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1. ABDOMINAL HERNIA
Professor Maitham AL-khateeb
Consultant surgeon
2018

2. contents
Definition
Anatomical causes
Etiological causes of abdominal hernia
Types of hernia by complexity
Clinical history and diagnosis
Examination of abdominal hernia
Investigations
Operative Approaches to abdominal hernia
Mesh in hernia repair
Types of abdominal hernia
-Divarication hernia
-Inguinal hernia
-Femoral hernia
-Epigastric hernia
-Umbilical hernia & paraumbilical hernia
-Incisional hernia
-Spigelian hernia
-Rare hernia

3. Definition:
A hernia is the bulging of part of the contents of the abdominal
cavity through a weakness in the abdominal wall.
Or
A protrusion of a viscus or part of a viscus through a defect in the
abdominal wall musculature or a weak natural pathway in the
abdominal wall.

4. Anatomical causes of abdominal wall Herniation
Inspite of the complex design of the
abdominal wall, the only natural
weaknesses caused by
inadequate muscular strength are
the lumbar triangles and the
posterior wall of the inguinal
canal

5. Many structures pass into and out of the abdominal cavity creating weakness which
can lead to hernia
Most common example is the inguinal canal in the male along which the testis
descends from abdomen to scrotum at the time of birth. The testicular artery, vein
and vas deference pass though this canal (the round ligament in the female).
80 per cent of all hernia repairs are for inguinal hernia
Other examples are: oesophagus ( hiatus hernia ), femoral vessels ( femoral hernia ),
(
obturator nerve ( obturator hernia ), sciatic nerve ( sciatic hernia

11. Causes of hernia
- Basic design weakness
- Weakness due to structures entering and leaving the abdomen
- Developmental failures
- Genetic weakness of collagen
- Sharp and blunt trauma
- Weakness due to ageing and pregnancy
- Primary neurological and muscle diseases
- ? Excessive intra-abdominal pressure
Failure of normal development; may lead to weakness of the abdominal wall. Examples are diaphragmatic,
umbilical and epigastric hernias. Muscles which should unite during development fail to form strong
unions with hernia development at birth or in later life.
Herniation at the umbilicus has both components, i.e. weakness due to structures passing through the
abdominal wall in fetal life and developmental failure of closure.
Weakness of abdominal muscles may be the result of sharp trauma. Most commonly, this results from
abdominal surgery but also occurs after stabbing. A surgical scar, even with perfect Wound healing, has
(only 70 per cent) of the initial muscle strength. This loss of strength can result in herniation in at least 10
per cent of surgical incisions. Smaller laparoscopic port-site incisions have a hernia rate of 1 per cent
Hernia development is more common in pregnancy due to hormonally induced laxity of pelvic ligaments and
raised intra abdominal pressure.
It is also more common in elderly people due to degenerative weakness of muscles and fibrous tissue.
It is also more common in smokers.

12. Common principles in abdominal hernia:
An abdominal wall hernia has two essential components: a defect in the wall and content,
that is tissue which has been forced outwards through the defect.
The weakness may be entirely in muscle, such as an incisional hernia It may also be In
fascia, like an epigastric hernia through the linea alba, or the defect may have a bony
component, such as a femoral hernia.
The defect varies in size and may be very small or indeed very large.
The content of the hernia may be tissue from the extraperitoneal space alone, such as fat
within an epigastric hernia or a part of urinary bladder wall as in a direct inguinal
hernia. However, if such a hernia enlarges then peritoneum may also be pulled into
the hernia secondarily along with intraperitoneal structures such as bowel or omentum;
a good example is a ‘sliding type’ of inguinal hernia
More commonly, when peritoneum is lying immediately deep to the abdominal wall
weakness, pressure forces the peritoneum through the defect and into the
subcutaneous tissues. This ‘sac’ of peritoneum allows bowel and omentum to pass
through the defect easily .

