depending on which part of ▪ It occurs in elderly males. the Hesselbach’s triangle, it is arising from. Coverings of direct hernia (from inside out) ▪ Extraperitoneal tissue ▪ Fascia transversalis ▪ Conjoined tendon ▪ External spermatic fascia ▪ Skin Predisposing factors AS BEFORE + Previous appendicectomy  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences Complications of hernia Irreducibility ▪ Protrusion of new contents ▪ Adhesions between contents or adhesions between sac and contents Obstruction ▪ Occurs in Irreducible hernia when the lumen of the herniated bowel is occluded manifested by intestinal obstruction but the hernia is still soft Recurrent hernia (inguinal) with an impulse on cough Incidence is 10%. ▪ Treatment is early surgery if failed conservative Predisposing Factors treatment Preoperative: Inflammation o Increased intra-abdominal pressure of any cause ▪ Due to Inflammed contents. Rough manibulation o Old age, Anaemia, Hypoproteinaemia. or unfitted truss Operative: Strangulation o Tension in the sutures or use of absorbable Strangulated Hernia sutures Pathology ▪ It occurs when blood supply of the contents of hernia o Weak anterior abdominal wall. is seriously impaired leading to formation of Postoperative: gangrene. o Infection (50%) or Haematoma formation during ▪ Strangulation occurs in the small bowel and also in earlier surgery. large bowel. Occasionally strangulated omentocele o Retained sac in pantaloon hernia or Straining. also can occur without any intestinal obstruction. Recurrence Rate ▪ Strangulation can occur in any hernias. * Bassini’s repair—10%. * ▪ Indirect inguinal hernia is more prone for Shouldice repair—1%. strangulation than direct inguinal hernia. It is due * Hernioplasty—1 to 3%. to narrow neck, adhesions, narrow external ring in Type of Recurrence children. ▪ True recurrenc: hernia occurs in inguinal region ▪ Constriction occurs in inguinal hernia at superficial after inguinal hernia repair ring while in femoral hernia occurs at the sharp edge ▪ False recurrence: other groin hernia occurs after of lacunar ligament inguinal hernia repair like femoral hernia or Incidence obturator ▪ Inguinal: 2-4% Treatment ▪ Femoral: 25-30% ▪ The cause of recurrence has to be treated and ▪ Paraumbilical:15-20% later hernioplasty is done. ▪ Incisional: 3-5% ▪ It is treated by mesh repair. Common bacteria in strangulated hernia HERNIOPLASTY ▪ E. coli, Anaerobic streptococci, Anaerobic ▪ It is strengthening of posterior inguinal wall bacteria and Klebsiella using a supportive material Obstruction Material Used ↓ Initially venous return is impaired and Congestion of the ▪ Synthetic: Prolene mesh ,Dacron mesh, Morlex mesh, bowel occurs Mersilene sheath ↓ ▪ Biological: Tensor fascia lata, temporal fascia and Further dilatation of the bowel which becomes purple skin. (biological materials are not well accepted as coloured infection is common and its efficacy is not proved). ↓ ▪ Nonabsorbable interspersed absorbed mesh Fluid collects in the sac (Vipro/Ultrapro). ↓ Complications Arterial blood supply is impaired ▪ Infection, Mesh extrusion or Foreign body ↓ reaction. Bowel becomes dark, brownish black coloured with flabby and friable wall ↓  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences Bacteria migrate transerosally and multiply in fluid of the Often in irreducible hernia, reduction of hernia is tried by sac elevation, sedation and taxis (i.e. with flexion and medial ↓ rotation of the hip, reduction of hernia is tried). Perforation occurs at the site of constriction ring In obstructed hernia, taxis may be dangerous as during ↓ taxis, contusion and rupture of the intestinal wall can occur. Peritonitis occurs. Reduction-en-masse may mask the gangrenous bowel Causes of strangulation existing in the sac. Inner gangrenous loop of Maydl’s hernia ▪ Narrow neck may be missed. Rupture of the sac extraperitoneally is also ▪ Adhesions a possibility. ▪ Irreducibility Taxis has no role in femoral hernia and strangulated ▪ Long-time, large hernia with adhesions hernia. If tried, contusion, reduction-en-masse, and rupture of the sac can occur. o Part of circumference of the bowel when strangulated, ▪ In strangulated omentum features of obstruction is called as Richter’s hernia wherein the patient are not present presents with diarrhoea, toxicity mimicking ▪ Omentum becomes congested, oedematous and gastroenteritis. black in colour which secretes toxic fluid with o Maydl’s Hernia (Hernia-in-W): Here a loop of bowel