2 - Abdominal Wall & Hernia

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“ ‫الدن َيا َوأهلها‬

َ ْ َّ ‫“إ َض َاعة ْال َو ْقت َأشد من ْال َم ْوت َلن إ َض َاعة ْال َو ْقت تقطعك َعن الله َو‬: ‫قال ابن القيم رحمه الله‬
‫الدار ال ِآْخ َرة َوال َم ْوت يقطعك عن‬ ِ ِ‫أ‬ ِ 5
ABDOMINAL WALL & HERNIA
abdominal incisions
Requirements : “SEGA” : Safety - Extensibility - Good cosmetic result - Accessibility
Accessibility Extensibility Safety Good cosmetic result
incision should provide should be possible to should inflict the minimal damage to e.g. : a transverse
good exposure of the enlarge the incision, if muscles, blood vessels and nerves suprapubic incision is
diseased area needed, to give more e.g. : Muscle splitting incisions are prefer- better looking than a
exposure able than muscle cutting ones low mid line incision
Types : Vertical incisions or Transverse incisions or Oblique incisions

1) Vertical incisions
POC Midline incision Paramedian incision Paramedian transrectal incision
technique -incision passes through the -upper or lower, right or left -similar to classical paramedian
linea alba and the two recti are -skin incision is one inch from incision BUT rectus muscle is split
retracted apart the middle line longitudinally in the same line
-incision in the linea alba -anterior rectus sheath is incised of incision in the anterior rectus
should be closed by a vertically, and the rectus muscle sheath
non-absorbable suture material is displaced laterally to preserve
as prolene to avoid incisional the vessels and nerves supplying
hernia and burst abdomen the rectus muscle from lateral
side
- posterior rectus sheath and
peritoneum are incised as one
layer
advantages -good exploratory incision -safe and the healing power is - quick , therefore,
allowing access to both sides of strong not recommended in
the abdomen -readily extensible and can give emergencies.
-quick and can be enlarged freely exposure to any abdominal - most useful in children because
organ atrophy is compensated for
during growth
disadvantages -time consuming , therefore, -scar is not as strong as that of the
not recommended in paramedian incision due to
emergencies devitalization of the medial part
of the rectus muscle
POC 2) Transverse incisions 3) Oblique incisions

