HERNIA

BY DR:NASSER
ELREFAI
HERNIA
Hernia defined as the
protrusion of the vesicus as
part or whole through normal
or abnormal{acquired}
opening or defect in the wall
of its containing cavity
through which they donot
.normally pass
Approximately 75% of all hernias
occur in the inguinal region. Two
thirds of these are indirect, and
the remainder are direct inguinal
.hernias
Men are 25 times more likely to have
. a groin hernia than women
There is a female dominance in
femoral and umbilical hernias of
approximately 10 to 1 and 2 to 1,
. respectively
Defect in the abdominal wall may be congenital (e.g.
inguinal canal, femoral canal) or acquired (e.g. an
.incision)
Raised intra-abdominal pressure further weakens the
defect allowing some of the intra-abdominal contents
(e.g. omentum, small bowel loop) to migrate through
.the opening
A chronic cough, straining on micturition or
straining on defecation lifting a heavy weight are all
increase the intra abdominal pressure
Smoking result of an acquired collagen deficiency
Stretching of the abdominal musculature because of
an increase in contents, as in intra abdominal mass
. like malignancy
Fat acts to separate muscle bundles and layers,
weakens aponeuroses and favours the appearance of
. paraumbilical, direct inguinal and hiatus hernias
congenital preformed sac
INGUINAL HERNIA
internal:- very rare
and difficult to diagnose
external:- hernia
.common
:-external hernia
groin hernia -1
inguinal.....femoral
umbilical&epigastric hernia-2
.
3-incisional hernia .
:-rare hernia-4
a-spigelian
hernia
b-lumbar hernia
c-perineal hernia
d-obturator
hernia
e-gluteal hernia
SPIGILIAN HERNIA
:-TERMINOLOGY
Richter,s hernia:-it is herniation of-1
anti mesentric part of bowel and may
.become strangulated
Maydle,s hernia 2 adjacent loop of-2
intestine are in the sac they are taken
W shape and the portion in the
abdomen is first to be suffer from
.ischemia
hernia en glissade(sliding hernia)-3
part of posterior wall is formed by
vesicus
Littre,s hernia when the sac contain- 4
appendix, ovary ,fallopian tube or
.Mickel,s diverticulum
Incarcerate hernia:- when there is-5
adhesion between the sac and its
content but there is no obstruction or
.strangulation
Reduction en mass:-it is reducing the-6
whole mass together with out reducing
the content apparently hernia is
.reduce but actually not
Dual hernia :- both direct and- 7
.indirect in the same patient
:- hernia consist of 3 parts
the sac-1
the covering-2
the contents-3
the sac:diverticulum derived- 1
from pertoneum and consist from
.mouth ,neck, body and fundus
the neck is usually well defined
except in incisional and direct
. inguinal hernai
the covering derived from layers- 2
of anterior abdominal wall through
.which the sac pass
the contents may be omentocele-3
,enterocele or part of intestinal
:-clinical types of hernia
.reducible-1
.irreducible-2
obstructed-3
strangulated-4
hernia can be reduced by its
self or by the patient or the
.surgeon
cough impulse is positive and
hernia is reduced with gurgling
sound the first part is the most
difficult but in case the hernia
is containing omentum there is
doughy feeling and the last is
mors difficult to reduced than
it is due to adhesion between sac and
contents so hernia cannot be reduced
and it is more common in femoral and
.umbilical hernia
:-obstructed hernia- 3
it is irreducible hernia containing
intestine the lumen of which become
obstructed with out interference with
blood supply but may lead to
.strangulation
it is difficult to differentiate from
strangulation but in case of
:-strangulated hernia- 4
the blood supply of the contents is
seriously impaired to start with the
venous returnis obstructed then
the arteries and so form wet
gangrene of bowel this is
commonly happened in femoral
hernia due to its tight and narrow
.neck
:-inflamed hernia- 5
inflamation of the contents with in
a- increased intr abdominal pressure
.due to any reason
lifting heavy-1
weight
whooping cough-2
straining at micturation-3
chronic constipation-4
b-stretching of the abdomenal
musculature due increase in the
.contents eg pregnancy,obesity
c-anatomical reason femoral hernia is
.more common in female than in male
:-strangulated hernia
hernia become strangulated when
the blood supply of its contents is
seriously impaired, gangrene will
.occur with in 5:6hrs
:-pathology
due to its resilience, venous- 1
return are first to be occluded so
the wall of the bowel became
congested then serous exudate
which is purple in color start to be
the wall of intestine become- 2
oedematous which will lead to
more compression on the
vessels and so arterial supply
became eventually occluded
also there will be ecchymotic
spots under the serosa and the
serous exudate became blood
staining
.
the serosa became dull-3
covered by fibrinous
.exudate
flappy friable wall of-4
.intestine
bacterial infection and-5
.gangrene occure
infection spread from the-6
sac to the pertoneal cavity
sudden pain first localized then
.-generalize
.vomiting-
.sever tenderness-
absence of expensile cough-
.impulse
.paralytic ileus due to peritonitis
.endotoxic shock-
:-strangulated Richters hernia
potion of circumference of
intestine is affected usually in
 INGUINAL HERNIA
INDIRECT -1
2- DIRECT

