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Forth stage

surgery

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د. سمير الصفار

27/10/2015

Abdominal Wall Hernia

Definition

A protrusion of a viscus or part of a viscus through an abnormal opening in the walls

of its containing cavity

Introduction:

Hernias by themselves usually are harmless, but nearly all have a potential risk of



Obstruction if their content is part of bowel.



Cut off blood supply of their content ( becoming strangulated).

Aetiology

 Acquired:



Any condition that increase intra-abdominal pressure;



Strong muscular effort



Chronic coughing



Straining



Obesity



Chronic smoking

 Congenital:



Patent processus vaginalis

Composition of hernia

Each Hernia consist of



Defect or weak point



Peritoneal sac

 Mouth

 Neck

 Body

 Fundus



Covering of the sac



Contents of the sac

Contents of the sac



Omentum



Intestine



Portion of circumference of intestine “Richter “



Portion of bladder



Ovary with or without Fallopian tube



Meckel’s diverticulum “Littre “



Fluid

Anatomical types:



External



Interparietal



Internal



Sliding

Pathological Types :



Reducible



Irreducible



Obstructed ( Incarcerated )



Strangulated



Inflamed

Reducible

The hernia either reduces itself when the patient lies down, or can be reduced by the
patient or the surgeon

Irreducible

Here the contents cannot be returned to the abdomen, but there is no evidence of
other complications

Obstructed

This is an irreducible hernia containing an intestine which is obstructed but there is
no interference of blood supply to the bowel.

Strangulated

A hernia becomes strangulated when the blood supply of its contents seriously
impaired rendering the contents ischaemic.

Inflamed

•

Inflammation of its contents

 Appendix

 Fallopian tube

• Inflammation of overlying wall

Locational Types:

• Groin

• Umbilicus

• Epigastric (Linea alba )

• Surgical incisions

• Spigelian (Semi-lunar line)

• Diaphragm

• Lumbar triangles

• Pelvis (Obturator)

Groin hernia

• Inguinal

• Femoral

Inguinal Hernia

Inguinal hernia : Makes up 75% of all abdominal wall hernias and occurring up to 25 times
more often in men than women.

• Indirect

• Direct

Anatomy of Inguinal Canal

• 3.75cm in length

• 1.25 cm cephalad and parallel to inguinal ligament

• Extends from deep to superficial inguinal rings

• In infants; the canal is almost not present as the DIR and SIR superimposed

Boundaries of Inguinal Canal

• Anterior EOA, CT

• Posterior C, TF

• Upper (roof) CT

• Lower (floor) IL

Anatomy of Groin

Contents of Canal

• Spermatic cord in male and round ligament in female

• Ileo-inguinal nerve

• Genital br of genito-femoral nerve

Indirect Inguinal Hernia

• Is the most common of all forms of hernia

• Most common in young

• Men > women

• Right > left

• 10% of premature babies

• 5% of adult population

In adults:

• 65% of all inguinal hernia is indirect

• 55% right

• 12 % bilateral

 Incomplete

• Bubonocele

• Funicular

 Complete

• Inguinoscrotal

Pathogenesis of Indirect Hernia

Indirect hernia

• Congenital

• Acquired

Congenital:

• Persistent processus vaginalis

• Within spermatic cord

• Follows indirect course

• Complete vs. incomplete sac

Acquired

Precipitating factors

• Increased intra-abdominal pressure

• Defects in collagen synthesis

• Smoking

Clinical Features

• Any age

• Right < Left

• Male < Female (20 times)

Presenting symptoms

• Swelling appear on standing or coughing

• Pain in the groin

• Swelling in the groin

• Swelling in the groin descended to scrotum

Examination

• Apparent on standing

• Expensile cough impulse

• Controlled on pressing over the DIR

Indirect Inguinal hernia

Diagnosis:

• Groin swelling that disappear with supine position

• Examine erect and supine

• Does not transilluminate

• Expensile cough impulse

Epigastric hernia

Umbilical hernia

Spigelian Hernia

Inguinal hernia

How to differentiate IIH from DIH

When the swelling localized to groin

The differential diagnosis:

