HERNIAS

Dr. Kosov E.V., Department of

Surgery
and OSTA
What is Hernia?
protrusion of an organ or the
fascia of an organ through the
wall of the cavity that
normally contains
ETIOLOGY AND PATHOGENESIS
 Hernias are divided into two main
groups: congenital and acquired.
The main reason of congenital hernias is
malformation. Thus, inguinal hernia
arose in case of noclosure of the process
of peritoneum, which passes by inguinal
channel during descending the testis. On
such hernias testis is located in the
hernia pouch. Acquired inguinal hernia
has hernia pouch and testis located
outside it.
 CLASSIFICATION

Depends on clinical presentations:

complete and incomplete
reducible and nonreducible
traumatic and postoperative
complicated and
noncomplicated.
 Reducible – if contents can be returned to
abdomen
 Irreducible – if contents cannot be returned
but there are no other complications
 Obstructed – if bowel in the hernia has good
blood supply but bowel is obstructed
 Strangulated – if blood supply of bowel is
obstructed
 Inflamed – if contents of sac have become
inflamed
 Incarcerated – if the portion of the colon
occupying a hernial sac is blocked with faeces
 Types of Abdominal Wall Hernias
Groin Hernias
- Inguinal Hernias
> Indirect Inguinal Hernia
> Direct Inguinal Hernia
> Combined (Pantaloon) Hernia
- Femoral Hernia

Pelvic Hernias
- Obturator Hernia
- Sciatic Hernia
- Gluteal Hernia
Anterior Abdominal Wall Hernias

- Umbilical Hernia
- Paraumbilical Hernia
- Epigastric Hernia
- Spigelian Hernia

Posterior Abdominal Wall Hernias

- Superior Lumbar Hernia

- Inferior Lumbar Hernia
External Abdominal Wall Hernias
 Etiologies
Increased abdominal pressure
Cough, urinary trouble, constipation,
straining, ascites, intra abdominal
malignancies, pregnancy
Weakness of abdominal wall
Congenital
Acquired
Excess fat (obesity)
Post Pregnancy
Surgical incisions
Connective tissue disorders like
Marfan’s syndrome
 Composition of a hernia
 A hernia consists of three parts :
 the sac
 the coverings of the sac
 the contents of the sac
 The sac is a diverticulum of peritoneum,
consisting of :
 Neck
 Body
 Fundus
The coverings are derived from the layers of the
abdominal wall through which the sac passes.
 Contents
 omentum = omentocele;
 intestine = enterocele; more commonly small
bowel but may be large intestine or appendix;
 a portion of the circumference of the intestine =
Richter’s hernia;
 a portion of the urinary bladder;
 ovary with or without the corresponding fallopian
tube;
 a Meckel’s diverticulum = a Littre’s hernia;
 fluid, as part of ascites or peritoneal fluid.
Groin Hernias
Inguinal Hernia (groin)
 75% of all abdominal wall hernias
 Occurs 25% more often in men than women
 2 types which occur both in the groin area
where the skin crease at the top of the thigh
joins the torso (inguinal crease):
 Indirect inguinal – hernia sac may protrude
into the scrotum; may occur at any age
 Direct inguinal hernia – middle-aged to
elderly as their abdominal walls weaken with
age
 Anatomy of inguinal canal
 4 cm in length passing downward and medially
from deep to superficial ring

 Deep/internal ring is ‘U’ shaped in fascia

transversus which lies 1.25 cm above the mid
inguinal point.

 Superficial/External ring is in external oblique

aponeurosis situated just above and lateral to the
pubic crest.
Anatomy of a Hernia
Boundaries of the inguinal canal
 Anterior – aponeurosis of the external oblique
muscle

