HERNIA dr sigid djuniawan. Introduction Introduction Protrusion of the peritoneum or preperitoneal...
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Transcript of HERNIA dr sigid djuniawan. Introduction Introduction Protrusion of the peritoneum or preperitoneal...
HERNIAHERNIAdr sigid djuniawan
dr sigid djuniawan
Introduction Introduction Protrusion of the peritoneum or preperitoneal fat through an abnormal Protrusion of the peritoneum or preperitoneal fat through an abnormal
opening in the abdominal wallopening in the abdominal wall Presents as a bulgePresents as a bulge Peritoneal contents may be trapped in “sac”Peritoneal contents may be trapped in “sac”
Asymptomatic bulge most commonAsymptomatic bulge most common SymptomsSymptoms
Physical effects of sac and contents on surrounding tissuesPhysical effects of sac and contents on surrounding tissues Obstruction and/or strangulation of hernia sac contentsObstruction and/or strangulation of hernia sac contents
EpidemiologyEpidemiology
700,000 hernia repairs year700,000 hernia repairs year Inguinal hernias -75% of all herniasInguinal hernias -75% of all hernias
2/3 Indirect, remainder are direct2/3 Indirect, remainder are direct Incisional hernias – 15 to 20%Incisional hernias – 15 to 20% Umbilical and epigastric – 10%Umbilical and epigastric – 10% Femoral – 5%Femoral – 5%
EpidemiologyEpidemiology
Prevelance of hernias increases with agePrevelance of hernias increases with age Most serious complication – Most serious complication –
strangulationstrangulation 1 to 3% of groin hernias 1 to 3% of groin hernias
Femoral – Femoral – highest rate ofhighest rate of complicationscomplications 15% to 20% 15% to 20% recommended all be repaired at time of recommended all be repaired at time of
discoverydiscovery
Anatomy Anatomy
Areas of Natural WeaknessAreas of Natural Weakness
Used with permission from the American College of Surgeons
AnatomyAnatomy Inguinal ligamentInguinal ligament
(Poupart’s) – inferior (Poupart’s) – inferior edge of edge of external external obliqueoblique
Lacunar ligamentLacunar ligament – – triangular extension of triangular extension of the the inguinal ligamentinguinal ligament before its insertion before its insertion upon the pubic tubercle upon the pubic tubercle
conjoined tendonconjoined tendon (5- (5-10%)- Internal oblique 10%)- Internal oblique fuses with transversus fuses with transversus abdominis aponeurosisabdominis aponeurosis
Cooper’s LigamentCooper’s Ligament - - formed by the formed by the periosteum and fascia periosteum and fascia along the superior along the superior ramus of the pubis. ramus of the pubis.
Inguinal CanalInguinal Canal
Between deep and Between deep and superficial inguinal ringssuperficial inguinal rings
BoundariesBoundaries Superifical – Superifical – external external
oblique aponeurosisoblique aponeurosis Superior – Superior – internal and internal and
transversustransversus Inferior – shelving edge of Inferior – shelving edge of
inguinal ligamentinguinal ligament and and lacunar ligamentlacunar ligament
Posterior (floor) – Posterior (floor) – transversalis fasciatransversalis fascia and and aponeurosis of aponeurosis of transversus abdominis transversus abdominis musclemuscle
Components of Components of Hesselbach’s triangle Hesselbach’s triangle include include which of the following anatomic landmarks?which of the following anatomic landmarks?
A.A. Pectineal ligamentPectineal ligament
B.B. Lateral border of the rectus sheathLateral border of the rectus sheath
C.C. Cooper’s ligamentCooper’s ligament
D.D. Inguinal ligamentInguinal ligament
E.E. Inferior epigastric vesselsInferior epigastric vessels
Hernia DiathesisHernia Diathesis
Varies with ageVaries with age Pediatric: congenital remnantPediatric: congenital remnant AdultAdult
Tissue weaknessTissue weakness Burst strength < abdominal wall tension Burst strength < abdominal wall tension
Varies with gender Varies with gender
Hernia DiathesisHernia Diathesis
Pediatric: major risk is premature Pediatric: major risk is premature birthbirth
AdultAdult ObesityObesity Previous abdominal surgery Previous abdominal surgery PregnancyPregnancy Abrupt abdominal wall exertionAbrupt abdominal wall exertion
What is a Hernia composed of?What is a Hernia composed of?1.1. Sac: Sac: a folding of a folding of
peritoneum consisting of peritoneum consisting of a mouth, neck, body and a mouth, neck, body and fundus.fundus.
2.2. BodyBody: : which varies in which varies in size and is not size and is not necessarily occupied.necessarily occupied.
3.3. Coverings: Coverings: derived derived from layers of the from layers of the abdominal wall.abdominal wall.
4.4. Contents: Contents: which could which could be anything from the be anything from the omentum, intestines, omentum, intestines, ovary or urinary bladder.ovary or urinary bladder.
A sliding inguinal hernia on the left side is A sliding inguinal hernia on the left side is likely to involve which of the following?likely to involve which of the following?
