Hernias

JKoh&DCheng

Hernias

HERNIAS

Anatomy
Layersoftheinguinalregion(superficialtodeep)
- Skin
- Campersfascia
- Scarpasfascia
- Externalobliquemuscle
- Internalobliquemuscle
- Transverseabdominismuscle
- Transversalisfascia

Inguinalligament
- Theaponeurosisoftheexternalobliquethickensandfoldsbackonitself,
formingafibrousbandextendingbtwASISandpubictubercle
- Midpointoftheinguinalligament:siteofdeepinguinalring;femoralnerve
- Midinguinalpoint:midpointfromASIStopubicsymphysis;femoralpulse
(artery)
- Superficialinguinalring:aboveandjustmedialtothepubictubercle

Inguinalcanal
- Oblique,inferomediallydirectedpassage(~4cmlong)thatrunsjustsuperior
totheinguinalligament
- Startsatthedeepinguinalringwheretheoutpouchingoftransversalisfascia
penetratesthroughthetransversusabdominismusclelateraltotheinferior
epigastricartery
- Endsatthesuperficialinguinalring,aslitlikeopeningintheaponeurosisof
theexternalobliquesuperolateraltothepublictubercle
- Boundaries
o Anteriorwall:aponeurosisofexternalobliquemuscle
o Posteriorwall:transversalisfascia+conjointtendon(medially)
o Roof:internalobliqueandtransverseabdominismuscle
o Floor:gutteringoftheinguinalligament
- Contents
o Spermaticcord/Roundligament
o Ilioinguinalnerve:suppliessensationtoscrotumandlabiamajusand
thigh,aswellasmotortointernalandexternalobliquemuscles

Contentsofthespermaticcord
- 3arteries
o Arteryofductusdeferens
o Testicularartery
o Cremastericartery(frominferiorepigastricartery)
- 3nerves
o Ilioinguinalnerve(outsidethecord)
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Hernias

o Cremastericnerve(genitalbranchofgenitofemoralnerve;supplies
cremastericmuscle)
o Autonomicinnervation:sympathetic+parasympathetic
3others
o DuctusDeferens
o Pampiniformplexus(venous)
o Lymphaticvessels:drainstestestoparaaorticLNs
NotethatinguinalLNsreceivelymphaticflowfromlowerlimb,
abdowallbelowumbilicus,anus,buttocks,perineum,pelvis
andscrotum;butNOTtesticlesunlesstherehasbeenprevious
transscrotaltesticularoperation,iesurgeryforundescended
testes

HesselbachsTriangle
Thistriangleisreferredtoinrelationtodirectinguinalhernias,andthese
protrusionsalwaysoccurthroughthistriangle
- Medialborder:rectusabdominis
- Lateralborder:inferiorepigastricartery
- Inferiorborder:inguinalligament

Hernia=abnormalprotrusionofviscus(orpartofviscus)throughanopeninginthe
cavityinwhichitisnormallycontained.

Componentsofahernia
- Composedofasacandthehernialcontents
- Sacconsistsofperitoneumwhichprotrudesthroughtheabdominalwall
defectorhernialorifice,andenvelopesthehernialcontents
o Neckofthesacissituatedatthedefect:herniaswithanarrow/rigid
neckmorelikelytoobstructandstrangulate
o Bodyisthewidestpartofthesac
o Fundusistheapexorfurthestextremity
- Visceramostlikelytoenterahernialsacarethosenormallysituatedinthe
regionofthedefectandthosewhicharemobile(omentum,smallintestine,
colon)

TypesofHernias
IndirectInguinalHernia:aperitonealsacprotrudesthroughthedeepinguinalring,
passesdowntheinguinalcanal,andmayextendintothescrotum.Thedefectis
congenitalandisduetoapatentprocessusvaginalis.
- Medial&superiortopubictubercle

DirectInguinalHernia:anacquireddefectintheabdominalwall(inHesselbachs
triangle).Itiscausedbyweaknessinthetransversalisfasciaintheposteriorwallof
theinguinalcanal.

FemoralHernia:defectisinthetransversalisfasciaoverlyingthefemoralringatthe
entrytothefemoralcanal.Theherniaepassthroughthefemoralcanal(NAVEL
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Hernias
Nerve,Artery,Vein,Empty/Canal,Lymphatics)andpresentinferolateraltothepubic
tubercle.

InguinalHernia
Mostcommontypeofhernia
Morecommoninmales
Indirect
Direct
FemoralHernia
Common(~80%)
Lesscommon(20%)
Lesscommon
Congenitaldefect
Acquireddefect
Morefrequentinfemales
Hardertoreduce
Reduceeasily
Frequentlyirreducible
Maystrangulate
Rarelystrangulate
Frequentlystrangulate
Neckislateraltothe
OccurinHesselbachs
Occurinferolateralto
Inferiorepigastricartery
triangle:superomedialto pubictubercle
pubictubercle
Unilateralusually
Oftenbilateral

Anyage,includinginfants Oftentheelderly

Riskfactors
- Male
- Embryologicaldevelopmentoftesticles
- Ageing
- Chronicincreasedintraabdominalpressure
- Urinaryobstruction
- Chronicconstipation
- Obesity

Painful,tenselumpthat
Sx/Sg
cannotbereduced=
- Oftenasymptomaticapartfromgroinlump
Strangulatedherniauntil
- Lump/Painthatisaggravatedwithinabdominalpressure
provenotherwise
- Achingordraggingsensation

