HERNIA 2023.pptx

excellent presentation

1. HERNIAs Gregory gachukia MBChb year six SUPERVISOR: DR. OGOMBE

2. Differential diagnosis’ for groin swellings: Inguinal hernia Femoral Hernia Undescended testes Inguinal Lymphadenitis Lipoma of the spermatic cord Saphena varix

3. OVERVIEW A hernia is an abnormal protrusion of an organ or part of an organ from one anatomic space to another. Composition of hernia: Defect in the wall/tissue The sac (mouth, neck, body) The content of the sac

4. anatomy

5. Anatomical causes of hernias Basic design weakness i.e. lumbar triangles, posterior wall of the inguinal canal Weakness due to structures entering and leaving the abdomen Developmental failures Genetic weakness of collagen e.g. Ehlers-Danlos syndrome, Marfan syndrome Sharp and blunt trauma Weakness due to ageing and pregnancy Primary neurological and muscle diseases e.g. traumatic nerve palsy, DMD/BMD, CMD

6. Pathophysiology of Hernia Formation A normal abdominal wall has sufficient strength to resist high abdominal pressure and prevent herniation of content. Herniation has been attributed to conditions that result in increased intraabdominal pressure however not a major factor e.g. constipation, weight-lifting, pregnancy, prostatic symptoms, COPD, ascites Hernia an inherited collagen disease? More common in pregnancy due to relaxin -induced ligamentous laxity. Also in the elderly due to senescent degeneration of muscles and fibrous tissue. Effect of smoking - decreases rate of collagen formation due to the effect of nicotine. which weakens the abdominal wall and impairs wound healing Being obese or overweight increases the strain and pressure on the abdominal muscles and makes them weaker and more prone to developing hernias

7. Classification By anatomical location By degree of complication Nyhus Classification

8. By anatomical location Anterior abdominal wall hernias Epigastric hernias Umbilical hernias Paraumbilical hernias Incisional hernias Spigelian hernias Parastomal hernias Posterior abdominal wall hernias Lumbar hernias Groin hernias Inguinal hernias Femoral hernias Obturator hernias

9. Anterior abdominal wall hernias

10. By degree of complication Occult hernia Reducible hernia Irreducible or incarcerated hernia Strangulated hernia

11. Nyhus classification of hernias Type Description Type 1 Indirect inguinal hernia; normal internal inguinal ring; no posterior floor defect Type II Indirect inguinal hernia; enlarged internal inguinal ring; does not extend to scrotum Type IIIA Direct inguinal hernia Type IIIB Indirect inguinal hernia; posterior inguinal wall defect Type IIIC Femoral hernia Type IV Recurrent hernias

12. Classification Ctd The European Hernia society suggested a simplified classification system: Primary or recurrent (P or R) Lateral,medial or femoral (L,M,F) Defect size in finger breadth assumed to be 1.5cm

13. Clinical history and diagnosis Self diagnosis is common Presents as a subcutaneous lump on the abdominal wall Often painless; severe pain suggests strangulation Reducibility? Bowel obstruction? Primary or recurrent hernia? Associated pathologies? Smoking?

14. Examination for hernia Examine the patient initially when lying down then while standing Overlying skin colour changes; bruising and overlying cellulitis suggests strangulation Surgical scars Reducibility Tenderness Cough impulse; may be negative in strangulated hernias and positive in saphena varix Size, rigidity and number of defects

15. Investigations Ultrasound CT scan

16. Management principles Not all hernias require repair; increasing size and irreducibility are indications Complicated and femoral hernias require repair All repairs follow the same basic principles: Reduction of the hernia content with necessary debridement and repair Excision and closure of the sac Reapproximation of the walls of the neck if possible Permanent reinforcement of the defect with sutures or mesh (net vs sheet; synthetic vs biological; light vs medium vs heavyweight; large pore vs small pore; intraperitoneal vs extrap ; non-absorbable vs absorbable)

17. Inguinal hernia Indirect inguinal hernia Also known as congenital, oblique or lateral hernia. M>F As the testis descends a tube of peritoneum is pulled with the testis and wraps around it ultimately to form the tunica vaginalis. Bowel is able to pass inside the peritoneal tube down towards the scrotum and may be referred to as scrotal hernia which is usually large. Most common type of inguinal hernia.