A.A. Jejunum composing the posterior wall Jejunum composing the posterior wall of the sacof the sac
B.B. Ovary and fallopian tube in a female Ovary and fallopian tube in a female infantinfant
C.C. OmentumOmentumD.D. Sigmoid colon composing the Sigmoid colon composing the
posterior wall of the sacposterior wall of the sacE.E. Cecum composing the anteromedial Cecum composing the anteromedial
wall of the sacwall of the sac
TerminologyTerminology
Pantaloon – Pantaloon – direct and indirectdirect and indirect components components Richter’s – contains Richter’s – contains antimesenteric portionantimesenteric portion of of
small bowelsmall bowel Sliding – involves Sliding – involves visceral peritoneumvisceral peritoneum of an organ of an organ
, i.e. bladder, ovary, i.e. bladder, ovary Littre’s – hernia contains Littre’s – hernia contains Meckel’s diverticulumMeckel’s diverticulum Petit – hernia at Petit – hernia at inferiorinferior lumbar triangle lumbar triangle Grynfelt – hernia at Grynfelt – hernia at superiorsuperior lumbar triangle lumbar triangle
Clinical Evaluation: HistoryClinical Evaluation: History DemographicsDemographics
AgeAge GenderGender
Presentation of bulgePresentation of bulge When, where, howWhen, where, how Activities that make it better or worseActivities that make it better or worse Discomfort vs. painDiscomfort vs. pain Signs/symptoms of bowel obstructionSigns/symptoms of bowel obstruction
Clinical Evaluation: HistoryClinical Evaluation: History
Surgery: Surgery: previous repairs/operationsprevious repairs/operations
Review of factors related to increased Review of factors related to increased intra-abdominal pressureintra-abdominal pressure Chronic coughChronic cough ConstipationConstipation Straining to urinateStraining to urinate
Clinical Evaluation: LocationClinical Evaluation: Location
Groin: 75% Groin: 75% InguinalInguinal FemoralFemoral
Anterior abdominal wall: 25%Anterior abdominal wall: 25% UmbilicalUmbilical EpigastricEpigastric SpigelianSpigelian Incisional Incisional
Hernia PathologyHernia Pathology Contents of hernia sacContents of hernia sac
Bowel (small and large, appendix)Bowel (small and large, appendix) Incarceration of portion of bowel wall: Richter’s Incarceration of portion of bowel wall: Richter’s
hernia: Strangulation occurs without hernia: Strangulation occurs without obstructionobstruction
Omentum, bladder, ovary, fallopian tubesOmentum, bladder, ovary, fallopian tubes
Sac wall may be formed by large bowel, Sac wall may be formed by large bowel, bladder, or the ovary/tube: Sliding herniabladder, or the ovary/tube: Sliding hernia
Hernia PathologyHernia Pathology
Fascial defect may exist without Fascial defect may exist without peritoneal hernia sacperitoneal hernia sac
Preperitoneal abdominal wall contents Preperitoneal abdominal wall contents may protrude through fascial defectmay protrude through fascial defect
Preperitoneal fatPreperitoneal fat Lymph nodeLymph node
Hernia PathologyHernia Pathology
IncarcerationIncarceration:: contents of hernia sac contents of hernia sac not not reducible reducible into peritoneal cavityinto peritoneal cavity Acute: fascial margins trap contentsAcute: fascial margins trap contents Chronic: contents adhesed in sacChronic: contents adhesed in sac
StrangulationStrangulation:: incarceration with incarceration with compromise of blood supplycompromise of blood supply Narrow neck at greatest risk: indirect Narrow neck at greatest risk: indirect
inguinal, femoral, and umbilicalinguinal, femoral, and umbilical
Hernia Repair IndicationsHernia Repair Indications Asymptomatic Asymptomatic
prevent visceral incarceration and/or prevent visceral incarceration and/or strangulationstrangulation
Symptomatic, non-obstructedSymptomatic, non-obstructed Treat discomfort from bulgeTreat discomfort from bulge Prevent incarceration/strangulationPrevent incarceration/strangulation
Visceral obstruction/strangulationVisceral obstruction/strangulation Release obstruction/manage visceraRelease obstruction/manage viscera Prevent recurrencePrevent recurrence
Groin HerniaGroin Hernia Men Men : : WomenWomen 25 25 : : 1 1
Right Right : : LeftLeft 2 2 : : 11
FemoralFemoral Women > MenWomen > Men Strangulation risk > inguinalStrangulation risk > inguinal
InguinalInguinal Indirect Indirect : : Direct 2 Direct 2 : : 11 Most common in men and womenMost common in men and women
Groin HerniaGroin Hernia Inguinal: relationship of sac to inguinal Inguinal: relationship of sac to inguinal
canal determines external bulgecanal determines external bulge
Movement from internal ring to scrotumMovement from internal ring to scrotum Bilateral hernias: direct 4x indirect Bilateral hernias: direct 4x indirect Indirect vs. direct hernia is Indirect vs. direct hernia is
intraoperative diagnosis, not clinical intraoperative diagnosis, not clinical diagnosisdiagnosis