a- Subcostal incision b- McBurney’s incision
Characters -Upper transverse epigastric and - it is called Kocher’s incision if on -a muscle splitting incision, usually
& low transverse suprapubic right side used for appendicectomy
Technique (Pfannenstiel) - a muscle cutting incision , one -5-6 cm and perpendicular to a
-in Pfannenstiel incision, anterior inch below & parallel to costal line passing from the A.S.I.S to
rectus sheath is cut transversely, margin the umbilicus at the junction of
and then the two recti are -Medially, rectus muscle and the its outer 1/3 with the inner 2/3
separated anterior and posterior rectus -external oblique aponeurosis is
-finally the peritoneum is sheaths are divided opened in the same direction of
opened -Laterally, the three abdominal the skin incision
muscles may be divided -internal oblique and transversus
abdominis muscles are split in
the direction of their fibres
advantages -scar is cosmetic as wound lies in -good exposure to the biliary -good exposure to caecum &
Langers lines apparatus or the spleen esp. in appendix -safe incision
- minimal ms tension on suture & obese patients with wide costal -cosmetic esp. with transverse skin
so pt can cough safely postop. angle incision ( Lanz incision )
disadvantages -time consuming -ms cutting -not exploratory -not exploratory -not recommended
-excessive bleeding -not extensible -injury to 8th,9th or if appendicitis diagnosis is not sure
10th intercostal n. --> hyposthesia or -if extended up or down it will be
partial abdominal wall paralysis a ms cutting incision
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Precautions during closure of an abdominal incision Complications of abdominal incisions
1. A non-absorbable monofilamentous suture material, 1. Haematoma : may be due to a bleeding tendency
e.g., polypropylene (prolene) is used in the patient but far more commonly due to careless
2. - Sound closure of the strongest layer ( linea alba or the surgical haemostasis
anterior rectus sheath ) is essential for safety of wound - causes dull aching pain in the wound which is
closure indurated and may be discoloured.
- Wide bites (1 cm) are taken from the edge of the fascial - If small --> left for spontaneous absorption
incision - If enlarging or large --> evacuated to avoid
- Suture length to the wound length should be 4:1 secondary infection
3. Sutures should not be under tension to avoid ischaemia of 2. Infection
the wound 3. Wound disruption (burst abdomen) : a serious
4. If there is a peritoneal defect, leave it as the peritoneum will complication which may lead to an incisional hernia
regenerate in a few days or may even cause mortality
4. Incisional hernia : causes of incisional hernia are
the same as burst abdomen, and as a matter of fact
many patients with incisional hernia had partial
disruption of the deeper layers of the abdominal
wound during the immediate or early post-operative
period
5. Desmoid Tumor
Burst ABdomen
Predisposing factors :
Pre-operative factors Operative factors Post-operative factors
1. Obesity 1. Ms cutting incisions Ms splitting ones 1. Poor recovery from anaesthesia
2. Factors causing poor healing as 2. Vertical incisions Transverse incisions leading to strong coughing
malnutrition, cirrhosis, DM, jaundice 3. Rough surgical technique with 2. Persistent increase in
& corticosteroid intake excessiye trauma to the muscles, intra-abdominal pressure due
3. Patients with respiratory problems blood vessels & nerves to repeated coughing, vomiting,
as chronic bronchitis, bronchial 4. Use of absorbable sutures in the hiccough or abdominal
asthma and chronic obstructive lung closure of the aponeurotic layer of an distension
disease abdominal wound , so, non-absorbable 3. Haematoma of the wound
ry
4. The nature of the 1 disease for sutures as polypropylene are 4. Surgical site infection is the
which the operation was performed, recommended & good bites should be most important factor , tissues
e.g., patients with abdominal taken on either side of this layer become friable due to collagen
malignancy are usually malnourished 5. Insertion of drainage tubes through the lysis allowing the sutures to cut
and patients with peritonitis will have main wound through them
abdominal distension and wound
sepsis
Types :
Partial Complete Evisceration Dehiscence
deep layers burst but if the intestine prolapses out of the if the intestine is retained inside
the skin is intact wound the abdomen
incisional hernia
Clinical features :
“Red sign” Onset Symptoms
- warning sign to the occurrence of burst 6 to the 8 th th
- patient often feels as if something
- serosanguinous discharge soaks the dressing day post- gives way
- due to straqgulation of a piece of omentum or a loop of bowel operatively - Symptoms of intestinal obstruction
which is prolapsed through a defect in the muscles may be present
Treatment : Urgent surgical closure 1- Cover the prolapsed bowel by a sterile dressing
2- Insert a nasogastric tube and start an IV infusion 3- using general anaesthesia, wash protruding loops
with saline & return them to abdominal cavity, omentum is spread over intestine, abdominal wall is closed as
one layer by through-and-through sutures, using strong non-absorbable polypropylene “Retention sutures”
as they are retained for at least three weeks + Care should be taken not to puncture a loop of bowel
4- Antibiotics are prescribed and an abdominal binder is recommended
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Minimal Access surgery
- many operations can now be performed through natural body orifices via fibre-optic endoscopy
fine stabs for introducing rigid endoscopes into
peritoneum
laparoscopy for abdominal surgery pleura
Frequently performed Iaparoscopic operations: joint cavities
1- Cholecystectomy 2- Appendicectomy 3- Inguinal hernia repair 4-Bariatric surgery
Tubal ligation
5- Fundoplication for gastro-oesophageal reflux 6- Gynaecologic operations :
Tubal adhesiolysis
Steps : 1- General anaesthesia
2- Insufflation of peritoneal cavity with CO2 using Veress needle that possibility of puncturing viscera during
its introduction ---> gas in peritoneal cavity makes space between ant. abdominal wall & viscera --> allows
visualization of organs & manipulation of instruments
3- Insertion of a trocar & cannula ( usually at umbilicus ) ,then trocar is removed while cannula (port) is used to
introduce telescope that is connected to a video camera ---> displays its its image on monitor ---> allows the
surgeon & assistants to see the interior of abdominal cavity
4- Inspection of peritoneal cavity
5- Insertion of other ports under direct vision through abdominal wall to allow introduction of instruments for
dissection , coagulation , retraction & cutting
Advantages Drawbacks
1. Minimal postoperative pain 1. Need for well-trained surgeons
2. Minimal impairment of pulmonary functions 2. High cost of the equipment
3. Fast recovery and early return to normal activities 3. Postoperative shoulder pain, which is caused by
4. Ability to visualize and explore the whole abdominal and irritation and stretching of the diaphragm by CO2
pelvic organs
5. Video recording of the operative procedures with obvious
educational advantages
6. Better appearance and decreased wound problems as
dehiscence or infection
Conversion of laparoscopic surgery --> conventional open surgery in the following situations :
1- Equipment failure considering the safety of patient is the absolute priority
2- Dense adhesions or anatomical abnormalities precluding safe performance of procedure
3- Uncontrolled bleeding 4- Accedintal injuries reqiring open repair
Diagnostic laparoscopy : rapidly gaining popularity in certain situations
to determine cause of acute lower to determine extent of malignant to detect the exact
abdominal pain , e.g. : acute pelvic disease , e.g. : small liver injuries in blunt
appencicits or torsion of an ovarian cyst secondaries or peritoneal nodules abdominal trauma
Diseases of abdominal wall
Diseases of umbilicus 7 : fistula - sinus - stone - polyp - granuloma - hernia - tumors
Umbilical fistula Umbilical sinus Umbilical stone
1- Faecal fistula : - congenital from patent vitello-intestinal duct - discharges pus - due to chronic inflammation
-traumatic -inflammatory from TB of small intestine - due to abdominal of umbilicus or from umbilical
-malignant from carcinoma of transverse colon that ulcerates wall abscess or granuloma
2- Urinary fistula : -congenital from patent urachus umbilical infection - should be removed
-rarely acquired - Pilonidal sinus of - granuloma is excised by diathermy
3-Biliary fistula : -very rare - due to operative bile duct injury umbilicus is rare --> & antiseptics applied
in cholecystectomy persistent discharge
Umbilical polyp Umbilical granuloma Umbilical Tumors

Umbilical Hernia
- due to persistence of the umbilical extremity - mass of granulation tissue 1. SCC : rare & gives metastasis to axillary
of the vitello- intestinal duct which becomes due to chronic infection of & inguinal lymph nodes on both
everted outwards umbilical scar sides
- irritative hyperplasia of epithelial - should be curetted & 2. 2ry carcinoma nodules :may be present
surface from friction --> polypoidal then cauterized by silver at umbilicus due to spread from
mass at bottom of umbilicus nitrate carcinoma of stomach , pancreas, liver
- should be excised or breast
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Desmoid Tumor
Pathology : -nature is not exactly known & may be considered as locally malignant fibrosarcoma
-it arises from the anterior or less commonly the posterior rectus sheath , or from the anterior abdominal wall
muscles -may occur on top of scars or incisions
-may be associated with intestinal polyposis “Gardner’s syndrome”
-Gross : non-encapsulated - slowly growing - infiltrate surroundings - pinkish white in cut section
-Microscopic : formed of cellular fibrous tissue
Clinical features : -usually affects females about age of 40 years
-patient presents by : painless - hard - ill-defined - slowly growing mass of abdominal wall with nodular surface
Treatment :
EXCISION with safety margin of at least one inch & RECONSTRUCTION of defect by flaps of fascia or synthetic
mesh BUT recurrence is very common if not adequately excised
Hematoma of rectus sheath due to trauma --> rupture of inferior
Clinical features : - pain - tenderness - swelling over rectus muscle epigastric vessels
Treatment : -if large --> evacuation of hematoma & ligation of epigastric vessels
General principles of
external abdominal hernias
Definition : protrusion of a viscus or part of it ,usually within a peritoneal sac, through an abdominal wall defect
Aetiology : Congenital (preformed) sac Acquired causes
- unobliterated processus vaginalis --> congenital inguinal - Raised intra-abdominal pressure due to : chronic cough,
hernia straining at micturition or stools , heavy work, obesity or
huge abdominal swelling (splenomegaly or pregnant uterus)
- unobliterated physiological umbilical hernia of fetus --> - Weak abdominal wall due to : obesity , senility , debility ,
congenital umbilical hernia (exomphalos) pregnancy , weak scar & damaged n. supply of muscles
Components :
Sac Contents Coverings
-peritoneal pouch which bulges out -any abdominal viscus can protrude out into sac except pancreas -structures that
through abdominal wall defect -usual contents are intestine, omentum or both are stretched over
-it has a neck (junction with peritoneum), -contents pass out through a defect in abdominal wall the sac
body & fundus -reduction of hernia means reduction of its contents into peritoneal
cavity while empty sac remains in place
Special Contents
Richter’s hernia Littre’s hernia Maydl’s (W) hernia Urinary bladder (Sliding hernia)
-content is part of -content is -contains 2 loops of -part of it may protrude into inguinal or
bowel Meckel’s intestine while an femoral hernia
circumference diverticulum intermediate loop lies -usually protrudes along inner side of
- common in in peritoneal cavity sac lying outside it forming a
femoral hernia SLIDING HERNIA
Diagnosis : when a clinical diagnosis of hernia is suspected , 7 questions need to be answered :