secondary bacterial infection. But here, initially in the form of ‘W’ lies in the hernial sac and the the sepsis is slower than that of strangulated centreportion of the ‘W’ loop is strangulated and lies intestinal obstruction. within the abdominal cavity. ▪ Strangulation without obstruction occurs in Richter’s hernia and Omentocele Investigations ▪ Plain X-ray abdomen in erect posture shows multiple air-fluid levels. ▪ Serum electrolytes, Blood urea and creatinine. ▪ U/S abdomen. Treatment of Strangulated Hernia ▪ The patient is admitted. ▪ Ryle’s tube aspiration. ▪ Intravenous fluids to correct dehydration and electrolyte imbalance. Clinical Features of Strangulated Hernia ▪ Antibiotics. ▪ Catheterisation to maintain adequate urine output. ▪ Emergency surgery Planned incision extending into the most prominent area of the swelling. ↓ ▪ Sudden severe pain, initially over a pre-existing Sac is exposed. hernia which later becomes generalised over the ↓ Constriction ring and superficial ring is released(cut). abdomen. ↓ ▪ Persistent vomiting, constipation and distension Sac is opened carefully without allowing the spillage of of the abdomen. fluid (Usually spillage occurs extraperitoneally) ▪ Hernia is Tense, Severely Tender, Irreducible And ↓ Without Any Expansile Impulse On Coughing. Fluid is sucked Rebound tenderness is diagnostic. ↓ ▪ Features of toxicity and dehydration (Oliguria) The bowel is held with fingers so as to prevent it from and Electrolyte imbalance. getting reduced. ▪ Abdominal distension with guarding and rigidity. ↓ The viability of the bowel is checked by colour, peristalsis, pulsation, bleeding. Taxis ↓  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences When gangrenous, resection and anastomosis is done Femoral Hernia and drain is placed. Surgical Anatomy of Femoral Canal ▪ It is the medial, compartment of the femoral ▪ Bassini’s repair is done by placing interrupted sheath, which extends from femoral ring above to non-absorbable sutures. Antibiotics, IV fluids are saphenous opening below. It contains fat, continued. Drain is removed in 4-5 days. lymphatics, lymph node of Cloquet. It is 1.25 cm ▪ Once the bowel movement begins, oral diet is long and 1.25 cm wide at the base. Below it is started (in 5 days). closed by cribriform fascia. Postoperative problems ▪ Femoral ring is bounded anteriorly by inguinal Infection, leak with fistula, septicaemia. ligament; posteriorly by ilio pectineal ligament pubic bone and fascia covering the pectineus muscle; medially by concave, sharp lacunar (Gimbernat’s) ligament; laterally by a thin septum separating from the femoral vein. Note: During surgery for strangulated hernia mesh is usually not used, only repair is done. Aetiology Sliding hernia (hernia-en-glissade) ▪ As before + Wide femoral canal. + Multiple ▪ Here posterior wall of the sac is not only formed pregnancies. by the parietal peritoneum, but also by sigmoid Pathology in Femoral Hernia colon on left side; caecum on right side and often ▪ Through femoral canal, hernial sac descends down with portion of the bladder (Both sides). vertically upto saphenous opening then forward ▪ Rarely small bowel sliding hernia can occur. then upward ▪ Content of the sac is usually small bowel or ▪ Because of its irregular pathway and narrow neck, omentum. it is more prone for obstruction and strangulation. ▪ Sliding hernia occurs exclusively in males. Mainly ▪ During surgery precaution should be taken about on the left side. the femoral vein and pubic branch of obturator ▪ Bilaterality is extremely rare. artery that may get injured leading to torrential ▪ It is seen commonly in adults and elderly. haemorrhage. Treatment: Always surgery Clinical Features ▪ Posterior wall of the sac should not be separated from large bowel or bladder. If tried, injury may result to these organs leading to faecal or urinary fistulas. ▪ Partially excised sac is pushed into the peritoneal cavity with posterior wall and repair is done usually using prolene mesh Pantaloon Hernia (Double Hernia, Saddle Hernia,) ▪ both direct and indirect inguinal sacs are present and clinically present as direct hernia. ▪ Common in females (2:1 ratio), common in ▪ During surgery, indirect sac may be missed and so multipara. leads to recurrent hernia through retained (or ▪ Rare before puberty. 20% occurs bilateral, unidentified) indirect sac. however more common on right side. ▪ Here both medial and lateral sacs straddle the ▪ Presents as a swelling in the groin below and inferior epigastric artery. lateral to the pubic tubercle. (Inguinal hernia is ▪ It is one of the causes for recurrent hernia. above and medial to the pubic tubercle).  