Femoral: relationship of sac to inguinal Femoral: relationship of sac to inguinal ligament determines external bulgeligament determines external bulge
Groin Hernia: Inguinal Groin Hernia: Inguinal AdultsAdults
Weakness of transversalis fasciaWeakness of transversalis fascia Indirect: sac is lateral to inferior Indirect: sac is lateral to inferior
epigastric vesselsepigastric vessels Direct: sac is medial to inferior Direct: sac is medial to inferior
epigastric vesselsepigastric vessels Pantaloon: both indirect and directPantaloon: both indirect and direct
Pediatric: patent processus vaginalisPediatric: patent processus vaginalis
Inguinal herniaInguinal hernia
Male inguinal hernia Female inguinal hernia
Groin Hernia: Differential Groin Hernia: Differential DiagnosisDiagnosis
TendonitisTendonitis Muscle tearMuscle tear Lymph nodeLymph node LipomaLipoma Varicose veinVaricose vein HydroceleHydrocele EpididymitisEpididymitis SpermatoceleSpermatocele
Groin Hernia ManagementGroin Hernia Management
Most hernias: ambulatory ORMost hernias: ambulatory OR
Local/regional/general anesthesiaLocal/regional/general anesthesia
Prohibitive operative risk: trussProhibitive operative risk: truss
Groin Hernia ManagementGroin Hernia Management Acute incarcerationAcute incarceration
Reduction (taxis)Reduction (taxis) Distal traction and gentle milkingDistal traction and gentle milking Caution: reduction en masseCaution: reduction en masse Successful reduction shows visuallySuccessful reduction shows visually
Urgent elective repair if reducedUrgent elective repair if reduced
Groin Hernia ManagementGroin Hernia Management
Emergent repairEmergent repair Irreducible acute incarcerationIrreducible acute incarceration StrangulationStrangulation
Fluid, electrolyte resuscitation Fluid, electrolyte resuscitation
Groin Hernia Groin Hernia Surgical Classification (Nyhus)Surgical Classification (Nyhus)
I: Indirect hernia w/normal internal ringI: Indirect hernia w/normal internal ring
2: Indirect hernia w/enlarged internal ring2: Indirect hernia w/enlarged internal ring
3a: Direct inguinal hernia3a: Direct inguinal hernia
3b: Indirect hernia with weak floor3b: Indirect hernia with weak floor
3c: Femoral hernia3c: Femoral hernia
4: All recurrent hernias4: All recurrent hernias
Direct Inguinal HerniaDirect Inguinal Hernia
Direct Inguinal HerniaDirect Inguinal Hernia
MedialMedial to the to the inferior epigastric inferior epigastric artery and veinartery and vein, , and within and within Hesselbach's Hesselbach's triangle triangle
acquired weakness acquired weakness in the inguinal floor in the inguinal floor
Indirect Inguinal HerniaIndirect Inguinal Hernia Accepted hypothesisAccepted hypothesis: :
incomplete or incomplete or defective obliteration defective obliteration of the of the processus processus vaginalisvaginalis during the during the fetal period fetal period
remnant layer of remnant layer of peritoneum forms a peritoneum forms a sac at the internal sac at the internal ring ring
more frequently on more frequently on the right the right
FemoralFemoral
More common in females More common in females Up to 40% present as Up to 40% present as
emergencies with hernia emergencies with hernia incarceration or incarceration or strangulation strangulation
Passes medial to the Passes medial to the femoral vessels and femoral vessels and nerve in the femoral nerve in the femoral canal through the empty canal through the empty space space
Inguinal ligament forms Inguinal ligament forms the superior borderthe superior border
Groin Hernia Surgery: OpenGroin Hernia Surgery: Open
Indirect sac: high ligationIndirect sac: high ligation
Men: ligation at internal ringMen: ligation at internal ring
Women: ligation/excision of round Women: ligation/excision of round ligament with closure of internal ringligament with closure of internal ring
Cord lipoma: excisionCord lipoma: excision
OperativeOperative
BassiniBassini ShouldiceShouldice McVayMcVay LichtensteinLichtenstein PreperitonealPreperitoneal LaparoscopicLaparoscopic
Bassini (early 20Bassini (early 20thth Century) Century) Transversus abdominis to ThompsonTransversus abdominis to Thompson’’s ligament and s ligament and
internal oblique musculoaponeurotic arches or internal oblique musculoaponeurotic arches or conjoined tendon to the inguinal ligamentconjoined tendon to the inguinal ligament
Shouldice (1930s)Shouldice (1930s) Multilayer imbricated repair of the posterior wall of the Multilayer imbricated repair of the posterior wall of the
inguinal canalinguinal canal McVay (1948)McVay (1948)
Edge of the transversus abdominis aponeurosis to Edge of the transversus abdominis aponeurosis to CooperCooper’’s ligament; incorporate Coopers ligament; incorporate Cooper’’s ligament s ligament and the iliopubic tract (transition suture) and the iliopubic tract (transition suture)
BASSINI
SHOULDICE