 Inferior (floor) – inguinal ligament and lacunar

ligament on medial side

 Superior (roof) – the arching fibers of the internal

oblique and the transversus abdominis muscles

 Posterior – transversalis fascia, reinforced medially

by the conjoint tendon
Inguinal Hernia
Contents of Inguinal Canal
 Ileoinguinal Nerve
 Spermatic Cord (in male)-
 Round ligament (in female)
Boundries of Hesselbach Triangle
 Laterally inferior epigastric artery
 Medially lateral border or rectus abdominis
 Inferiorly (Base) Inguinal ligament
Types of Inguinal Hernia
Indirect Inguinal Hernia
 From the internal to external ring.
 Usually due to processus vaginalis.
Types of Indirect Inguinal
Hernia
Direct Inguinal Hernia
 A direct inguinal hernia is always acquired.
 The sac passes through a weakness or defect of the
transversalis fascia in the posterior wall of the
inguinal canal.
Clinical Features
 Symptoms • Signs
 Swelling – Inguino-scrotal swelling
 Dragging pain – Expansile cough
 Suggesting increased – Cannot get above the
abdominal pressure swelling
 Symptomless – Reducibility
 Accidental finding – Finger invagination test
– Deep ring occlusion test
– Ziemen test (Three
finger test)
Finger invagination test
 Femoral Hernia
 Femoral hernia enters the femoral ring,
traverses the femoral canal and comes
out through the saphenous opening.
• The female to
male ratio is
about 2:1.
• The right side is
affected twice as
often as the left.
 Femoral Ring
• Oval opening ½” to 1” in diameter
Boundaries
 Anteriorly inguinal
ligament
 Posteriorly
iliopectineal ligament,
pubic bone and fascia
over pectinious muscle
 Medially lacunar
ligament
 Laterally septum
separating from
femoral vein.
 Femoral Canal
 Most medial compartment of femoral sheath.
 Conical in shape, 1.25 cm long and 1.25 cm wide at base
(Femoral ring).
 Extends from Femoral ring (above) up to saphenous
opening (below).
 Contents- fats, lymphatic and lymph nodes.
 Umbilical Hernia
 Common hernias (10-30%) often noted at birth as
a protrusion at the bellybutton (umbilicus)
 Caused by an opening in the abdominal wall,
which normally closes before birth, does not close
completely
 Less than ½ inch – closes gradually by age 2
 Large hernias – surgery at age 2-4 years
 Even if closed, may reappear later in life (weak
spot in the abdominal wall)
 Can occur in women who are having/have had
children
 Incisional Hernia
 Abdominal surgery causes flaw in the
abdominal wall – create an area of
weakness where hernia may develop
 Occurs after 2-10% of all abdominal
surgeries, although some people may be
more at risk
 May return even after surgical repair
 Epigastric Hernia
 Occurs between the navel and the lower
part of the rib cage in the midline of the
abdomen
 Usually composed of fatty tissue and rarely
contain intestine
 Formed in the area of relative weakness of
the abdominal wall
 Often painless and unable to be pushed
back into the abdomen when first
discovered
Epigastric Hernia
 Symptoms
 Reducible hernia
 New lump in the groin or other abdominal wall
area
 May ache but not tender when touched
 Sometimes pain precedes the discovery of the
lump.
 Lump increases in size when standing or when
abdominal pressure is increased (ex.
coughing).
 May be reduced (pushed back into the
abdomen) unless very large
 Symptoms
 Irreducible hernia
 Occasionally painful enlargement of a
previously reducible hernia that cannot be
returned to the abdominal cavity on its own or
when you push it.
 Some may be long term without pain.
 Also known as incarcerated hernia
 Can lead to strangulation
 Signs and symptoms of bowel obstruction may
occur, such as nausea and vomiting.
 Symptoms

 Strangulated hernia
 Irreducible hernia in which the entrapped
intestine has its blood supply cut off
 Pain is always present, followed quickly by
tenderness and sometimes symptoms of
bowel obstruction (nausea and vomiting).
 The affected person may appear ill with or
without fever.
Diagnosis program

 Anamnesis examination.
 Physical examination.
 Blood analysis and urine analysis.
 Survey X-Ray of abdominal cavity organs
 Ultrasound
 CT-scan
Treatment
 Conservative treatment
 Surgical treatment

Applying Truss as a
conservative
management of inguinal
hernias.
 Surgical Treatment
 Herniorrhaphy (herniotomy with strengthening of the
posterior wall)
 Bassini repair
 Shouldice repair
 McVay repair
 Hernioplasty (herniorrhaphy with application of
prosthesis)
 Lichtenstein repair
 Plug and patch repair
 Laparoscopic repair
 TEP (Total Extra Peritoneal)
 TAPP (Trans Abdominal PrePeritoneal)
Clinical variants

 Retrograde incarceration
 Parietal incarceration (the Richter’s hernia)
 The Littre’s hernia
 Incarceration at sliding hernia
Retrograde incarceration
Retrograde incarceration
the Richter’s hernia