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences ▪ Swelling, impulse on coughing, reducibility, ligament. Sac is dissected from below, neck from above gurgling sound during reduction, dragging pain, and repair is done from above. It gives a very good are the usual features. exposure of both neck, fundus of sac and repair is also ▪ Obstruction and strangulation are more common easier. It is done in strangulated femoral hernia. ▪ Lotheissen’s operation: It is through inguinal canal ▪ Often femoral hernia can be associated with approach (like for inguinal hernia). Transversalis fascia inguinal hernia also. is opened and neck of the sac is identified in the ▪ 40% of femoral hernias present as emergency femoral ring. Sac is dissected from above, neck is hernia with obstruction/strangulation. ligated and repair is done. Lotheissen’s repair: After ▪ Gaur’s sign: in femoral hernia, distension of herniotomy, conjoined tendon is sutured to ilio- superficial epigastric and/or circumflex iliac veins pectineal line (ligament) by interrupted sutures (2 or occurs due to the pressure by the hernial sac. 3), using non-absorbable monofilament sutures. Care Differential diagnosis should be taken to avoid injury to femoral vein, pubic ▪ Inguinal hernia branch of obturator artery, bladder. ▪ An enlarged Cloquet lymph node of any cause VENTRAL HERNIA ▪ Psoas abscess or Distended psoas bursa ▪ Any protrusion through abdominal wall with the ▪ Lipoma exception of hernia through the inguinofemoral ▪ Femoral aneurysm region is defined as ventral hernia. ▪ Saphena varix o Incisional hernia (80%) ▪ Haematoma in the region o Primary defects in abdominal fascia which can Note that cause umbilical hernia, epigastric hernia, ▪ Hydrocele of femoral hernia occurs when adherent paraumbilical hernia or Spigelian hernia are omentum which is the content secretes fluid into the grouped under ventral hernia. sac. Ventral hernia can be : ▪ Herniation through a gap in the lacunar ligament ▪ Reducible, Irreducible, Obstructed or (medial) is always strangulated and is called as Strangulated. Laugier’s femoral hernia (L for L). INCISIONAL HERNIA ▪ In congenital dislocation of hip, femoral hernia occurs behind the femoral vessels—Narath’s femoral hernia. ▪ If the sac lies under the pectineal fascia, is called as Cloquet’s hernia. ▪ Strangulation and Richter’s hernia are common in femoral hernia. ▪ It is herniation through a weak abdominal scar (scar of previous surgery). ▪ It is common in old age and obese individuals. Additional History to be Collected in Incisional Hernia ▪ Details of surgery that patient has undergone earlier. Often on medial side, a portion of bladder forms the wall of the ▪ Duration after how long incisional hernia has occurred femoral hernial sac—sliding-femoral hernia. is important. ▪ History of wound infection, wound dehiscence, Treatment; surgery whether surgery done was an emergency or elective, Approaches: and tension sutures placed or not. ▪ Lockwood low operation: Here sac is approached ▪ History of pain, irreducibility and details of below the inguinal ligament through groin crease precipitating factors to be asked. incision (or over the swelling) so that fundus of sac is ▪ Other precipitating factors are similar to inguinal dissected by direct vision and repair is done from hernia like smoking, urinary/respiratory/abdominal below. Here inguinal ligament is sutured to Cooper’s symptoms. ligament. Predisposing Factors ▪ Mc’Evedy-High operation: A incision is made over the ▪ Vertical scar, midline scar, lower abdominal scar femoral canal extending vertically above the inguinal ▪ Scar of major surgeries (biliary, pancreatic).  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences ▪ Scar of emergency surgeries (peritonitis, acute Massive incisional hernia after reduction might abdomen). cause (abdominal compartment syndrome). It is ▪ Faulty technique of closure. prevented by prior increasing the capacity of ▪ Poor nutritional status of the patient. peritoneal cavity by creating pneumoperitoneum ▪ Presence of cough, tuberculosis, jaundice, anaemia, using CO2 so as to increase the peritoneal pressure by hypoproteinaemia. ▪ Malignancy, immunosuppression. 