HERNIAS

(1) INGUINAL HERNIAS

Inguinal hernias compromise a large part of the general surgical workload and as such
often find their way into surgical final medical examinations. Inguinal hernias are more
common in males than in females (2:1). There are two peaks in their incidence, namely
before the age of 5 and over the age of 50. This predisposition is thought to be due to the
potential abdominal wall weakness as a result of testicular descent and those that occur in
childhood are always of developmental origin.

Surgical anatomy

A. Boundaries of the inguinal canal

Anterior wall: External oblique aponeurosis covers entire canal
Internal oblique covers the lateral one-third
Posterior wall: Conjoint tendon medially
Transversalis fascia laterally
Superiorly: Internal oblique and transversus abdominis
Inferiorly: Inguinal ligament

B. Location of the deep ring

2 cm above and lateral to the femoral pulsation
Mid-point of the inguinal ligament

C. Location of an inguinal hernia

Above and medial to the pubic tubercle
Direct: Medial to the inferior epigastric artery
Indirect: Lateral to the inferior epigastric artery
 D. Contents of the inguinal canal
Spermatic cord
External spermatic fascia
Cremasteric
Internal spermatic fascia
Testicular artery, artery to the vas, cremasteric artery
Vas deferens
Pampiniform plexus of veins
Lymphatics
Nerve to the cremaster, sympathetic nerves
Ilioinguinal nerve

Aetiology

A direct inguinal hernia typically protrudes directly through the transversalis fascia and
enters the inguinal canal through the posterior wall. They tend to bulge forward and
rarely enter the scrotum. They are usually found in elderly patients with deficient
muscles and weak transversalis fascia.

An indirect inguinal hernia leaves the abdomen via the deep inguinal ring to follow an
oblique course through the inguinal canal through the abdominal wall. In an indirect
hernia the peritoneal sac may represent a patent or re-opened processus vaginalis. It may
extend as far as the tunica vaginalis surrounding the testis.

Typically the peritoneal sac may contain peritoneum and associated extra-peritoneal fat.
However, it may also contain omentum or small bowel and occasionally may contain
large bowel or bladder. Sometimes a retroperitoneal structure slides down the posterior
abdominal wall and herniates into the inguinal canal. This is known as a sliding hernia.
 Sliding hernias lie behind and outside the peritoneal sac and diagnosis can only be made
at operation.

Presentation

Inguinal hernias develop slowly and are typically exacerbated by any condition which
raises intra-abdominal pressure (chronic cough, obesity, constipation). Initially the
peritoneal sac and its contents are reducible. The longer the hernia is present and the
larger it is the more difficult it is to reduce. A chronically irreducible but not strangulated
hernia is described as incarcerated.

A strangulated hernia by contrast is irreducible, tender and erythematous. Symptoms and

signs of bowel obstruction develop followed by peritonitis if the bowel perforates.
Strangulation occurs if the hernial contents become constricted by the neck of the sac or
by twisting. Obstruction of venous return leads to swelling and thus arterial occlusion.

Management

Inguinal hernias in adults should be repaired by herniorrhaphy. An elective procedure

soon after diagnosis reduces the risk of strangulation. If an operation is unable to be
performed (patient is unfit for anaesthesia) an abdominal truss may keep the hernia
reduced and therefore relieve symptoms.

The typical herniorrhaphy is performed using the Lichtenstein repair. This utilizes a
patch of non-absorbable mesh to strengthen the posterior wall of the inguinal canal.
Laparoscopic hernia repair is gaining widespread acceptance but is more often utilized
where there are either bilateral hernias or a recurrent hernia.

Complications of herniorrhaphy include scrotal haematoma and wound infection. Late

complications include chronic groin pain from entrapment of the ilio-inguinal nerve and
testicular atrophy caused by inadvertent damage to the testicular artery. Recurrence rates
of less that 3% are acceptable. Recurrent hernias may occur following repair as a result
of poor operative technique, or ongoing problems with chronic cough, constipation or
inherently poor musculature.

(2) FEMORAL HERNIAS

Femoral hernias are formed by protrusion of peritoneum into the potential space of the
femoral canal. The sac may contain abdominal viscera or omentum. They are more
common in females than in male (although inguinal hernias are more common in both
sexes). Femoral hernias are acquired as a result of increased intra-abdominal pressure
and are therefore rare in children.

Surgical Anatomy

A. Boundaries of the Femoral Triangle

Superiorly: Inguinal ligament
Laterally: Medial border of sartarious muscle
Medially: Medial border of adductor longus
Floor: Iliacus, psoas, pectineus, adductor longus
Roof: Superficial fascia, great saphenous vein

B. Contents of the femoral triangle

Femoral artery
Femoral vein
Femoral nerve

C. Boundaries of the femoral canal

Anteriorly: Inguinal ligament
Medially: Lacunar ligament
Laterally: Femoral vein
 Posteriorly: Pectineal ligament

D. Contents of the femoral canal

Lymph node: Cloquets gland
Fat

E. Location of femoral hernias

Below and lateral to the pubic tubercle

Presentation

A femoral hernia presents as a small grape-sized lump immediately below the inguinal
ligament and just lateral to it medial attachment to the pubic tubercle. A cough impulse is
rarely detected due to the narrow neck of the hernial sac. As a result it can be difficult to
distinguish a femoral hernia from other lumps in the femoral canal, such as a lipoma or
inguinal lymph nodes. Due to the narrow neck of a femoral hernia it is more likely to
strangulate but localizing signs are usually absent and patient present with a small bowel
obstruction. A Richters hernia is where only part of the bowel circumference is trapped
in the hernial sac. As a result there is a partial bowel obstruction with vomiting but the
patient continues to pass flatus.

Management

All femoral hernias should be surgically repaired. This is because of the narrow neck of
the hernia, which may predispose to strangulation. Emptying and excising the peritoneal
sac forms the basis of an elective repair. The femoral canal is then closed with non-
absorbable sutures between the pectineus fascia and the inguinal ligament.

(3) OTHER IMPORTANT HERNIAS

Spigelian hernia: Herniation occurs through a fascial defect at the lateral border of the
rectus abdominus. The hernial sac comes to lie interstitially between the layers of
internal and external oblique or transversus abdominus. Spieglian hernias lie higher and
more medially than an inguinal hernia and may be difficult to palpate due to the
abdominal wall coverings.

Umbilical hernia: True umbilical hernias typically occur in premature newborn babies.
The majority regresses spontaneously within the first two years. Following this there is
little likelihood of improvement and surgical repair should be considered. A small sub-
umbilical incision allows for the contents of the sac to be emptied and the sac excised.
The umbilicus is sutured to the repair to restore its cosmetic appearance.

Incisional hernia: These occur as a late complication of abdominal surgery with an

incidence of 10 15% of all abdominal wounds. They typically present within the first
post-operative year. Predisposing factors include abdominal obesity, distension and poor
muscle quality, poor choice of incision site, inadequate closure technique, post
operative wound infection and multiple operations through the same incision. Incisional
hernias may be asymptomatic at presentation but tend to enlarge progressively. Rarely,
they may cause strangulation. Repair is usually indicated for pain or strangulation.