Hernia pdf - د. ثروت

Baghdad College of Medicine / 4

grade

Student’s Name :

Dr. Tharwat Edrees
Lec. 3

HERNIA

Mon. 7 / 3 / 2016

DONE BY : Ali Kareem

مكتب اشور

لالستنساخ

2015 – 2016

Hernia Dr. Tharwat Edrees

7-3-2016

©Ali Kareem 2015-2016

Hernia

Hernia is a protrusion of a viscous or part of a viscous with peritoneal covering
through an abnormal opening.

ETIOLOGY

o Any condition that raises intra-abdominal pressure, such as powerful

muscular effort, may produce a hernia.

o Chronic cough, straining or micturition or straining on defaecation may

precipitate a hernia in an adult.

o Hernias are more common in smokers.
o Stretching of the abdominal musculature because of an increase in contents,

as in obesity may predispose to hernia.

TYPES OF HERNIA

 Reducible – contents can be returned to abdomen.
 Irreducible – contents cannot be returned but there are no other

complications.

 Obstructed – bowel is obstructed but bowel in the hernia has good blood

supply.

 Strangulated – blood supply of bowel is obstructed.
 Inflamed – contents of sac become inflamed.

COMPOSITION OF A HERNIA

As a rule, a hernia consists of three parts : The sac, The coverings of the sac and
the contents of the sac .

Hernia Dr. Tharwat Edrees

7-3-2016

©Ali Kareem 2015-2016

The Sac is a diverticulum of peritoneum consisting of mouth, neck, body and
fundus.

Coverings are derived from layers of the abdominal wall through which the sac
passes.

Contents : These can be

o Omentum = Omentocele
o Intestine = Enterocele; more commonly small bowel but may be large

intestine or appendix

o A portion of the circumference of the intestine = Richter’s hernia
o A portion of the bladder ( or a diverticulum) may constitute part of or be

sole content of a direct inguinal, a sliding inguinal or femoral hernia.

o  Ovary with or without the corresponding fallopian tubes.
o  A meckel’s diverticulum = a Littre’s hernia
o  Fluid as part of ascites.

REDUCIBLE HERNIA

The hernia either reduces it self when the patient lies down or can be reduced by
the patient or the surgeon. Intestine gargles while omentum is doughy.

IRREDUCIBLE HERNIA

In this case the contents cannot be returned to the abdomen but there is no
evidence of other complication.

OBSTRUCTED HERNIA

This is an irreducible hernia containing intestine that is obstructed from without or
within, but there is no interference to the blood supply to the bowel.

Hernia Dr. Tharwat Edrees

7-3-2016

©Ali Kareem 2015-2016

INCARCERATED HERNIA

The term “incarceration” is often used loosely as an alternative to obstruction or
strangulation but is correctly employed only when it is considered that the lumen
of that portion of the colon occupying a hernia sac is blocked with faeces.

STRANGULATION HERNIA

o A hernia becomes strangulated when the blood supply of its contents is

seriously impaired, rendering the contents ischaemic.

o  Present with local then general abdominal pain & vomiting.
o  A normal hernia can strangulate at any time.
o  Most common in hernias with narrow necks such as  femoral hernia.
o  Require urgent surgery.

INFLAMED HERNIA

Inflammation can occur from inflammation of the contests of the sac; e.g. acute
appendicitis or salpingitis, or from external causes e.g. the trophic ulcers that
develop in the dependent areas of large umbilical or incisional hernias.

Natural history of hernia

  Irreducible hernias – there is a risk of strangulation at any time.
  Obstructed hernias – usually go on to strangulation.
  Strangulated hernias – gangrene can occur within 6 hours.

INGUINAL HERNIAS

o Inguinal hernias in babies are the result of a persistent processus vaginalis.
o Indirect inguinal hernia is the most common hernia of all, especially in the

young.

Hernia Dr. Tharwat Edrees

7-3-2016

©Ali Kareem 2015-2016

o Direct inguinal hernia becomes more common in the elderly.

Indirect Inguinal Hernias

Three types of indirect inguinal hernia occur

1- Bubonocele : the hernia is limited to the inguinal canal.
2- Funicular : the processus vaginalis is close just above the epididymis. The

contents of the sac can be felt separately from the testis, which lies below the
hernia.

3- Complete (Scrotal) : a complete inguinal hernia is commonly encountered in

infancy. It also occurs in adolescence or in adulthood. The testis appears to
lie within lower part of the hernia.