13. Types of hernia by complexity:
- Occult – not detectable clinically; may cause severe pain
- Reducible – a swelling which appears and disappears
- Irreducible – a swelling which cannot be replaced into the abdomen, high risk of complications
- Strangulated – painful swelling with vascular compromise, requires urgent surgery
- Infarcted – when contents of the hernia have become gangrenous, high mortality
- Obstructed- irreducible hernia with intestinal obstruction
- Incarcerated- irreducible non obstructed may complicate
In most hernia cases, the intraperitoneal organs can move freely in and out of the hernia, a
‘reducible’ hernia, but if adhesions form or the defect is small, bowel can become trapped
and unable to return to the main peritoneal cavity, an ‘irreducible’ hernia, with high risk of
further complications.
The narrowest part of the sac,( is at the abdominal wall defect ), is called the ‘neck of the sac’
When tissue is trapped inside a hernia it is in a confined Space The narrow neck acts as a
(constriction ring) impeding venous return and increasing pressure within the hernia the
resulting tension leads to pain and tenderness. If the hernia contains bowel then it may
become ‘obstructed’, partially or totally.
If the pressure rises sufficiently, arterial blood will not be able to enter the hernia and the
contents become ischaemic and may infarct. The hernia is then said to have ‘strangulated’.
The risk of strangulation is highest in hernias which have a small neck of rigid tissue leading first
to irreducibility and then to strangulation.

14. The term ‘incarcerated’ hernia is not a clearly defined nomenclature and used to
imply a hernia which is irreducible and developing towards strangulation .
In Richter’s hernia only part of the bowel wall circumference will enter the hernia
Bowel obstruction may not be present but the bowel wall may still become necrotic
and perforate with life-threatening consequences. Femoral hernia may Present in
this way often with diagnostic delay and high risk to the patient .

15. An interstitial hernia: occurs when the hernia extends or passes between the
layers of the abdominal wall muscles and not directly through them. This
is typical of a Spigelian hernia

16. An internal hernia: is a term used when adhesions form within the peritoneal
cavity leading to abnormal pockets into which bowel can enter and
become trapped another example is the passage of a loop of small bowel
through the foramen of winslow or the mesentery of large or small
bowel leading to mechanical intestinal obstruction . As there is no defect
within the abdominal wall muscles the name of hernia may be cofusing

17. Clinical history and diagnosis in hernia cases :
Patients are usually aware of a lump on the abdominal wall under the skin,
therefore Self-diagnosis is common

18. The hernia is usually painless but patients may complain of an aching pain or
heavy feeling
Sharp, intermittent pain suggest pinching of tissue
Severe pain should alert the surgeon to a high risk of strangulation
The surgeon should determine whether the hernia reduces spontaneously or
needs to be helped ,and the patient should be asked about symptoms
which might suggest bowel obstruction (pain, vomiting ,distention ,and
constipation)
It is important to know if this is a primary hernia or whether it is a recurrence
after previous surgery. Recurrent hernia is more difficult to treat and may
require a different surgical approach.

19. Checks
- Reducibility
- Cough impulse
- Tenderness
- Overlying skin colour changes
- Multiple defect and or
/contralateral side
- Signs of previous repair (surgery)
- Scrotal content for groin hernia
- Associated pathology

20. Examination for hernia
The patient should be examined lying down flat initially and then standing
as this will usually increases the hernia size and becomes more obvious.
In some cases no hernia will be apparent with the patient lying flat. The
patient is asked to cough, when an occult hernia may appear, this test is
called visible cough impulse . Gentle pressure is applied to the lump and
the patient is asked to cough again In most cases a cough impulse is felt
palpable cough impulse , In cases where the neck is tight and the hernia
is irreducible there may be no cough impulse, This can lead to failure of
diagnosis and this is typical of femoral hernia where lack of an impulse
leads the clinician to misdiagnose the case as a lymph node.
In contrast cough impulse can also occur in a saphena varix which may be
referred to a surgeon as a suspected Inguinal hernia.
The overlying skin is usually of normal colour. If bruising is present this may
suggest venous engorgement of the content and If any sign of
inflammation is found over the swelling the case should be treated as an
emergency( strangulation )

