Learn hernia by hard... best n important for medical student.... Have a nice day...

1. HERNIAS
MOHD HANAFI RAMLEE

2. WE START WITH Q&A
SESSION FIRST?

3. ARE YOU REMEMBER????

4. INGUINAL
• Anteriorly
• Skin, superficial fascia and
external oblique aponeurosis;
internal oblique covers its lateral
1/3.
• Posteriorly:
• The conjoint tendon
(representing the fused common
aponeurotic insertion of internal
oblique and transverse
abdominis muscle into the pubic
crest), forms the posterior wall of
the canal medially ; the
transversalis fascia lies laterally.
• Above:
• Lowest fibers of internal oblique
and transverse abdominis.
• Below:
• Lies the inguinal ligament
FEMORAL CANAL
• Superioranteriorly [rigid openig]
• inguinal ligament
• Inferoposteriorly
• pubic ramus and the pectineus
muscle
• Medially
• Gimbernat’s ligament(pubic part
of inguinal ligament) and pubic
bone
• Laterally
• femoral vein
HOW DO YOU DIFFERENTIATE
IT ANATOMICALLY?

5. HOW DO YOU
DIFFERENTIATE IT
ANATOMICALLY?
INGUINAL CANAL

6. HOW DO YOU
DIFFERENTIATE IT
ANATOMICALLY?
INGUINAL CANAL

7. HOW DO YOU
DIFFERENTIATE IT
ANATOMICALLY?
FEMORAL CANAL

8. FEMORAL CANALINGUINAL CANAL

9. Inguinal ligament
• Attached to
pubic tubercle
and anterior
superior iliac
spine.
Mid-inguinal
point
• half way
between ASIS
and pubis -
landmark for
femoral artery
in groin. (see
lower limb
pulses and
cardiovascular
examination).
Midpoint of
inguinal ligament
• Half way
between ASIS
and pubic
tubercle -
landmark for
deep inguinal
ring and
indirect inguinal
hernia. Medial
to this for direct
inguinal hernia.
TERMS:
INGUINALOGY?

10. MID-PT INGUINAL LIGMID-INGUINAL POINT

11. INGUINAL
• Sex: males more
than females.
• Age: all ages.
• Peak time of
presentation: 1st
few months of life,
late teens and
early twenties, 40
– 60.
• Occupation: heavy
work (lifting)
FEMORAL
• Age: uncommon in
children, majority
found in 60-80 y/o
women
• Sex: more
common in women
HOW DO YOU
DIFFERENTIATE IT
EPIDEMOLOGICALLY? [age
& sex]

12. INGUINAL
• Local symptoms:
discomfort, pain,
swelling in the groin.
• Systemic symptoms
(if hernia is
obstructing the
lumen of loop of
bowel): colicky
abdominal pain,
vomiting, abdominal
distension, absolute
constipation.
FEMORAL
• local: lump in groin,
pain and discomfort
• Systemic (if
obstructed): colic,
distension, vomiting
and constipation
HOW DO YOU DIFFERENTIATE IT
BY HISTORY?

13. INGUINAL
•SITE: just above the pubic crest
and the pubic tubercle and is widest
medial to the pubic tubercle
•SIZE:1-2cm in diameter/extend
down to the knee joint
•SHAPE: pear-shaped or hour-
glass appearance
•SKIN:normal as the surrounding
skin. But if strangulated, the skin
,may be a little reddened
•SURFACE:usually smooth
•SURROUNDING: Normal
•TEMPERATURE: normal but if
strangulated or infected, it become
hot
•TENDERNESS: discomfort. If
strangulated, it can be very tender
•COMPOSITION: gut (soft,
resonant, fluctuant, bowel sounds),
omentum (firm, dull, non-fluctuant)
•COUGH IMPULSE: positive
•REDUCIBILITY: positive
FEMORAL CANAL
•SITE: below and lateral to the pubic
tubercle
•SIZE: small
•SHAPE: flattened
•SKIN: normal as the surrounding
skin. But if strangulated, the skin
,may be a little reddened
•SURFACE: smooth
•SURROUNDING: Normal
•TEMPERATURE: normal but if
strangulated or infected, it become
hot
•TENDERNESS: discomfort. If
strangulated, it can be very tender
•COMPOSITION: depend on content
•COUGH IMPULSE: many femoral
hernia do not have a positive cough
impulse
•REDUCIBILITY: reduced
incompletely
PHYSICAL EXAMINATION? 6S 2T C F
2C
R

14. Incarcerated
• irreducible hernia
where the
irreducibility is
due to adhesions
within the sac in
the absence of
obstruction or
strangulation.
• OR hypotheses -
because of
faeces within the
large bowel.
• SIMPLY: a
hernia as being
irreducible but
not obstructed
or strangulated.
Obstructed
• The bowel within
the hernia is
obstructed. The
patient may have
the four cardinal
signs of
obstruction (pain,
vomiting,
distention and
constipation).
Strangulated
• occluded blood
supply by
pressure at the
neck of the
hernia.
• Viability of bowell
will impaired
[except if contain
omentum only]
• 1st veins are
occluded P 
2nd arterial
occlusion 
gangrene
developing.
TERMS:
INGUINALOGY?