Clinical examination

The examiner looks and feels for the impulse and then addresses the following
questions :

  Is the hernia right, left or bilateral ?
  Is it inguinal or femoral hernia ?
  Is it a direct or indirect hernia ?
  Is it reducible or irreducible (the patient may have to lie down for this to be

ascertained)

 What are the contents ?

Looking at all ages, males are 20 times more commonly affected than famales.

DDx in males :

o  Vaginal hydrocele
o  Encysted hydrocele of the cord
o  Spermatocele

Hernia Dr. Tharwat Edrees

7-3-2016

©Ali Kareem 2015-2016

o Femoral hernia
o Incompletely descended testis in the inguinal canal – an inguinal hernia is

often associated with the condition.

o Lipoma of the cord.

DDx in the females :

o Hydrocele of the canal of nuck – this is the most common differential

diagnostic problem.

o Femoral hernia

Rx of Hernias

 Surgery is the treatment of cause of choice.
 Surgery include herniotomy, repair of the internal rind and herniorapathy

or mesh repair.

 Herniotomy means excision of the sac after reduction of the contents and

isolation of the sac from the cord.

 Herniorapathy means repair of the posterior wall of the canal by prolene in

two layers (Bassini repair) or darning.

 Mesh repair means the use of prolene mesh to enforce the posterior wall of

the canal.

 Laparoscopic repair by mesh (transpritoneal TRAP or peritoneal TEP)

Direct Inguinal hernia

o  Usually occur in elderly,
o  No sac or wide neck sac.
o  It is actually weakness of the posterior wall of the inguinal canal.
o  Direct inguinal hernia will not attain a large size or protrude to scrotum
o  It will not be obstructed or strangulated.

Hernia Dr. Tharwat Edrees

7-3-2016

Strangulated Inguinal hernia

Indirect inguinal hernias strangulate more commonly, the direct variety not so
often because of wide neck of the sac.

In order of frequency, the constricting agent is :

1-  The neck of the sac.
2-  The external inguinal ring in children.
3-  Adhesions within the sac (rare).

Preoperative treatment of strangulated inguinal hernias

o  Resuscitate with adequate fluids.
o  Empty stomach with nasogastric tube.
o  Give antibiotics to contain infection.
o  Catheterize to monitor haemodynamic state.

Open the sac, deliver the contents, incision of the neck, assure the viability of the
contents, excision of the dead omentum, ligation of the sac & repair of the
posterior wall.

FEMORAL HERNIA

  Is the third most common type of primary hernia.
  It accounts for about 20% of hernias in women & 5% in men.
  It is the most liable to become strangulated, mainly because of the

narrowness of the neck of the sac and the rigidity of the femoral ring.

  Strangulation is the initial presentation of 40% of femoral hernias
  More common in women
  Cannot be controlled with truss.
  Have a high incidence of strangulation.
  Should be operated on as soon as possible.

Hernia Dr. Tharwat Edrees

7-3-2016

SURGICAL ANATOMY

The femoral canal occupies the most medial compartment of the femoral sheath
and extends from femoral ring above to the saphenous opening below. It is 1.25 cm
long and 1.25 cm wide at its base, which is directed upwards. The femoral canal
contains fat ,lymphatic vessels and the lymph node of Cloquet. It is closed above by
the septum crurale, a condensation of extraperitoneal tissue pierced by lymphatic
vessels, and below by the cribriform fascia.

The femoral ring is bounded :

 Anteriorly by the inguinal ligament.
 Posteriorly by the iliopectineal ligament, the pubic bone and the fascia over

the pectineus muscle.

 Medially by the concave knife-like edge of lacunar ligament, which is also

prolonged along the iliopectineal line as iliopectineal ligament.

 Laterally by a thin septum separating it from femoral vein.

DDx

A femoral hernia has to be distinguished from

o  Inguinal hernia
o  Saphena varix
o  Enlarged femoral lymph node
o  Lipoma
o  Femoral aneurysm
o  Psoas abscess

A femoral hernia strangulates frequently and gangrene rapidly develops. This
explained by the narrow, underlying femoral ring

Operative treatment

o Low operation (Lockwood)

Hernia Dr. Tharwat Edrees

7-3-2016

o High operation (McEvedy)
o Inguinal operation (Lotheissen

To Be Continued …

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