Hernia MALT 2024+pp_051011 PDF

HERNIAS — Definition: Protrusion of a viscus either in part or in whole from its enclosed cavity, through a potential space or anatomical weak point Morphology: A hernia has a SAC made up of: The mouth The neck The body The fundus [Except incisional and Epigastric hernias. HERNIA SAC ...

HERNIAS — Definition: Protrusion of a viscus either in part or in whole from its enclosed cavity, through a potential space or anatomical weak point Morphology: A hernia has a SAC made up of: The mouth The neck The body The fundus [Except incisional and Epigastric hernias. HERNIA SAC  HERNIAS — NOMENCLATURE. This depends on contents of the sac: Small bowel content ……………Enterocoele Omentum…………………………….Omentocoele Meckel’s diverticulum…………..Littre’s hernia Posterior abdominal wall………Sliding hernia (Hernia- en-glissade) Inflamed Appendix……………….Amyand’s hernia Gangrenous loop in abdomen/viable loop in sac…..Maydl’s hernia (hernia-en-W)  HERNIAS — Hernia could also be classified according to its accesibility: Internal hernias; External hernias. — INTERNAL HERNIAS: 1. Tentorial hernias (in the brain) 2. Diaphragmatic hernias: (a) Bochdaleck hernia –via foramen of Bochdaleck (b) Morgagni’s hernia – via foramen of Morgagni (c) Hiatus hernia – Type-I, Type –II, Type III, Type IV 3. Stammer’s (Patterson’s) hernia – Mesenteric hernia 4. Paraduodenal Hernias  HERNIAS — Hancock’s hernia – one passing through the conjoint tendon — Parastomal hernias – one adjacent to a stoma — Perineal hernias — Intra-parietal hernias – (between layers of the abdominal wall) — Pre-peritoneal hernia (an interparietal hernia between peritoneum and transversalis fascia)  HERNIAS EXTERNAL HERNIAS — (A) VENTRAL HERNIAS (One between the two anterior axillary folds) :- 1. Groin hernias Femoral hernia – 2-5% of all hernias Inguinal Hernias 80-92% of all hernias 2. Umbilical Hernias Supra-umbilical hernia Infra-umbilical hernia 3 VENTRAL HERNIAS CONTD. Incissional hernias (via previous scars) “Notice a scar” 3. Epigastric Hernia – 1% of all hernias  HERNIAS — B. LATERAL HERNIAS (Between the anterior and posterior axillary folds) 1. Spigelian hernias (1-6% of all hernias) (also known as ‘spontaneous lateral ventral hernia’) 2. The Lumbar Hernias:- (a) Grynfelt - Lesshaft Hernia (the superior Lumbar Triangle) (b) Pettit’s hernia (the inferior Lumbar or Pettit’s triangle 3. Obturator Hernia. Via obturator foramen. (females>males). Obturator nerve compression with pain on medial thigh is called Howship-Romber Sign 4. Sciatic hernia via the sciatic foramen (lesser or greater sciatic foramen  HERNIAS — AETIOLOGY OF HERNIAS 1. Weakened abdominal Wall 2. Increased Intra-abdominal pressure WEAKENED ABDOMINAL WALL (a) Congenital (i) Patent processus vaginalis) – 20% of adults. (ii) Omphalocoeles (major and minor) (iii) Weakened internal ring – Marfan’s syndrome, Prune-belly syndrome (iv) Sites of vascular penetration causing pre-peritoneal  HERNIAS Acquired causes of Weakened abdominal wall * Infection e.g omphalitis causing umbilical hernia; wound infection causing incissional hernias Obesity causing interparietal/Spigelian hernias Ageing Injury to motor nerves – Grid-iron incission causing inguinal hernias. INCISIONAL HERNIA  HERNIAS INCREASED INTRA ABDOMINAL PRESSURE Chronic Cough – COPD Bladder outlet obstruction – stricture, BPH Heavy manual work Pregnancy – Frequent/multiple pregnancies Ascites/Abdominal tumours etc PATHOGENESIS OF HERNIAS Progressive peritoneal pouch becomes the sac ; protrusion of viscus into the sac then proceed into a weak spot or bigger space internally or externally.  HERNIAS — NATURAL HISTORY OF HERNIAS — Hernias starts as Reducible hernia – contents go back spontaneously or by taxis. — Then becomes Irreducible. — Obstructed Hernia: No venous return but arterial flow. Mass becomes bigger, painful, irreducible but viable. — Strangulated hernia. Both venous and arterial supplies are cut-off. Contents become ischemic, putrfy and gangrene sets in. [5% of inguinal hernias and 30% of femoral hernias strangulate] Indirect hernias strangulate more often than direct  HERNIAS — Untreated Strangulated hernia may perforate either to the exterior causing entero-cutaneous fistula or to the interior causing peritonitis. Note: (i) A strangulated hernia is tender over the swelling and there is also tenderness in the abdomen. (ii) Strangulated small bowel is commoner on the right (2:1) than on the left – due to anatomy of the bowel.  