21. Examination
- A swelling with a cough impulse is not necessarily a hernia
- A swelling with no cough impulse may still be a hernia
If the patient, on lying down flat, the hernia does not reduce spontaneously, the
surgeon should ask the patient to attempt self reduction of the hernia as he may
be well practised in this task while the surgeon might cause unnecessary
discomfort. If neither the patient nor surgeon can reduce the hernia then
treatment should be more urgent (incarcerated hernia)
Investigations
- Plain x-ray – of little value
- Ultrasound scan – low cost, operator dependent
- CT scan- in complex incisional hernia
- MRI scan – good in sportsman’s groin with pain
- Contrast radiology – in absence of CT scan
- Laparoscopy

22. • Plain x-ray: of the abdomen is of little value, although useful in hiatus hernia and other
diaphragmatic Hernia which may be seen on chest x-ray .
• Ultrasound scan : may be helpful in cases of irreducible hernia, where the differential
diagnosis includes a mass or fluid collection, or when the nature of the hernia content is in
doubt.
• Computed tomography scanning: is helpful in complex incisional hernia, determining the
number and size of muscle defects, identifying the content, giving some indications of the
presence of adhesions and excluding other intra-abdominal pathology such as ascites, occult
malignancy, portal hypertension, etc.
• Contrast barium radiology: is occasionally useful in the absence of CT scan.
• Magnetic resonance imaging (MRI): can help in the diagnosis of sportsman’s groin where
pain is the Presenting feature and the surgeon needs to distinguish an occult hernia from an
orthopaedic injury.
• Laparoscopy: it self may be used. In incisional hernia, initial laparoscopy may determine
that a laparoscopic approach is feasible or not depending on the extent of adhesions.

23. Management principles:
_ Not all hernias require surgical repair
_ Small hernias can be more dangerous than large hernias
_ Pain, tenderness and skin colour changes means high risk of strangulation and
should be repaired urgently
_ Femoral hernia should always be repaired
A small Asymptomatic abdominal wall hernia does not necessarily require repair.
A patient may request surgery for relief of symptoms of discomfort, cosmetic
reasons and complications or to establish the diagnosis when in doubt
The surgeon should( recommend repair ) when complications are likely , the most
worrying being strangulation with bowel obstruction and bowel infarction.
All cases of femoral hernia, with high risk of strangulation, should be repaired
surgically.
case of irreducible hernia, especially where there is pain and tenderness ,should be
offered repair unless coexisting medical factors place the patient at very high risk
from surgery or anaesthesia.

24. Increasing difficulty in reduction and increasing size are indications for surgery
Any patient who presents with acute pain in a hernia, particularly if it is irreducible,
should be offered surgery as soon as possible.
Often, in a patient with an irreducible hernia, after admission to hospital and adequate
analgesia, the hernia will reduce due to muscle relaxation ( reduction trial ),
The likelihood of similar episodes is very high and surgery should be recommended at this
admission or soon after (next operative list ).
Operative approaches to hernia:
All surgical repairs follow the same basic principles
1- reduction of the hernia content into the abdominal cavity with removal of any non-
viable tissue and bowel repair if necessary
2- excision and closure of a peritoneal sac if present or replacing it deep to the muscles
3- reapproximation of the walls of the neck of the hernia if possible
4- permanent reinforcement of the abdominal wall defect with sutures or mesh

25. • Reduction of hernia content is essential for a successful repair.
• Excision and closure of the peritoneal sac is ideal but not essential.
• Closure of the abdominal wall defect is ideal but may not be possible
when the defect is large or when tissues are rigid.
• Surgeons have realised that simple closure of a hernia defect by
sutures alone leads to a high recurrence rate.
• Additional reinforcement of the defect with a non-absorbable mesh is
now widely practised in most hernia repairs and evidence has shown
that recurrence rates have improved .
• A recent large-scale study reported that mesh repair delays but does
not prevent recurrence.
• With Improved surgical techniques and new meshes it is hoped that
recurrence after surgery will fall further

26. Mesh in hernia repair
The term ‘mesh’ refers to prosthetic material, either a net or a flat sheet which is used to
strengthen a hernia repair.
Mesh can be used :
• to bridge a defect: the mesh is simply fixed over the defect as a tension-free patch
• to plug a defect: a plug of mesh is pushed into the defect
A well-placed mesh should have good overlap around all margins of the defect, at least 2 cm but
up to 5 cm if possible( on lay).
Suturing a mesh edge-to-edge into the defect with no overlap, is not recommended
Mesh plug operations : are fast, but plugs can form a dense ‘meshoma’ of plug and collagen.
Other complications include : - migration,
- erosion into adjacent organs,
- fistula formation
- Chronic pain

