Documente Academic
Documente Profesional
Documente Cultură
abdominal wall
Presents as a bulge
Peritoneal contents may be trapped in “sac”
Boundaries
Superifical – external
oblique aponeurosis
Superior – internal and
transversus
Inferior – shelving edge of
inguinal ligament and
lacunar ligament
Posterior (floor) –
transversalis fascia and
aponeurosis of transversus
abdominis muscle
Components of Hesselbach’s triangle include which
of the following anatomic landmarks?
A. Pectineal ligament
B. Lateral border of the rectus sheath
C. Cooper’s ligament
D. Inguinal ligament
E. Inferior epigastric vessels
Hernia Diathesis
Varies with age
Pediatric: congenital remnant
Adult
Tissue weakness
Burst strength < abdominal wall tension
Preperitoneal fat
Lymph node
Hernia Pathology
Incarceration: contents of hernia sac not
reducible into peritoneal cavity
Acute: fascial margins trap contents
Chronic: contents adhesed in sac
Symptomatic, non-obstructed
Treat discomfort from bulge
Prevent incarceration/strangulation
Visceral obstruction/strangulation
Release obstruction/manage viscera
Prevent recurrence
Groin Hernia
Men : Women 25 : 1
Right : Left 2 : 1
Femoral
Women > Men
Strangulation risk > inguinal
Inguinal
Indirect : Direct 2 : 1
Most common in men and women
Groin Hernia
Inguinal: relationship of sac to inguinal canal
determines external bulge
Local/regional/general anesthesia
Emergent repair
Irreducible acute incarceration
Strangulation
acquired weakness in
the inguinal floor
Indirect Inguinal Hernia
Accepted hypothesis:
incomplete or
defective obliteration
of the processus
vaginalis during the
fetal period
remnant layer of
peritoneum forms a
sac at the internal
ring
more frequently on
the right
Femoral
More common in females
Up to 40% present as
emergencies with hernia
incarceration or
strangulation
Passes medial to the
femoral vessels and nerve
in the femoral canal
through the empty space
Inguinal ligament forms
the superior border
Groin Hernia Surgery: Open
Bassini
Shouldice
McVay
Lichtenstein
Preperitoneal
Laparoscopic
Bassini (early 20th Century)
Transversus abdominis to Thompson’s ligament and
internal oblique musculoaponeurotic arches or
conjoined tendon to the inguinal ligament
Shouldice (1930s)
Multilayer imbricated repair of the posterior wall of the
inguinal canal
McVay (1948)
Edge of the transversus abdominis aponeurosis to
Cooper’s ligament; incorporate Cooper’s ligament and
the iliopubic tract (transition suture)
BASSINI MCVAY
SHOULDICE
Lichtenstein
First pure prosthestic, tension-free repair
to achieve low recurrence rates
Groin Hernia Surgery: Open
Laparoscopic
Indications
Recurrent hernia
Bilateral hernias
Must be able to tolerate general anesthesia
More expensive
Groin Hernia Repair
Complications
Recurrence
Tissue repair: 1.3—25%
Tension-free mesh: 0.5—5%
Risks
Recurrence
Umbilical necrosis
Injury to sac contents
Hematoma
Infection
Epigastric Hernia
Repair
Open repair similar as for umbilical hernia
Focal discomfort/pain
Open repair
Primary suture: < 52% recurrence
Mesh: < 24% recurrence
Incisional Hernia Repair
Complex open repairs
Stoppa mesh repair
Component separations repair
Laparoscopic repair
Multiple fascial defects detected
Large on-lay intraperitoneal mesh
5 cm marginal overlap
Incisional Hernia
Complications of repair
Recurrence
Seromas
Injury to sac contents
Bleeding
Infection
Review
Pediatric hernias Adult hernias
Inguinal Groin
Umbilical Inguinal
Femoral
Umbilical
Epigastric
Spigelian
Incisional
Points to Remember
Hernias represent fascial defects with protrusion
of a peritoneal sac or preperitoneal fat
Asymptomatic bulge most common
Hernia risk is related to visceral obstruction or
strangulation
Tension-free repair with mesh produces lowest
recurrence rates
Summary
Differential Diagnoses:
Inguinal Hernia.
Femoral Artery Aneurism.
Femoral Lymphadenopathy.
Psoas Abscess.
Umbilical & paraumbilical Hernia
A. Umbilical Hernia:
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.
Ventral wall (Incisional)
Highest incidence in midline
and transverse incisions
Up to20% after laparotomy
1/3 present in 5-10 years
postoperatively
Risk factors
obesity, DM, ascites, steroids,
smoking malnutrition, wound
infection
Technical aspects of wound
closure
Type of incision
Excessive tension (prone to
fascial disruption)
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:
Since many organs or parts of organs can herniate through many orifices,
it is very difficult to give an exhaustive list of hernias, with all synonyms
and eponyms. But her are Other hernial types and unusual types of
visceral hernias:
1. Spiglian Hernia:
Occurs at the spaces of the semilunar line and the lateral edge of
the rectus muscle (inferior to the arcuate line).
The posterior rectus sheath jis weak thus leading to the
protrusion.
Preoperative diagnosis is diffucult & only correct in 50% of the
patients.
u/s & c.t are helpful tools in the diagnosis
Depending on the size of the defect, treatment varies from suture
approximation to using a mesh.
Rare hernias (cont..)
2. Lumbar Hernias:
In the lumbar region, in the form of a broad bulging hernia, that are
not vulnerable to incarceration.
Devided into:
A. Petit’s hernia: which occurs in the inferior lumbar triangle.
B. Grynfeltt’s Hernia: which occurs in the superior lumbar
triangle and is less common that Petit’s.
Lumbar
Acquired lumbar hernias
–
back or flank trauma,
poliomyelitis, back surgery,
and the use of the iliac
crest as a donor site for
bone grafts
Contains to anatomic
triangles, inferior and
superior lumbar triangles
Grynfelt’s
Petit’s
Strangulation is rare
Soft swelling in lower
posterior abdomen
Rare hernias (cont..)
3. Obturator Hernia:
The obturator canal is covered by a
membrane pierced by the obturator
nerve and vessels. Any enlargement
in the canal or weakness in the
membrane may lead to herniation of
the intetines.
Because of differences in anatomy, it
is much more common in women
than in men.
It often presents with bowel
obstruction.
The Howship-Romberg sign is
suggestive of an obturator hernia,
exacerbated by thigh extension,
medial rotation and adduction. It is
characterized by lancilating pain in
the medial thigh/obturator
distribution, extending to the knee;
caused by hernia compression of the
obturator nerve.
Obturator
Rare form of hernia
Protrusion of intra-abdominal
contents through obturator
foramen
F:M ratio 6:1
The obturator foramen is
formed by the ischial and pubic
rami
obturator vessels and nerve lie
posterolateral to the hernia sac
in the canal
Small bowel is the most
likely intraabdominal
organ to be found in an
obturator hernia
Obturator
4 cardinal signs :
intestinal obstruction (80%)
Howship-Romberg sign (50%) –History of
repeated episodes of bowel obstruction that
resolve quickly and without intervention
Palpable mass (20%)