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