27. Mesh types:
1-Synthetic mesh:
The majority of meshes used today
are synthetic polymers of:
• Polypropylene
• polyester
• polytetrafluoroethylene (PTFE)
Polypropylene: makes a strong
monofilament mesh It does not
have any antibacterial properties
but its hydrophobic nature and
monofilament microstructure
impede bacterial ingrowth

28. Polyester: is a braided filament mesh. This
structure may allow infection to take
place aided by its hydrophilic property
PTFE: meshes are flat sheets and as a result
do not allow any tissue ingrowth
They are used as a non-adhesive barrier
between tissue layers
All meshes provoke a fibrous reaction,
More dense or heavyweight meshes
provoke a greater reaction

29. The term ‘mesh shrinkage’ is often used to describe a progressive decrease in size
of a mesh over time. It is due to natural contraction of fibrous tissue embedded in
the mesh, reducing the area of mesh itself. This Can lead to tissue tension and
pain ,which is a complication of mesh repair, It can also lead to hernia recurrence
if the mesh no longer covers the defect. Meshes can shrink by up to 50 percent of
it’s original size and, in occasional cases, even more.

30. Meshes with (thinner strands and larger spaces between them) ‘lightweight, large-
pore meshes’, are preferred as they have better tissue integration, less
shrinkage, more flexibility and improved comfort.
2-Biological mesh
which are sheets of sterilised ,decellularised , non-immunogenic connective tissue.
They are derived from human or animal dermis, bovine pericardium or porcine
intestinal submucosa. They provide a ‘scaffold’ to encourage neovascular in-
growth and new collagen deposition. Host enzymes eventually break down the
biological implant which is replaced and remodelled with ‘normal’ host fibrous
tissue.
Mesh characteristics:
- Woven , knitted or sheet
- Synthetic or biological – mainly synthetic
- Light, medium or heavyweight – lightweight becoming more popular
- Large pore, small pore – large pore causes less fibrosis and pain
- Intraperitoneal use or not – non-adhesive mesh on one side
- Non-absorbable or absorbable – mainly non-absorbable

31. Absorbable meshes:
There are also synthetic absorbable meshes, such as those made from polyglycolic
acid fibre . They are used in temporary abdominal wall closure and to buttress
sutured repairs.
They have no current role in hernia repair as they absorb and induce minimal
Collagen deposition.
Tissue-separating meshes:
New meshes have been designed for intraperitoneal use. Most of these have very
different surfaces, one being sticky and one being slippery can be used
intraperitoneally as the peritoneum will grow in through its perforations while
bowel will not adhere to its inside surface.

32. Positioning of the mesh:
The strength of a mesh repair depends on host–tissue in-growth .Meshes should be placed on a
firm, well-vascularised tissue bed With generous overlap of the defect.
The mesh can be placed:
• just outside of the muscle in the subcutaneous space (on lay);
• within the defect (inlay) – only applies to mesh plugs Small defects;
• between fascial layers in the abdominal wall (intraparietal or sublay);
• immediately extraperitoneally, against muscle or fascia (also sublay);
• Intraperitoneally.
At open surgery all of these planes are used, but laparoscopic surgeons currently
only use intraperitoneal or extraperitoneal planes

33. Limitations to the use of mesh:
The presence of infection limits the use of mesh, particularly heavyweight types. If a
mesh becomes infected then it often needs to be removed. Some infected
meshes can be salvaged using a combination of debridement of non-incorporated
mesh, appropriate antibiotics and modern vacuum-assisted dressings.

34. Divarication hernia
is nothing but attenuated stretched linea alba above the umbilicus usually,
which bulges out with any rise in intra abdominal pressure like coughing or
sneezing and is best seen by asking a supine patient to simply lift his head off
the pillow (head raising test) there is no sac and no contents just stretched weak
linea alba .
It is common in multiparous females, for cosmetic reasons it can be treated
conservatively by abdominal binder or surgically by the open or closed repair .