15. DIRECT INGUINAL
HERNIA
• Hernia pushes its
way directly
forward through
posterior wall of
inguinal canal.
• Does not go down
into the scrotum
INDIRECT
INGUINAL HERNIA
• Pass through
internal ring, along
the canal in front
of spermatic cord,
within layers of
spermatic fascia
and cremasteric
fascia,
• If large enough,
descend into the
scrotumHOW DO YOU DIFFERENTIATE
IT ANATOMYCALLY?

16. HOW DO YOU
DIFFERENTIATE IT
ANATOMICALLY?
DIRECT INGUINAL HERNIA

17. HOW DO YOU
DIFFERENTIATE IT
ANATOMICALLY?
INDIRECT INGUINAL HERNA

18. DIRECT INGUINAL HERNIA
• Reduces upwards and then
straight backwards.
• Not controlled, after reduction,
by pressure over the internal
inguinal ring.
• The defect may be felt in the
abdominal wall above the pubic
tubercle.
• After reduction the bulge
reappears exactly where it was
before.
• Uncommon in children and
young adults.
• Always acquired
• Large orifice
• appears immediately on
standing, disappearing at
once when lies down.
INDIRECT INGUINAL HERNIA
• Reduces upwards, then
laterally and backwards
• Controlled, after reduction, by
pressure over the internal
inguinal ring
• The defect is not palpable as it
is behind the fibers of the
external oblique muscle
• After reduction the bulge
reappears in the middle of the
inguinal region and then flows
medially before turning down to
the neck of the scrotum.
• Narrow opening of internal
ring:
• hernia does not reach its full
size until the patient has been
up for some time.
• tendency to strangulate
WHAT OTHER FEATURES COULD DIFFERENTIATE BETWEEN

19. LEFT INGUINAL HERNIA
WHAT IS THIS HERNIA?

20. STRANGULATED HERNIA
Patient presented with acute, painful, non-reducible inguinal hernia. It's worth
mentioning that in spite of rapid diagnosis and prompt surgical exploration,
gangrenous bowel was identified. This highlights the potential seriousness of
this condition
WHAT IS THIS HERNIA?

21. FEMORAL HERNIA
Femoral hernias occur just below the inguinal ligament, when
abdominal contents pass into the weak area at the posterior
wall of the femoral canal. They can be hard to distinguish from
the inguinal type (especially when ascending cephalad):
however, they generally appear more rounded, and, in contrast
to inguinal hernias, there is a strong female preponderance in
femoral hernias. The incidence of strangulation in femoral
hernias is high. Repair techniques are similar for femoral and
inguinal hernia.
WHAT IS THIS HERNIA?

22. UMBILICAL HERNIA
They involve protrusion of intraabdominal
contents through a weakness at the site of
passage of the umbilical cord through the
abdominal wall. These hernias often resolve
spontaneously. Umbilical hernias in adults
are largely acquired, and are more frequent
in obese or pregnant women. Abnormal
decussation of fibers at the linea alba may
contribute.
WHAT IS THIS HERNIA?

23. INCISIONAL HERNIA
An incisional hernia occurs when the defect is
the result of an incompletely healed surgical
wound. When these occur in median laparotomy
incisions in the linea alba, they are termed
ventral hernias. These can be the most
frustrating and difficult to treat, as the repair
utilizes already attenuated tissue.
WHAT IS THIS HERNIA?

24. EPIGASTRIC HERNIA
An epigastric hernia is a type of hernia which
may develop in the epigastrium. Epigastric
hernias are most common in infants but may
occur in humans of any age. They typically
result from a minor defect of the linea alba
between the rectus abdominis muscles. This
allows tissue from inside the abdomen to
herniate anteriorly. On infants, this may
manifest as an apparent 'bubble' under the
skin of the belly between the umbilicus and
xiphisternum.
WHAT IS THIS HERNIA?

25. LITTRE HERNIA
a hernia involving a Meckel's diverticulum.
WHAT IS THIS HERNIA?

26. SPORT HERNIA
It is a syndrome characterized by chronic groin pain in athletes
and a dilated superficial ring of the inguinal canal. Football and
ice hockey players are affected most frequently, and both
recreational and professional athletes may be affected. A hernia
cannot be found on physical examination or medical imaging,
and is not revealed during surgery. The term hernia thus is a
misnomer,[3] but has persisted, as surgical reconstructions
similar to those performed for inguinal hernias are often
effective for "sports hernias" as well.
WHAT IS THIS HERNIA?

27. PERINEAL HERNIA
a hernia involving the perineum (pelvic floor).
The hernia may contain fluid, fat, any part of the
intestine, the rectum, or the bladder. It is known
to occur in humans, dogs, and other mammals,
and often appears as a sudden swelling to one
side (sometimes both sides) of the anus.
WHAT IS THIS HERNIA?
WHAT IS THIS HERNIA?

28. LECTURE:
HERNIA
abnormal weakness or hole in an anatomical
structure which allows something inside to protrude
through.