HERNIAS Causes of irreducibility of Hernias (i) Incarcerated hernia. This hernia may not be acutely tender but it is irreducible. Causes of incarceration include: * Impacted faeces in the herniated part of the bowel Adhesions between sac and contents – e.g. omentum Adhesions between loops of bowel Distended loops of bowel becoming too bulky Sliding Hernia – where a viscus forms part of the sac. CAUSES OF IRREDUCIBILE HERNIA CONTD — 2. OBSTRUCTED HERNIA — 3. STRANGULATED HERNIA — [SEE BELOW FOR DETAILS]  HERNIAS GROIN HERNIAS The groin is that part body that lies between the anterior abdominal wall crease (called the inguinal crease) and the upper part of the anterior surface of the thigh – the hip flexure or (the groin crease). In other words, the groin is that part of the body that lies between the inguinal crease above, and the groin crease below. The hernias in this region are : The Inguinal hernias and The Femoral hernias.  HERNIAS — THE INGUINAL HERNIAS — These are hernias that occour in the inguinal part of the groin. — They are described as oblique or indirect - if it comes through the internal ring, the inguinal canal and exists through the superficial ring. — 50% of inguinal hernias are indirect and, — 5-16% of men have indirect inguinal hernia. — It is the commonest type of hernia in both males and females. — 10% of indirect hernias are bilateral. INGUINAL HERNIA  HERNIAS — In the male, indirect inguinal hernia is twice as common on the right than on the left – due to late descent of the testis o the right. — In the female, indirect inguinal hernia is equally common on both sides.  HERNIAS — Inguinal hernias occour in 16% of males — Inguinal hernias are commonest hernias in both males and females. — They account for 95% of herniae in males and 40- 50% of hernias in females. The male:female ratio varies from 1/20 to 1/25.  HERNIAS — An inguinal hernia that comes through the posterior wall of the inguinal canal and emerges through the triangle of Hasselbach is described as a “Direct Hernia” — About 10% of all inguinal hernias in people over 25yrs are direct and the incidence rises with age such that most direct hernias are seen in people 30yrs! — 25% of groin hernias are direct – mainly acquired. — Direct hernias are as common on the left as on the right in both sexes — Direct hernias lie posterior to the cord and inferior  HERNIAS — 10% of all inguinal hernias are direct — Direct inguinal hernias are rare in females  HERNIAS — An inguinal hernia in which part of the sac is indirect – passing through the internal ring and exiting lateral to the pubic tubercle; while another comes directly through the triangle of Hasselbach exiting medial to the pubic tubercle - having the inferior epigastric artery in-between the two is called a Pantaloon hernia.  HERNIAS — Groin Hernias that remain above the groin crease are called “Incomplete hernias”. — If the hernia exits the external ring and enters the scrotum (or labium majus) it is called Complete –(inguino-scrotal or inguino-labial) hernia. — An incomplete hernia that is limited to the inguinal canal is called a bubonocoele — If the hernia has traversed the external ring and lies just above the pubic tubercle – on the spermatic cord, it is described as funincular – a funinculocoele BUBONOCOELE  HERNIAS — Sometimes, an indirect hernia, on emerging through the internal (deep) ring, turns upwards to lie: Between the transversalis fascia and peritoneum and called pro-peritoneal hernia OR it lies between the transversalis fascia and transverse abdominis muscle where it is called interstitial hernia; It may also lie between the internal oblique or transversus abdominis or even external oblique and thus called Interparietal hernia.  