1- Is this swelling a hernia ? hernia is characterized by a) present at one of anatomical sites e.g. : inguinal,
exact site femoral, umbilical, epigastric or incisional
2- Which type ? depends on special features b) has an expansile impulse on cough EXCEPT if
3- What are the contents ? special tests strangulated
POC Intestine (enterocele) Omentum (omentocele) c) reducible EXCEPT if (irreducible-obstructed-
strangulated)
Consistency soft doughy
d) opaque by transillumination EXCEPT in infants
Gurgling during reduction none 4- Is it Complicated ?
5- Is there any causes for intra-abdominal P or weak
ease of 1st part is more difficult last part is more
reduction to reduce than last difficult to reduce abdominal wall ?
-History & examination of chest,abdomen,UT & anus are essential
Percussion may be resonant dull -such causes should be ttt before hernia operation
-Weak abd. ms presents by: a) Multiplicity of hernias
6- Is there any other hernia ? cardiac complications b) Divarication of recti
7- Is patient fit for surgery ? respiratory complications c) bulge of lower abd. on straining
-History & examination for the following before surgery HTN & DM (Malgaigne bulge)
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avoid complications of hernia
Treatment : 1- Operation is always advised to
- Uncomplicated hernias are prevent its progressive enlargement which widens the
repaired by elective surgery after defect & weakens musculoaponeurotic layers around it
eradication of predisposing factors
2- It is better to avoid truss to control herniation BUT may be used for extremely unfit patients
Herniotomy (herniectomy) Herniorrhaphy Hernioplasty
-excision of sac -entails herniotomy -entails herniotomy & closure of defect without tension using imported
-done alone or as part of & repair of defect material ,which are not from the vicinty of the defect
herniorrhaphy or hernioplasty by approximation -this material may be tissues from distant parts of the body, e.g., fascia lata
of local tissues or synthetic material. The usual example is the use of synthetic mesh,
e.g., polypropylene
- No-tension repair by mesh hernioplasty is popular nowadays as it has the
lowest incidence of hernia recurrence
Complications : N.B. : hernia complications are those of contents 6 complications as follows :
Irreducibility Obstruction Inflammation
- failure to return contents into abd. -occurs in irreducible hernias -uncommon & means inflammation of contents
-causes: a) Adhesions forming within due to occlusion of intest. -causes: rough taxis - ill-fitting truss - spont. inf. of
sac either between contents & sac lumen from without or from contents (appendix-fallopian tube-ovary)
or between contents themselves within -clinical features: tenderness BUT NOT tense &
b) Protrusion of more omentum
within sac
-if purely obst. --> bl. supply is
unaffected
Strangulation overlying skin is red & oedematous
-ttt : operation is essential as strangulation can’t be
-presidposes to obstruction & -symptoms of intest. obst. are excluded
strangulation,so operation’s essential vomiting-distention-colics &
-if without other symptoms of obstruct. constipation Hydrocele of the hernia sac
---> diagnostic of an omentocele -picture simulates strangul. but
less severe -in narrow-necked sacs if contents return to abdomen
-locally, hernia becomes & fail to descend in sac again
distended, irreducble BUT still -neck becomes occluded by omentum & serous fluid
soft collects in sac
-Distinction between it & -clinically : cystic swelling in upper part of spermatic
strangulation may be difficult cord
so it’s safer to ttt it as strang.
& performing an early surgery
Torsion of the omentum
Strangulated hernia most serious hernia complication

Definition : contriction of contents --> interruption of their bl. supply & if not relieved --> gangrene within hrs
Incidence : - varies according to type of hernia 2-4% : inguinal - Strangulation may occur at any age
- Although it’s higher in femoral hernias , 3-5% : incisional
& is commoner after prolonged use
yet, strangulated inguinal hernias account 15-20% : paraumbilical
25-30% : femoral of a truss
for 50% of all strangulated ext. hernias
Causes : 1- Straining --> extrusion of new contents 2- Repeated reduction attempts --> Oedema
Pathology : constricting agent may be superficial inguinal ring
a resistant structure outside sac as deep inguinal ring
neck of the sac Gimbernat’s ligament
bands of adhesion within sac
Consequences : if contents are intestine