12-15 cm of H2O, daily for 3-6 weeks. Later definitive ▪ Smoking in postoperative period. surgery is done. ▪ Causes which increases the intra-abdominal pressure Treatment Strategy for Incisional Hernia Clinical Features ▪ Cattell’s operation: When the defect is less than 3 cm, ▪ Swelling in the scar region with Impulse on coughing and if the patient is having adequate abdominal and Gurgling sound. muscle tone, layer by layer anatomical repair is done ▪ Pain. using monofilament nonabsorbable suture material ▪ Often bowel peristalsis may be visible under the skin. like polypropylene/polyethylene, ideally with ▪ Eventually features of irreducibility, obstruction, interrupted sutures. Sac should be dissected, ligated strangulation is seen. and excised prior to repair. Peritoneum and posterior ▪ Defect is felt and assessed** rectus sheath is apposed as first layer and anterior ▪ Hernia is common in lower abdomen. rectus sheath as second layer. Double breasting of the ▪ It may be small or large; huge or massive (diffuse). rectus sheath using interrupted non-absorbable ▪ Scar, its extent and location, whether healed primarily sutures using monofilament suture material. It is or secondarily, skin over the scar and swelling is noted. overlapping the rectus sheath in two layers with two rows of sutures. ▪ Mesh repair of the incisional hernia defect is always better and ideal with less chances of recurrence. Adequate sized mesh is placed either outer to peritoneum (inlay), or outer to musculoaponeurotic abdominal layer (onlay / overlay), or occasionally combined inlay and onlay mesh placement, ▪ Rive’s Stoppa’s mesh placement for incisional hernia Type of defects in incisional hernia is placing mesh between posterior rectus sheath and Small defect rectus muscle. Commonly polypropylene mesh is Large and wide defect used. Very large defect ▪ Laparoscopic mesh repair is done for incisional hernia Massive / diffuse by placing a mesh under the defect laparoscopically in intraperitoneal plane. Now dual mesh (PTFE) or Multiple defects four layered mesh are available. to creep underneath. Note: 2nd layer is PDS / PTFE mesh ▪ Size of the defect is important to decide the type ▪ Keel operation is done in large defect. Scar is excised of surgical closure in incisional hernia. and is dissected beyond the margin of the defect. Sac ▪ Midline hernia expels the content more outwards is never opened unless there is obstruction of the due to contraction of rectus muscles on both content. Sac in inverted using sides. continuous/interrupted inverting non-absorbable Investigations: Always the precipitating factors must sutures, layer by layer until the defect margins are be looked for: apposed together Chest X-ray. Postoperative Care U/S abdomen. A. Antibiotics, Analgesics, Abdominal binder for Tests relevant for causes. support and Abdominal binder Preoperative Preparations for Incisional Hernia B. Prevention of paralytic ileus,(Nasogastric Surgery aspiration) Reduction in weight and control of obesity. C. Control of obesity and other precipitating factors. Nutrition, control of anaemia. D. Drain should be kept until drainage becomes Treatment for diabetes, hypertension, cardiac minimal. diseases, respiratory problems. E. Early ambulation. Treating the precipitating causes. F. Fluid management, catheterisation. Chest X-ray, U/ S abdomen to be done.  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences UMBILICAL HERNIA ▪ It has got tendency to go for adhesion, ▪ It is herniation through a weak umbilical scar (cicatrix). irreducibility and obstruction. ▪ Male : female :: 2:1. It is seen in 20% of newborn infants. ▪ It may be congenital, infantile or adult Congenital umbilical hernia Clinical Features ▪ Common in females (5:1 ratio). ▪ It presents as a swelling which has smooth surface, distinct edges, soft, resonant with dragging pain and impulse on coughing. Large hernias can present with intestinal colic due to subacute intestinal obstruction. ▪ Eventually strangulation can occur. Treatment Is always surgery Infantile umbilical hernia ▪ Mayo’s operation: Double breasting of the defect in the rectus is done by interrupted nonabsorbable sutures. ▪ Strangulation: as before. ▪ Additional lipectomy (panniculectomy) may be done in case of pendulous abdomen. ▪ Postoperative weight reduction, use of abdominal ▪ Presents with a swelling in the umbilical region binder is required for these patients. within first few months after birth, the size EPIGASTRIC HERNIA (Fatty hernia of linea alba) increases during crying. It is hemispherical in shape. ▪ Can go for irreducibility and obstruction