Hernia

1. HERNIA

2. “Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it”

3. Common Hernias INGUINAL UMBILICAL FEMORAL EPIGASTRIC INCISIONAL Rare Hernias SPIGELIAN LUMBAR GLUTEAL SCIATIC OBTURATOR

4. Factors: Weakness of abdominal musculature Congenital Persistence of processus vaginalis Patent canal of Tuck Incomplete obliteration of umbilicus Acquired Fat Pregnancy Incision Infection Connective tissue – smoking, aging, CTD, systemic illness

5. Increased abdominal pressure Chronic constipation Chronic cough Bladder outlet obstruction – stricture, prostrate Straining – weight lifting Intra-abdominal malignancy Vomiting Repeated pregnancy

6. Sac Covering Contents Omentocoele Enterocoele Cystocoele Ovary

7. Richter’s Littre’s Maydl’s

8. Classification Reducible Irreducible Obstructed/ Incarcerated Strangulated

9. Reducible Hernia Characteristic signs Reducibility Cough impulse

10. Irreducible Hernia Due to Adhesions Narrowing of neck Incarceration Massive hernia inside scrotum

11. Obstructed Hernia Irreducibility + Intestinal obstruction Features No cough impulse Irreducible Painless Non tender Features of intestinal obstruction

12. Strangulated Hernia Blood supply of its contents impaired Intestinal obstruction ± Pathology Intestinal obstruction Dilation of hernial contents Impairment of venous return Stasis --------- Arterial impairment

13. Appearance Congested and bright red Ecchymosis Extravasation of blood into lumen/ sac loss of tone Translocation of gut bacteria – peritonitis/ sepsis Gangrene

14. Symptoms Pain, vomiting Ceases with onset of gangrene, ileus Signs Ill looking Tense, tender Irreducible, no cough impulse Acute intestinal obstruction Peritonitis

15. Strangulated Omentocele No features of intestinal obstruction Gangrene onset delayed

16. Strangulated Richter’s Hernia Features mimic gastroenteritis Obstruction > 50 % of circumference Colic, diarrhoes Constipation - ileus

17. Maydl’s Hernia Retrograde strangulation On opening sac – contents appear normal Generalized peritonitis may set in early

18. Inflamed Hernia Outside Abrasion, ill fitting truss Inside Diverticulitis, appendicitis Signs of inflammation + Not associated with intestinal obstruction

19. Inguinal hernia

20. Anatomy

21. Inguinal canal Triangular slit 3.75 cm long Above the inner half of inguinal ligament Deep to superficial inguinal ring Developed due to the descent of testis in embryonic life

22. Deep Inguinal Ring Opening in the fascia transversalis 1.25 cm above mid inguinal point Medially – inferior epigastric artery Spermatic cord in males; round ligament in females

23. Superficial Inguinal Ring Aponeurosis of external oblique – crurae Above and lateral to pubic crest Spermatic cord/ round ligament and illio -inguinal nerves

24. Anteriorly – skin, fascia, EO aponeurosis , lateral third – IO aponeurosis Posteriorly – transversalis fascia, medial ½ - conjoint tendon Above – transversus abdominins and internal oblique fibres Below – inguinal ligamnet

25. Contents Illioinguinal nerves Spermatic cord Vas defrens Testicular artery, art to vas defrens , cremasteric Pampiniform plexus of veins Lymph vessels Testicular plexus of sympathetic nerve s, genital branch of genitofemoral

26. Hassenbach’s Triangle Site of direct hernia Medially – lateral border rectus abdominis Laterally – inferior epigastric vessel Inferiorly – inguinal ligament Floor – fascia transversalis Umbilical fold – obliterated umbilical artery

27. Mechanisms for preventing hernia Obliquity of inguinal canal Shutter mechanism of fibres of IO, TA Sphincter action of TA, IO at deep inguinal ring Ball valve action of cremasteric Fibres of internal oblique over deep inguinal ring Conjoint tendon

28. INDIRECT INGUINAL HERNIA More common Young individuals More common on the right side On basis of extent Bubonocele Funicular hernia Complete hernia

29. Coverings Peritoneum Extraperitoneal fat Internal spermatic fascia Cremasteric fascia External spermatic fascia Superficial fascia skin

30. DIRECT INGUINAL HERNIA Directly through the hasselbach’s triangle Acquired (ex- Oglive hernia) More common in elderly, malgaigne bulgings Rarely gets strangulated

31. Symptoms Pain/ discomfort Lump Systemic symptoms – obstruction, strangulation Predisposing factors – constipation, chronic bronchitis, urinary obstruction Past history

32. Signs REDUCIBILITY COUGH IMPULSE Position – d/f femoral hernia Get above the swelling Invagination test Ring occlusion test

33. Rare Varieties Interstitial hernia Between muscle layers of abdominal wall Commonly associated with undescended testis Preperitoneal Intraperitoneal Extraperitoneal

34. Rare Varieties Sliding hernia Older men Extraperitoneal bowel with sac of peritoneum Caecum , pelvic colon, bladder Strangulation of intestine within and outside the peritoneum Richter’s Maydl’s Littre’s

35. TREATMENT Conservative management Surgical management

36. Conservative management : No Treatment Indications Severe ill health Short life expectency Refuse operation

37. Conservative management : Truss Indications Refuse operation Old patients with severe co morbidities Children ( c/I – undescended testis) Contraindications Irreducible hernia Undescended testis Chronic bronchitits , strenous labour Associated with large hydrocele Not intelligent enough to position properly