DUAL -3
4-SLIDING
THE SURGICAL ANATOMY OF
INGUINAL CANAL
:-the superficial inguinal ring- 1
is triangular opening in the
aponeurosis of external oblique
muscle about 1.25 cm above
and medial to the pubic
tubercle and has supero medial
crus and inferio lateral crus
normally just admitt the tip of
deep inguinal-2
:-ring
is U shape
opening in the
fasia tranversalis
1.25 cm above
:-the inguinal canal- 3
cm directed down ward 3.75
and medially the upper
boundary is conjoint muscle
inferiorly is the inguinal
ligament, anteriorly is external
obliqueaponeurosis and
internal oblique with skin and
superficial fasia,posteriorly is
.fasia transversalis
the inguinal canal
transmit the spermatic
cord in male
ilioinguinal nerve and
the genital branch of
genitofemoral nerve
,in female instead of
spermatic cord it
Direct IH Indirct IH
Older more than Any age
45yrs
acquired congenital
Directly forward Descend obliquly through
through Hasselbachs inginal canal
triangle
spherical pyriform
Commonly bilateral Usually unilateral
Test is -ve Deep ring occlusion test is
+ve
Very rare Obstruction&strangulation
No definitive sac Operative finding:well
hernia through formed sac anterolateral to
posterior wall of spermatic cord and its
commonest form of all hernia
,apear at any age into preformed
sac which is patent prossus
vaginalis
:types are
pubonocele: in which hernia is- 1
limited to inguinal canal at
.superficial inguinal ring
funicular:hernia just above- 2
.epididemis
:-CLINICAL FEATURE
any age .male :female =20:1
pt complaining from dull-
aching pain in the groin
radiating to the testicle
precipitated by heavy exercise,
coughing or straining and
.disappear by lying down
there is visible and palpable
.positive cough impulse
:-differential diagnosis
vaginal hydrocele-1
encysted hydrocele of the-2
cord
spermatocele-3
femoral hernia-4
undesended testis-5
lipoma of the cord-6
LN-7
saphena varix-8
herniotomy-1
herniorrhaphy&hernioplasty-2
herniotomy:-this form of repair in- 1
children
:-herniorrhaphy&hernioplasty- 2
incise the skin 1.25 cm above the
medial two third of inguinal ligament
identify the sac and excise it after
reducing its content then ligate the
.neck
repair by darning, Bassinis repair or
facial flap
DIRECT INGUINAL HERNIA
it is hernia through weakness or
adefect in the transversalis fascia
in the posterior wall of inguinal
canal area known as triangle of
Hasselbach, always aquired, and
.usually bilateral
it is laying behind spermatic cord
and rarly strangulate due to
awide opening of ill defined sac
,its size is not large and rarely
practically women never
develope this type of
.hernia
injury to the ilio inguinal or
iliohypogastric nerves
during appendcectomy
associated with
development of direct
DUAL,SADDLE
SHAPE,PANTALOON HERNIA

here there are indirect and

direct inguinal hernias in the
same patient stradling the
inferior epigastric artry in
between and it is important
.cause of recurrence
Maydl,s hernia or W shape
:causes
preoperative faulty selection of- 1
.cases
operative faulty technique-2
/a- sac not ligated
.b-tight stetching
.c- imperfect hemostasis
d- usage of improper suture
.material
postoperative infection or persistent-3
.of increase intra abdominal pressure
treatment is by treating the cause and
SLIDING HERNIA
posterior wall of the sac
is formed by part of
vescus for instence in the
left side by sigmoid colon
,in the right side by
cecum or urinary
.bladder
happen mostly in male
,bilateral hernia is rare and
.usualy on the left side
should be suspected in every
large lobulated inguinal
hernia descended to the
.scrotum
treatment by surgery
invagination of the sac with
FEMORAL HERNIA
it is the third common type of hernia
and account for about 20% of hernia
.in female
its importance comes from the fact
that it is most likely to become
strangulated due to its tight neck and
.it cannot be controlled by truss
:-surgical anatomy
.
femoral canal occupying
the most medial part of
femoral sheath and it
extends from femoral ring
above to saphenous
.opening below
it is about 1.25 cm length
it contains fat ,lymphatics
and LN
anteriorly
iliopectineal
ligament,pubic bone
posteriorly
concave knife edge of
lacunar
ligament[Gimberants lig]
medialy and septum
it is commoner in
.female than in male
it had very mild
symptoms till
,strangulate
rare before20s some
times bilateral more in
DD of lump in the groin
.inguinal hernia-1
saphena varix which saccular- 2
enlargment of the termination of long
saphenous vein usually accompanied by
.other signs of varicose veins
the swelling is compressible but not
reducible and there is palpable fluid thrill
on coughing
.enlarged LN-3
.lipoma-4
.femoral aneurysm-5
.psoas abscess-6
.large psoas bursa- 7
strangulation is common due
.to its tight neck
treatment is by surgery as
soon as diagnosis is
suspected by removing of
the sac and closure of the
.canal
surgery is by low
approach[Lockwood]
examphalos [omentocele]
.minor,major
failure of all or part of midgut
to returne to the celom during
.early life
it is hernia through weak scare
due to neonatal sepsis and
strangulation or obstruction is
.uncommon
up to 2yrs it may close by it
:-Paraumbilical hernia
it may be supra or infra
umbilical.protrusion of sac above
umbilicus usually it contain
.omentum ,intestine
.it is loculated due to adhesion
pt complaining of draging pain if it is
larga pt might have intestinal
.obstruction
treated by surgery if there is
irreducibility,obstruction or
strangulation.treatment by Mayo,s
EPIGASTRIC HERNIA
fatty hernia in linea alba
prtrusion of extrapertoneal
.fat throughlinea alba
symptomless some times
local pain
.treatment by Mayo,s repair
ventral hernia which develope through area of
.surgical scare
:-predisposing factors
.postoperative chest infection- 1
.wound infection-2
.faulty wound closure-3
.midline, T incision-4
general factors include-5
obesity,jaundice,malignancy,anemia,hypoprotein
emia,corticosteroid all lead to poor wound
.healing
there is hernia through scar which may be small
or large
treatment is by treating causitve factor and
.proper repair