Hernias

Definition :
Protrusion of abdominal content through a defect or weakness part on the abdominal wall Weak site : musculo -aponeurotic part Hernias consist of : ring sac content.

Types of Hernias of Abdominal wall

INGUINAL ABDOMINAL WALL Indirect inguinal, Direct inguinal, Femoral ANTERIOR ABDOMINAL WALL

Umbilical, Epigastric, Spigelian, Supravesical

PELVIC Obturator, Sciatic, Perineal

LUMBAR
Superior lumbar triangle (Grynfelt) Inferior lumbar triangle (Petit)

Anatomy of abdominal wall :

Inguinal Anatomy

Inguinal Hernia :
Incidence
Not known Western countries : 10-15%, Male : female = 12:1 Peak incidence : infant , adult : 40 - 60 years old Lichtenstein 1993: 700000 operations/year in USA

Etiology
Congenital or Acquired Three important factors
Existing preformed sac
Repetition of increased intraabdominal pressures

Weakness of muscle & aponeurotic tissues ~ time (age)

Types of Inguinal Hernia :

Clinical Manifestations :
Predisposition : occupation weight lifting Local symptoms:
reducible - irreducible lump
groin discomfort, pain

Systemic symptoms: Cardinal signs of obstruction

Colicky abdominal pain, vomiting, abdominal distention, and constipation.

Clinical Grading
Reduction Grade reponible irreponible incarceration + colic + pain Obstruction toxic

strangulation

steady increase

++
leucocytosis

Physical Examination

Position Temperature Pain Size Shape Tensile strength Composition (solid, gas, liquid) Changes with cough

Differential Diagnosis
Femoral hernia Vaginal hydrocele

Hydrocele of cord / canal of Nuck

Undescended testis

Lipoma of the cord

Treatment
Indication of Surgery
All groin/inguinal hernias
Minimal operative risks (~0)
Risk of untreated hernia : Strangulation with attendant risks concomitant medical problems do not preclude the need of undergoing surgery

Treatment :
1500 BC First reported case of groin hernia 700 AD Paul from Aegina
Hernial sac ligation Excision of hernial sac

Treatment :
1884 Edoardo Bassini (Italy)

Father of Modern Herniorrhaphy Dissection and reconstruction of the inguinal canal Splitting of obliqus externus aponeurosis Dissection & high ligation of hernial sacc Suturing the obl. int m., transv. Fascia, to inguinal ligament

Eduardo Bassini Herniorhhapy

Chester B McVay, MD, PhD 1940 (Coopers ligament repair)

S EE Shouldice, 1945

multilayer repair
recurrence rate < 1% complicated

extensive dissection

Tension Free = Mesh Graft

1987 : Gilbert

Ger 1990, Velez und Klein 1990

Laparoscopic Inguinal Hernia Repair Transperitoneal / preperitoneal

Femoral Hernia :
Incidence :
Female : Male = 4/1 Multiparous woman Elderly woman

Frequent complications : Strangulation, Richters hernia Treatment : Mc Vay Herniorraphy

Umbilical Hernia
Protrusion of abdominal content through the umbilical ring into the abdominal wall. Congenital defect

> 2 cm :
Regression (-) Often incarcerated Th/ : vest over pan, mesh graft

Epigastric hernia :
Protrusion of abdominal content through a defect in the linea alba. May mimic peptic ulcer Th/ reposition the sac, close the defect

Ventral Hernia
Incisional hernia : post operative Predispostion :
wound infection faulty technique wound dehiscence

obesity
malnutrition

Spigelian hernia :
Hernia at linea semilunaris Spigeli D/: USG Th/ Herniotomy and close the defect

Lumbar hernia :
Hernia :
Grijnfelt Petit

Th :
Herniotomy

Hernioplasty

Pelvic Hernia
Obturator hernia,:
Howship Romberg sign

DRE : hernial lump

Sciatic hernia Th/: operative

Perineal hernia
protrusion of tissues through the muscles and fasciae of the pelvic diaphragm. Anterior hernia: labial, pudendal, or vaginolabial Posterior hernia Th:transabdominal

Other Hernias :
Littre Hernia, Scrotal hernia Internal Hernia :
paraduodenal
mesenteric Foramen of Winslow Hernias Diaphragmatic hernia

The end