36. Inguinal hernia
Is the most common hernia in men and women but much more common in men.
There are two basic types which are fundamentally different in anatomy, causation
and complications
However, they are anatomically very close to one another, surgical repair techniques
are very similar and ultimate reinforcement of the weakened anatomy is identical
so they are often referred to together as inguinal hernia
The congenital inguinal hernia is known as indirect, oblique or lateral while the
acquired hernia is called direct or medial. There is a third ‘sliding’ hernia which
is acquired but is lateral in position
Basic anatomy of the inguinal canal
As the testis descends from the abdominal cavity to the scrotum in the male
it first passes through a circle shaped defect called the deep inguinal ring
in the transversalis fascia, just deep to the abdominal muscles
The inferior epigastric vessels lie just medial to the deep inguinal ring

37. The transversus muscle and the internal oblique muscle, arch over
the deep inguinal ring from lateral to medial before descending
fuse together and become tendinous, hence this arch is
referred to as the conjoint tendon. Below this arch there is no
muscle but only transversalis fascia(posterior wall) and
anteriorly external oblique aponeurosis resulting in weakness
The testis finally emerges through a v-shaped defect in the
external oblique aponeurosis which is called the superficial
inguinal ring, and descends into the scrotum
The inguinal canal in the male contains the testicular artery, veins,
lymphatics and the vas deferens. In the female, the round
ligament descends through the canal to end in the vulva(labia
majora)

38. Three important nerves pass through the inguinal canal:
1 - the ilioinguinal nerve
2 - the iliohypogastric nerve
3 - the genital branch of the genitofemoral nerve
As the testis descends down to the scrotum, a tube of peritoneum(processus
vaginalis) is pulled with the testis and wraps around it ultimately to form the
tunica vaginalis.This peritoneal tube should be obliterated, possibly under
hormonal control before delivery, but it commonly fails to fuse either in part or
totally , leading to indirect inguinal hernia later on.
Inguinal hernia in neonates and young children is always of this congenital type.
However , in other patients, the muscles around the deep inguinal ring are able to
prevent a hernia from developing until later in life
when under the constant positive abdominal pressure, the deep inguinal ring and
muscles are stretched and a hernia becomes apparent(indirect inguinal hernia)
As the hernia increases in size, the contents are directed down into the scrotum.
These hernias can become massive and may be referred to as a scrotal hernia

40. The second type of inguinal hernia, referred to as direct or medial, is acquired
It is a result of stretching and weakening of the abdominal wall just medial to the
inferior epigastric (IE) vessels

41. A direct, medial hernia is more likely in elderly patients. It is broadly based
and therefore unlikely to strangulate. The medially placed bladder can be
pulled into a direct hernia

42. The third type of inguinal hernia is referred to as a sliding hernia. This is also an acquired hernia
due to abdominal wall weakness but this occurs in deep inguinal ring lateral to the IE vessels.
On the left side, sigmoid colon may be pulled into a sliding hernia and on the right side the
caecum. Surgeons need extra caution during repair.
Occasionally, both lateral and medial hernias are present in the same patient (pantaloon hernia).
Diagnosis of an inguinal hernia:
In most cases, the diagnosis of an inguinal hernia is simple and patients often know their
diagnosis as they are so common.
Clinically:
• The presence of inguinal swelling
• Reducibility
• Visible cough impulse
• Obliteration test
• Palpable cough impulse
• Three fingers test (Zieman test)
• You can not get above it while in scrotal masses usually you can get above it unless too large

43. Surgeons will often accept the diagnosis on history alone but re-examination at a
later date or investigation by ultrasound scan may be requested. If an inguinal hernia
becomes irreducible and tense there may be no cough impulse.
Differential diagnosis of inguinal hernia:
-a lymph node
-groin mass
-abdominal mass
-a hydrocele or other testicular swelling
-Femoral hernia or spigelian hernia
-a saphena varix
-a varicocoele