29. Groin Hernias
 96% Inguinal – 9:1 M:F
 4% Femoral – 4:1 F:M
 Lifetime risk approximately 25% in
males and <5% in females
 700,000 repairs each year

30. Incidence
 Approximately 700,000 hernia repairs are
performed as an outpatient procedure each
year
 Approximately 75% of all hernias occur in
the inguinal region
 Approximately 50% of hernias are indirect
inguinal hernias
 A vast majority occur in males
 Hernias more commonly occur on the right
side

31. Abdominal Wall Layers
Skin
External oblique
Internal oblique
Transversus abdominus
Transversalis fascia (major strength layer)
Peritoneum

32. GROIN HERNIA
Anterior superior iliac spine
Pubic tubercle
Femoral
Inguinal

33. ABDOMINAL WALL HERNIAS
ABOVE THE GROIN
Linea alba
Linea semilunaris
Arcuate
line Spigelian hernia
Epigastric hernia
Umbilical hernia
Incisional hernia

34. A hernia consist of 3 parts:
 Sac; consist of a
diverticulum of
peritoneum.
 Contents; Omentum,
small or large intestine,
urinary bladder,
Omentum, ovaries
malignant nodules or
ascetic fluid.
 Coverings; derived from
the layers of abdominal
wall.
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35. Complications Of Hernias
 Irreducible the hernia contents cannot
be manipulated back into the abdominal
cavity
 Incarcerated the contents of the sac
are literally inpresiond in the sac of
Hernia
 Obstruction  the loop of the bowel
become non functioning with normal
blood supply
 Strangulated cut off the blood supply
to the content sac (tender)
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36. Types of Abdominal Hernia
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37. Aetiology
 Hernia occurs at sites of weakness in
the abdominal wall. (may be
congenital weakness)
 Occur at site of penetration of
structures through abdominal wall
(e.g. femoral canal)
 Occur through the layers of abdominal
wall which was weakened following a
surgical incision (incisional hernia)

38. Aetiology
 Presence of preformed sac
◦ Patent processus vaginalis; prime cause of indirect hernia
in infants and children
 Repeated elevations in intra-abdominal pressure
◦ COPD
◦ BPH
◦ Constipation / IO
◦ Strains
◦ Pregnancy
◦ Ascites
◦ Peritoneal Dialysis
◦ Ventriculo-peritoneal shunt

39. Aetiology - Continue
 ↑ intra-abdominal P
◦  Weak areas (Transversalis
fascia/Internal inguinal ring)  Direct
Hernia
 Weakening of the body muscles and
the tissue
◦ Lack of physical exercise, adipocity,
multiple pregnancies
◦ Abnormality of collagen

40. RISK
FACTORS
 Congenital
◦ Persistence of
processus
vaginalis testis
◦ Prematurity
◦ Low birth weight
◦ Prolonged
mechanical
ventilation in
neonates
 Acquired
◦ Occupation (heavy lifting)
◦ Ascites
◦ Pregnancy
◦ Smoking
◦ Weak abdominal muscles
◦ Underlying diseases
which cause abdominal
straining,eg constipation,
chronic cough, urinary
obstruction
◦ Surgical incision
◦ Damage to nerves
causes paralysis of
abdominal muscles

41. classification
Congenital /
acquired
Anatomical
site
Nature
HOW TO CLASSIFY?

42. CLASSIFICATION - ORIGIN
 Congenital
◦ Indirect inguinal
hernia
◦ Umbilical hernia
 Acquired
◦ Direct inguinal
hernia
◦ Femoral hernia
◦ Incisional hernia
◦ Paraumbilical hernia
◦ Epigastric hernia

43. CLASSIFICATION (Anatomical
sites)
 Inguinal ( Direct and Indirect)
 Femoral
 Umbilical (Exomphalos, Congenital
umbilical Hernia)
 Para-umbilical
 Epigastric
 Others (Obturator, Gluteal, Sciatic,
Lumbar)

44. CLASSIFICATIONS -
NATURE

45. CLASSIFICATIONS -
NATURE
 Reducible
◦ can be replaced completely into peritoneal cavity.
◦ Disappear on lying down
◦ painless
◦ Cough impulse
 Irreducible
◦ cannot be return to the abdomen
◦ no expansile cough impulse
◦ not painful
◦ due to adhesion between the sac and its contents or overcrowding within the
sac
 Strangulated
◦ blood supply to the organ is impaired causing gangrene
◦ sudden, severe pain and central abdominal colicky pain
◦ irreducible, no expansile cough impulse

46. INGUINAL
HERNIA
Protrusion of abdominal contents through the
inguinal region – Most Common in Hernia – mostly
indirect

47. ANATOMY OF INGUINAL
CANAL
 The inguinal canal is an
oblique passage in the lower
anterior abdominal wall,
directed downwards and
medially from internal to
external inguinal ring
 In male, transmits the
spermatic cord, ilioinguinal
nerve, and the genital branch
of genitofemoral nerve.
 In female, transmit the round
ligament of the uterus and
ilioinguinal nerve

48.  Internal/deep inguinal ring
◦ Oval opening in the fascia
transversalis
◦ 0.5 inc above the inguinal
ligament midway between ASIS
and symphysis pubis
◦ Related to it medially is inferior
epigastric vessels
 External/superficial inguinal
ring
◦ Triangular defect in the
aponeurosis of the external
oblique muscle
◦ Situated above and medial to
pubic tubercle

49. BOUNDARIES OF INGUINAL
CANAL
 Anteriorly- external
oblique aponeurosis (B)
 Posteriorly- fascia
transversalis (C)
 Superiorly- conjoined
muscles (fibres of
internal oblique and
transversalis fascia )
 Inferiorly- inguinal
ligament and lacunar
ligament

50. Q:if there is a canal, why
don’t hernias occur more
frequently?

51. The answers are:
 1.The canal is oblique
 2. The external oblique contraction forces the anterior
wall to approximate
 3.Contraction of the internal oblique and transverse
abdominal muscles causes the roof to descend.
 In other words ,hernias can only occur when the rises in
intra abdominal pressure exceeds the ability of these
mechanisms to maintain the position of abdominal
viscera.

