HERNIASHERNIAS

Historical PerspectiveHistorical Perspective

1515thth century - century - Castration with Castration with wound wound cauterization or cauterization or hernia sac hernia sac debridementdebridement

recommended a recommended a trusstruss

Father of Modern Inguinal Father of Modern Inguinal Hernia RepairHernia Repair

EDUARDO BASSINI

HerniaHernia

Latin for Latin for rupturerupture

an abnormal protrusion of an organ an abnormal protrusion of an organ or tissue through a defect in its or tissue through a defect in its surrounding wallssurrounding walls

Occur at sites where aponeurosis and Occur at sites where aponeurosis and fascia are not covered by striated fascia are not covered by striated muscle muscle

Which of the following statements Which of the following statements is/are true regarding incidence of the is/are true regarding incidence of the abdominal wall hernia?abdominal wall hernia?

A.A. Two-thrirds of all inguinal hernias Two-thrirds of all inguinal hernias are classified as indirect.are classified as indirect.

B.B. Femoral hernias are more common Femoral hernias are more common in females than in males.in females than in males.

C.C. Direct hernias are common in Direct hernias are common in females.females.

D.D. Hernias generally occur with equal Hernias generally occur with equal frequency in males and femalesfrequency in males and females

E.E. Premature babies have a 10% Premature babies have a 10% incidence of having inguinal hernia.incidence of having inguinal hernia.

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 Prevelance of hernias increases with ageage

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

Abdominal Wall Abdominal Wall AnatomyAnatomy

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 upon the pubic tubercle 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 superficial inguinal ringsrings

BoundariesBoundaries Superifical – Superifical – external external

oblique aponeurosisoblique aponeurosis Superior – Superior – internal and internal and

transversustransversus Inferior – shelving edge Inferior – shelving edge

of of inguinal ligamentinguinal ligament and lacunar ligamentand lacunar ligament

Posterior (floor) – Posterior (floor) – transversalis fasciatransversalis fascia and aponeurosis of and aponeurosis of transversus abdominis transversus abdominis musclemuscle

Inguinal CanalInguinal Canal Contains the Contains the

spermatic cord and spermatic cord and round ligament of the round ligament of the uterusuterus

Spermatic cordSpermatic cord Cremasteric muscle Cremasteric muscle

fibersfibers Testicular vesselsTesticular vessels Genital branch of Genital branch of

genitofemoral nervegenitofemoral nerve Vas deferens Vas deferens Cremasteric vesselsCremasteric vessels

Components of Hesselbach’s triangle Components of Hesselbach’s triangle include which of the following anatomic include which of the following anatomic landmarks?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

TerminologyTerminology

ReducibleReducible – can be replaced – can be replaced within surrounding musculaturewithin surrounding musculature

IncarceratedIncarcerated – cannot be reduced – cannot be reduced

StrangulatedStrangulated – compromised blood – compromised blood supply to its contentssupply to its contents

Sends sensory branches to the inner Sends sensory branches to the inner thigh and medial aspect of the thigh and medial aspect of the scrotumscrotum

A.A. Ileoinguinal nerve Ileoinguinal nerve

B.B. Genitofemoral nerveGenitofemoral nerve

C.C. BothBoth

D.D. NeitherNeither

A sliding inguinal hernia on the left A sliding inguinal hernia on the left side is likely to involve which of the side is likely to involve which of the following?following?

A.A. Jejunum composing the posterior Jejunum composing the posterior wall of the sacwall of the sac

B.B. Ovary and fallopian tube in a Ovary and fallopian tube in a female infantfemale infant

