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Hernia

Amador, Sheena G.
Surgical Intern Department of Surgery SHH-CCMC Consortium

Protrusion through a defect usually containing a visceral organ.

Hernia
Components
1. Protrusion( organ) 2. Hernial orifice- defect in the innermost aponeurotic layer of the abdomen 3. Hernial sac- outpouch of peritoneum

Hernia
Layers of the Abdominal Wall
Skin Campers fascia Scarpas fascia External aponeurosis and muscle Internal aponeurosis and muscle Transversus abdominis Transversalis fascia Preperitoneal fat Peritoneum

Inguinal Canal
Anteriorly = external oblique aponeurosis Superiorly = internal oblique and transversus abdominis muscle Inferiorly = inguinal and lacunar ligament

Anterior perspective of posterior inguinal canal musculature. The external oblique aponeurosis has been removed to display the internal ring and inguinal canal floor.

Hernia
Etiology
Multifactorial; familial predisposition plays a role. Connective tissue disorder increased the incidence of hernia In children with congenital hip dislocation inguinal hernia is five times more common in female than in male

Hernia
Classification
A.) Location - external: sac protrudes completely through the abdominal wall, inguinal, umbilical - interparietal: in between different layers of abdominal wall - internal: sac within the visceral cavity

Hernia
B.) Reducibility - reducible: protruded viscus can be returned to the abdomen; spontaneous reduction with change in position - irreducible: cannot be returned 2 types: incarcerated hernia strangulated hernia

Strangulation of the Gut: A loop of gut protrudes through a


fascia and the edges of the opening impinge upon the blood supply of the entire circumference of the lumen. If only a part of the circumference of the gut is pinched in the opening, it is called a Richter hernia.

Hernia
Sites of Herniation
- groin/ inguinal area - umbilicus - linea alba - semilunar line of Speighel - diaphragm - surgical incisions

Anterior Abdominal Wall or Ventral Hernias


Represent defects in the parietal abdominal wall fascia and muscle through which intra-abdominal or preperitoneal contents can protrude. With Valsalva manuever, mass on the anterior abdominal wall may increase in size.

Anterior Abdominal Wall Hernia


A.) Incisional Hernia
- A bulge near an operative scar usually indicates an incisional hernia. - The lack of fascial support can be readily palpated. - If present, herniation occurs adjacent to the scar.

Anterior Abdominal Wall Hernia


B.) Epigastric Hernia (Fatty Hernia of the
Linea Alba) - a small bulge of fat protruding from the deep layers through an opening in the linea alba. - may not be detected unless the patient is examined in the standing position and the examining finger is run down the linea alba. - Usually this hernia does not have a peritoneal sac.

Anterior Abdominal Wall Hernia


C.) Umbilical Hernia
- A defect in the abdominal fascia occurs normally where the umbilical vessels and urachus exit the abdomen into the umbilical cord.

Anterior Abdominal Wall Hernia


C.) Umbilical Hernia
- congenital type: distinguished by protrusion through the umbilical scar; palpation of the ring reveals a complete fibrous collar continuous with the linea alba. - adult type: the collar is lacking; the upper part of the hernia is covered only by skin; properly termed a paraumbilical hernia.

Umbilical Hernia, congenitally-acquired.

Anterior Abdominal Wall Hernia


D.) Spigelian hernia
- can occur anywhere along the length of the Spigelian line or zonean aponeurotic band of variable width at the lateral border of the rectus abdominis. - However, the most frequent location of these rare hernias is at or slightly above the level of the arcuate line.

Anterior Abdominal Wall Hernia


D.) Spigelian hernia
- may come to medical attention because of pain or incarceration.

Inguinal Hernia
- 75% of abdominal wall hernias occur in the groin and more commonly on the right side - Ratio of indirect and direct hernia is 2:1 - Male to female ratio of 7:1

Physical Examination
Essential to forming the diagnosis Ideally, the patient should be examined in a standing position, with the groin and scrotum fully exposed. Standing position has the advantage over the supine position in that intraabdominal pressure is increased, and thereby, the hernia can be more easily elicited.

