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Lecture (3) surgery / Dr. H. Zaini Abdominal Wall.. Kufa / university Hernia.. * is a protrusion of a viscous or part of a viscous through an abnormal opening through a wall of its cavity. * the ext. abnormal hernia is the commonest form of spontaneous hernia which is mostly:- a. inguinal 73% b. femoral 17% commonly in female c. umbilical 8.5% d. rare forms 1.5% * incisional hernia occur post-operatively through surgical incision, it is increasingly common variety of ext. acquired hernia.

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General Features to All Hernias:- *Aetiology:- - Is a powerful muscular effort or a strain by lifting heavy weight or any condition that raised intra abdominal pressure that precipitate hidden hernia which is congenital. As indirect inguinal hernia is almost always congenital & not appear until there is precipitating factors, while umbilical & paraumbilical mainly acquired ---so the these factors are:- 1. whooping cough. 2. chronic cough (heavy smokers, corpulmonale.

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3. straining in micturation specially old male :-. Bladder out obstruction.. prostatic enlargement.. Bladder neck obstruction.. Congenital posturethral valve. *Hernia is more common in smokers. * peritoneal dialysis can cause development of hernia from a previously occult weak or enlargement of processes vaginalis. *obesity result in umbilical, direct inguinal or Hiatus hernia. 4. chronic constipation (old age more liable).

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5. Ascites 6. pregnancy 7.obesity cause increase intra abdominal pressure & stretching of the muscular wall, weakness especially in multiparous women and increase fat in the body causing muscular weakness. 8. Malignancy. 9. premature infant have higher incidence of hernia. - inguinal hernia is a common form in male 5-10% of normal male population. m:f 20:1.

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composition of Hernia - consists of three parts:- 1) the sac contain content & covering - the sac is diverticulum of peritoneum (that protrude through the defect) composed of mouth, neck,body & fundus. * the diameter of neck is very important because strangulated bowel is likely complication when is narrow as femoral & umbilical hernia. * the body varies greatly in size. In case of infancy & child hood the sac is very thin as gossamer, but in long standing cases the sac become thick with time because of fibrosis due to irritation. - in some incisional & direct ing.H. there is no actual neck.

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2) the covering composed of layers of abd. wall through which the sac pass. In long standing cases atrophy of sac if not treated and undistinguishable from each other. 3) contents may be any abdominal content except the liver, but the commonest are:- A. fluid from peritoneal exudates or transudate. B. part of ascites serous fluid (yellowish, clear), blood stained fluid associated with strangulation. C. part of omentum omentocele (epiplocele).

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D. part of intestine enterocele. E. part of bladder specially in direct inguinal H., sliding H. or femoral H. F. ovary with or without fallopian tube. G. Meckels diverticulum Littres hernia. H. portion of intestinal circumflex Richters hernia mainly in femoral or obturator.

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Classification of Hernia 1- reducible 2- irreducible 3- obstructed 4- strangulated 5- inflamed

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Reducible Hernia. It is either reduced by itself when lie down or can be reduced by pt. or surgeon.. The intestine show gurgles on reduction & first portion is very difficult to reduce initially sign of intestine if easy initially then become difficult indicate that the content is not intestine e.g. omentum.. Also show expansile impulse visible cough impulse.

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Irreducible Hernia. The contents cannot be retained to abdomen with no evidence of other complication. This is because of - adhesion between sac. & its content - overcrowding of the content. It. doesn't have expansile impulse. Obstructed Hernia. This an obstructed from without or within, But there is no interference with blood supply.

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strangulated Hernia. Become strangulated when the B. supply of its content is seriously impaired gangrene. The area is tender, red, tense with signs of inflammation may occur 5-6 hr. of occurring symptoms.. A though inguinal H. is 4 times more common than femoral H. But F.H. is more likely to be strangulated because of narrowness of the neck of sac & its rigid wall.

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pathology of strangulated H. :-. The intestine is obstructed except in Richters hernia.. B. supply is constricted, at first the venous return is imbedded ( because the vein is more superficial & its wall mainly adventitial with little muscular content).. The wall become congested & the bright red & fluid secreted to the sac. (inflammation). as the congestion increased, the intestine become purple in color & the loop become distended twice its lumen.

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. With time the arterial supply is more impaired & the blood is extravasated ( the fluid become blood stained ) under serosa give rise to ecchymosis then into the lumen.. The wall of the loop lose their tone & become flabby & very friable.... this give rise to transmigration of bacteria through its wall the fluid become rich with bacteria peritonitis.. Gangrene appear first at ring of constriction then spread. The color change from black to green which may also involve the mesentery.

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. The perforation occur either on convexity of loop or at site of ring which is mainly affected.. The perforation complicated by peritonitis because the fluid exits from the sac to peritoneal cavity.. The transmigration of bacteria is more dangerous than the strangulation itself.

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Clinical Features of strangulated Hernia:- 1- sudden pain at first situated at sit of hernia followed by generalized abd. pain often located at umbilicus. 2- very forceful vomiting, may be repeated projectile or effortless. 3- the pt. say that H. has recently become larger. 4- O/E the hernia become tense, tender, irreducible & no expansible impulse on coughing. 5- unless strangulation is relieved by operation, the pain is continued until the peristalsis is ceased with onset of gangrene. 6- spontaneous cessation of pain is a grave sign this cessation is due to paralytic ileus.

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Strangulated Richters Hernia:- is particularly dangerous as operation is frequently delayed because there is no obstruction and the strangulation is small mainly in femoral hernia or fatty women.. Pt. not vomit or might once or twice.. There may be diarrhea because of toxicity.. Constipation is delayed until the paralytic ileus develop.. Clinical features may mimic gastroenteritis.

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Strangulated omentocele:-. Symptoms are similar to strangulated bowel but:- 1) vomiting & constipation may be absent. 2) the onset of gangrene is delayed.. Unrelieved cases a bacterial invasion of dyeing contents of sac occur. At the beginning is limited to sac days weeks. But in the case of inguinal H. infection usually terminates as a scrotal abscess, or retroperitoneal.

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Inflamed Hernia:- inflammation occur from irritation or sepsis from within the sac as in acute appendicitis, salpingitis or from external press by ill fitting truss or from external caused as incisional hernia atrophic ulcer.. The hernia is tender but not tense & the overlying skin is red & edematous.. The operation is necessary to deal with.. Treatment depends on underlying cause.