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 Cecum composing the

anteromedial wall of the sacanteromedial wall of the sac

TerminologyTerminology

Pantaloon – Pantaloon – direct and indirectdirect and indirect components components Richter’s – contains Richter’s – contains antimesenteric portionantimesenteric portion

of small bowelof small bowel Sliding – involves Sliding – involves visceral peritoneumvisceral peritoneum of an of an

organ , i.e. bladder, ovaryorgan , i.e. bladder, ovary Littre’s – hernia contains Littre’s – hernia contains Meckel’s Meckel’s

diverticulumdiverticulum Petit – hernia at Petit – hernia at inferiorinferior lumbar triangle lumbar triangle Grynfelt – hernia at Grynfelt – hernia at superiorsuperior lumbar lumbar

triangletriangle

Groin HerniasGroin Hernias

IndirectIndirect DirectDirect FemoralFemoral

Inguinal HerniaInguinal Hernia

Classified as congenital vs. acquiredClassified as congenital vs. acquired

commonly thought that repeated commonly thought that repeated increases in intra-abdominal pressure increases in intra-abdominal pressure contribute to hernia formationcontribute to hernia formation

collagen formation and structure collagen formation and structure deteriorates with age, and thus hernia deteriorates with age, and thus hernia formation is more common in the older formation is more common in the older individual. individual.

Clinical PresentationClinical Presentation

Groin bulgeGroin bulge Often asymptomaticOften asymptomatic Dull feeling of discomfort or Dull feeling of discomfort or

heaviness in the groinheaviness in the groin Focal pain – raise suspicion for Focal pain – raise suspicion for

incarceration or strangulationincarceration or strangulation Symptoms of bowel obstructionSymptoms of bowel obstruction

Inguinal herniaInguinal hernia

Male inguinal hernia Female inguinal hernia

DiagnosisDiagnosis

Physical Exam Physical Exam 74.5% sensitive and 74.5% sensitive and

96.3% specific96.3% specific examine the patient examine the patient

in the standing and in the standing and supine positionssupine positions

difficult to difficult to distinguish direct distinguish direct and indirect on and indirect on exam on aloneexam on alone

DiagnosisDiagnosis

Radiologic InvestigationsRadiologic Investigations Herniography Herniography

Suspected hernia, but clinical dx unclearSuspected hernia, but clinical dx unclear Procedure done under flouroscopy following Procedure done under flouroscopy following

injection of contrast mediuminjection of contrast medium Frontal and oblique radiographs are taken Frontal and oblique radiographs are taken

with and without increased intra-abdominal with and without increased intra-abdominal pressure pressure

Ultrasonography Ultrasonography MRI MRI CTCT

HerniographyHerniography

Right direct inguinal hernia

Left indirect inguinal hernia

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 in the inguinal floor floor

Indirect Inguinal herniaIndirect Inguinal hernia

Abdominal contents protrude through Abdominal contents protrude through internal inguinal ringinternal inguinal ring

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 More common in

females 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

FemoralFemoral

palpation of the femoral canal just palpation of the femoral canal just below the inguinal ligament in the below the inguinal ligament in the upper thigh upper thigh

NAVELSNAVELS

Which of the following statements Which of the following statements is/are true regarding direct inguinal is/are true regarding direct inguinal hernias?hernias?

A.A. The most likely cause is destruction of The most likely cause is destruction of connective tissue resulting form physical connective tissue resulting form physical stress.stress.

B.B. Direct hernias should be repaired Direct hernias should be repaired promptly because of the risk of promptly because of the risk of incarceration.incarceration.

C.C. A direct hernia may be a sliding hernia A direct hernia may be a sliding hernia involving a portion of the bladder wall.involving a portion of the bladder wall.

D.D. A direct hernia may pass through the A direct hernia may pass through the external inguinal ring.external inguinal ring.

E.E. Colon carcinoma is a known cause of Colon carcinoma is a known cause of direct inguinal hernias.direct inguinal hernias.