Physical Examination
Inspection is performed first, with the goal of identifying an abnormal bulge along the groin or within the scrotum. If an obvious bulge is not detected, physical examination is performed to confirm the presence of the hernia. Palpation is performed by placing the index finger into the scrotum, aiming it toward the external inguinal ring. Valsalva's maneuver will reveal an abnormal bulge and allow the clinician to determine whether the bulge is reducible or not.

Physical Examination
Inguinal Occlusion Test
differentiate direct and indirect hernias involves placement of a finger over the internal inguinal ring and the patient is instructed to cough If the cough impulse is controlled, then the hernia is indirect. If the cough impulse is still manifested, the hernia is direct. If the cough impulse is felt on the fingertip, the hernia is indirect; if felt on the dorsum of the finger, it is deemed direct.

Direct Inguinal Hernia


Protrude directly through floor of inguinal canal (Hesselbachs Triangle) Wide neck hernial sac Covered by external oblique aponeurosis Medial to inferior epigastric vessels

Hesselbachs Triangle

2 factors important in the development of direct inguinal hernia: - Increased intra-abdominal pressure

- Relative weakness of posterior inguinal wall

Indirect Inguinal Hernia


Passes through the deep inguinal ring, within spermatic cord to scrotum. Most common type Saccular theory of indirect inguinal hernia formation remains popular Saccular theory: presence of a developmental diverticulum associated with a patent processus vaginalis, was essential in every case.

The role of PPV


Congenital hernias, which make up the majority of pediatric hernias, can be considered an impedance of normal development, rather than an acquired weakness. During the normal course of development, the testes descend from the intra-abdominal space into the scrotum in the third trimester. Descent is preceded by the gubernaculum and a diverticulum of peritoneum, which protrudes through the inguinal canal and ultimately becomes the processus vaginalis.

The role of PPV


Between 36 and 40 weeks, the processus vaginalis closes and eliminates the peritoneal opening at the internal inguinal ring. Failure of the peritoneum to close results in a patent processus vaginalis (PPV) and thus explains the high incidence of indirect inguinal hernias in preterm babies. Children with congenital indirect inguinal hernias will present with a PPV; however, its presence does not necessarily indicate an inguinal hernia.

Varying degrees of closure of the processus vaginalis

The presence of a PPV likely predisposes the patient to the development of an inguinal hernia.

Indirect Inguinal Hernia


2 types: a. complete- hernia reach the scrotum below the inguinal ring b. incomplete- does not reach the scrotum above the inguinal ring

Femoral Hernia
- defect at the medial side of femoral sheath below the inguinal ligament. - more common among females, and more common on the right side - felt as a bulge at the femoral triangle - highest incidence of strangulation

Classification of Groin Hernia


Gilbert Classification System Nyhus Classification System

Gilbert Classification System


Type 1 Type 2 Type 3 Small, indirect Medium, indirect Large, indirect

Type Type Type Type

4 5 6 7

Entire floor, direct Diverticular, direct Combined (pantaloon) Femoral

Nyhus Classification System


Type I Indirect hernia; internal abdominal ring normal; typically in infants, children, small adults Type II Type IIIA Type IIIB Indirect hernia; internal ring enlarged without impingement on the floor of the inguinal canal; does not extend to the scrotum Direct hernia; size is not taken into account Indirect hernia that has enlarged enough to encroach upon the posterior inguinal wall; indirect sliding or scrotal hernias are usually placed in this category because they are commonly associated with extension to the direct space; also includes pantaloon hernias Femoral hernia

Type IIIC

Type IV

Recurrent hernia; modifiers AD are sometimes added, which correspond to indirect, direct, femoral, and mixed, respectively

Other Types of Hernia


1.Sliding hernia- any hernia in which part of the sac is the wall of a viscus 2. Richters hernia- contents of the sac consists only one side of the wall of intestine; always anti-mesenteric 3. Littres hernia- only part of intestinal wall inside; appendix goes inside 4. Pantaloon hernia- both direct and indirect components

Other Types of Hernia


5. Bochdaleks hernia- occur between subcostal and diaphragmatic; located posterolaterally. 6. Morgagni hernia- occur between sternal and costal diaphragmatic attachment in the retriosternal or parasternal position; located anteriorly

Inguinal Hernia
- Initial treatment in the absence of
strangulation, is taxis. TAXIS- performed with the patient sedated and placed in the Trendelenburg position. - Hernia sac is grasped with one hand, with the other applying pressure on the most distal part of the hernia. - Goal: To elongate the neck of the hernia so that the contents of the hernia may be guided back into the abdominal cavity with a rocking movement.

