Rob Padwick MRCS MMedEdSpR General Surgery
Definition of hernia Overview of types of hernia Presentation and Management of common types of hernia
Quick overview of the rest
What is the definition of a hernia?
An abnormal protrusion of a viscus from the body
cavity of its origin into another cavity of the
body
Via natural orifices Via natural ‘weaknesses’ Via iatrogenic orifices Via iatrogenic ‘weaknesses’
Hiatus Inguinal Femoral Umbilical/
Paraumbilical Epigastric Incisional Parastomal Perineal
Spygelian Lumbar Obturator ‘Internal’ Other
diaphragmatic herniae
• Nothing• Lump• Pain• Incarcerate;
– Something gets stuck• Obstruct;
– Something gets stuck and blocks off• Strangulate;
– Something gets stuck and loses its blood supply
VERY COMMON! Via Oesophageal hiatus Most commonly stomach Occasionally transverse colon or small
bowel if very large Rarely cause major problems
• Types;– Rolling– Sliding
• Presentation;– Asymptomatic– Heartburn– Acid reflux– Cough– Chest symptoms if very large
Diagnosis
•Chest X-Ray•Barium Meal•CT•OGD
Complications; Barrett’s Oesophagus Obstruction/incarceration/strangulation (rare)
Treatment; None PPI Nissen’s Fundoplication
• Site;– Inguinal canal– Right/Left groin
• Types;– Direct– Indirect
• Causes;– Congenital– Raised intra-abdominal
pressure
M>>F
Contents; Spermatic Cord;
Vas deferens Testicular artery and veins Pampiniform plexus Artery to the Vas
Ilioinguinal nerve Genital branch of Genitofemoral nerve Iliohypogastric nerve
Presentation; Lump Pain Bowel obstruction Scrotal symptoms
Take the ‘Indirect’ route; Exit abdomen via deep ring Through whole inguinal canal Exit superficial ring May enter scrotum
Take the ‘Direct’ route; Exit abdomen via Hesselbach’s Triangle Exit superficial ring Do not enter scrotum
Complications; Pain Incarceration Obstruction Srangulation
Treatment; Conservative (e.g. Truss) Surgery;
Open Laparoscopic
• Complications of Surgery;– Bleeding– Infection– Pain– Bruising– Parasthesia– Recurrence– Testicular problems;• Small ball• Blue ball• Black ball• No ball
Site; Into the femoral canal Via the femoral ring
Presentation; Lump Pain Symptoms of obstruction
Treatment; Surgery
F>M
Site; Midline Into umbilical skin
Umbilical; Relatively rare Most commonly in children Congenital defect
Paraumbilical Very common!
Presentation; Usually asymptomatic Lump Pain
Treatment; Vast majority need none Repair if troublesome – most commonly
contain omentum only
Site; Midline Above paraumbilical herniae Rest see above
NB Divarication of rectus
Site; Via any surgical incision
Treatment; Depends on whether causing problems Leave alone Surgery
Site; Around stoma
Treatment; Conservative Surgery;
Repair Resiting stoma
• Site;– Via perineal orifices;• Vagina• Rectum
• Presentation;– Pain– Feeling of lump descending– Urinary symptoms– Bowel Symptoms
• Treatment;– Conservative– Surgery
• Spygelian;– Through linea semilunaris
• Lumbar;– Petit (inferior)– Grynfeltt (superior)
• Internal• Obturator;
– Through obturator canal• Other diaphragmatic herniae;
– Bochdalek– Morgagni
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