TreatmentTreatment

Non-OperativeNon-Operative ObservationObservation Trusses can provide symptomatic relief Trusses can provide symptomatic relief

Hernia control in ~30% of patientsHernia control in ~30% of patients

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

Prosthetic RepairProsthetic Repair Polypropylene mesh most common and Polypropylene mesh most common and

preferred preferred allows for a fibrotic reaction to occur allows for a fibrotic reaction to occur

between the inguinal floor and the posterior between the inguinal floor and the posterior surface of the mesh, thereby forming scar surface of the mesh, thereby forming scar and strengthening the closure of the hernia and strengthening the closure of the hernia defect defect

Polytetrafluoroethylene (PTFE) meshPolytetrafluoroethylene (PTFE) mesh often used for repair of often used for repair of ventral or incision ventral or incision

herniashernias in which the fibrotic reaction with in which the fibrotic reaction with the underlying serosal surface of the bowel the underlying serosal surface of the bowel is best avoided is best avoided

Prospective studyProspective study Danish Hernia Danish Hernia

database of over database of over 13,000 hernia repairs13,000 hernia repairs

Compared re-Compared re-operations for operations for recurrent hernia recurrent hernia

Results: After 5 years Results: After 5 years significantly lower significantly lower (1/4 less) recurrence (1/4 less) recurrence with mesh vs. with mesh vs. sutured repair sutured repair

LaparoscopicLaparoscopic

The cause of neuropathic The cause of neuropathic postherniorrhaphy inguinodynia postherniorrhaphy inguinodynia includes which of the following?includes which of the following?

A.A. Formation of scar tissueFormation of scar tissue

B.B. Transection of the ilioinguinal, Transection of the ilioinguinal, iliohypogastric, or the iliohypogastric, or the genitofemoral nervesgenitofemoral nerves

C.C. Suture entrapment of nervesSuture entrapment of nerves

D.D. Staple entrapment of nervesStaple entrapment of nerves

E.E. Periosteal reactionPeriosteal reaction

Surgical ComplicationsSurgical Complications

RecurrenceRecurrence Infection Infection NeuralgiaNeuralgia Bladder injuryBladder injury Testicular injuryTesticular injury Vas Deferens injuryVas Deferens injury

Other HerniasOther Hernias

Which of the following is/are true Which of the following is/are true statements regarding umbilical statements regarding umbilical hernias?hernias?

A.A. They are embryonic equivalent of a They are embryonic equivalent of a small omphalocelesmall omphalocele

B.B. Repair in infants is usually deferred until Repair in infants is usually deferred until approximately 4 years of ageapproximately 4 years of age

C.C. Repair in adults is usually indicatedRepair in adults is usually indicated

D.D. The “vest-over-pants” type of repair is The “vest-over-pants” type of repair is stronger than simple approximation of stronger than simple approximation of fascial marginsfascial margins

E.E. They are most common in Caucasian They are most common in Caucasian infantsinfants

UmbilicalUmbilical

IncidenceIncidence Reported ~10%Reported ~10% several times greater in Black childrenseveral times greater in Black children more common in premature children all more common in premature children all

racesraces Most close spontaneously by age 2 or 3Most close spontaneously by age 2 or 3 Acquired rather than congenital in Acquired rather than congenital in

adultsadults Female to male ratio 3:1 Female to male ratio 3:1

EpigastricEpigastric midline junction of the midline junction of the

aponeuroses (linea aponeuroses (linea alba) alba) betweenbetween the the xiphoid processxiphoid process and and umbilicusumbilicus

Paraumbilical hernia - Paraumbilical hernia - epigastric hernia that epigastric hernia that borders the umbilicusborders the umbilicus

Estimated frequency Estimated frequency 3-5%3-5%

More common in More common in Males 3:1Males 3:1

20% may be multiple20% may be multiple

EpigastricEpigastric ClinicalClinical

Often asymptomatic, incidental findingOften asymptomatic, incidental finding If symptomatic, vague abdominal pain above the If symptomatic, vague abdominal pain above the

umbilicus exacerbated by standing or coughing; umbilicus exacerbated by standing or coughing; relieved in supine positionrelieved in supine position

Severe pain secondary to incarceration/strangulation of Severe pain secondary to incarceration/strangulation of preperitoneal fat (often no peritoneal sac) or omentumpreperitoneal fat (often no peritoneal sac) or omentum

