Abdominal Wall HerniaEssentials

MA MURPHY FRCSI

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Objectives Understand the term hernia Basic anatomical knowledge Clinical features of common hernia Complications of hernias Examination of a hernia Differential diagnoses of a lump in the

groin Management of hernia

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Hernia

A protrusion of an organ or tissue outside its’ normal compartment

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Common External Hernias ABDOMINAL WALL & GROIN

Midline• Umbilical• Para- umbilical• Epigastric

Inguinal• Direct/ Indirect/ Combined

Femoral Incisional

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Common Presentations A lump

Comes and goes Appears on straining /coughing

A pain Dragging pain/ Pain on exertion

Incidental finding on examination/ imaging Presenting as a complication

Incarceration/ Intestinal obstruction

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Inguinal Hernia Commonest external hernia Male preponderance Infant / adult Direct / indirect / combined Weakness / increased pressure Cause pain / discomfort Carry risk of complications Treated surgically

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Inguinal Hernia - History

OBJECTIVES Establish differential diagnoses Identify risk factors and significant co-

morbid pathologies (e.g. increased intra-abdominal

pressure due to ascites or chronic airways disease)

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Inguinal Hernia - History Onset Duration Symptoms Other hernia(e) Irreducibility Gastrointestinal system Respiratory system Surgery / anaesthesia

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Inguinal Hernia - Examination Surface markings

Anterior superior iliac spine

Pubic tubercle

Midpoint of inguinal ligament

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asis

pubic tubercle

midpoint of inguinal liagament

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Inguinal Hernia - Examination

OBJECTIVES Confirm diagnoses Out rule differentials Establish type Determine contents Reducibility Identify co-morbid pathologies

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Direct V’s Indirect Direct Post wall Less common Older Smaller Hesselbachs Medial Lower risk

Indirect Deep ring 70% Congenital Scrotal Deep ring Lateral Strangulate

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Inguinal Hernia Examination

Standing / Lying Supine Cough impulse Reducibility Contents Bowel sounds Scrotal contents

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Differential Direct /Indirect/Combined Femoral hernia Hydrocele Lipoma Lymph node Testicular tumour Saphenous varix

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Inguinal Anatomy The inguinal canal represents the

oblique passage through the anterior abdominal wall of the vas deferens (round ligament)

It is 5cm long and lies directly above the medial half of the inguinal ligament

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Inguinal Anatomy Floor

• Transversalis fascia• Medially the conjoint tendon

Roof• External oblique aponeurosis• Laterally the conjoint tendon• Skin and superficial fascia

Above • Conjoint tendon

Below• The inguinal ligament

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Inguinal Anatomy Three nerves

• Ilio-inguinal (on not in)• Sympathetic fibers• Genitofemoral

Three layers of fascia• Internal spermatic (transversalis f.)• Cremasteric (conjoint tendon)• External spermatic (ext. oblique)

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Inguinal Anatomy Three arteries

• Testicular (from the aorta)• Artery of the vas (external iliac)• Cremasteric (inferior epigastric)

Three other structures• The vas deferens• The pampniform plexus of veins• Lymphatics (to aortic nodes)

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TESTIS CORD STRUCTURES

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Inguinal Anatomy

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Hernia Anatomy

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Indirect Hernia

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Direct Inguinal Hernia

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Hernia Complications Incarceration

Strangulation

Intestinal obstruction

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Varieties of Hernias Maydls

• W loop of intestine Richters

• Partial inclusion of intestinal wall

Sliding hernia• Bladder• Sigmoid colon/ appendix

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Richters’ Hernia

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Maydls’ Hernia

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Hernia Management Investigations

None required for routine uncomplicated case

Plain X-ray for suspected bowel obstruction

Ultrasound in case of diagnostic uncertainty

Herniogram rarely used Routine pre-op investigations

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Hernia Treatment Surgery

To relieve symptoms To prevent complications

Operations Open hernia repair Laparoscopic hernia repair

Pre-peritoneal Intra- abdominal

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Open Hernia Repair Day-case surgery Anaesthesia

General Local

Operations Tension free Mesh repair

(Lichtenstien) Darn repairs (Shouldice, Bassini)

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Open Hernia Repair Incision above medial half of inguinal

ligament External oblique opened from external

ring to expose the cord and overlying ilioinguinal nerve

Internal (deep) ring exposed Hernial sac identified and reduced Prolene mesh inserted to reinforce

posterior wall and deep ring

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Open Hernia Repair

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Open Hernia Repair

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Open Hernia Repair

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Open Hernia Repair

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Open Hernia Repair

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Laparoscopic Repair

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Laparoscopic Repair

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Laparoscopic Repair

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Surgery Complications Trauma

• Nerve• Artery (testicular atrophy)• Intestine

Haemorrhage• Haematoma (infection)

Infection• Wound infection• Chest Infection

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Femoral Hernia Herniation through femoral canal Appears below and lateral to pubic

tubercle Relatively uncommon Commoner in females Contains omentum or small intestine High risk of strangulation Repaired surgically

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Femoral Hernia

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Femoral Hernia Repair

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Summary Inguinal hernia is the commonest

external hernia Indirect hernias have a higher risk of

strangulation Hernias are treated by surgery, to relieve

symptoms and prevent complications Femoral hernias have a high risk of

strangulation

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Recommended Reading Ellis H. Clinical Anatomy www.vesalius.com