52. Groin Hernia
Surgical Classification (Nyhus)
 I: Indirect hernia w/normal internal
ring
 2: Indirect hernia w/enlarged internal
ring
 3a: Direct inguinal hernia
 3b: Indirect hernia with weak floor
 3c: Femoral hernia
 4: All recurrent hernias

53. Inguinal Hernia
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54. INGUINAL HERNIA
 Can be divided into:
1. Direct
2. Indirect
3. Pantaloon
-include both direct and indirect components
-protrusions medial and lateral to inferior
epigastric vessels
-common in elderly men
-twice as common in males than in females

55. Indirect Inguinal Hernia
 Is a congenital lesion
 Occurs when bowel, omentum or
other abdominal organs protrudes
through the abdominal ring within a
patent processus vaginalis
 If the processus vaginalis does not
remain patent an indirect hernia
cannot develop
 Most common type of hernia

56. Indirect Hernia Route
Note:
The hernia sac
passes outside
the boundaries of
Hesselbach's
triangle and
follows the
course of the
spermatic cord.

57. INGUINAL TRIANGLE /
HASSELBACH TRIANGLE
The inguinal triangle contains a depression
referred to as the medial inguinal fossa,
through which direct inguinal hernias
protrude through the abdominal wall.
It is defined by the following structures:
* Rectus abdominis muscle (medially)
* Inferior epigastric vessels (superior and
laterally).
* Inguinal ligament, sometimes referred to
as Poupart's ligament (inferiorly)
This can be remembered by the mnemonic
RIP (as direct inguinal hernias rip directly
through the abdominal wall).

58. Indirect Inguinal Hernia Track
 Lateral to inferior
epigastric vessels
 Through deep inguinal
ring and canal
 Through external inguinal
ring
◦ Often into scrotum
 Hernial sac formed by
processus vaginalis
 Hernia is w/in the
coverings of the
spermatic cord
http://www.aafp.org/afp/990101ap/143.html

59. Indirect Inguinal Hernia
 Epidemiology
◦ Most common groin hernias in men and women
◦ 20x more common in males
◦ Most are congenital due to defective obliteration of the processus
vaginalis and lack of closure of internal inguinal ring
 Sx
◦ Bulge medial to pubic tubercle and into the scrotum
◦ Heaviness or dull discomfort more pronounced with lifting or
straining
◦ Pain with straining or standing
◦ Severe pain and/or peritoneal signs with strangulation, fevers,
N/V
 PE
◦ Reducible versus non-reducible
◦ Can be mildly tender to exquisitely tender (strangulated)

60. Direct Inguinal Hernia
 Proceeds directly through the posterior
inguinal wall
 Direct hernias protrude medial to the
inferior epigastric vessels and are not
associated with the processus vaginalis
 They are generally believed to be
acquired lesions
 Usually occur in older males as a result
of pressure and tension on the muscles
and fascia

61. Direct Hernia Route
Note:
The hernia sac
passes directly
through
Hesselbach's
triangle and may
disrupt the floor
of the inguinal
canal.

62. Hernia Track
 Bulges through Hesselbach’s Triangle
in hernial sac formed by transversalis
fascia
 Traverses the medial portion of the
inguinal canal
 Emerges around conjoint tendon to
reach the superficial inguinal ring
 Gains an outer covering of external
spermatic fascia
http://www.hernia.net.au/hernia_inguinal.html

63. Direct Inguinal Hernia
 Common in older males, rare in women
 Occur as a result of weakness in the floor of the abdominal wall
medial to the inferior epigastric arteries
◦ Inborn Defect
◦ Smoking
◦ Chronic steroid use
◦ Collagen disorders
◦ Some studies have shown a correlation with heavy lifting
 Sx
◦ Similar to Indirect hernias without extension of the hernia into the scrotum
 PE
◦ Symptoms similar to indirect inguinal hernias
◦ Often more easily reducible than indirect hernias

64. Origin Pass through deep
inguinal ring, lateral to
inferior epigastric vessels
Pass through posterior
wall of inguinal canal,
medial to inferior
epigastric vessels
Location More common on the
right side
Usually bilateral
Age group More common in children
and young adult
Common in old man with
weak abdominal muscle
Congenital/
acquired
May be congenital
[processus vaginalis]
Always acquired
Extends to
scrotum /
labium
majus
Often Rarely
Strangulate Commonly (narrow neck
of the hernia, confined by
the border of internal ring)
Rarely
INDIRECT DIRECT

65. INDIRECT DIRECT
Reducibility Reduce upwards, then
laterally and backwards
Reduces upwards and
straight backwards
How the
bulge
reappears
after
reduction
Reappears in the middle
of inguinal region and
then flows medially
before turning down to
the neck of scrotum
The bulge reappears
exactly where it was
before
Controlled by
pressure
over internal
inguinal ring
Yes No
Palpable
defect
Defect not palpable as it
is behind fibers of
external oblique muscle
Defect maybe felt in
abdominal wall above
pubic tubercle
Recurrence Uncommon Common