Exam: palpate small, soft, reducible mass superior to Exam: palpate small, soft, reducible mass superior to the umbilicusthe umbilicus

RARERARE to have strangulated bowel to have strangulated bowel TxTx

Excise fat and sac, close primarilyExcise fat and sac, close primarily

An 82-year-old previously healthy woman has a 12-hour An 82-year-old previously healthy woman has a 12-hour history of severe epigastric pain associated with nausea and history of severe epigastric pain associated with nausea and vomiting. She has had no previous abdominal operations. Her vomiting. She has had no previous abdominal operations. Her WBC count is 21,000/cu mm. The plain films and abdominal WBC count is 21,000/cu mm. The plain films and abdominal CT shown are obtained.CT shown are obtained.

Which of the following best Which of the following best describes this patient’s describes this patient’s diagnosis?diagnosis?A.A. Pain in the medial thigh and knee is Pain in the medial thigh and knee is

uncommonly associated with this uncommonly associated with this conditioncondition

B.B. It is unusual in womenIt is unusual in women

C.C. It is unusual in elderly patientsIt is unusual in elderly patients

D.D. It is seldom associated with It is seldom associated with intestinal necrosisintestinal necrosis

E.E. It is usually unilateralIt is usually unilateral

ObturatorObturator Rare form of herniaRare form of hernia Protrusion of intra-Protrusion of intra-

abdominal contents abdominal contents through 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 obturator vessels and nerve lie posterolateral to nerve lie posterolateral to the hernia sac in the canal the 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 that resolve quickly and without intervention intervention

Palpable massPalpable mass (20%) (20%)

Tx: Sugical RepairTx: Sugical Repair

Spigelian HerniaSpigelian Hernia occurs along the occurs along the

semilunar line, which semilunar line, which traverses a vertical traverses a vertical space along the space along the lateral rectus border lateral 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 lower abdomen lateral to rectus lateral to rectus musclemuscle

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

LumbarLumbar

Acquired lumbar hernias Acquired lumbar hernias – – back or flank trauma, back or flank trauma,

poliomyelitis, back surgery, poliomyelitis, back surgery, and the use of the iliac and the use of the iliac crest as a donor site for crest as a donor site for bone grafts bone grafts

Contains to anatomic Contains to anatomic triangles, inferior and triangles, inferior and superior lumbar superior lumbar trianglestriangles Grynfelt’sGrynfelt’s Petit’s Petit’s

Strangulation is rareStrangulation is rare Soft swelling in lower Soft swelling in lower

posterior abdomenposterior abdomen

SciaticSciatic Via greater or lesser Via greater or lesser

sciatic notch sciatic notch greater sciatic notch is greater sciatic notch is

traversed by the traversed by the piriformis muscle, and piriformis muscle, and hernia sacs can protrude hernia sacs can protrude either superior or inferior either superior or inferior to this muscle to this muscle

suprapiriform defect 60%suprapiriform defect 60% Infrapiriform 30% Infrapiriform 30% subspinous (through the subspinous (through the

lesser sciatic foramen) lesser sciatic foramen) 10% 10%

Which of the following hernias is most Which of the following hernias is most likely to recur after primary repair?likely to recur after primary repair?

A.A. Epigastric herniaEpigastric hernia

B.B. Spigelian herniaSpigelian hernia

C.C. Indirect herniaIndirect hernia

D.D. Femoral herniaFemoral hernia

E.E. Incisional herniaIncisional hernia

Ventral wall (Incisional)Ventral wall (Incisional) Highest incidence in Highest incidence in

midline and transverse midline and transverse incisions 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)

Which of the following hernias Which of the following hernias represent an incarceration of a limited represent an incarceration of a limited portion of small bowel?portion of small bowel?

A.A. Spigelian herniaSpigelian hernia

B.B. Grynfelt’s herniaGrynfelt’s hernia

C.C. Petit’s herniaPetit’s hernia

D.D. Richter’s herniaRichter’s hernia

E.E. Littre’s herniaLittre’s hernia