44. Ten per cent of all patients will present with bilateral inguinal hernias and up
to 20 per cent more will have an occult contralateral hernia (on laparoscopic
evaluation)
Management of inguinal hernia:
In early asymptomatic, direct hernia , particularly in elderly patients who do not wish surgical
intervention It is safe to recommend no active treatment ( no surgery ) just follow up
( Surgical trusses are not recommended )
Elective surgery for inguinal hernia is a common and simple operation. It can be undertaken
under local, regional , spinal or general anaesthesia with minimal risk even in high-risk
patients
Type of operation:
- Herniotomy
- Herniorrhaphy ( Bassini repair or modified bassini )
- Open flat mesh repair
-Open preperitoneal repair-
- Laparoscopic inguinal hernia repair The totally extraperitoneal (TEP) approach is more widely
used than the transabdominal preperitoneal (TAPP) approach

45. Ninety-five per cent of inguinal hernia patients present at clinics as a cold
case and only 5 per cent present as an emergency with a painful irreducible
hernia which may progress to strangulation and possible bowel infarction and
should be dealt with as emergency
Complications of surgery:
• Early – pain, bleeding, urinary retention, anaesthetic related complications
• Medium – seroma, wound infection
• Late – chronic pain, testicular atrophy ,skin paraesthesia

46. Femoral hernia:
The walls of a femoral canal are :
- The femoral vein laterally
- The inguinal ligament anteriorly
- The pelvic bone covered by the ileopectineal ligament (Astley Cooper’s) posteriorly
- the lacunar ligament (Gimbernat’s) medially
The lacunar ligament is a strong curved ligament with a sharp unyielding edge which
impedes reduction of a femoral hernia

47. • Less common than inguinal hernia
• It is more common in females than in males ( wider pelvis )
• Easily missed on examination ( exposure problem in females )
• Fifty per cent of cases present as an emergency with very high risk of
strangulation
femoral hernia is commonly seen in low-weight, elderly females.
• Diagnostic error is common and often leads to delay in diagnosis and treatment.
The hernia appears below and lateral to the pubic tubercle and lies in the upper
leg rather than in the lower abdomen.
• Inadequate exposure of this area during routine examination leads to failure to
detect the hernia.
• The hernia often rapidly becomes irreducible and loses any cough impulse due to
the tightness of the neck

48. -

49. Differential diagnosis:
• Direct inguinal hernia
• Lymph node
• Saphena varix
• Femoral artery aneurysm
• Psoas abscess
• Rupture of adductor longus muscle or tendon with a haematoma
All patients with unexplained small bowel obstruction should undergo careful
examination for a femoral hernia, in suspicious cases CT scan may be indicated
There is no alternative to surgery for femoral hernia and it is wise to treat such cases
with some urgency
There are three open approaches and in the appropriate cases can be managed
laparoscopically
1-Low approach (Lockwood) : This is the simplest operation for
femoral hernia but only suitable when there is no risk of bowel resection

50. The inguinal approach (Lotheissen):
The initial incision is identical to that of a Bassini operation into the inguinal canal the
transversalis fascia opened from deep inguinal ring to pubic tubercle, Once
reduced, the neck of the hernia is closed with sutures or a mesh plug, protecting
the iliac vein throughout
High approach (McEvedy):
This more complex operation is ideal in the emergency situation where the risk of
bowel strangulation is high.
Laparoscopic approach:
Both the TEP and TAPP approaches can be used for femoral hernia and a standard
mesh inserted, This is ideal for reducible femoral hernias presenting electively but
not in emergency cases nor for irreducible hernia.

51. VENTRAL HERNIA:
- Umbilical – paraumbilical
- Epigastric
- Incisional
- Parastomal
- Spigelian
- Lumbar
-Traumatic
This term refers to hernias of the anterior abdominal wall. Inguinal and femoral hernias are not
included even though they are ventral. Lumbar hernia is included despite being dorsolateral
Umbilical hernia
The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually
within a week of birth. This process may be delayed, leading to the development of
herniation in the neonatal period. The umbilical ring may also stretch and reopen in adult
life This common condition occurs in up to 10 per cent of infants, with a higher incidence in
premature babies. The hernia appears within a few weeks of birth and is often
symptomless but increases in size on crying and assumes a classical conical shape. Sexes are
equally affected but the incidence in black infants is up to eight times higher than in white.
Obstruction and/or strangulation are extremely uncommon below the age of three years.