• Femoral hernia

• Lipoma of cord

• Inguinal lymphadenopathy

• Incompletely descended testis

• Ectopic testis

• Femoral artery aneurysm

Differential Diagnosis
When the swelling is inguino-scrotal



Vaginal hydrocele



Encysted hydrocele of cord



Spermatocele



Varicocele



Epididymoorchitis



Torsion of testis



Testicular tumor

In female



Femoral hernia



Hydrocele of canal of
Nuck



Inguinal
lymphadenopathy

Treatment:

• Operation is treatment of choice:

• Open surgery

• The standard method

• Laparoscopic hernia repair

• should be reserved for bilateral or recurrent hernia

• Open surgery

• Herniotomy

• Herniorrhaphy

• Anaesthesia

• Local

• Spinal

• General

Herniotomy

• Indications:

• In infants, children and adolescents

• Steps of surgery:

• Dissection of sac

• Open of sac

• Reduction of contents

• Transfixation of neck

• Cut of reminder

Herniorrhaphy

• Repair of stretched DIR and transversalis fascia

• Reinforcement of posterior wall by:

• Shouldice repair

• Mesh repair

Complications:

• Bleeding

• Skin bruises, SC hematoma

• Scrotal hematoma

• Retention of urine

• Wound infection

• Injury to vas deference

• Ischemic orchitis

• Neuralgia

-Ilioinguinal
-Iliohypogastric
-Genitofemoral
-Lateral cutaneous

• Recurrence >1%

Direct Inguinal Hernia

• Acquired

• Adults

• 35% of inguinal hernia

• 12% bilateral

• Not occur in females

Anatomy of Direct Hernia:

• Hesselbach’s triangle

– Inguinal ligament (base), rectus (medial), inferior epigastric vessels (lateral)

Hesselbach’s triangle

• Pathogenesis:

• Through weak posterior wall of inguinal canal

• Medial to Inferior epigastric vv

• Not attain large size or descent into scrotum

• Lies behind spermatic cord

• Wide neck

• Varieties

• Dual ( Pantoloon,saddle bag)

• Funicular (Prevesical)

Clinical Features:

• Swelling in the groin

• On examination:

• controlled on pressing on SIR

• ECI

Treatment:

• Surgical repair

• Dissection of sac

• Inverted

• Repair of transversalis fascia

• Mesh(Lichtenstein) or Shouldice repair

Strangulated Inguinal Hernia

• Can occur at any time

• More liable to occur in patients with irreducible hernia.

• More commonly occur in IIH

• Less often in DIH

Constricting agent

• Neck of sac

• External inguinal ring

• Adhesions within the sac

Content of hernia

• Small intestine

• Omentum

• Both

Clinical features:

• Severe pain in the groin

• Vomiting

• General upset

• Fever ?

• Swelling with skin discoloration in the groin

• Severely tender

• Abdominal signs

Treatment:

• Urgent surgery

• Pinciples:

-Dissection of sac

-Open the sac

-Exploration of content

-Excision of gangrenous tissues

Femoral Hernia

Anatomy of the femoral canal

• Boundaries of femoral ring

• Anterior border is the inguinal ligament

• Posterior border is the pectineal ligament

Gangrenous bowel

• Medial border is the lacunar ligament

• Lateral border is the femoral vein

Femoral Hernia

• Women> men

• 20% of hernias in women

• More in parous

• Most liable for strangulation

Clinical features

• Rare before puberty

• May be un-noticed by the patient

• Strangulated hernia

• Sudden painful swelling in the groin

• Abdominal symptoms

Examination

• The swelling is inferior to inguinal ligament and lateral to pubic tubercule

• Mostly irreducible

Differential Diagnosis:

• Inguinal hernia

• Lymphadenopathy

• Saphena varix

• Ectopic testis

• Psoas abscess

• Distended Psoas bursa

• Lipoma

• Rupture of adductor longus

Treatment:

• Uncomplicated hernia:

• Operation as early as possible

• Strangulated hernia

• Urgent surgery

• Approaches for the surgery

• Low approach – Lookwood

• High approach - McEvedy

• Inguinal approach - Lotheissen

• Principle of surgery

• Dissection of sac

• Open sac

• Reduction of contents if healthy otherwise gangrenous tissue must be

excised.