66. Differences
pathway of protrusion coming down the
inguinal canal, may
enter the scrotum
pass through
Hesselbach’s
triangle, rarely enter
the scrotum
contours of sac elliptic, pear-shaped semispheric, wide
base
compress the internal
ring after reduced
controlled not controlled
Relationship of sac
neck with inferior
epigastric artery
Sac neck is lateral
to it
Sac neck is medial
to it
Incarcerated
incidence
high low

67. History,symptoms…
 Any age, but peak in few months of life,late
teens,early 20ties,between40-60yrs old
 Occupation : heavy lifting
 Local symptoms: discomfort,pain,dragging,
aching sensation in groin
 chronic constipation,straining(Intra-abdominal
malignancy eg.carcinoma of left colon)
 Persistent coughing (chronic bronchitis)
 Difficulty in micturition

68. Diagnosis
 Physical exam
◦ The patient should be standing and facing the
examiner
◦ Visual inspection may reveal a loss of symmetry
in the inguinal area or bulge
◦ Having the patient perform valsalva’s maneuver
or cough may accentuate the bulge
◦ A fingertip is then placed in the inguinal canal;
Valsalva maneuver is repeated
◦ Differentiation between indirect and direct
hernias at the time of examination is not
essential

69. PHYSICAL EXAMINATION
 Ask the patient to stand up.
 Look at the lump from in front.
 Inspection
 See the exact site and shape of
the lump
◦ Inguinal hernia- appear above &
medial to pubic tubercle and bulges
above the groin crease
◦ Reveal whether the lump extends
down into the scrotum
◦ Femoral hernia-bulge behind the skin
crease of the groin
 Feel from the front
◦ examine the scrotum and its contents
◦ if you cannot feel the upper edge of
the lump, it is likely to be hernia

70.  Feel from the side.
◦ Stand on the side of patient,
same side of hernia. Place one
hand in the patient’s back to
support him & your examining
hand on the lump parallel to the
inguinal ligament
◦ Position, temperature,
tenderness, shape, size,
surface, composition
 Expansile cough impulse.
◦ Compress the lump firmly with
your fingers, ask the pt to turn
his head towards the opposite
side, and then to cough
◦ If the swelling expands with
coughing, it has an expansile
cough impulse

71. Ask the pt to put his hands on
the lump and lifts it upwards and
backwards
- Direct (2)- Reduces upwards
and straight backwards
◦ Indirect (1)- Reduce upwards,
then laterally and backwards
The way the bulge appears after
reduction will also help to confirm
the site of origin
◦ Direct (2)- The bulge reappears
exactly where it was before
◦ Indirect (1)-Reappears in the
middle of inguinal region and
then flows medially before
turning down to the neck of
scrotum
Is the swelling reducible?

72.  Can the hernia be
controlled by pressure?
◦ Press your finger over the
internal inguinal ring
(Midpoint of inguinal
ligament- between pubic
tubercle and anterior
superior iliac spine)
and ask the patient to cough
◦ Bulge present (cannot be
controlled) – direct
inguinal hernia
◦ Bulge not present( can be
controlled) – indirect
inguinal hernia

73. end
 Percuss and auscultate the lump
◦ -If there is gut in the sac it may be resonant
◦ and there may be audible bowel sounds
 Examine the other side of the inguinal
region
 Examine the abdomen
◦ Look for anything that may increase the intra-
abdominal pressure, eg. Large bladder,
enlarged prostate, ascites
 General examination

74. Diagnosis
 The patient usually presents (for groin
hernia) with the complaint of a bulge in the
inguinal region
 They may describe minor pain or vague
discomfort associated with the bulge
 Extreme pain usually represents
incarceration with intestinal vascular
compromise
 Paresthesias may be present if inguinal
nerves are compressed

75. Inguinal Hernia Treatment
 Medical Management
◦ Watchful Waiting Trial with 720 men >18 y/o and
asymp/minimal sx; easily reducible
 Open tension free repair versus Waitful Watching
 23% and 31% of WW group had surgery at 2 and 4 years
◦ Truss use is not supported in the literature
 Incarceration/Strangulation
◦ Only true indications for repair
◦ Emergent reduction
◦ Bowel can be saved in most patients if operation
occurs within four to six hours

76. Tx Cont’d
 Operative Repair
◦ Only definitive repair
◦ Recurrence in .5 to 15% depending on type of repair
◦ Open Repair versus Laparoscopic repair
 Lap with less post op pain and faster return to work
 Increase risk of complications with longer surgery, higher risk of
nerve, vascular, bowel, and bladder injury
◦ Mesh versus suture repair
 Mesh repair creates less tension but very few studies to compare
the techniques
 One meta-analysis of 26000 hernia repairs found mesh repairs
with a lower reoperation rate
◦ Complications include recurrence, infection, seromas, pain
and neuralgia

77. SURGICAL MANAGEMENT
 Herniotomy (infants)
◦ patent processus vaginalis is ligated & the
hernial sac excised at the age of ≈1 yr
 Hernioplasty
◦ excision of the sac & repair of the
weakened inguinal canal, commonly
performed either by:
 Shouldice repair
 Lichtenstein repair

78.  Truss
◦ used to control certain
types of hernia when
surgery is either
inappropriate/
unacceptable to patient
◦ Pressure truss-hernia
is easily reducible &
can be kept reduced &
free of symptoms
◦ ‘Bag truss’ – support
the very large hernia
which cannot be
reduced