MCVAY
Lichtenstein Lichtenstein First pure prosthestic, tension-free First pure prosthestic, tension-free
repair to achieve low recurrence repair to achieve low recurrence ratesrates
Groin Hernia Surgery: OpenGroin Hernia Surgery: Open
Inguinal floor: tension-free repair with Inguinal floor: tension-free repair with mesh mesh
Anterior plug and patchAnterior plug and patch Anterior patchAnterior patch Posterior patch (Stoppa)Posterior patch (Stoppa)
Groin Hernia SurgeryGroin Hernia Surgery Open tissue repair for risk of infection Open tissue repair for risk of infection
(example: strangulated hernia)(example: strangulated hernia)
LaparoscopicLaparoscopic IndicationsIndications
Recurrent herniaRecurrent hernia Bilateral herniasBilateral hernias
Must be able to tolerate general anesthesiaMust be able to tolerate general anesthesia More expensiveMore expensive
Groin Hernia Repair Groin Hernia Repair ComplicationsComplications
RecurrenceRecurrenceTissue repair: 1.3—25%Tissue repair: 1.3—25%Tension-free mesh: 0.5—5%Tension-free mesh: 0.5—5%
Greatest risk is repair of previous Greatest risk is repair of previous hernia at same location hernia at same location
Groin Hernia Repair Groin Hernia Repair ComplicationsComplications
Chronic groin pain: up to 30%Chronic groin pain: up to 30%
Numbness over base of scrotumNumbness over base of scrotum
Groin Hernia Repair Groin Hernia Repair ComplicationsComplications
WoundWound Hematoma: 1.0%Hematoma: 1.0% Infection: 1.3%Infection: 1.3% Seroma Seroma
InfertilityInfertility Injury to vas deferensInjury to vas deferens Ischemic orchitis is uncommonIschemic orchitis is uncommon
Urinary retentionUrinary retention
Other HerniasOther Hernias
Umbilical HerniaUmbilical Hernia Fascial defect at the umbilicus with Fascial defect at the umbilicus with
peritoneal sac covered by skinperitoneal sac covered by skin
External bulge at the umbilicus or External bulge at the umbilicus or periumbilically depending on periumbilically depending on subcutaneous migration of sacsubcutaneous migration of sac
Exam: External bulge at or adjacent to Exam: External bulge at or adjacent to the umbilicusthe umbilicus
Pediatric Umbilical HerniaPediatric Umbilical Hernia
Present in 10-30% of babiesPresent in 10-30% of babies
80% close spontaneously by age 280% close spontaneously by age 2
Indications for primary suture repairIndications for primary suture repair Hernia present after ages 2-4Hernia present after ages 2-4 Large (5 cm) defect at age 1Large (5 cm) defect at age 1
Adult Umbilical HerniaAdult Umbilical Hernia
Increased intra-abdominal Increased intra-abdominal pressurepressure PregnancyPregnancy Obesity Obesity AscitesAscites
Differential diagnosis (rare)Differential diagnosis (rare) Embryologic remnantsEmbryologic remnants Metastatic cancerMetastatic cancer
Adult Umbilical HerniaAdult Umbilical Hernia
Symptoms relate to cosmesis, Symptoms relate to cosmesis, traction on the sac, or trapped traction on the sac, or trapped contentscontents OmentumOmentum Small or transverse colonSmall or transverse colon
Acute incarceration: reduction en Acute incarceration: reduction en masse problematicmasse problematic
Adult Umbilical Hernia RepairAdult Umbilical Hernia Repair Assess contents and manage Assess contents and manage
appropriately based on viabilityappropriately based on viability Open hernia repairOpen hernia repair
< 1 cm defect: primary suture repair< 1 cm defect: primary suture repair >> 1 cm defect: mesh repair lowers 1 cm defect: mesh repair lowers
recurrencerecurrence Laparoscopic hernia repair: size of Laparoscopic hernia repair: size of
access ports often > hernia incisionaccess ports often > hernia incision
Adult Umbilical Hernia RepairAdult Umbilical Hernia Repair
RisksRisks RecurrenceRecurrence Umbilical necrosisUmbilical necrosis Injury to sac contentsInjury to sac contents HematomaHematoma InfectionInfection
Epigastric HerniaEpigastric Hernia
Fascial defect in supraumbilical Fascial defect in supraumbilical linea albalinea alba Most < 1 cmMost < 1 cm 20% with multiple defects20% with multiple defects Beware diastasis rectiBeware diastasis recti
MenMen: : Women Women 22::11
EpigastricEpigastric
midline junction of the midline junction of the aponeuroses (linea alba) aponeuroses (linea alba) betweenbetween the the xiphoid xiphoid processprocess and and umbilicusumbilicus
Paraumbilical hernia - Paraumbilical hernia - epigastric hernia that epigastric hernia that borders the umbilicusborders the umbilicus
Estimated frequency 3-Estimated frequency 3-5%5%
More common in Males More common in Males 3:13:1
20% may be multiple20% may be multiple
Epigastric HerniaEpigastric Hernia
ContentsContents Incarcerated preperitoneal fat or Incarcerated preperitoneal fat or
falciform ligament falciform ligament Peritoneal sacPeritoneal sac
RepairRepair Open repair similar as for umbilical Open repair similar as for umbilical
