Hernia

INGUINAL HERNIA

A hernia: Is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity.

Epidemiology

10 % of the population 75% of all abdominal wall hernias are in the groin Of which: 95% are inguinal hernias

Etiology

Coughing Straining Obesity Smoking: causes acquired collagen defect Intra-abdominal malignancy Congenital Multiparous women

Composition of a hernia

The sac: is a diverticulum of peritoneum.The coverings: layers of abdominal wall. The contents: OmentumIntestinePortion of circumference of intestine (Richter’s hernia).Bladder or ovary and fallopian tube.Meckel’s diverticulum (Littre’s hernia).Fluid.

Classification

Reducible hernia (expansile impulse), reduced on lying down or by the surgeon. The bowel gurgles on reduction, and the first part is more difficult to reduce than the last. Irreducible hernia (adhesion or overcrowding) Obstructed hernia (irreducible hernia containing bowel) with colicky pain and tenderness over the hernia. Incarcerated hernia (colon blocked with feces) Strangulated hernia (blood supply is impaired) Inflamed hernia: inflammation of the contents or from external causes

Inguinal hernia

Surgical anatomy: The superficial inguinal ring: it is a triangular aperture in the external oblique aponeorosis. The deep inguinal ring: is a U-shaped condensation of the transversalis fascia. Lies 1.25 cm above the mid inguinal point. The inguinal canal: between the superficial and deep inguinal ring, in infants the two rings are superimposed, in adult it is 3.75 cm and oblique. The canal transmits the spermatic cord, the ilioinguinal n. and the genital branch of the genitofemoral n.

Pubic tubercle

Pubic symphysis
Pubic crest
Medial crus
Lateral crus
External oblique
Inguinal lig.

Hesselbach’s Triangle

Boundaries of the inguinal canal: Anterior : external oblique apponeurosis Posterior: fascia transversalis + contribution from the apponeurosis of the transversus abdominis muscle. Superior: Conjoined muscles (internal oblique and transversus abdominis) Inferior : Inguinal ligament. Medial: lateral border of the rectus sheath

Indirect inguinal hernia

Is the most common form of hernia, it is more common in the young. Inguinal hernias in babies are the result of a persistent processus vaginalis. In adult males, 65% of inguinal hernias are indirect and 55% are right sided. The hernia is bilateral in 12%.

Anatomy

Ilioinguinal provides sensory to pubic region, upper labia, scrotum. Most commonly injured. Iliohypogastric supplies sensory to skin superior to the pubis. Genitofemoral sensory to scrotum and thigh. Three types of inguinal hernia: Bubonocele: limited to the inguinal canal. Funicular: closed above the epididymus. Complete: the testis lie within the lower part of the hernia

Clinical features: Males are 20 times more affected than females. The patient complains of pain in the groin or pain referred to the testicle on heavy work. When asked to cough, a small transient bulging may be seen and felt together (expansile impulse). In large hernias there is a swelling in the inguinal region with sensation of weight and dragging on the mesentery. This may produce epigastric pain. If the contents of the sac is reducible the inguinal canal will be found to be commodious.

Differential diagnosis in males

Vaginal hydrocele Encysted hydrocele Spermatocele Femoral hernia Incompletely descended testis Lipoma of the cord

Differential diagnosis in females

Hydrocele of the canal of Nuck Femoral hernia

Treatment

Operation is the treatment of choice. The basic operation is inguinal herniotomy, it is sufficient for the treatment of hernia in infants adolescents and young adults. Herniotomy and herniorrhaphy are Excision of the hernial sac (herniotomy). Repair of the deep inguinal ring (Lytle, or Shouldice). Reinforcement of the posterior wall of the inguinal canal (herniorrhaphy) this is achieved by suturing without tension the tendinous aponeurotic arch of the internal oblique to the undersurface of the inguinal ligament.

Complications Bleeding Infections Constipation Torsion of the testes Testical atrophy Gastric retention Recurrence (rare

Direct inguinal hernia

In adult male, 35% of inguinal hernias is direct, a direct inguinal hernia is always acquired. The sac passes through a weakness or a defect of the transversalis fascia in the posterior wall of the inguinal canal.Often the patient has poor lower abdominal musculature and having a longitudinal bulging (Malgaigne’s bulges). Women never develop direct inguinal hernia.


Predisposing factors: Smoking Straining and heavy lifting. Damage to the ilioinguinal n. Direct inguinal hernia very rarely attain a large size or descend into the scrotum. the sac lies behind the spermatic cord. direct inguinal hernia does not strangulate. Treatment :is herniorrhaphy

Sliding hernia

As a result of slipping of the posterior parietal peritoneum on the underlying retroperitoneal structure, the posterior wall of the sac is formed by the peritoneum and sigmoid colon and its mesentery on the left, the caecum on the right. Clinical features: occurs in men above 40 years, mainly on the left, it should be suspected in a very large globular inguinal hernia Treatment: surgery (Saddle-bag, pantaloon) hernia: contains two sacs that straddle the inferior epigastric artery. recurrence may occur as one of the sacs overlooked at operation.

Strangulated hernia

Clinical features: Sudden pain at site of hernia, is followed by generalized abdominal pain, colicky in character, with nausea and vomiting ensue. O/E The hernia is tender, tense, irreducible, with no expansile cough impulse. If not relieved the peristaltic contraction ceases, then paralytic ileus and septicemia develops

Pathology of strangulated hernia

Initially the venous supply is impeded, the intestine is congested, with transudation of fluid into the sac. As venous stasis increases, the arterial supply impaired, blood is extravasated into the lumen and under the serosa. The fluid in the sac becomes blood stained, and the shining serosa becomes dull. Bacterial transudation occurs and the fluid becomes infected. If unrelieved gangrene and perforation occur.

Richter’s hernia: In which the sac contain only portion of the circumference of the intestine, it usually complicate femoral hernia.Strangulated Richter’s hernia: The operation usually delayed because the presentation mimic gastroenteritis. The patient may not vomit and, although colicky pain is present, bowel motion is normal and there may be diarrhea. Therefore gangrene and perforation occur before operation is undertaken.

Strangulated inguinal hernia

Preoperative treatment: Resuscitation with adequate fluids Empty stomach with nasogastric tube Antibiotic Monitor hemodynamic state Empty bladder

Paraumbilical herniaRisk Factors

Multiple Pregnancies Prolonged labor Ascites Large Abdominal tumors strenuous physical activity Obesity Flabbiness of the abdominal muscles.


Paraumbilical hernia
It occurs through the linea alba just above or just below the umbilicus, it is oval or round in shape, it can become very large, the neck of the sac is very narrow compared with the size of the sac, the sac contains greater omentum and sometimes small intestine or transverse colon.

Clinical features: women are affected five times more than men, patients are usually overweight, 35-50 years old. The hernia is usually irreducible. A large Para umbilical hernia causes a dragging pain. Gastrointestinal symptoms are due to traction on the stomach or transverse colon. intestinal colic because of partial intestinal obstruction. Intertrigo or ulcers of the skin. .

Treatment

Herniorrhaphy: If the defect is small, a primary herniorrhaphy. If the defect is large, the repair is performed with buttressing of the abdominal wall, the classic primary repair is described by Mayo. Hernioplasty: facial defect >4cm, or for recurrent paraumbilical hernia. The use of polypropylene mesh is recommended.