proximal intestine Strangulated loop distal
intestine
-Obstructed 1- Impeded venous return : it becomes congested & distended with accumulating gas & fluid -collapsed
-progressive ( congestion secretions & absorption ) , increased congestion --> Hge in intest. wall ,
Distention into its lumen & from its surface into sac
2- Later, Impaired arterial supply & devitalized intestine exudes its content(fluid-blood-
-Hyperperistalsis
bacteria) through its wall to sac and so it contains dark highly toxic fluid
3- Finally, Gangrene occurs : starts at constriction ring --> affects antimesenteric border
(convexity) of loop --> perforation may occur at these sites & later gangrene affects whole
loop & its mesentery
4- Peritonitis is the terminal event , as there is infection spread from sac to peritoneum
--> septic shock & dehydration in neglected cases --> death
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Clinical Features :
Symptoms Signs
1- Acute pain in the hernia General examination Local examination
2- Sudden enlargement --> bigger hernia
3- Irreducibility (hernia which used to disappear on -usually shows no abnormality except -Hernia is :
lying down or by pressing it ) now fails to reduce , in neglected cases where shock a) Tense
sometimes a hernia presents for the 1st time by (hypovolemic or even septic) exists b) Tender
strangulation c) Irreducible
4- If hernia contains intestine --> symptoms of intest. d) No impulse on cough
obstruction (colicky abd. pain-vomiting-absolute
constipation-distenaion)
N.B.: Intest. Obst. is NOT present if content is :
a) omentum
b) part of bowel circumference”Richter’s hernia”
c) Meckel’s diverticulum “Littre’s hernia”
Treatment : URGENT SURGERY
Preoperative preparation Postoperative management
-as any case of intestinal obstruction 1- Nasogastric tube suction & IV fluids continued until intestinal
1- Nasogastric tube suction sounds are audible
2- IV infusion of lactated Ringer’s solution to correct hypovolemia 2- Prophylactic antibiotics
3- IV broad spectrum antibiotics to guard against septicaemic shock 3- Drains removed when they stop discharging (usually 5-7 days)
1. incision should 2. fundus of sac STEPS 5. Dealing with 7. SC drains

be planned to is opened at 1 3. constricting ring is divided
st
contents are usually
4. contents are
expose the to evacuate toxic & a grooved director or left needed
pulled out &
fundus of sac fluid that is full of finger inserted inside ring
examined, that
organisms 6. repair of hernia
& its coverings are divided is important so
defects via
from outside till constriction as not to miss a
polypropylene
is relieved strangulated
sutures which
Maydl’s hernia
are inert with
viable intestine non-viable intestine no inflammatory
1.Normal Luster 1.Lusturless reaction
2.Pink 2.Grey or Black a) omentum c) resection &
3.Pulsating mesenteric arteries 3.NOT Pulsating b) viable
always excised intestine 1ry
anastomosis
4.Bleeds if injured 4.Does not bleed of gangrenous
5.Firm 5.Flabby & thin returned to
abdomen small intestine e) if suspicious intestine,
6.Contracts if pinched 6.No response apply warm packs and
give pt oxygen for few
d) resection of gangrenous segment of colon and
minutes , then decision is
clostomy BUT anastomosis of unprepared colon is
taken whether intestine is
better avoided,in such cases elective anastomosis
viable or gangrenous
after colon preparation is done after few weeks
Sliding Hernia
bladder
Definition : a hernia where a viscus forms a part of wall of sac , commonest are caecum & common in
sigmoid colon
Clinical Features : - usually a longstanding hernia in an obese elderly man old-standing hernias
- hernia is usually complete oblique inguinal males
old age
- hernia is partially reducible , after reduction of contents there is still fullness at site of hernia
- Urinary symptoms are present e.g. : pressing hernia --> desire to void - double micturition -
reduction of hernia size after micturition
Treatment :
- DO NOT try to dissect sliding viscus from sac --> devascularization or injury of viscus
- FREE the sliding sac & viscus from surrounding structures & push them back behind transversalis fascia + repair
of transversalis fascia + strong repair to inguinal canal using mesh if required
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Surgical anatomy of inguinal region

layers of abdominal wall in inguinal region
-They are 6 layers (from superficial to deep as follows) : 1-Skin 2-Superficial fascia 3-External oblique muscle
4-Internal oblique muscle 5-Transversus abdorninis 6-Transversalis fascia
Superficial fascia Transversalis fascia
-composed of a superficial faty layer ( Camper’ fascia ) & a -thin but strong fascial layer that lies in front of the
deep membraneous layer ( Scarpa’s fascia ) which allows peritoneum
free gliding of fat over the muscles -most important defense against hernia formation
-superficial fascia of the abdomen does not communicate -its lower part is thickened forming the iliopubic tract
with the corresponding layer of thigh due to the presence which runs just above and parallel to the inguinal
of an inguinal crease where skin is attached to deep fascia, ligament
one inch below inguinal ligament -its upper part is thickened forming the arch of the
-No deep fascia is abdominal wall to allow for free transversus abdominis which lies at the lower border of
respiratory movements , gastric fullness & pregnancy the transversus muscle
External oblique muscle Internal oblique muscle Transversus abdorninis
-origin : arises by fleshy digitations from the -origin : arises by fleshy digitations -origin : lower part arises by
lower 8 ribs from lateral half (or two thirds) of fleshy fibres from
the reflected surface of the the lateral third of
inguinal ligament the ing. ligament
-course: run downwards and forwards, and -course & insertion: -course & insertion :
become aponeurotic from the level of - its lower border covers the deep - arches horizontally
the umbilicus down to its free lower inguinal ring and the beginning of higher than the internal
border which is infolded & thick and the spermatic cord oblique to be inserted
is called inguinal (Poupart’s) ligament - It arches horizontal!y above the through the conjoint
cord and fuses with the lowest fibres tendon in the pubic
-inguinal (Poupart’s) ligament : of transversus muscle to form the tubercle & iliopectineal
- stretches between the pubic tubercle conjoint tendon which, passes line
medially & the A.S.I.S laterally vertically downwards behind the
- its free posterior margin fuses with cord to be inserted into the pubic
lower ends of fascia transversalis and iliaca tubercle & iliopectineal line
- in its medial fourth, its infolded part is
thick and is attached to the iliopectineal
line of the pubic bone to form the lacunar
(Gimbernat’s) ligament
-thus, the infolded surface of the inguinal &
lacunar ligaments makes a floor for the
spermatic cord
-it is convex downwards, being attached
to the deep fascia of the thigh (fascia lata)
Inguinal canal Development : by the passage of the testis from the abdomen to the scrotum
Dimensions and site : - in adults the canal is 1.5 inches (4cm) long
-course : extends obliquely downwards, medially and forwards in the lower and lateral part of the anterior abdominal
wall from the deep to the superficial inguinal rings (above the medial half of the inguinal ligament)
Contents : -sperrnatic cord (round ligament in female) -ilioinguinal nerve
Inguinal rings :
Deep inguinal ring. Superficial inguinal ring
-opening in the transversalis fascia 1/2 inch above -triangular opening in the external oblique aponeurosis
midinguinal point (midway between the symphysis pubis that is situated half an inch above & medial to the pubic
and the A.S.I.S tubercle
-inferior eigastric vessels run medial to it -bounded by the pubic crest below and the medial and
-covered anteriorly by the lower border of the internal lateral crura which are joined by intercrural fibres
oblique muscle -normally it does not admit the tip of the little finger
-it is an exit for the spermatic cord and the ilioinguinal
nerve
-it is backed by the conjoint tendon
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Boundaries : constitute the relations of the spermatic cord
Posteriorly Anteriorly Superiorly Inferiorly
-fascia transversalis -external oblique aponeurosis -conjoint muscles -infolded surface of ing. lig.
-inferior epigastric vs laterally -lower part of internal oblique ms ( int. oblique & with the upper surface of
-conjoint tendon medially laterally transversus) lacunar lig. medially
Spermatic cord
Course Constituents Coverings
-begins just deep to the deep 1. Vas deferens -has three coverings which are derived
inguinal ring by gathering of 2. Testicular artery from the penetrated layers of the
its constituents 3. Pampiniform plexus of veins (testicular abdominal wall during testicular descent
-enters the deep ring ,traverses veins) -they surround the testis & cord like
the inguinal canal and exits 4. Artery of the vas 3 sockets
from the superficial ring 5. Testicular lymphatics 1. internal spermatic fascia: derived from
-then passes down in front of 6. Genital branch of genito-femoral nerve transversalis fascia at the deep ring
the pubic bone, crosses the 7. Testicular autonomic nerves 2. cremasteric muscle and fascia : derived
scrotal neck and enters the 8. Vestige (remnant) of processus vaginalis, from the lower border of the internal
scrotum where it is attached to which is anterolateral to the vas and the oblique muscle as it overlies the deep
the top and back of the testis vessels ring & cremasteric muscle is supplied
by the genital branch of genitofemoral
N.B. :All the structures of the cord are nerve and it acts to elevate the testis
embedded in loose fat and areolar tissue 3. external spermatic fascia: derived from
the external oblique aponeurosis at
the superficial ring
Anatomical basis of inguinal hernia