HERNIAS ANATOMY OF THE INGUINAL CANAL — The Inguinal canal is an oblique passage; — It measures about 4-5cm long — It directed from the internal (or deep) ring, downwards and medially to end in the external (or superficial) ring. THE INTERNAL RING This a “U” shaped oblique opening 6-10mm wide in the transversalis fascia. It lies 1.25 cm above and perpendicular to the mid- inguinal point.  HERNIAS — The mid-inguinal point is the midway between the ASIS and pubic symphysis. [Note: Midpoint of the inguinal ligament is midway between the ASIS and the pubic tubercle. It is the land mark for Femoral artery.] — Obliteration of the internal (or Deep) ring with a finger or two blocks an indirect hernia. — The deep ring is bounded above by the lower arching fibres of the internal oblique, then below and medially by the inferior epigastric vessels. — Boundaries — The inguinal canal is bordered by anterior, posterior, superior (roof) and inferior (floor) walls. It has two openings – the superficial and deep rings. — Walls — Anterior wall – aponeurosis of the external oblique, reinforced by the internal oblique muscle laterally. — Posterior wall – transversalis fascia. — Roof – transversalis fascia, internal oblique, and transversus abdominis. Floor – inguinal ligament (a ‘rolled up’ portion of the  HERNIAS The Inguinal Canal The anterior wall of the canal is formed by the aponeurosis of the external oblique; The posterior wall is formed by the transversalis fascia! The floor is formed by the inguinal ligament The roof by the lower fibres of the internal oblique. The Contents of the Inguinal Canal are the spermatic cord in the male (or round ligament – Canal of Nuck) – vas deferens, testicular artery/vein, pampiniform plexus, cremasteric muscle, fascia and vessels, artery to the vas, genital branch of genito-femoral nerve;  HERNIAS — Note: The Ilio-inguinal nerve run ON the spermatic cord. It can be severed with conscent. — In indirect hernias, the sac lies (antero-)medial to the cord: — In direct hernias, the sac lies behind the cord with the inferior epigastric artery lying lateral to the neck. — The external ring is the triangular opening in the external oblique 2.5x1.25cm with its apex directed upwards and laterally. Its base is the pubic tubecle.  HERNIAS — MECHANISM OF THE INTERNAL RING — The edges of the ring are thickened and spread out as a sling supporting the cord. — It is attached firmly to the posterior aspect of the transversus in a fan-like manner such that: — Its lateral crus is attached to the ASIS; its thickened medial crus is attached to the back of the rectus sheath.  HERNIAS — With increased intra-abdominal pressure: — The transversus contracts, — The internal ring is thus pulled upwards and laterally behind it – thus closing the ring behind it and around the cord – preventing herniation of peritoneum. — A big hernia, dilates and weakens the internal ring. — This ring therefore must be tightened (by Lyttle’s stitch or Plug and patch technique) during hernia repairs to avoid recurrence. — That explains why 60-75% of recurrent indirect hernias are also indirect!  HERNIAS The Triangle of Hasselbach This is the triangular fascial part in the posterior inguinal canal bounded: Medially by the lateral border of the rectus sheath, Laterally by the inferior epigastric artery Inferiorly by the Inguinal ligament. Being a fascial compartment, it is not supported. If its fibres are deficient (as happens in 20% of people) or rupture or gets weak or gets attenuated with age, a direct hernia forms and emerges from within this triangle.  HERNIAS — The fibres in the triangle of Hasselbach can therefore: — Be congenitally weak as seen in (20% of people): or — Be weak due to attenuation with age. Or be weak from — Transmitted trauma following repeated increase in intra-abdominal pressure. — The resultant direct inguinal hernia has a wide neck, and — Does not readily strangulate  HERNIAS PANTALOON HERNIA — A Pantaloon hernia which has an indirect hernia on the lateral side of the inferior epigastric artery and also a direct hernia at the medial to the inferior epigastric artery; such that the inferior epigastric artery is the divide. — Such a direct hernia sac lies posterior to the cord.  