79. Specific Surgical
Procedures
 Lichenstein (Tension Free)
Repair
 McVay (Cooper’s
Ligament) Repair
 Shouldice (Canadian)
Repair
 Laproscopic Hernia Repair
 Bassini Repair

80. Bassini Repair
◦ Is frequently used for indirect inguinal
hernias and small direct hernias
◦ The conjoined tendon of the transversus
abdominis and the internal oblique
muscles is sutured to the inguinal
ligament

81. Bassini Repair

82. McVay Repair
 AKA: Cooper’s ligament Repair
◦ Is for the repair of large inguinal hernias,
direct inguinal hernias, recurrent hernias
and femoral hernias
◦ The conjoined tendon is sutured to
Cooper’s ligament from the pubic cubicle
laterally

83. McVay Repair
Note:
This repair reconstructs the inguinal canal without using a mesh
prosthesis.

84. Shouldice Repair
AKA: Canadian Repair
◦ A primary repair of the hernia defect with 4 overlapping layers of tissue.
◦ Two continuous back-and-forth sutures of permanent suture material are employed. The closure can be
under tension, leading to swelling and patient discomfort.

85. Shouldice Repair

86. Lichtenstein Repair
AKA: Tension-Free Repair
One of the most commonly performed procedures
A mesh patch is sutured over the defect with a slit to allow passage
of the spermatic cord

87. Lichtenstein Repair
Note:
Open mesh repair. Mesh is used to reconstruct the inguinal canal. Minimal tension is used to bring tissue together.

88. Laparoscopic Hernia Repair
◦ Early attempts resulted in exceptionally
high reoccurrence rates
◦ Current techniques include
 Transabdominal preperitoneal repair (TAPP)
 Totally extraperitoneal approach (TEPA)

90. Laparoscopic Mesh Repair
Note:
Viewed from inside the
pelvis toward the direct
and indirect sites. A
broad portion of mesh
is stapled to span both
hernia defects. Staples
are not used in
proximity to
neurovascular
structures.

91. Hernia Complications
 Incarceration
 14 to 31% of inguinal hernias, usually in infants < 1y/o
 Swelling due to decreased venous and arterial flow
 Outright pain, irritability and crying in children
 Bowel obstruction (N/V/colicky abdominal pain/distention)
 Tender, edematous, erythematous
 Strangulation
 Severe pain secondary to bowel ischemia
 Bowel obstruction
 Swelling, erythema, tenderness, peritoneal signs, fever, N/V
 Study of 439 patients showed probability of strangulation
was 2.8% at three months, 4.5% at two years for groin
hernias

92. Femoral
Hernia
www.icareunit.com

93. Left Femoral Hernia
www.icareunit.com

94. Femoral hernia
 Protrusion of extraperitoneal fat,peritoneal sac and
abdominal contents through femoral canal
 Femoral hernias often appear within the femoral
triangle, INFEROLATERAL to the pubic tubercle
 Anatomically ,Femoral triangle is bounded by :
◦ Inguinal ligament superiorly and anteriorly
◦ Adductor longus medially
◦ Femoral vein laterally
◦ Pubic ramus and pectineus muscle posteriorly

95. Femoral Hernia
 40% present with emergencies
(incarceration/strangulation)
 Most commonly in females, especially older
women
◦ Less bulky musculature
◦ Weakness of pelvic floor muscles 2/2 childbirth
◦ Pelvic floor muscle atrophy 2/2 age
◦ Prior inguinal hernia repair is a RF
http://herniaplasty.med.nyu.edu/strangulatedhernia.html

96. FEMORAL SHEATH
 Is a downward protrusion into the thigh of the
fascial envelope lining the abdominal walls
 Continuous above with the fascia transversalis
 Surrounds femoral vessels and lymphatics for
1 inch below the inguinal ligament
 Divided into 3 compartments:
-lateral: femoral artery
-intermediate: femoral vein
-medial: lymph vessels

97. ANATOMY OF FEMORAL
CANAL
 Medial compartment of femoral sheath
 Upper opening known as femoral ring
 Femoral septum closes the opening
 Contents: fatty connective tissue, lymph
vessels, 1 deep inguinal lymph node

98. Hernia Track
 Hernia protrudes through medial aspect of
femoral canal/sheath
 Below the inguinal ligament medial to the
femoral vein
 Below and lateral to the pubic tubercle
through the femoral ring
 Becomes more pronounced when it passes
through the saphenous opening
http://www.aafp.org/afp/990101ap/143.html

99. FEMORAL HERNIA
 Protrusion of the extraperitoneal fat, a
peritoneal sac and sometimes abdominal
contents through the femoral canal
 More common in females due to wider female
pelvis (but note that inguinal hernias are
commoner than femoral in females)
 Never due to congenital sac, usu acquired
 Usu. In middle-aged and elderly
 Neck is narrow and therefore usually
irreducible and prone to strangulation

100. FEMORAL HERNIA
 Presents as a globular swelling below
and lateral to the pubic tubercle
 Swelling is seen directly behind the
skin crease of the groin
 As the hernia enlarges, it passes
through the saphenous opening in the
deep fascia and then turns upwards
so that it may project above the
inguinal ligament