52. Treatment:
Conservative treatment is indicated under the age of two years when the hernia is
symptomless. Parental reassurance is all that is necessary
Ninety-five per cent of hernias will close spontaneously
If the hernia persists beyond the age of two years it is unlikely to resolve and surgical
repair is indicated
Conditions which cause stretching and thinning of the midline raphe (linea alba), such
as pregnancy, obesity and liver disease with cirrhosis, predispose to reopening of
the umbilical defect In adults
Mayo repair. Two -layered (double breasted) repair with Non-absorbable sutures are
used. For defects larger than 2 cm in diameter, mesh repair is recommended
Repair can be either open repair or
laparoscopic repair.
Laparoscopic umbilical hernia repair

53. Epigastric hernia
These arise through a defect in the midline raphe (linea alba)
anywhere between the xiphoid process and the umbilicus
usually midway When close to the umbilicus they are called
supraumbilical hernias the defect occurs at the site where
small blood vessels pierce the linea alba or, more likely, that
it arises at weaknesses due to abnormal decussation of
aponeurotic fibres related to heavy physical activity commonly
contain only extraperitoneal fat which gradually enlarges,
spreading in the subcutaneous plane to resemble the shape of
a mushroom. When very large they may contain a peritoneal
sac but rarely any bowel. More than one hernia may be present.

54. The patients are often fit, healthy males between 25 and 40 years of age. These
hernias can be very painful even when the swelling is the size of a pea due to the
fatty contents becoming nipped sufficiently to produce partial strangulation. The
pain may mimic that of a peptic ulcer but symptoms should not be attributed to
the hernia until gastrointestinal pathology has been excluded
On examination:
A soft midline swelling can often be felt more easily than it can be seen. It may be
locally tender. It is unlikely to be reducible because of the narrow neck. It may
resemble a lipoma. A cough impulse may or may not be felt.
Very small epigastric hernias have been known to disappear spontaneously, probably
due to infarction of the fat. surgery should only be offered if the hernia is
sufficiently symptomatic( painful ).

55. Incisional hernia:
These arise through a defect in the musculofascial layers of the abdominal wall in the
region of a postoperative scar. Thus they may appear anywhere on the abdominal
surface, Incisional hernias have been reported in 10–50 per cent of laparotomy
incisions and 1–5 per cent of laparoscopic port-site incisions
Factors predisposing to their development are:
- Patient factors : obesity, and (general poor healing) due to malnutrition,
immunosuppression or steroid therapy, chronic cough, cancer
-wound factors : (poor quality tissues, wound infection)
-Surgical factors : (inappropriate suture material, incorrect suture placement)
An incisional hernia usually starts as disruption of the musculofascial layers of a wound in
the early postoperative period.
Many incisional hernias may be preventable with the use of good surgical technique.
The classic sign of wound disruption is a serosanguinous discharge.
These hernias commonly appear as a localised swelling involving a small portion of the
scar but may present as a diffuse bulging of the whole length of the incision
Incisional hernias tend to increase steadily in size with time. The skin overlying large hernias
may become thin and atrophic
io

56. Attacks of partial intestinal obstruction are common as there are usually coexisting
internal adhesions. Strangulation is less frequent

57. Treatment :
Asymptomatic incisional hernias may not require treatment at all.
The wearing of an abdominal binder or belt may prevent the hernia from increasing in
size.
For the majority of incisional hernias surgery is relatively straightforward and both
open and laparoscopic options are available.
The repair should cover the whole length of the previous incision. Approximation of
the musculofascial layers should be done with minimal tension and prosthetic
mesh should be used

58. Spigelian hernia:
These hernias are uncommon although are probably under diagnosed. They affect
men and women equally and can occur at any age, but are most common in the
elderly
They arise through a defect in the Spigelian fascia which is the aponeurosis of the
transversus abdominis muscle
Most Spigelian hernias appear below the level of the umbilicus near the edge of the
rectus sheath but they can be found anywhere along the ‘Spigelian line’