Causes of weaknes of anterior abdominal wall Protective mechanisms
1. Muscles of the abdominal wall in the inguinal 1. Obliquity of the inguinal canal
region are aponeurotic & therefore, this area is 2. Transversalis fascia although thin, is a strong layer that supports
weaker than the fleshy parts of the abdomen. the posterior wall
2. Internal oblique and transversus abdominis 3. Weak parts of the canal are supported by strong structure:
muscles arch up to form the roof of inguinal - deep inguinal ring is reinforced by condensation of the
canal transversalis fascia and by the fleshy fibres of lower part of
3. Spermatic cord passes between the muscles and internal oblique in front of it
adds more weakness to the inguinal area - superficial inguinal ring is supported by the conjoint tendon
posteriorly
4. Shutter mechanism : -During contraction of the abdominal
muscles, the lower border of the conjoint tendon straightens
& descends downwards toward the inguinal ligament, thus
closing the posterior wall
5. Valvular mechanism : -Contraction of the external oblique ms
tightens its aponeurosis and narrows the superficial ing. ring
6. Cremasteric mechanism : -Contraction of the cremasteric
muscle plugs the superficial inguinal ring and causes bulging
of the spermatic cord in the middle third of inguinal canal
leading to its obliteration
7. Contraction of the transversus abdominis muscle pulls and
tenses the edges of the internal ring
Oblique (indirect) inguinal hernia due to the presence of an

unobliterated processus vaginalis
Aetiology : sac of an oblique inguinal hernia is either : Congenital (preformed) sac
Anatomy of oblique inguinal hernia : Acquired (pulsion) sac
due to raised intra-abdominal
1. The hernia defect is the stretched deep ring pressure and weak abdominal wall
2. The hernia sac (congenital or acquired) escapes from deep ring and lies always inside the cord within the coverings, being
anterolateral to the vas and vessels 3. The contents are usually small intestine, omentum or both
4. Coverings : a. In the inguinal region the coverings include the skin, superficial fascia, external oblique aponeurosis, then the two
cord coverings in this region; cremasteric muscle and fascia and internal spermatic fascia
b. In the scrotum the coverings include the skin, non fatty superficial fascia containing the dartos muscle then the 3
cord coverings;external spermatic fascia, cremasteric muscle and fascia and internal spermatic fascia
َ ْ َ ْ ُّ
Anatomical types :
Congenital type Infantile type (operative finding) Adult type
a. It is due to persistence of - tunica vaginalis extends upwards to the -which may be :
the whole processus external ring, so that the sac passes down a. Bubonocele : i. The hernia is limited
vaginalis, hernia reaches behind it to the inguinal canal and is seen as a
down to the bottom of the - at operation, the tunica is liable to be bulge or a swelling in the groin
scrotum (scrotal or complete opened in mistake for the true sac which ii. The processus vaginalis is
hernia) will be found behind it (two sacs) obliterated at the superficial inguinal
b. The testis lies among the ring
contents of the sac, i.e., the b. Funicular hernia : hernia reaches down
testis lies within the lower to the neck of the scrotum
part of the hernia i. The processus vaginalis is closed
c. Although called congenital, it only at its lower end, just above the
may appear in adult life epididymis.
ii. The tunica vaqinalis is normal
and the sac represents the
proximal part of processus
vaginalis only
iii. The testis can be felt separate
from the hernia and below it
c. Complete (scrotal) hernia :
i. The hernia descends to the
bottom of the scrotum
ii. The testis is behind the hernia
and is difficult to locate
Clinical features : 1. Painless inguinal or inquino-scrotal swelling , sometimes there is mild groin pain in early stages.
The presence of severe acute pain indicates a complication
2. Swelling shows an expansile impulse on cough and is reducible
3. Site: it may be limited to the inguinal canal forming an inguinal swelling (bubonocele) or it may extend to the scrotum
forming an inguino-scrotal swelling (funicular and scrotal types). Inguinal hernias lie above the inguinal ligament, and
above and medial to the pubic tubercle. In contrast femoral hernias lie below the inguinal ligament, and below and
lateral to the pubic tubercle
4. Direction of descent of contents is downwards, forwards and medially
5. Direction of reduction is obliquely upwards, laterally and backwards
6. Shape: the swelling is oblong with a narrow neck and wide fundus
7. Internal ring test to differentiate oblique from direct hernia. This test is not needed if the hernia is scrotal as in such
case it is sure to be of the oblique variety : a. The patient lies down and flexes the knees to relax the abdominal ms
b. The hernia is reduced by grasping it by one hand, and squeezing it upwards and laterally, while other hand
manipulates at the external ring to push the contents backwards
c. The deep ring is determined. It lies half an inch above the mid inguinal point
d. The deep ring is pressed by the thumb and the patient stands up and coughs; an oblique hernia does not come out
except after release of the thumb while a direct hernia comes out despite occluding the internal ring, as it comes
directly from posterior wall of inguinal canal
Treatment : -Surgery is necessary because of the risk of strangulation
-BUT truss is indicated only if there is a contraindication to surgery
-Preoperative preparation : Treat any cause of increased intra-abdominal pressure as difficulty in micturition, bronchitis,
ascites, abdominal swellings, or obesity.
-Types of surgery : A. Herniotomy B. Herniorrhaphy C. Hernioplasty (see table next page)
Recurrent inguinal hernia a. Leaving a part of the original sac, i.e., failure
Aetiology : 1. causes leading to incisional hernia to ligate the sac at the proper neck
2. specific causes b. Missing of a direct hernia sac which was
N.B. : In most of the patients with a recurrence after a repair of an present in addition to the oblique one
oblique inguinal hernia, the recurrence will be in the medial end c. Failure to do the proper repair, e.q. doing a
of the repair and will present as a direct inguinal hernia Bassini’s repair in a patient with a weak conjoint
tendon or doing the repair under tension.
Treatment :
1. Correction of any predisposing factors. A truss may be applied until the patient is fit for surgery
2. Hernioplasty by a synthetic mesh is usually performed
َ ْ َ ْ ُّ
inguinal hernia in infants & children