38. Dangers Pressure atropht of muscles of inguinal region Ostruction or strangulation Used with partially reduced hernia – may cause trauma Improper cleanliness – unhealthy skin Adhesions between sac and canal Chance of strangulation remains

39. Operative treatment Herniotomy Neck of sac transfixed, ligated and excised Infants and children ; young men with good musculature Herniorrhaphy Herniotomy + repair of postrior wall Indirect hernias Adults with good muscle tone

40. Hernioplasty Herniotomy + reinforcement of posterior wall Autologous Fascia lata External oblique aponeurosis Anterior rectus sheath flap Skin flap – dermoplasty / skin ribbon Heterogenous Prolene Stainless steel

41. Indications Indirect hernia – poor muscle tone Direct hernia Recurranthernia Predisposing factors – chronic cough,etc

42. Treatment of Strangulated Hernia Emergency surgery Resuscitation Reduction of hernia Foot end elevation Ice pack NG, IV fluids Analgesia, antibiotic

43. Assess viability Green/ black color Flaccid , lustureless appearance No peristalssis Blood stained, foul smelling fluid in sac Bowel viable - HERNIORRHAPHY

44. Bowel nonviable Linear patch of gangrene – invagination Loop of bowel – resection and anastomosis if gen condition permits Bowel large intestine – exteriorisation

45. RECURRENT INGUINAL HERNIA Types of hernia Sliding Large/ long standing Large direct hernia Types of patients – chronic cough Inadequate preoperative preparation

46. RECURRENT INGUINAL HERNIA Operative faults Failure to ligate sac Tension in repair Use of absorbable sutures Bleeding – infection Fault in selection of operation Postoperative care Wound infection Lifting heaavy weights Persistence of predisposing factors Appearance of new hernia

47. FEMORAL HERNIA

48. Femoral ring – femoral canal – saphenous opening More common in Females Old age Most liable to strangulate

49. Anatomy

50. Coverings of the sac of femoral hernia Skin Superficial fascia Cribriform fascia Anterior layer of femoral sheath Fatty contents of femoral canal Femoral septum Peritoneum

51. Rare types of femoral hernia Prevascular hernia( Velpeu’s ) – ass with posterior dislocation ( Narath’s hernia) Retrovascular hernia - Serafini Pectineal hernia – Cloquet’s External femoral hernia – Hesselbach’s Lacunar hernia – Lingier’s

52. Symptoms Swelling Pain Systemic symptoms Zeimenns technique Invagination technique Ring occlusion test Position of swelling

53. Treatment No conservative management Surgery – herniorrhaphy High operation( McEvedy’s ) Lottheissen’s Lockwood

54. UMBILICAL HERNIA Three major types Exomphalos Umbilical hernia in infants and children Paraumbilical hernia in adults

55. Exomphalos Minor Small sac Summit attached to the umbilical cord Treatment twisting of umbilical cord and strapping

56. Exomphalos Major Umbilical cord attached to inferior aspect of swelling Contains intestines, liver Surgical emergency Immediate decompression and reduction

57. Umbilical hernia in children and infants Weak umbilical scar following neonatal sepsis Usually asymptomatic 90% cured within 12 – 18 months > 18 months – surgery

58. Paraumbilical hernia of adults Supraumbilical or infraumbilical Adhesions - seldom reducible Predisposing factors – Women Obesity Repeated pregnancy Treatment – Mayo’s operation

59. EPIGASTRIC HERNIA ( Fatty Hernia of Linea Alba) Through fibres of linea alba Blood vessels pierce linea alba Initially extraperitoneal fat only M.c . – young muscular men with strenous activity Usually irreducible, no cough impulse If symptomatic - surgery

60. INCISIONAL HERNIA ( Ventral Hernia) Defect with patient Obesity Chronic cough perioperative period Undue abdominal distention Malnutrition Operative Injury to nerves Careless wound closure Hemorrhage – infection Tube drainage through laparotomy wound Midline infraumbilical

61. Postoperative Infection Postop cough, distention Postop peritonitis Early removal of sutures Postop steroid therapy

62. Types of incisional hernia Type 1 Upper abdomen/ midline lower abdomen Wide gap in musculature Low risk of strangulation Type 2 Lateral part of abdomen Small defect Strangulation risk high

63. Treatment Prevention of incisional hernia Weight reduction Correct nutritional defects Treat chronic cough Careful closure of abdomen Prevent post op wound infection

64. Conservative management Reducible type 1 SURGICAL MANAGEMENT

65. LUMBAR HERNIA Superior lumbar hernia Inferior lumbar hernia

66. Incisional lumbar hernia Renal surgery with post op infection Paralysis of lumbar muscles( phantom hernia ) Treatment Primary hernia – herniorrhaphy Incisional hernia

67. OBTURATOR HERNIA Rare; old women Through obturator foramen Thigh flexed, abducted and externally rotated Referred pain to knee joint Strangulation - surgery

68. SPIGELEAN HERNIA Interparietal hernia At level of arcuate line, lateral to rectus Treatment - surgery

69. Gluteal hernia Sciatic hernia

70. CONCLUSION Protrusion of a part or whole of viscus through an abnormal opening in the wall of the cavity that contains it Inguinal hernia most frequent Usual mode of treatment is surgical

71. Thank you