herniahernia Must palpate or visualize entire Must palpate or visualize entire
supraumbilical linea albasupraumbilical linea alba Laparoscopic approach is suboptimalLaparoscopic approach is suboptimal
Spigelian HerniaSpigelian Hernia
Defect through transversus abdominus Defect through transversus abdominus and internal oblique musclesand internal oblique muscles Occurs at junction of arcuate line and Occurs at junction of arcuate line and
linea semilunarislinea semilunaris Fascial defect 1-2 cmFascial defect 1-2 cm Covered by external oblique Covered by external oblique
aponeurosisaponeurosis
Spigelian HerniaSpigelian Hernia
occurs along the occurs along the semilunar line, which semilunar line, which traverses a vertical traverses a vertical space along the lateral space along the lateral rectus border rectus border
where more than 90% where more than 90% of spigelian hernias of spigelian hernias are foundare found
Spigelian HerniaSpigelian Hernia
ClinicalClinical Swelling in middle to Swelling in middle to
lower abdomen lateral lower abdomen lateral to rectus muscleto rectus muscle
Usually reducibleUsually reducible Up to 20% present Up to 20% present
with incarcerationwith incarceration Tx: surgicalTx: surgical
Mesh not requiredMesh not required Recurrence is Recurrence is
uncommonuncommon
Spigelian HerniaSpigelian Hernia PresentationPresentation
Lower abdominal swelling lateral to Lower abdominal swelling lateral to rectusrectus
Focal discomfort/painFocal discomfort/pain
May require imaging studies for diagnosisMay require imaging studies for diagnosis Ultrasound or CTUltrasound or CT
Repair: open or laparoscopic, on-lay meshRepair: open or laparoscopic, on-lay mesh
Incisional HerniaIncisional Hernia Bulge in region of scar from surgery or Bulge in region of scar from surgery or
penetrating traumapenetrating trauma
Chronic wound failure Chronic wound failure Up to 20% of abdominal incisionsUp to 20% of abdominal incisions
Subcutaneous sac may be more Subcutaneous sac may be more complexcomplex Multi-loculatedMulti-loculated Contents adhesed within sacContents adhesed within sac
Incisional Hernia: Risk Incisional Hernia: Risk FactorsFactors
Previous incisional hernia repairPrevious incisional hernia repair ObesityObesity SmokingSmoking Chronic lung diseaseChronic lung disease DiabetesDiabetes MalnutritionMalnutrition Wound infectionWound infection
Incisional Hernia RepairIncisional Hernia Repair
Fix conditions that promoted Fix conditions that promoted hernia occurrencehernia occurrence
Open repairOpen repair Primary suture: Primary suture: << 52% recurrence 52% recurrence Mesh: Mesh: << 24% recurrence 24% recurrence
Incisional Hernia RepairIncisional Hernia Repair Complex open repairsComplex open repairs
Stoppa mesh repairStoppa mesh repair Component separations repairComponent separations repair
Laparoscopic repairLaparoscopic repair Multiple fascial defects detectedMultiple fascial defects detected Large on-lay intraperitoneal mesh Large on-lay intraperitoneal mesh 5 cm marginal overlap5 cm marginal overlap
Incisional HerniaIncisional Hernia
Complications of repairComplications of repair RecurrenceRecurrence SeromasSeromas Injury to sac contentsInjury to sac contents BleedingBleeding InfectionInfection
ReviewReview Pediatric herniasPediatric hernias
InguinalInguinal UmbilicalUmbilical
Adult herniasAdult hernias GroinGroin
InguinalInguinal FemoralFemoral
UmbilicalUmbilical EpigastricEpigastric SpigelianSpigelian IncisionalIncisional
Points to RememberPoints to Remember
Hernias represent fascial defects with Hernias represent fascial defects with protrusion of a peritoneal sac or protrusion of a peritoneal sac or preperitoneal fatpreperitoneal fat
Asymptomatic bulge most commonAsymptomatic bulge most common Hernia risk is related to visceral Hernia risk is related to visceral
obstruction or strangulationobstruction or strangulation Tension-free repair with mesh produces Tension-free repair with mesh produces
lowest recurrence rateslowest recurrence rates
SummarySummary
Etiology, pathology, clinical evaluation, Etiology, pathology, clinical evaluation,
and treatment of abdominal wall hernias and treatment of abdominal wall hernias
including inguinal, femoral, umbilical, including inguinal, femoral, umbilical,
epigastric, Spigelian, and incisional epigastric, Spigelian, and incisional
herniashernias
Scenario Scenario
Direct HerniaDirect Hernia
Indirect Indirect inguinal hernia inguinal hernia
Direct inguinal Direct inguinal herniahernia
Relation to Relation to epigastric epigastric vessels vessels
Lataral Lataral medialmedial
Processus Processus vaginalis vaginalis
Present Present Absent Absent
Causes Causes congenitalcongenital Acqiured Acqiured
Individual herniasIndividual hernias
1.1. Direct & indirect Inguinal Direct & indirect Inguinal
hernia.hernia.