1. Hernia is always due to presence of preformed sac 2. always of the oblique type
3. operation can be done at any age provided a skilled anaesthetist is available
4. Herniotomy alone is performed. In infants the operation can be performed through the external ring without the need
to open the inguinal canal
5. Recurrence is rare and is due to failure to ligate the sac at the proper neck
6. If strangulation is neglected, testicular atrophy may occur
Herniotomy Herniorrhaphy Hernioplasty

-excisron of the sac only and is pertormed in cases -indicated for hernias of adults -means obliteration of the hernia defect
of hernias in infants and children -The idea is to strengthen the using tissues which are not from the
-Technique : posterior wall of the ing. canal vicinity of the hernia
1. Anaesthesia: General, spinal or local -Excision of the sac (herniotomy) -generally indicated whenever the defect
2. Inguinal incision is made half an inch above should be done first is very wide (any repair under tension is
and parallel to medial two thirds of the inguinal -As a rule, repair of any hernia doomed to failure) or When the
ligament. The two layers of the superficial fascia defect (hemiorrhaphy) should be musculoaponeurotic boundaries are too
are incised performed by nonabsorbable weak to hold sutures. Currently
3. The external oblique aponeurosis is incised in suture material as prolene hernioplasty is gaining popularity for the
the direction of its fibres and the superficial ring -In all patients , plication of the treatment of all adult inguinal hernias
is slit open. The spermatic cord is seen lying in fascia transversalis & because it is not associated with tissue
the canal with the conjoint tendon arching over reconstruction of the internal ring tension and consequently has the lowest
it. The ilioinguinal nerve traverses the canal in with lateral displacement of the recurrence rate
front of the cord and comes out through the cord are performed , placating
superficial ring. In infants, the inguinal canal is sutures pass through the arch of -Onlay mesh hernioplasty.: After excision
short and the superficial ring lies opposite the transversus abdominis superiorly of the sac a mesh which is made of
deep ring. There is no need to open the and the iliopubic tract inferiorly, synthetic material is placed behind the
external oblique because the surgeon can then an additional procedure spermatic cord, and is fixed to the
easily reach the neck of the sac without is added, and in any of them the transversus abdominis and its
opening the inguinal canal repair should not be under aponeurotic arch superiorly, and to the
4. The upper flap of the external oblique tension iliopubic tract and the inguinal ligament
aponeurosis is dissected up to expose the inferiorly. The interstices of the mesh will
conjoint tendon. The lower flap is dissected -Bassini’s repair : the ing. lig. is be impregnated with a dense sheet of
down to expose the infolded surface of inguinal sutured to the aponeurotic part of fibrous tissue. This operation is called
ligament the conjoint tendon behind the “Lichtenstein tension free mesh repair”
5. The cord or the round ligament is elevated to spermatic cord, to be successful,
clear the posterior wall of the canal ( transversalis the gap between the two -Preperitoneal hernioplasty : In this case
fascia and the conjoint tendon medially) structures should not be wide and the mesh is placed between the
6. The coverings of the cord (cremasteric muscle the conjoint tendon should be peritoneum and the fascia transversalis.
and fascia then the internal spermatic fascia) strong This can be achieved either by open or
are opened longitudinally. The hernia sac is -This operation is performed for by laparoscopic surgery
identified by its opaque pearly white colour, young patients
definite edges and crescentic fundus. It lies -Previous operations as shouldice
anterolateral to the vas and vessels. The sac is or McVay’s repair are not commonly
dissected up to its neck which is identified by performed now
the presence of the inferior epigastric vessels at
its medial side, by being the narrowest part of
sac and by the presence of extra peritoneal fat incisional hernia
7. The sac is opened at its fundus and explored.
Adherent intestine is separated and returned to -hernia that develops at the site of a previous abdominal incision
the abdomen. Adherent omentum is excised. -the aetiology and clinical picture have been discussed before
A finger is passed in the sac to explore for the -the commonest cause is surgical site infection
presence of a direct or femoral hernia Treatment :
8. A transfixation ligature is applied to the neck. -If the patient is unfit for surgery and provided the hernia is reducible ---> an
The sac is divided leaving a half inch stump abdominal binder will keep hernia reduced
distal to the ligature to avoid its slipping. The -Surgery offers the only definitive cure
stump retracts up to lie flush with peritoneum -Many operation are available, but it is to be stressed that any repair under
9. The cord is returned back in place and its tension is doomed to failure
coverings are stitched 1. Anatomical repair : The idea is to expose the hernia defect, remove sac
10. The external oblique aponeurosis is closed. and then repair the abdominal wall in layers according to the site of the
Medially, it is sutured comfortably around cord incision. If the sac has a wide neck it is not necessary to excise. It is just
thus narrowing external ring if wide pushed inside and is covered by the repair.
11. Skin closure by silk 2. Hemioplasty : If the hernia defect is wide or the musculoaponeurotic
edges are weak, it is recommended to perform hernioplasty using a
synthetic mesh
َ ْ َ ْ ُّ
direct inguinal hernia