DDxoflumpingroin
- Aboveinguinalligament
o Lymphadenopathy:eglymphoma,infection,metastaticdisease
Wouldnotchangewithpositionorcoughing/straining
Tenderifduetoinfection
Firm/hardand/orrubberyifduetomalignancy
o Undescendedtestes(ininfants/young)
o Spermaticcordlipomaorhydrocele
- Belowinguinalligament
o Lymphadenopathy
o Femoralhernia
o Femoralarteryaneurysm:expansilepulsation
o Saphenavarix
Abnormallydilatedorswollenvein,oftentortuous
A/wvaricoseveinsandatransmittedimpulsewhenthe
varicoseveinsarebrisklytapped
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Hernias
Inferolateraltopubictubercle;resolveswithlyingdown
(femoralherniausuallydoesnot)
o Psoasabscess

Howtodifferentiatebetweenthem?
- Coughimpulse+prominentonstanding=herniaORsaphenavarix
- Saphenavarix:transmittedimpulse,below&lateraltopubictubercle
- Inguinalhernia:above&medialtopubictubercle
- Femoralhernia:usuallydoesntsimplyresolve
- Inguinallymphadenopathy:nochangewithposition/coughing/straining

O/E
- Patientmustbestandingfirsttoidentifythehernia
o Comparelumpwithotherside(bilateraldirect?)
o Coughimpulse:pushlumpinandaskpatienttocough,+veif
protrusionbulgesoutuponcoughing
- Patientnowliesdown
o Askpatienttoreducehernia(ifirreducible,cantdeduceorigin)
o Applypressureoverdeepinguinalringandaskpatienttocough;if
lumpappearmedial,thenherniaislikelytobedirect
o PutfingeroverDIRandSIR,askpatienttocough:iflumpbulgesoutat
SIR=direct;ifnot=indirect(controlledatDIR)

Complications:Mostherniasareuncomplicatedatpresentation.

Irreducibility
- Irreduciblemeanssaccannotbeemptiedcompletelyofcontents
- Canbecausedby
o Adhesionsbtwthesacanditscontents
o Fibrosisleadingtonarrowingattheneckofthesac
o SuddeninIAPthatcausestransientstretchingoftheneckand
forcefulmovementintothesac,whichcannotsubsequentlyreturnto
theiroriginallocation
- Usuallypainful;shouldbeoperatedonsoonafterpresentation

Obstruction
- Whenneckissufficientlynarrowtooccludethelumenoftheintestine
containedw/ithesac
- Obstructedherniasarenearlyalwaysirreducibleand,ifnottreated,may
becomestrangulated
- Often,thereisaHxofsuddeninIAPthathaspushedintestineorother
contentsintothesac
- Sx/Sgofintestinalobstruction:colic,vomit,constipation,distension
- Difficulttodistinguishfromstrangulationsclinically:treaturgently

Strangulation
- Bloodsupplyofcontentshasceasedduetocompressionatthehernialorifice
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Hernias
-

Initially,lymphaticandvenouschannelsareobstructed,leadingtooedema
andvenouscongestionbutwithcontinuedarterialinflow
Whentissuepressure=arterialpressure,arterialflowceasesnecrosis
Ifintestineisinvolved,canleadtoperitonitis
Astrangulatedherniaisbothirreducibleandobstructed,verytense&tender
Erythemaoftheoverlyingskinisalatesign
AstrangulatedRichtersherniaisnotprecededbyintestinalobstructionand
theremayfewlocalsigns
Mustbeoperatedonurgently

Management
- Analgesia
- SurgicalMx
o Herniotomy(sacremoval)andrepairofthedefect
o Laparoscopic>Openapproaches
o Meshrepair(Lichtenstein)haslargelyreplacedthesuturemethod
(Shouldice)
o Oftenonlyanovernightstayisrequired
o Noheavyliftingorstrainingfor68weeks

SpecificSurgicalCx
- Urinaryretention(common)
- Haematoma
- Ischaemicorchiditis:occursfromvenousthrombosisofthepampiniform
plexus,notusuallyfromtraumatothetesticularartery
- Herniarecurrence(13%)

PostopCxfromBowelSurgery
- Haemorrhage
- Abscess
- Perforation
- Fistulae
- Obstruction
- Sepsis

5WsofPostOpFever
- Wound:checkforwoundinfection.Rxisdrainage
- Wind:atelectasiswithin48hrs,aspiration,pneumonia
- Water:UTIs,especiallyifcatheterized
- Walking:DVTs,phlebitisandPEscancausefeverandriskwithwalking
- Wonderdrugs:drugreactions(uncommon)

Lumpinthescrotum
- Testicle:testicularcancer,lymphoma,trauma,TB,infection(orchiditis)
o Causesenlargementandirregularityandhardnessofthetestis
o Testiculartumour:germcellorothers;testwithAFP,hCG&LDH
- Epididymis:cysts,infection,calculi,embryonicappendages

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Hernias

o Lumpisbehindorjustabovethetesticleitself
Testicularveins:varicoseveinsorvaricocoeleareusuallyontheleftandare
muchmoreprominentwhenstandingcomparedtolyingdown
Tunicavaginalis:hydrocele
o Palpatingthetesticleisimpossibleasthefluidfilledsackenvelopes
thetestes;transilluminable
o Posttraumatichydrocelewillnottransmitlight,owingtoblood
Indirecthernia

Investigations
- U/Sisthebestimagingtest:differentiatessolidfromcysticmasses;
localisationofmasses
- Ifclinicalevidencestronglypointstotesticularcancerthenchest/abdo/pelvis
CTisalsodone,withbloodtestsforhCG,AFPandLDH

References
AcknowledgementstoPNgu,MBBS
th
Moore&Dalley,ClinicalOrientedAnatomy,5 Edition
NettersAnatomy
th
Talley&OConner,ClinicalExamination,5 Edition
rd
Tjandraetal,TextbookofSurgery,3 Edition

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