2.2. Femoral hernia.Femoral hernia.
3.3. Umbilical hernia & Umbilical hernia &
paraumbilical hernia.paraumbilical hernia.
4.4. Incisional hernia.Incisional hernia.
5.5. Epigastric hernia.Epigastric hernia.
6.6. Rare external Hernias.Rare external Hernias.
Femoral HerniaFemoral Hernia Femoral Hernias occur just below Femoral Hernias occur just below
the inguinal ligament, when the inguinal ligament, when abdominal contents pass through a abdominal contents pass through a naturally occurring weakness called naturally occurring weakness called the femoral canal.the femoral canal.
The Femoral canal : The Femoral canal : The most medial structure in The most medial structure in
the femoral sheath,.the femoral sheath,. extending from the femoral extending from the femoral
ring to the saphenous ring to the saphenous opening.opening.
1.25cm x 1.25cm.1.25cm x 1.25cm. Contains fat, lymph vessels Contains fat, lymph vessels
and the lymph node of and the lymph node of cloquet.cloquet.
Femoral Hernia (cont..)Femoral Hernia (cont..)
Symptoms:Symptoms: Femoral hernias are more common in women, Femoral hernias are more common in women, They typically present as a groin lump. They may or may not be They typically present as a groin lump. They may or may not be associated with pain, a femoral hernia has often been found to associated with pain, a femoral hernia has often been found to be the cause of unexplained small bowel obstruction.be the cause of unexplained small bowel obstruction.
Signs:Signs: an absent Cough impulse, with a more globular lump an absent Cough impulse, with a more globular lump than the pear shaped lump of the inguinal hernia. than the pear shaped lump of the inguinal hernia.
Differential DiagnosesDifferential Diagnoses: : Inguinal Hernia.Inguinal Hernia. Femoral Artery Aneurism.Femoral Artery Aneurism. Femoral Lymphadenopathy.Femoral Lymphadenopathy. Psoas Abscess.Psoas Abscess.
Umbilical & paraumbilical HerniaUmbilical & paraumbilical Hernia
A. Umbilical Hernia:A. Umbilical Hernia:
Seen in infants & children.Seen in infants & children. Effecting boys more than Effecting boys more than
girls.girls. tend to resolve without any tend to resolve without any
treatment by around the age treatment by around the age of 5 years. of 5 years.
Obstruction and strangulation Obstruction and strangulation of the hernia is rare.of the hernia is rare.
Babies are prone to this Babies are prone to this malformation because of the malformation because of the process during fetal process during fetal development by which the development by which the abdominal organs form abdominal organs form outside the abdominal cavity, outside the abdominal cavity, later returning into it through later returning into it through an opening which will become an opening which will become the umbilicus.the umbilicus.
B. Paraumbilical Hernia:B. Paraumbilical Hernia: Affects adults.Affects adults. The defect is either supra or The defect is either supra or
infraumbilical through the infraumbilical through the linea alba.linea alba.
The female to male ratio is The female to male ratio is 20:1.20:1.
May contain omentum, small May contain omentum, small intestine or transverse colon.intestine or transverse colon.
Etiology: Etiology: 1.1. Obesity.Obesity.
2.2. Flabbiness of the abdominal Flabbiness of the abdominal muscles.muscles.
3.3. Multiparity.Multiparity.
Clinical Features:Clinical Features:Clolicky pain and/or Clolicky pain and/or
irreducibilty due to omental irreducibilty due to omental adhesions.adhesions.
Incisional HerniaIncisional Hernia
Definition:Definition: An An incisional herniaincisional hernia occurs when the area of weakness is the occurs when the area of weakness is the result of an incompletely healed surgical wound. These can be among result of an incompletely healed surgical wound. These can be among the most frustrating and difficult hernias to treat. It can occur at any the most frustrating and difficult hernias to treat. It can occur at any incision, but tend to occur more commonly along a straight line from the incision, but tend to occur more commonly along a straight line from the sternum breastbone straight down to the pubis, and are more complex sternum breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence.in these regions. Hernias in this area have a high rate of recurrence.
Causes: Causes: Any reasons leading to an icrease in intraabdominal pressure Any reasons leading to an icrease in intraabdominal pressure
postoperatively such as: chronic cough, vomitting, infection, postoperatively such as: chronic cough, vomitting, infection, malnutrition diabetes, steroid treatment or a tension closure done malnutrition diabetes, steroid treatment or a tension closure done during the previous operation.during the previous operation.
Clinical Features:Clinical Features: Swelling at the incisional site +/- pain.Swelling at the incisional site +/- pain.