HERNIAS — In indirect hernias, the strangulating element at the level of the internal ring is the transversalis fascia; — In direct hernias, the strangulating element is also the transversalis fascia but more medially. — In children with undeveloped inguinal canal, the strangulating element in inhuino-scrotal hernias is the superficial ring.  HERNIAS EXAMINATION OF AN INGUINAL HERNIA Confirm the presence of Hernia – (lying or standing): palpable cough impulse; Visible cough impulse Determine whether it is inguinal or femoral hernia: The neck of an inguinal hernia is above the inguinal ligament (Poupart ligament) – a line joining the ASIS to the pubic tubercle.  HERNIAS — Determine whether it is a direct or indirect hernia: [Tip: A complete inguinal hernia is nearly always indirect: Very rarely does a direct hernia enter the scrotum; An indirect hernia comes out obliquely through the inguinal canal, a direct hernia comes out directly forwards into the canal] So reduce the hernia, occlude the internal ring and repeat the ‘cough impulse’ test. An indirect hernia remains occluded, a direct hernia bursts through.  HERNIAS DIFFERENTIAL DIAGNOSIS Femoral Hernia Hydrocoeles Malgaignes’ bulges Undescended and ectopic testes Lymphadenopathy Saphena varix, femoral artery aneurysm Lipoma Psoas Abscess.  HERNIAS After examining a hernia, answer the following questions: — On which side is it? — Direct or indirect? — Complete or incomplete? — Reducible or irreducible?  HERNIAS — The treatment for Hernia is Surgery (Operation) — Herniotomy — Lyttle’s procedure — Repair of Defect: (i) Herniorhapphy – Basini, Shouldice, McVay (ii) Hernioplasty – Lichenstein (Mesh) repair; Plug and Patch. Nylon Darn (iii) Laparoscopic: TEPA (Totally Extra Peritoneal Approach; TAPP (Trans Abdominal Pre-Peritonal repair, COMPLICATIONS OF A HERNIA — OBSTRUCTED: PAINFUL, IRREDUCIBLE BUT VIABLE – BECAUSE EVEN THOUGH VENOUS SUPPLY IS CUT OFF, ARTERIAL SUPPLY IS STILL PRESENT. — STRANGULATED: PAINFUL, IRRIDUCIBLE BUT NON-VIABLE – BECAUSE BOTH ARTERIAL AND VENOUS SUPPLIES ARE CUT OFF. — INCARCERARTED: MAY BE PAINFUL, IRREDUCBLE BUT VIABLE STRUCTURES. STRANGULATED HERNIA  HERNIAS Indications for Laparoscopic Repair: (Bilateral, Big, Irreducible, Recurrent, Recurrent surgery) — Recurrent hernia — Bilateral hernia — Need for speedy return to work. Contra-indications for Laparoscopic Hernia repair. Huge inguino – Scrotal hernia Irreducible hernias Lower midline incissions Previous pre-peritoneal surgery like prostatectomy  HERNIAS — Post-operative complications of Hernia repair. — Early: Pain; Urinary retension; Scrotal Haematoma; Vasectomy. — Late: Wound infections, Testicular complications – testicular infarction, Transient testicular orchitis, Post- operative Hydrocoele, Impotence, Recurrence.  HERNIAS About Hernia Recurrence: — 5-10% of indirect inguinal hernias recur — 1-25% of direct inguinal hernias recur — 10% of recurrent hernias, recur – except with Shouldice or Lichenstein repairs. — About 60-70% of recurrent indirect inguinal hernias are also indirect – the rest are direct. — Recurences from direct hernias are still direct. — About 60% of all recurrences are within 5 years.  HERNIAS Causes of Recurrence: — Size and duration of the hernia — Age of the patient. Recurrence is higher over 48yrs — Sliding hernias recur more — Over-looked Pantaloon hernia — Technical details – like suture material, Lylle stich, Tension repairs recur earlier. — Persistent increase in abdominal pressure — Wound infection — Sex. Recurrence is less in women  HERNIAS FEMORAL HERNIAS — Femoral Hernias account for 2-5% of all hernias — They are twice commoner in females. 85% of patients with femoral hernia are females — More in multiparous than nulliparous women — Rare before the age of 15 years. — Still the commonest hernia in females is an indirect inguinal hernia. — Almost all femoral hernias are acquired  HERNIAS — Femoral Hernias appear via the Femoral ring. — The Femoral ring is the medial compartment of the Femoral sheath - a prolongation of the superficial and deep fascia of the anterior abdominal wall, 4cm below the inguinal ligament. It is about 1 cm wide — Contents of the femoral sheath are NAVEL: Femoral nerve, artery, vein, empty space (the femoral ring) then Lymph node of Cloquet. — The femoral canal is a vertically placed gap (1.25- 3cm long) that begins from the femoral ring to the saphenous opening.  