Aetiology : common in elderly males - often the patient has weakness of the lower abdominal muscles with chronic
cough or straining due to urinary problems.
-Injury of the ilioinguinal nerve during appendicectomy --> paralysis .of conjoint tendon --> direct ing. hernia
Pathology : Direct inguinal hernia protrudes through Hasselbach’s triangle which is bounded medially by lateral border
of rectus muscle, laterally by the inferior epigastric vessels and inferriorly by the medial half of the ing. lig.
Clinical features : -usually affects old males -bilaterality is commom -complications are unusual
POC Olique Direct
Age Any age Elderly
Side uni or bilateral commonly bilateral
Shape oblong hemispherical
Direction of Descent downwards-forwards-medially forwards
Direction of reduction upwards-backwards-laterally backwards
Descent to scrotum may occur very rare
Size may attain large size usually small
Complications liable to occur rare
Internal ring test hernia does not protrude hernia protrudes
relation of sac neck to inf. epigast. a. lateral to artery medial to artery
at operation
Treatment: ESSENTIALLY SURGICAL
1. Removal of the cause of straining e.g.: In an elderly male with senile enlargement of the prostate, prostatectomy
should precede hernia repair
2. Operation: Herniotomy is not usually needed as the sac is small and is composed mainly of extraperitoneal fat.
Repair of the weak posterior wall of the inguinal canal by plication of the fascia transversalis and mesh hernioplasty
is indicated
3. truss may be indicated if the patient is not fit for surgery
it is the most medial compartment of femoral sheath
Femoral hernia
the intermediate compartment is occupied by the femoral
Surgical anatomy of the femoral canal :
vein and the lateral one by the femoral artery
it is about 1/2 inch long
Contents of femoral it is cone shaped, its mouth (femoral ring) is open upwards behind the
Its function is to canal are fat, lymphatics inguinal ligament & its apex is below & is formed by fusion of the medial
give a space for and one lymph node of border of femoral sheath and the septum between the femoral canal and
expansion of the Cloquet the femoral vein Anteriorly : ing. ligament
femoral vein Relations of the femoral ring : Posteriorly : pectineal fascia & lig.
Laterally : femoral vein
Femoral hernia components: Medially : lacunar ligament
Sac Contents Coverings
-proceeds downwards in the femoral canal then -femoral hernia usually 1. Stretched femoral septum
forwards stretching the cribriform fascia then contains omentum,bowel of 2. Transversalis fascia from the anterior wall of
upwards and laterally towards inguinal ligament only part of the the canal
-The neck of the sac is narrow, therefore femoral circumference of bowel 3. Cribriform fascia 4. Superficial fascia. 5. Skin
hernia is liable to irreducibility and strangulation (Richter’s hernia)
which are common
Clinical features : -more common in females especially after repeated pregnancies -gives an expansile impulse on cough
-presents as a rounded swelling, below the medial part of inguinal ligament, and below and lateral to the pubic tubercle
-direction of reduction is downwards then backwards and finally upwards
-Pressure on the saphenous opening obliterates the impulse and prevents descent of the hernia, BUT pressure on the internal
inguinal ring fails to do so
-femoral hernia may present for the first time with strangulation ---> acutely painful groin swelling and sometimes features of intestinal
obstruction & the hernia is tense, tender, irreducible with no impulse on cough
َ ْ َ ْ ُّ
Differential Diagnosis : Reducible femoral hernia Irreducible femoral hernia
1- Inguinal hernia 1. Irreducible inguinal hernia
2- Saphena varix 2. Lipoma
3- Aneurysm of the femoral artery 3. Inguinal lymphadenopathy
4- Psoas abscess 4. Iliopsoas bursa
Treatment : -A truss is contraindicated due to the possibility of strarngulation -Surgery is the only line of treatment
Approach : 3 approaches for the repair

low approach high approach (Lotheissens operation) preperitoneal approach
-incision is 1/2 inch below and -incision is made above and parallel to the -suitable for both the uncomplicated and the
parallel to the inguinal lig. medial 2/3 of the inguinal ligament (similar to complicted femoral hernias.
-The sac is transfixed as high as that of inguinal hernia) -It is either done through a lower midline
possible and the femoral ring -The external oblique aponeurosis is incised so incision or a pararectal incision (McEvedy’s
is closed by suturing the ing. to that the inguinal canal is opened and the cord is operation) at the outer border of the lower
Cooper’s ligament isolated upwards part of the rectus abdominis. The latter is
-Transversalis fascia in the floor of inguinal canal extended down to beyond the inguinal lig.
is incised medial to the inferior epigastric vessels in case of strangulation, to empty the sac of
exposing the peritoneum and the neck of the its toxic contents before releasing the
sac as it enters the femoral canal strangulation agent
-The abdominal incision is deepened dividing
the fascia transversalis till the peritoneum
and the protruding sac are exposed
-sac is excised -defect (femoral ring) is obliterated by either Suturing the inguinal ligament (anterior
border of femoral ring) to Coopers lig.
(posterior border of femoral ring) by
interrupted polypropylene sutures
strangulated Femoral hernia Synthetic mesh as for inguinal hernia
-Strangulation is common because the neck of the sac is narrow and the constricting agent which is the crescentic edge of Gimbernat’s
ligament is sharp.
N.B. : Intestinal obstruction is absent if the content of the sac is omentum, Meckel’s diverticulum (littre’s hernia) or part of the
circumference of bowel (Richter’s hernia).
Treatment : - Urgent surgery, preferably by the McEvedy’s operation is indicated.
-sac is exposed, and the fundus is opened to evacuate the toxic fluid
-femoral ring is then exposed from above and the lacunar ligament is incised against the finger within the neck of sac
-In dealing with the lacunar ligament, avoid injury of the abnormal obturator artery which is present in 30% of cases
-contents are delivered above the inguinal ligament and are dealt with as usual
-During repair of a femoral hernia the surgeon should be aware of the femoral vein on the lateral side and of the urinary
bladder on the medial side
umbilical hernia 3 types : congenital - infantile - adult (seen in ascites patients)
1. Congenital UH (exomphalos) :
Exornphalos minor Exornphalos major

