HERNIA

Presenter: David Masta (4th Year).

Moderator: Dr Miyoba.
 OUTLINE

 DEFINITION & EPIDEMIOLOGY

 ETIOLOGY & RISK FACTORS
 CLINICAL PRESENTATION
 CLASSIFICATION
• ETIOLOGICAL
• CLINICAL
• ANATOMICAL
• CONTENT
 INVESTIGATIONS
 COMPLICATIONS
 MANAGEMENT
 DEFINITION &
EPIDEMIOLOGY
 Hernia is defined as an abnormal protrusion of a
viscous or a part of a viscous through an opening,
artificial or natural with a sac, covering it.
 Hernias are more common in males than females
with a prevalence ratio of 9:1.
 The percent occurrence of hernias in population:
• 75% are Inguinal Hernias (50% Indirect & 25% Direct).
• 14% are Umbilical hernias.
• 10% are Incisional hernias.
• 3-5% are Femoral hernias.
• 0.5% are Epigastric hernias.
 ETIOLOGY & RISK FACTORS
 Increased Intra-abdominal Pressure:
• Lifting Heavy Weights,
• Obesity,
• Pregnancy,
• Chronic
• Constipation,
• Chronic Cough,
• Ascites,
• Urinary (BPH).
 Weakness in Abdominal Walls:
• Obesity,
• Surgeries (appendectomy),
• Familial collagen disorders (Pure Belly Syndrome),
• Collagen deficiency (Mastatic Emphysema of Read),
 CLINICAL PRESENTATIONS OF
HERNIAS
Hernias have different presentations depending
on the type. Some common presentations at the
site of the hernia are:
 Visual Swelling/Bulging:

• Reducible where contents are able to be returned

into the abdomen (expands upon coughing.)
• Irreducible where contents are unable to be
returned into the abdomen (narrow neck, adhesions,
overcrowding.)
 Tenderness: when touched at hernia site.
 Pain and Discomfort: during activities that
increases intra-abdominal pressure.
 CLASSIFICATION
 ETIOLOGICAL
 CLINICAL CLASSIFICATION
 ANATOMICAL SITE
CLASSIFICATION
 CONTENT CLASSIFICATION
 ETIOLOGICAL CLASSIFICATION

Congenital: Acquired:
 Are hernias from  Are hernias that
defects in fetal develop later in life
development resulting due to weakness in
in weakness or abdominal wall or
opening in abdominal increase in abdominal
wall. pressure.
 Most common types  Common types are
are hiatal, indirect- inguinal (indirect and
inguinal and umbilical direct), incisional and
hernia. femoral.
 CLINICAL CLASSIFICATION

Reducible: Hernia that is capable of being

reduced by its own or by the patient or
doctor.

Irreducible (Incarcerated): Hernia that

are incapable of being reduced on its own
or by patient or doctor.
CLASSIFICATION ACCORDING TO
ANATOMICAL SITE
 Inguinal Hernia
 Is a hernia as a result of protrusion through the
inguinal canal.
 Is more common in men than women and is the
most commonly occurring hernia.
 Presents as dragging pain and swelling in groin. It
is better seen when standing and coughing
(positive cough impulse). In females, ipsilateral
thickening of labia majora.
 Clinical tests:
 Internal ring occlusion test (thumb),
 Ring invagination test (pinky on scrotum),
 Zeiman’s test (index deep middle superficial),

Inguinal Canal
 Inguinal (Hesselbach’s)
Trinagle
 Boarders:
 Medial: lateral boarder of
rectus abdominus
 Lateral: inferior epigastric
vessels
 Inferior: inguinal ligament.

 Contents: Layers of
Abdomen - skin,
subcutaneous tissue
(Campers & Scarpas facia),
external oblique muscle,
internal oblique muscle,
transversus abdominus
muscle, transversalis fascia
and parietal peritoneum.
Direct vs Indirect
Inguinal Hernia
Indirect Hernia According to
Extent
 Umbilical & Paraumbilical
Hernia
 Umbilical hernia is  Paraumbilical
most common in hernia is most
children. common in obese
 It’s a result of a women.
defect in abdominal  Is a result of defect
wall at the umbilicus.
above the
 Rarely requires umbilicus
surgical intervention
only in cases of
 If strangulated and
strangulation and irreducible Mayo
incarceration. repair is used.
 Incisional Hernia
 Is hernia that protrudes
through an old
abdominal wound.
Accounts for 10% of
abdominal surgeries.
 Is common in old and
obese people
 Risk Factors: vertical
incisions, emergency
surgeries, laparatomy,
chronic cough etc
 Presents with swelling at
scar site, cough
 Femoral Hernia