• Repair of femoral ring

Richter’s hernia



Frequent complication of femoral hernia



Only part of circumference of bowel enclosed in the hernia sac which
may become gangrenous



Clinically; abdominal symptoms of IO but with no constipation

Diagnosis:
High index of suspicion
Urgent surgical interference
Almost always the diagnosis made at surgery

Umbilical hernia

In neonates

Exomphalos
1/6000 of births
Failure of all or part of midgut to return to the coelom

In infants and children

Defect in the umbilical cicatrix

Equal sex incidence
Black infants 8 times more

Clinical features

Symptomless
More prominent during crying
Obstruction or strangulation is rare below 3 years of age
Most of cases resolve by itself within 2 years

Diagnosis

Swelling with umbilical cicatric at fundus of swelling
Reducible
ECI +ve -----Crying

Treatment

Conservative below the age of 2 years – reassurance of parents
After 2 years needs surgical repair

Paraumbilical Hernia

Adults
Women> men
Risk factors :Obesity ,Pregnancy
Repair primarily or with mesh

Pathogenesis

Weak point in the linea alba just above or just below the

umbilical cicatrix

Round or oval in shape
May sag downwards
May become a large size
The neck of sac is often remarkably small in size
Contents; mostly small intestine or omentum or both(Sometimes part of transverse colon)

Clinical features
Classical patient:

Adult Female (F:M ; 5:1)
Aged between 35 and 50 years
Overweight

multipara

Symptoms

Abdominal swelling
Dragging pain
Intestinal colics—obstruction
Epigastric pain (stomachache)

Complications
1. Irreducibility with possibility of IO
2. Ulceration of skin over fundus of sac
3. Intertrigo
Diagnosis -------> clinical :

Swelling just above or below the umbilicus
Prominent on standing
Disappear on lying
Expensile cough impulse

Treatment
Operation is advised in nearly all patients.

Indications:
1. Liable for complication
2. Cosmetic
The operation is "Herniotomy and Repair" ,Either Myo’s repair or Mesh repair.
Mesh repair is indicated for
1. Large defect > 4 cm
2. Recurrent hernia
Postoperative complications
Local and specific
1. Collection(Hematoma,Seroma )
2. Infection (Wound infection,Pus collection)
3. Recurrence

Epigastric Hernia(Fatty hernia of linea alba)

Incidence 1-5%
Men> women
Between xiphoid and umbilicus
20% multiple
Repair primarily

Pathogenesis

Extraperitoneal fat protrusion through decussating fibers at linea alba
At sites of blood vessels

Clinical features

Symptomless:
Accidental finding
The size of a Pea
Felt not seen
Painful ---local pain and tenderness
Referred pain----DU like symptoms

Treatment: operation

Spieghelian Hernia

Rare
Hernia through subumbilical portion of semi-lunar line
Difficult to diagnose

– Clinical suspicion (location)
– CT scan

Repair primarily or with mesh

Incisional Hernia

This occurs after 2-10% of all abdominal surgeries, although some people are more at risk.
After surgical repair, these hernias have a high rate of returning (20-45%).
Risk factors

– Technical
– Wound infection
– Smoking
– Hypoxia/ ischemia
– Tension
– Obesity
– Malnutrition

Laparoscopic vs. open repair

Lumbar Hernia

Congenital, spontaneous or traumatic
Grynfeltt’s triangle:

– 12th rib, internal oblique and sacrospinalis muscle
– Covered by latissimus dorsi

Petit’s triangle:

– Latissimus dorsi, external oblique and iliac crest
– Covered by superficial fascia

Pelvic Hernia

1) Obturator hernia
– Most commonly in women
– Howship-Romberg sign
2) Sciatic hernia
3) Perineal hernia

Parastomal Hernia

Variant of incisional hernia
Paracolostomy > paraileostomy
Low rate if through rectus muscle
Traditionally relocate stoma, repair defect
Concern for mesh erosion
Laparoscopic repair

Abdominal Wall Hernia

1) Richter’s hernia
2) Littre’s hernia
3) Hernia in W
4) Pantallon

Umbilical Hernia

Common in infants
Close spontaneously if <1.5 cm
Repair if > 2 cm or if persists at age 3-4 years
Repair primarily or with mesh