HERNIAS The boundaries of the Femoral canal: — Anteriorly – Inguinal ligament — Posteriorly – Pectineal fascia (Cooper’s ligament) — Medially – lacunar ligament — Laterally – Femoral Vein. — Femoral hernia lies below and lateral to the inguinal ligament. — Thus the neck of a femoral hernia is always below and lateral to the pubic tubercle FEMORAL IS BELOW  HERNIAS FACTORS PREDISPOSING TO FEMORAL HERNIA — Women, Pregnancy and exertion. — Even though the fascia from the ilio-pubic tract is the immediate medial relation, it is the adhesion to the crescentic edge of the lacunar ligament that causes strangulation.  HERNIAS COURSE OF A FEMORAL HERNIA — The sac passes via the femoral ring ino the femoral canal and emerges through the fossa ovalis (of the saphenous opening. — It then turns upwards into the subcutaneous tissue, describing a “J” course because of the fusion of the superficial and deep fascia, and comes to lie in front of; or above the inguinal ligament.  HERNIAS — The contents of the sac are usually omentum and small intestine + any other viscera. — A femoral hernia is more liable to strangulate than any other hernia because of: — (i) the very narrow constricting ring at the neck, — (ii) the sharp medial margin of the femoral ring — (iii)and the narrowness of the neck of the sac.  HERNIAS ON EXAMINATION: The neck is below and lateral to the pubic tubercle (i.e. below the inguinal ligament unlike an inguinal hernia whose neck is above the inguinal ligament and medial to the pubic tubercle) It may have a visible and palpable cough impulse but since the narrow neck may be plugged by omentum or extra peritoneal tissue, these may not always be present. While an inguinal hernia is reduced laterally and backwards, a femoral hernia is reduced downwards,  HERNIAS DIFFERENTIAL DIAGNOSIS Inguinal hernia Lipoma Lymph node Femoral aneurysm  HERNIAS TREATMENT (using mesh or nylon) — Low operation of Lockwood (Crural, Basini) — High operations: (i) Lotheisein inguinal approach (aka Moschowitz) – ideal for repairing both inguinal and femoral hernias. Recurrence rate is 30% (ii) McEvedy abdominal (or extra peritoneal approach) aka suprapubic, retroperitoneal, preperitoneal, Henry, Cheatle approach. Uses a pararectal incission. Good for strangulated hernia  HERNIAS PROTOCOL FOR MANAGING HERNIAS It has been shown that mortality after elective hernia is almost zero but mortality after repair of a strangulated hernia increases with age: 3% at 60yrs; 6% at 70 yrs, 12% at 80 yrs. Resuscitation lowers mortality. Consequently, Asymptomatic hernias should have an Elective appointment Obstructed hernias, - reduce and repair on next available list Strangulated hernias – emergency repair.  HERNIAS REDUCTION OF AN OBSTRUCTED HERNIA — Apply ice to the incarcerated mass – this stimulates contraction and reduces oedema. — Sedate pt to alleviate pain and allow relaxation — Trendelenburg position encourages venous return, reducing oedema and enhances return of viscus to abd — Apply gentle manual pressure while guarding the neck – this is reduction by Taxis  HERNIAS Complications of Hernia Reduction — Reduction-en-mass. This is return of unreduced hernia contents together with the sac into the peritoneal cavity. If this was done by patient it is called “auto reduction-en-masse”. (hence observe patient after reduction for ~24hrs) — Reduction of de-vitalised tissue into the peritoneal cavity. — Bowel may develop stricture at point of strangulation  HERNIAS FOR IRREDUCIBLE HERNIAS Resuscitate before Surgery Moyniham’s quote: “We have made surgery safe for the patient, we must now make the patient safe for surgery”. N/G tube, Urinary catheter, Antibiotics, Adequate fluid input/output Adequate analgesia Monitor vital signs: BP, Pulse, RBS, Sp02 Blood tests and transfusion  HERNIAS PROGNOSIS for Femoral hernias — Recurrence is 10-20% — 7% of high operations develop inguinal hernia.