101. History
 Age : not common until the age of 50
 Sex: more common in women (because of their
wider female pelvis)than in men (but never forget
that even in women, the commonest hernia in
groin is still inguinal hernia)
 Symptoms:
 Local: lump in the groin ,pain,discomfort
 General : if it cause intestinal obstruction; abdominal.colic
,distension, vomiting,constipation
 Femoral hernia is able to strangle a part of
bowel,without occluding lumen and cause
obstruction (Richter’s hernia)

102. Examination:
 Examination includes description of
 1.Position:(A femoral hernia appear at
INFEROLATERAL to the pubic tubercle, whereas
inguinal hernias appear SUPEROMEDIAL to the pubic
tubercle.)
 2.size, shape,
 3.Skin colour
 4.tempreture
 5.Tender/Non-tender
 6.Composition, consistency
 7.Cough Impulse
 8. Reducibility

103. Normally the bulge appears to be directly behind the skin crease
of the groin

104. PATHOLOGY OF FEMORAL HERNIA
Pathology- If the femoral
hernia becomes large,
it tends to be deflected
upwards and may
seem to arise above
the inguinal ligament

105. Femoral hernia
Female: male = 2:1
Bulges behind the skin
crease of the groin
Many do not have
expansile cough impulse
Not reduce easily
Inguinal hernia
Bulges above groin crease
Expansile cough impulse
Can be reduced

108. MANAGEMENT
Repaired by excision of the sac
closure of the femoral canal

109. Treatment
 All femoral hernias should undergo
operation, because of it’s constant risk
of strangulation and be repaired by
excision of the sac and closure of
femoral canal

110. Umbilical Hernia
 Congenital
◦ Opening in linea alba when umbilical scar fails to heal at
birth
◦ More common in AA children
◦ Most close in first 12-18 months of life
◦ Repair rarely recommended prior to 3 y/o
 Acquired
◦ 3:1 F:M – Men more likely have incarceration
◦ Associated with increased
◦ intra-abdominal pressure
 Obesity
 Ascites
 Abdominal distention
 Pregnancy
http://medicine.ucsd.edu/clinicalimg/abdomen-incarcerated-umbo.html

111. Umbilical
hernia
congenital acquired paraumbilical

112. CONGENITAL UMBILICAL
HERNIAE
 Appear at the site where the umbilical
vessels enter the abdomen during
fetal life

113. Umbilical hernia
 Exomphalos (rare)
 failure of midgut to return to
abdominal cavity in early fetal
life.
 Bowel contained in sac, if
rupture can cause fatal
peritonitis.
Normal umbilicus

114. Incisional Hernia
 Sx
◦ Bulge of abdominal wall deep to skin scar
◦ Cosmetic concern versus discomfort
◦ Worsened with coughing or straining
◦ Incarceration
 <1cm, >7-8 cm unlikely to incarcerate
 Tx
◦ Most should be repaired (unlike groin hernias)
◦ Suture versus mesh repair
 Suture repair in one European study showed 60%
recurrence with mesh recurrence at 30%

115. Congenital umbilical hernia
 Failure of complete closure
of the umbilical cicatrix.
 Umbilicus everted.
Acquired umbilical
hernia
• Raised intra-abdominal
pressure (pregnancy,
ascites, fibroids)
• Umbilicus everted.

116. Paraumbilical hernia
 Adult (acquired)
 Just above or below
umbilicus
 Often in obese, multiparous,
middle-aged woman.
 Hernia protrude through
defect beside umbilicus,
turning it into crescent-
shaped slit.
 Neck narrow.

117. Congenital umbilical hernia
 Usually hemispherical
 Soft, compressible, easy to
reduce
 Common in black children
 Management:
◦ surgical repair should not be carried
out unless the hernia persists after
the child is 2 years old
◦ strapping the hernia/ providing a
truss to allay parental anxiety

118. ACQUIRED UMBILICAL HERNIAE
 Hernia through umbilical
scar, so it is a true umbilical
hernia and has the umbilical
skin tethered to it
 History
◦ Finding the cause of the
raised abdominal
pressure eg. Pregnancy,
ascites, ovarian cysts,
fibroids, and bowel
distension

119. Incisional Hernia
Definition: An incisional hernia occurs when the area of weakness is
the result of an incompletely healed surgical wound. These can be
among 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 sternum breastbone straight down to the pubis, and are
more complex in these regions. Hernias in this area have a high rate
of recurrence.
Causes:
 Any reasons leading to an icrease in intraabdominal pressure
postoperatively such as: chronic cough, vomitting, infection,
malnutrition diabetes, steroid treatment or a tension closure done
during the previous operation.
Clinical Features:
 Swelling at the incisional site +/- pain.

120. Incisional Hernia
 Due to failure of fascial tissues to heal
and close
 Promoted by inhibition of wound
healing
 10-15% of abdominal incisions
 Highest incidence with midline
incisions
◦ Incisional hernia more likely with vertical

121. Incisional hernia
 Hernia protrudes through
an acquired scar in the
abdominal wall.
 Neck wide.
 Aetiology: poor suture,
poor material, coughing,
infection, haematoma, n.
damageparalysis of
abdominal m.

122. B. Paraumbilical Hernia:
Affects adults.
The defect is either supra or
infraumbilical through the linea alba.
The female to male ratio is 20:1.
May contain omentum, small
intestine or transverse colon.
Etiology:
1.Obesity.
2.Flabbiness of the abdominal
muscles.
3.Multiparity.
Clinical Features:
Clolicky pain and/or irreducibilty due
to omental adhesions.