Surgical Management of Hernia


Herniotomy- surgical correction of a hernia by cutting through a band of tissue that constricts it. Hernioraphy- repair/ strengthen floor Hernioplasty- reconstruct to prevent peritoneal protrusion through the myopectineal orifice APPROACHES: 1. Anterior approach= groin incision 2. Posterior approach= abdominal incision

Anterior Hernioplasty
Basic components: 1. Dissection of inguinal canal 2.Repair of myopectineal orifice 3.Closure of hernial sac

Open Anterior, Nonprosthetic Repair


1. Classical a. Marcy - simplest nonprosthetic repair - main indication is in Nyhus type I indirect inguinal hernias where the internal ring is normal - the internal ring form by transversalis fascia is closed on the medial aspect with multiple sutures displacing cord laterally

b. Bassini

Open Anterior, Nonprosthetic Repair

- gold standard; 2 layer repair, least recurrence consist of high ligation of sac and approximation of conjoined tendon - a complete and deliberate dissection of inguinal canal consists of internal oblique, transversus abdominis and transversalis fascia shelving the edge of inguinal ligament using interrupted sutures

Open Anterior, Nonprosthetic Repair


c. Moloney Darn
- A long nylon suture is repeatedly passed between the tissues to create a weave that one might consider similar to a mesh.

d. Shouldice repair - similar to Bassini but modified four-layer repair. - particular importance is placed upon freeing the cord from its surrounding adhesions, resection of the cremasteric muscle, high dissection of the hernia sac, and division of the transversalis fascia - indicated in both direct and indirect inguinal hernia

e. Mc- Vay Lotheissen Coopers ligament repair


-repairs the 3 most vulnerable area: deep ring, hesselbachs triangle and femoral canal

Open Anterior, Prosthetic


a.) Lichtenstein Tension-Free Hernioplasty b.) Mesh Plug and Patch
- used for femoral and recurrent inguinal hernia when the defect is fibrous, circumscribed and not too large
- groin is entered through a standard anterior approach - hernia sac is dissected away from surrounding structures and reduced back into the preperitoneal space - a flat sheet of polypropylene mesh is rolled up like a cigarette and held in place with suture - plug is inserted into the defect and secured.

Open Preperitoneal, Nonprosthetic


Preperitoneal space can be entered via either anterior approach through the inguinal floor, or more commonly, using the posterior. Cheatle and Henry- the first to suggest the posterior approach to the preperitoneal space for repair of an inguinal hernia

Open Preperitoneal, Prosthetic


The Anterior Approach a.) Read- Rives
- starts like a classic Bassini, including opening the inguinal floor; a 12x16 cm piece of mesh is positioned in the preperitoneal space deep to the inferior epigastric vessels and secured with 3 sutures.

The Posterior Approach a.) Wantz/Stoppa/Rives

- these 3 procedures are grouped together under the heading of the giant prosthetic of the visceral sac, because there are only minor variations between them.

Open Preperitoneal, Prosthetic


The Posterior Approach b.) Nyhus/ Condon (Iliopubic Tract Repair) -transverse abdominal incision is made 2 fingerbreadths above the symphysis pubis.The anterior rectus sheath is opened and retract rectus muscles and 2 transversus abdominis muscle. c.) Kugel/ Ugahary - developed to compete with laparoscopic repairs by using a small (2 to 3 cm) skin incision, 2 to 3 cm above the internal ring

Laparoscopic Inguinal Herniorraphy


- Introduced in early 80 and 90s - Advantages are less postoperative procedure or pain, easier repair of recurrent hernia because the repair is on the tissue, ability to treat bilateral hernia

Complications of Hernioplasty
1. Ischemic orchitis and testicular atrophyinjury of vascular supply lead to testicular swelling and regression 2. Neuralgia- pain secondary to nerve injury maybe due to obliteration of the nerve 3. Recurrence- which is the most common complications due to excessive tension on repair, deficient tissue, inadequate repair and overlooked hernia

Thank you!