- small defect (less than 5 cm) is present at the - large defect (more than 5 cm) in the center of the abdom. wall,
umbilicus through which a small peritoneal sac usually above the umbilical cord
protrudes - contents may include many viscera and occasionally a part of the
- contents are usually intestine or Meckel’s liver
diverticulum - covering is only a layer of amniotic membrane
- coverings are a thin layer of Wharton’s jelly and a - there is a danger of rupture of the sac followed by peritonitis
layer of amniotic membrane -Treatment : is by urgent operation -Usually there is no room in
-Treatment : contents are reduced & returned to the abdomen to accommodate the contents
abdomen, the sac is excised & defect is repaired - If the sac is intact, the defect is closed by a synthetic mesh
in layers - If the sac has ruptured skin flaps are used
- skin on either sides of the defect is undermined creating skin
flaps which are brought together over the sac and sutured
- Release incisions in the flanks are needed
-After several months the peritoneum and muscles can be
approximated and closed in layers
َ ْ َ ْ ُّ
2. Infantile UH :
Aetiology Pathology Clinical features Treatment
-weakness of the umbilical -defect is exactly at the -there is umbilical protrusion -Reassurance of the parents &
scar from infection of the umbilicus which inc. with cough or follow-up are the usual measures
umbilical cord stump -umbilical scar is stretched crying -defect closes spontaneously within
-Increased intra-abdominal & is present at the top of -the edge of the defect can 2 yrs in most of cases
pressure from coughing the hernia be palpated as a firm ring -Correction of the cause of
or abdominal distension -neck of the sac is wide -Obst. & strangulation are straining, if any
and the coverings are rare below the age of 3 yrs -Operation is indicated when defect
extraperitoneal fat and -this type occasionally affects is more than 2 fingers wide or
umbilical scar adults when the hernia persists after the
age of two years
- A semicircular incision is done
below the umbilicus, and a skin
flap is turned upwards
- sac is transfixed and excised, and
the defect in linea alba is closed
with few stitches of prolene
2. Adult UH : principles of the treatment are the same as paraumbilical hernia
paraumbilical hernia
Aetiology : -more frequent in middle aged females, esp. in obese multiparous women
-it is actually paraumbilical and not umbilical hernia
Surgical pathology :
-para-UH defects lie in linea alba & in most cases it lies above umbilicus bec. linea alba is thinner & broader above than
below the umbilicus -Occasionally the defect is below the umbilicus -It is never lateral to it
-umbilical scar lies below the swelling, it is compressed by the hernia and looks like a crescent
-the sac has a narrow neck with a small defect in the linea alba & Adhesions inside the sac are very common especially at
the fundus, rendering the hernia irreducible
-Complications as strangulation and irreducibility are very common due to the narrow neck, sharp edge and adhesions
inside the sac
Clinical features : -painless swelling above the umbilicus --> expansile impulse on cough
-Mild dragging pain may be present in a huge hernia BUT Severe acute pain indicates strangulation
-frequently found to be irreducible or partially reducible & are liable to strangulation
Treatment : - Surgery is the only method of treatment
-truss is not satisfactory because the hernia is usually irreducible & its use carries high risk of strangulation
-For the obese reduction of weight is advised prior to surgery
-An elliptical transverse incision is made over the max. convexity of the hernia and skin flaps are undermined upwards
and downwards - sac is exposed and dissected down to the neck then sac is opened at its neck-because adhesions
are usually present at the fundus -contents are dealt with and reduced into the abdomen -sac is excised at the neck
-defect is then repaired: *If the defect is small --> closed by non-absorbable suture
*If the defect is large or the musculoaponeurotic layer is weak ---> a prolene mesh
*The previous Mayo’s repair is not commonly performed nowadays
EPIGASTRIC hernia -starts as a protrusion of the extraperitoneal fat through a defect in the
supraumbilical part of the linea aiba and is called “fatty hernia of linea alba”
-As the protrusion enlarges the fat pulls through the defect a small peritoneal pouch which may contain intestine or
omentum, and is called “epigastric hernia”
Clinical features : -may be symptomless -it may cause local pain or cause dyspepsia due to traction on stomach
-a swelling in the epigastrium which is soft, frequently irreducible & gives expansible impulse on cough
-Occasionally there are multiple hernias
Treatment : -If there is pain, the surgeon should be sure that it is not due to an underlying disease, e.g. peptic ulcer or
gallstones
-Operation is performed by excision of the protruding extraperitoneal fat and the hernia sac followed by simple closure of
the linea alba defect BUT if the defect is large ---> prolene mesh hernioplasty
-separation of recti due to stretching of the linea alba by a chronically
Divarication of recti raised intra-abdominal pressure
Clinical features : -common in middle aged females with repeated pregnancies and pts with ascites and splenomegaly
-if abdomen is relaxed --> nothing is visible BUT on raising the shoulders --> the linea alba bulges as a longitudinal
ridge and the fingers can be dipped into the abdomen between the two recti
Treatment : -abdominal belt is satisfactory in most cases
-Surgical repair is likely to fail until the cause of high intra-abdominal pressure is treated

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َ ْ َ ْ ُّ

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Types : Vertical incisions or Transverse incisions or Oblique incisions

POC 2) Transverse incisions 3) Oblique incisions

Umbilical polyp Umbilical granuloma Umbilical Tumors

Diagnosis : when a clinical diagnosis of hernia is suspected , 7 questions need to be answered :

Strangulated hernia most serious hernia complication

Consequences : if contents are intestine

1. incision should 2. fundus of sac STEPS 5. Dealing with 7. SC drains

Surgical anatomy of inguinal region

Anatomical basis of inguinal hernia

Oblique (indirect) inguinal hernia due to the presence of an

inguinal hernia in infants & children

Herniotomy Herniorrhaphy Hernioplasty

direct inguinal hernia

Approach : 3 approaches for the repair

Exornphalos minor Exornphalos major

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