123. Epigastric Hernia
 Due to a defectin the linea alba between the
xiphoid process and the umbilicus
 Starts as a protrusion of the extraperitoneal fat
at the site where a small vessel pierces the lina
alba and as it enlarges it drags a pouch of
peritoneum after it.
Clinical Features:
 Swelling +/- pain similar to a peptic ulcer pain.

124. Epigastric hernia
 Protrusion of
extraperitoneal fat,
sometimes small
peritoneal sac between
defect in the linea alba
some where between
xiphisternum and
umbilicus.
 Firm.
 Irreducible.

125. Ventral hernia
 A large hernial sac
containing abd. visceral
bulges forward between
elongated gap of two
rectus abdominis muscle.
 In elderly, pregnancy,
repeated midline abd.
operation.
 Majority cases – no Rx

126. Diaphragmatic hernia
1. Congenital diaphragmatic hernia
Hernia protrudes through:
 Foramen of Mogagni
 Foramen of Bochdalek
 Deficiency in the whole central tendon
 A congenital large hiatal hernia
2. Traumatic diaphragmatic hernia
• Aetiology: crush injury, penetrating injury.
• Left more often affected than right.
• Herniation of stomach and spleen into thoracic cavity.

127. 3. Acquired hiatal hernia
Sliding (90%)
 Stomach slides through
hiatus.
 Anterior is covered with
peritoneal sac; posterior is
extraperitoneal.
 Space occupying.
 Disturbances of cardio-
oesophageal sphincter.

128. Rolling/ Para-oesophageal
(10%)
 Stomach rolls up anteriorly,
producing partial volvulus.
 No disturbances of the cardio-
oesophageal mechanism.

129. Unusual hernias

130. Spigelian Hernias
 Lateral ventral hernia
◦ Junction of vertical semilunar line and horizontal semicircular line
(arcuate line)
 90% located 0 - 6 cm above anterior superior iliac spine
◦ Sharp pain, swelling, easily reducible
◦ 20% present with incarceration
◦ median age = 50 years
◦ more common in males and on (R)
◦ Rare
 PE
◦ Difficult to diagnose
◦ Below EAO
◦ U/S or CT can aid in diagnosis
http://herniaplasty.med.nyu.edu/spigelianhernia.html

131. Richter’s
 Hernia where only a portion of the
bowel wall circumference incarcerates
or strangulates

132. Littre’s
 Any groin hernia that involves a
Meckel’s Diverticulum
 Usually incarcerated or strangulated

133. Armand’s
 Any hernia that contains the appendix
 Can cause symptoms of Appendicitis

134. Pantaloon Hernia
 Simultaneous Direct and Indirect
Inguinal Hernias
 Two bulges straddle the inferior
epigastric vessels

135. Treatment
Most abdominal hernias can be surgically
repaired.
Uncomplicated hernias are principally repaired by
herniorrhaphy.
a Herniorrhaphy (Hernioplasty) is a surgical
procedure for correcting hernia, which can be
devided into four techniques:
Groups 1 and 2: open "tension" repair:
 in which the edges of the defect are sewn back
together without any reinforcement or prosthesis.
In the Bassini technique, the conjoint tendon
(formed by the distal ends of the transversus
abdominis muscle and the internal oblique
muscle) is approximated to the inguinal canal and
closed. [4]
 Although tension repairs are no longer the
standard of care due to the high rate of
recurrence of the hernia, long recovery period,
and post-operative pain, a few tension repairs are
still in use today.

136. Treatment (cont..)
Group 3: open "tension-free" repair:
 Almost all repairs done today are open
"tension-free" repairs that involve the
placement of a synthetic mesh to strengthen
the inguinal region.
 This operation is called a 'hernioplasty'. The
meshes used are typically made from
polypropylene or polyester. The operation is
typically performed under local anesthesia, and
patients go home within a few hours of surgery,
often requiring no medication beyond aspirin or
acetaminophen.
 Recurrence rates are very low - one percent or
less, compared with over 10% for a tension
repair

137. Treatment (cont..)
Group 4: laparoscopic
repair
 "Lap" repairs are also tension-free, although
the mesh is placed within the preperitoneal
space behind the defect as opposed to in or
over it.
 It is further sub-devided into:
T.A.P.P repair (transabdominal
preperitoneal)
T.E.P repair (totally extraperitoneal)
 It has no proven superiority to the open
method other than a faster recovery time
and a slightly lower post-operative pain
score.
 laparoscopic surgery, though, requires
general anesthesia, more expensive and
consumes more O.R. time than open repair
and carries a higher risk of complications,
and has equivalent or higher rates of
recurrence compared to the open tension-

138. Take Home Points
 Hernias can involve the small bowel, appendix, a
Meckel’s diverticulum, ureter
 Incarceration with frank pain or strangulation are
operative emergencies and bowel can be saved if done
within 4-6 hours
 An attempt at reduction should be made with a hernia,
but operative reduction is the only definitive treatment
 Femoral hernias have a high rate of incarceration and
should be repaired, but other inguinal hernias may be
watched if asymptomatic
 With abdominal incisions, try not to put excessive
tension or damage the suture in any way as it can
promote incisional hernias