Ventral wall (Incisional)Ventral wall (Incisional)
Highest incidence in midline Highest incidence in midline and transverse incisions and transverse incisions
Up to20% after laparotomyUp to20% after laparotomy 1/3 present in 5-10 years 1/3 present in 5-10 years
postoperativelypostoperatively Risk factors Risk factors
obesity, DM, ascites, obesity, DM, ascites, steroids, smoking steroids, smoking malnutrition, wound malnutrition, wound infectioninfection
Technical aspects of wound Technical aspects of wound closureclosure Type of incision Type of incision Excessive tension (prone to Excessive tension (prone to
fascial disruption)fascial disruption)
Epigastric HerniaEpigastric Hernia
Due to a defectin the linea alba between Due to a defectin the linea alba between the xiphoid process and the umbilicusthe xiphoid process and the umbilicus
Starts as a protrusion of the Starts as a protrusion of the extraperitoneal fat at the site where a extraperitoneal fat at the site where a small vessel pierces the lina alba and as small vessel pierces the lina alba and as it enlarges it drags a pouch of it enlarges it drags a pouch of peritoneum after it.peritoneum after it.
Clinical Features:Clinical Features:
Swelling +/- pain similar to a peptic ulcer Swelling +/- pain similar to a peptic ulcer pain.pain.
Rare external HerniasRare external Hernias
Since many organs or parts of organs can herniate through many orifices, it Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. But her are Other hernial types and unusual types of visceral eponyms. But her are Other hernial types and unusual types of visceral hernias:hernias:
1.1. Spiglian Hernia:Spiglian Hernia: Occurs at the spaces of the semilunar line and the lateral edge of Occurs at the spaces of the semilunar line and the lateral edge of
the rectus muscle (inferior to the arcuate line).the rectus muscle (inferior to the arcuate line). The posterior rectus sheath jis weak thus leading to the protrusion.The posterior rectus sheath jis weak thus leading to the protrusion. Preoperative diagnosis is diffucult & only correct in 50% of the Preoperative diagnosis is diffucult & only correct in 50% of the
patients.patients. u/s & c.t are helpful tools in the diagnosisu/s & c.t are helpful tools in the diagnosis Depending on the size of the defect, treatment varies from suture Depending on the size of the defect, treatment varies from suture
approximation to using a mesh.approximation to using a mesh.
Rare hernias (cont..)Rare hernias (cont..)2. Lumbar Hernias:2. Lumbar Hernias:
In the lumbar region, in the form of a broad bulging hernia, In the lumbar region, in the form of a broad bulging hernia, that are not vulnerable to incarceration.that are not vulnerable to incarceration.
Devided intoDevided into: :
A. Petit’s hernia: A. Petit’s hernia: which occurs in the inferior lumbar which occurs in the inferior lumbar triangle.triangle.
B. Grynfeltt’s Hernia: B. Grynfeltt’s Hernia: which occurs in the superior which occurs in the superior lumbar lumbar triangle and is triangle and is less common that Petit’s. less common that Petit’s.
LumbarLumbar Acquired lumbar hernias Acquired lumbar hernias
– – back or flank trauma, back or flank trauma,
poliomyelitis, back poliomyelitis, back surgery, and the use of the surgery, and the use of the iliac crest as a donor site iliac crest as a donor site for bone grafts for bone grafts
Contains to anatomic Contains to anatomic triangles, inferior and triangles, inferior and superior lumbar trianglessuperior lumbar triangles Grynfelt’sGrynfelt’s Petit’s Petit’s
Strangulation is rareStrangulation is rare Soft swelling in lower Soft swelling in lower
posterior abdomenposterior abdomen
Rare hernias (cont..)Rare hernias (cont..)3. Obturator Hernia:3. Obturator Hernia:
The obturator canal is covered by The obturator canal is covered by a membrane pierced by the a membrane pierced by the obturator nerve and vessels. Any obturator nerve and vessels. Any enlargement in the canal or enlargement in the canal or weakness in the membrane may weakness in the membrane may lead to herniation of the intetines.lead to herniation of the intetines.
Because of differences in anatomy, Because of differences in anatomy, it is much more common in women it is much more common in women than in men.than in men.
It often presents with bowel It often presents with bowel obstruction.obstruction.
The Howship-Romberg sign is The Howship-Romberg sign is suggestive of an obturator hernia, suggestive of an obturator hernia, exacerbated by thigh extension, exacerbated by thigh extension, medial rotation and adduction. It is medial rotation and adduction. It is characterized by lancilating pain in characterized by lancilating pain in the medial thigh/obturator the medial thigh/obturator distribution, extending to the knee; distribution, extending to the knee; caused by hernia compression of caused by hernia compression of the obturator nerve.the obturator nerve.
ObturatorObturator
Rare form of herniaRare form of hernia Protrusion of intra-abdominal Protrusion of intra-abdominal
contents through contents through obturator obturator foramenforamen
F:M ratio 6:1F:M ratio 6:1 The obturator foramen is The obturator foramen is
formed by the ischial and formed by the ischial and pubic rami pubic rami
obturator vessels and nerve obturator vessels and nerve lie posterolateral to the lie posterolateral to the hernia sac in the canal hernia sac in the canal
Small bowel is the most Small bowel is the most likely intraabdominal likely intraabdominal organ to be found in an organ to be found in an obturator herniaobturator hernia
ObturatorObturator
4 cardinal signs : 4 cardinal signs : intestinal obstructionintestinal obstruction (80%) (80%) Howship-Romberg signHowship-Romberg sign (50%) –History of (50%) –History of
repeated episodes of bowel obstructionrepeated episodes of bowel obstruction that resolve quickly and without intervention that resolve quickly and without intervention
Palpable massPalpable mass (20%) (20%)
Tx: Sugical RepairTx: Sugical Repair
SciaticSciatic Via greater or lesser sciatic Via greater or lesser sciatic
notch notch greater sciatic notch is greater sciatic notch is
traversed by the piriformis traversed by the piriformis muscle, and hernia sacs muscle, and hernia sacs can protrude either can protrude either superior or inferior to this superior or inferior to this muscle muscle
suprapiriform defect 60%suprapiriform defect 60% Infrapiriform 30% Infrapiriform 30% subspinous (through the subspinous (through the
lesser sciatic foramen) 10% lesser sciatic foramen) 10%
EXAMINATION:EXAMINATION:
Hernias must be examined with the patient standing Hernias must be examined with the patient standing and in supineand in supineAlways examine both groins.Always examine both groins.