 Is a hernia that passes

through the femoral
canal.
 Most common in females
 Can be a result of wide
femoral canal or multiple
pregnancies.
 Mostly on right side
(20% are bilateral)
 Gaurs sign: is distension
of superficial epigastric
and/or circumflex iliac
veins due to pressure.
 Epigastric Hernia
 Are hernias that
occur between
xiphisternum and
umbilicus.
 Most commonly
herniated
extraperitoneal fat
and rarely
omentum.
 Presents as tender
swelling in midline.
 Treatment is
 Internal Henia
Diaphragmatic Hernia: Mesenteric Hernia:
 Hernia as a result of  Hernia as a result of defect in
abnormal opening in mesentery. May present with
diaphragm. abdominal pain and distention,
nausea and vomiting and
 If congenital may presents bowel habit changes.
with cyanosis, respiratory
distress and scaphoid
(concave) abdomen.
Omental Hernia:
 If acquired may present with  Hernia as a result of protrusion
abdominal pain and of omentum through weakness
difficulty breathing. in the abdominal wall. May
 Haital hernia is present with abdominal pain
diaphragmatic hernia and distention, nausea and
caused by protrusion of vomiting and bowel habit
stomach through opening in changes.
diaphragm.
 CLASSIFICATION ACCORDING
TO CONTENTS
 Omentocele—omentum.
 ™Enterocele—intestine.
 ™Cystocele—urinary bladder.
 ™Littre’s hernia—Meckel’s diverticulum (congenital
outpouching of small intestines.)
 Maydl’s hernia —the presence of two adjacent loops
of bowel within the hernia sac, with an interspersed
segment that is not included in the hernia.
 Sliding (Paraesophageal) hernia — part of the
stomach and the gastroesophageal junction slide or
roll into the chest through the esophageal hiatus.
 Richter’s hernia—part of the bowel wall.
 INVESTIGATIONS OF
HERNIA
 Physical Examination: palpation of hernia to assess
tenderness and size of hernia.
 Cough Test: to assess the reducibility of hernia.
 Blood Tests: to assess for complications, signs of
inflammation and infection.
 Ultrasound: to assess size and contents of hernia, for
detection in female, assess for surgical complications
after repair (gold standard).
 MRI: used to confirm negative hernia results on
ultrasound if clinically suspicious.
 Herniography: contrast die injected into hernia sac and
then X-ray done.
 Endoscopy: for stomach and esophagus evaluation to
rule out hiatal hernia.
 Barium Swallow: used to evaluate for hiatal hernia.
 Complications of Hernias
 Obstructed Hernia: irreducible with bowel lumen
obstruction, but bowel blood supply is intact (leads to
strangulation). Presents with intestinal obstruction symptoms
(vomiting, distention, constipation etc.)
 Strangulated Hernia: irreducible with obstruction and
obstruction of blood flow. Garrey’s Stricture is constriction of
small bowel due to ischemia. No cough impulse (bulging).
 Inflamed Hernia: inflammatory response within the hernia
due to infection, poor perfusion and chronic irritation,
 Incarceration (Irreducible) Hernia: when protruding
organ/tissue becomes stuck in hernia sack.
 Peritonitis: if intestines perforate can cause inflammation of
peritoneum.
 Hydrocele: fluid accumulation in the scrotum.
 Recurrence: appearance of bulge at site of previous
occurrence.
 Management of Hernias
 Non-Surgical:
 Observation,
 Supportive Clothing (garment/belt),
 Weight loss,
 Reduce Strainious Activity,
 Addressing Constipation
 Surgical:
 Herniorrhaphy (sewing weakened tissue no mesh),
 Hernioplasty (sewing tissue with mesh),
 Laparascopic Repair,
 Open Repair (incision at hernia site).
 Complications of Surgical Hernia Repair

 Hemorrhage and Hematoma at incision site.

 Acute urinary retention: this frequently follows bilateral repair
 Wound infection: this should be rare as hernia repair is a clean
operation however, it occurs in 5-8%.
 Post-herniorrhaphy Hematocele – accumulation of blood within
the scrotum.
 Post-herniorrhaphy Lymphocele - accumulation of lymphatic fluid
within the cyst (scrotum).
 Chronic pain at upper thigh and lower abdomen due to
Ilioinguinal nerve injury.
 Hyperesthesia over the medial side of inguinal canal due to
injury to iliohypogastrc nerve-neuralgia (15%)
 Testicular pain and swelling followed by atrophy usually means
that the repair is too tight and testicular artery is compromised.
Testicular atrophy will occur when the swelling subsides.
 Recurrence of hernia (5%): if it occurs within 3 years it is called
early and late if it occurs after.