59. - in fact the defect is almost always above the arcuate line
- In young patients they usually contain extraperitoneal fat only
- but in older patients there is often a peritoneal sac and they can become very
large indeed
- They have also been described in infants and may be congenital
- Young patients usually present with intermittent pain, due to pinching of the fat,
similar to an epigastric hernia
- Older patients generally present with a reducible swelling at the edge of the rectus
sheath and may have symptoms of intermittent obstruction
- The diagnosis should be suspected because of the location of the symptoms and is
confirmed by CT
- Surgery is recommended as the narrow and fibrous neck predisposes to
strangulation. Surgery can be open or laparoscopic

60. Lumbar hernia:
Most primary lumbar hernias occur through the inferior lumbar triangle of Petit
bounded below by the crest of the ilium, laterally by the external oblique muscle
and medially by the latissimus dorsi

61. Less commonly, the sac comes through the superior lumbar triangle, which is
bounded by the 12th rib above, medially by the sacrospinalis and laterally by the
posterior border of the internal oblique muscle, Primary lumbar hernias are rare,
but may be mimicked by incisional hernias arising through flank incisions for renal
operations or through incisions for bone grafts harvested from the iliac crest.
A lumbar hernia must be distinguished from:
• a lipoma
• a cold (tuberculous) abscess pointing to this position;
• pseudo-hernia due to local muscular paralysis ,the most common cause being injury
to the sub costal nerve during a renal operation
surgery is recommended because the natural history for these hernias is to increase in
size
Lumbar hernias can be approached by open or laparoscopic surgery. The defects can
be difficult to close with sutures and mesh is recommended
Lumbar incisional hernias: can be approached in the same way

62. Parastomal hernia
When surgeons create a stoma, such as a colostomy or ileostomy, they are effectively
creating a hernia by bringing bowel out through the abdominal wall
The rate of parastomal hernia is over 50 %
The ideal surgical solution for the patient is to rejoin the bowel and remove the
stoma altogether but this is not always possible
Various open suture and mesh techniques have been described to repair parastomal
hernia but failure rates are high. Laparoscopic repair is also possible

63. Traumatic hernia:
These hernias arise through non-anatomic defects caused by injury.
They can be classified into three types:
1- Hernias through abdominal stab wound sites.(These are effectively incisional
hernias)
2- Hernias protruding through splits or tears in the abdominal
muscles following blunt trauma.
3- Abdominal bulging secondary to muscle atrophy which
occurs as a result of nerve injury or other traumatic denervation
The key to the aetiology is in the history and the non-anatomic location of the hernia
Surgery may be justified if the hernia is sufficiently symptomatic or it has a narrow
neck

64. Rare external hernias:
Perineal hernia
This type of hernia is very rare and includes:
• postoperative hernia through a perineal scar, which may occur after excision of the
rectum
• median sliding perineal hernia, which is a complete prolapse of the rectum
• anterolateral perineal hernia, which occurs in women and presents as a swelling of
the labium majus
• posterolateral perineal hernia, which passes through the levator ani to enter the
ischiorectal fossa.
A combined abdominoperineal operation is generally the most satisfactory for the
last two types of hernia

65. Obturator hernia
Obturator hernia, which passes through the obturator canal, occurs six times more
frequently in women than in men. Most patients are over 60 years of age
The swelling is liable to be overlooked because it is covered by the pectineus muscle
It seldom causes a definite swelling .
Strangulated obturator hernia occurs in more than 50% of the cases.
pain is referred along the obturator nerve by its geniculate branch to the knee joint
On vaginal or rectal examination the hernia can sometimes be felt as a tender
swelling in the region of the obturator foramen
These hernias have often undergone strangulation, frequently of the Richter type, by
the time of presentation
Operation is indicated:
The diagnosis is rarely made preoperatively and so it is often approached through a
laparotomy incision
It is best closed using a mesh plug

67. Gluteal and sciatic hernias:
Both of these hernias are very rare.
A gluteal hernia passes through the greater sciatic foramen, either above or below the
piriformis muscle
A sciatic hernia passes through the lesser sciatic foramen
Differential diagnosis must be made between these conditions and:
• a lipoma or other soft tissue tumour beneath the gluteus maximus;
• a tuberculous abscess
• a gluteal aneurysm
All doubtful swellings in this situation can be characterized with CT scanning but, if in
doubt, they should be explored by operation