INSPECTION:INSPECTION:Visible swelling. (site, size and shape)Visible swelling. (site, size and shape)Visible cough impulse.Visible cough impulse.Easily reducibleEasily reducibleReappear on straining, standing or coughing Reappear on straining, standing or coughing Elucidate Fothergill and Carnet signs.Elucidate Fothergill and Carnet signs.
PALPATION:PALPATION:Examine as a mass and then Examine as a mass and then Palpable cough impulsePalpable cough impulseReduceReduceOcclusion testOcclusion testThree Finger test ( Zimman’s test)Three Finger test ( Zimman’s test)
ExaminationExamination
also asses the following:also asses the following:PositionPositionTemperatureTemperatureTendernessTendernessShapeShapeSizeSizeTensionTensionCompositionCompositionExpansile cough impulseExpansile cough impulseReducible.Reducible.
PERCUSSION AND AUSCULTATION:PERCUSSION AND AUSCULTATION:
Bowel sound.Bowel sound.
TreatmentTreatmentMost abdominal hernias can be surgically Most abdominal hernias can be surgically repaired.repaired.
Uncomplicated hernias are principally Uncomplicated hernias are principally repaired by herniorrhaphy.repaired by herniorrhaphy.
aa Herniorrhaphy (Hernioplasty) is a surgical Herniorrhaphy (Hernioplasty) is a surgical procedure for correcting hernia, which can procedure for correcting hernia, which can be devided into four techniques:be devided into four techniques:
Groups 1 and 2: open "tension" repair:Groups 1 and 2: open "tension" repair: in which the edges of the defect are sewn back in which the edges of the defect are sewn back
together without any reinforcement or prosthesis. together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus (formed by the distal ends of the transversus abdominis muscle and the internal oblique abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and muscle) is approximated to the inguinal canal and closed. closed. [4]
Although tension repairs are no longer the Although tension repairs are no longer the standard of care due to the high rate of standard of care due to the high rate of recurrence of the hernia, long recovery period, recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are and post-operative pain, a few tension repairs are still in use today.still in use today.
Treatment (cont..)Treatment (cont..)Group 3: open "tension-free" repair:Group 3: open "tension-free" repair:
Almost all repairs done today are open Almost all repairs done today are open "tension-free" repairs that involve the "tension-free" repairs that involve the placement of a synthetic mesh to placement of a synthetic mesh to strengthen the inguinal region.strengthen the inguinal region.
This operation is called a 'hernioplasty'. The This operation is called a 'hernioplasty'. The meshes used are typically made from meshes used are typically made from polypropylene or polyester. The operation polypropylene or polyester. The operation is typically performed under local is typically performed under local anesthesia, and patients go home within a anesthesia, and patients go home within a few hours of surgery, often requiring no few hours of surgery, often requiring no medication beyond aspirin or medication beyond aspirin or acetaminophen.acetaminophen.
Recurrence rates are very low - one Recurrence rates are very low - one percent or less, compared with over 10% percent or less, compared with over 10% for a tension repairfor a tension repair
Treatment (cont..)Treatment (cont..)
Group 4: laparoscopic repairGroup 4: laparoscopic repair "Lap" repairs are also tension-free, although "Lap" repairs are also tension-free, although
the mesh is placed within the preperitoneal the mesh is placed within the preperitoneal space behind the defect as opposed to in or space behind the defect as opposed to in or over it.over it.
It is further sub-devided into:It is further sub-devided into: T.A.P.P repair (transabdominal T.A.P.P repair (transabdominal
preperitoneal)preperitoneal) T.E.P repair (totally T.E.P repair (totally
extraperitoneal)extraperitoneal)
It has no proven superiority to the open It has no proven superiority to the open method other than a faster recovery time and method other than a faster recovery time and a slightly lower post-operative pain score.a slightly lower post-operative pain score.
laparoscopic surgery, though, requires general laparoscopic surgery, though, requires general anesthesia, more expensive and consumes anesthesia, more expensive and consumes more O.R. time than open repair and carries a more O.R. time than open repair and carries a higher risk of complications, and has higher risk of complications, and has equivalent or higher rates of recurrence equivalent or higher rates of recurrence compared to the open tension-free repairs.compared to the open tension-free repairs.