presents with pain, distension, vomiting. ▪ Defect can be felt with finger during crying. Treatment ▪ Initially conservative. In 93 to 95% of cases, it ▪ It is 10% common and 20% of epigastric hernias disappear spontaneously in few months after are multiple—Swisscheese like. birth. It can be hastened by adhesive strapping ▪ through a defect in the linea alba, any where across the abdomen. between xiphoid process and umbilicus. ▪ Surgery is through an infraumbilical curvilinear ▪ Extraperitoneal fat protrudes presenting like a incision. Sac is identified and ligated by swelling in the upper midline with an impulse on transfixation. Defect is closed with interrupted coughing. nonabsorbable sutures. ▪ It is sacless hernia. Later protrusion enlarges and Indications for surgery: drags a pouch of peritoneum, presenting as a true ▪ If persists even after the age of two years. epigastric hernia. ▪ If the defect is more than 2 cm in size. ▪ Content of true epigastric hernia is usually Paraumbilical Hernia (Supra- And Infra) omentum, sometimes it may be small bowel. ▪ It occurs commonly in adults. It is a protrusion or Clinical Features herniation through linea alba, just above or below ▪ Often asymptomatic the umbilicus. ▪ Swelling in the epigastric region which is tender with ▪ It enlarges ovally, often attains a large size and Impulse on coughing. sags downwards. ▪ Pain in epigastric region. ▪ Neck of the sac is relatively narrow. ▪ Irreducibility, obstruction, strangulation can also occur ▪ Contents are usually omentum, small bowel, in epigastric hernia. sometimes large bowel.  King Salman International University Faculty of Medicine Department of Clinical Medical Sciences Treatment Clinical Features ▪ Through a vertical incision, sac is dealt with. ▪ Usually presents with features of intestinal obstruction ▪ Defect is closed with non-absorbable interrupted and more often confirmed only on laparotomy.’ sutures. ▪ Rarely seen as a swelling in Scarpa’s triangle, deep to ▪ Large defect is supported with preperitoneal the pectineus muscle, with limb in flexed and abducted position. Movement of limb is painful. mesh. ▪ Referred pain in knee joint through geniculate branch SPIGELIAN HERNIA of obturator nerve signifies not only obturator hernia but also strangulation—Howship-Romberg sign. ▪ On per vaginal examination, tender swelling is felt over the obturator foramen. ▪ Here strangulation is usually of Richter’s type. Treatment ▪ Laparotomy is done and the sac is identified. It is dissected and ligated. ▪ If strangulation is present (common), resection and ▪ It is a type of interparietal hernia occurring at the anastomosis is done. Broad ligament is stitched over level of arcuate the opening to prevent recurrence. ▪ Hernial sac lies either deep to the internal oblique ▪ Mesh placement is the ideal way of repairing the or between external and internal oblique muscles. obturator defect. ▪ Equal in both sexes. LUMBAR HERNIA ▪ It is common between arcuate line to umbilicus (in wider and weaker area). Clinical Features ▪ Presents as a soft, reducible mass lateral to the rectus muscle and below the umbilicus, with impulse on coughing. Strangulation is common in spigelian hernia. Differential Diagnosis Superior lumbar triangle is bounded by sacrospinalis, 12th rib and ▪ Abdominal wall lipoma. posterior border of internal oblique. ▪ Soft tissue sarcoma. Inferior lumbar triangle is bounded by latissimus dorsi, external ▪ Abdominal wall haematoma. oblique and iliac crest (triangle of Petit). Investigation ▪ It is herniation either through superior or inferior ▪ Ultrasound abdomen. lumbar triangle. Treatment ▪ Lumbar hernia is common through inferior lumbar ▪ Through a lengthy transverse incision herniotomy triangle. and later closure of the defect layer by layer using It can be: nonabsorbable interrupted sutures. ▪ Primary. ▪ Often mesh is required to cover the defect ▪ Secondary, which is due to previous renal properly. surgery, more common. OBTURATOR HERNIA Differential diagnosis ▪ Occurs through obturator canal between superior ▪ Lipoma. ramus of pubis and obturator membrane. It is a rare ▪ Cold abscess. entity, seen in elderly females (6:1 ratio female to ▪ Lumbar phantom hernia. male). Treatment Repair using fascial flaps or mesh. PHANTOM HERNIA ▪ It is a muscular bulge as a result of local muscular paralysis due to interference with nerve supply of the affected muscles, like poliomyelitis. ▪ It is common in lumbar region. It is often seen in lower abdomen.