18. Types of indirect inguinal hernia Bubonocele: the hernia sac stops within the inguinal canal after entering the deep inguinal ring Funicular: the hernia sac after emerging out of superficial inguinal ring stops just above the testis Complete scrotal: processus vaginalis is patent throughout being continuos with tunica vaginalis of the testis

19. Direct Inguinal Hernia Also known as the acquired or medial hernia. It is a result of stretching and weakening of the abdominal wall just medial to the inferior epigastric vessels in the Hassel Bach's triangle (area of weakness) whereby the abdominal wall here only consists of transversalis fascia. Almost always occurs in the middle-aged and elderly because their abdominal walls weaken as they age. It is usually broadly based hence unlikely to strangulate A medially placed bladder can be pulled into the direct hernia

20. Special tests for hernias

21. Test Leg raising test-manifested by malgaigne’s bulging

22. Inguinal hernias-Special types Dual Hernia Sliding Hernia Ritcher’s Hernia Maydl’s Hernia Littre’s Hernia Amyand’s hernia

23. Differential diagnosis Lymph node groin mass or an abdomnal mass Hydrocele Femoral hernia Spigelian hernia Saphena varix Varicocele

24. Management Watchful waiting in asymptomatic hernias Herniotomy with some form of muscle strengthening (herniorrhaphy). Open suture repair: Bassini type Shouldice Modification Maloney's modification Desarda modification

25. Cont’d Open flat mesh repair: Lichtenstein – commonly used and has lowered hernia recurrence rate and accelerated post operative recovery. most common operation in resource rich countries . Prolene Hernia system Open preperitoneal repair – Stoppa’s Laparoscopic repair TEP/TAPP- usually indicated in recurrent and bilateral hernias.

26. Complications of surgery Bleeding- due to accidental damage to inferior epigastric or iliac vessels Urinary retention Femoral nerve blockade causing patient to be unable to move. usually resolves in 12hrs. Medium seroma- may resolve spontaneously or require aspiration and can be misdiagnosed as an early recurrence SSI Chronic pain Hernia recurrence Testicular atrophy

27. Femoral Hernia Occurs through the femoral canal Less common than the inguinal hernia. More common in females than in males- Due to the difference in shape of their pelvis: in females the shape increases the size of the femoral canal thus increase risk of hernia more common in low weight elderly women Easily missed on examination. 50% of cases present as an emergency with very high risk of strangulation.

28. Diagnosis: Appears below and lateral to the pubic tubercle and lies in the upper leg rather than in the lower abdomen. Often rapidly becomes irreducible and loses any cough impulse due to the tightness of the neck Differential diagnosis : Inflamed lymph node Direct inguinal hernia. Saphena varix. Femoral artery aneurysm. Psoas abscess. Rupture of adductor longus with haematoma .

29. Investigations: If there’s uncertainty, request for ultrasound or CT scan should be requested. All patients with unexplained small bowel obstruction should undergo careful examination for a femoral hernia. It is now common to perform CT scanning in cases of bowel obstruction primarily to exclude malignancy, but it can identify an obstructing femoral hernia missed by clinicians.

30. Management: There is no alternative to surgery for a femoral hernia, treat them with urgency. There are three approaches and appropriate cases can be managed laparoscopically. Low approach (Lockwood)- suitable when there is no risk of bowel resection Inguinal approach ( Lotheissen ) High approach ( McEvedy )- ideal in emergency situations where risk of strangulation is high AK henry’s approach Laparascopic approach- TEP and TAPP: ideal for elective cases

31. UMBILICAL HERNIA The umbilical defect is present at birth but closes as the stump of the umbilical cord heals, usually within a week of birth. This process may be delayed, leading to the development of herniation in the neonatal period. The umbilical ring may also stretch and reopen in adult life. Umbilical hernia in children: Common (1 in every 10 live births), with a higher incidence in premature babies. M=F; black infants X8 more than in white. Obstruction and/or strangulation are extremely uncommon below the age of three years. Conservative treatment is indicated under the age of 2 years when the hernia is asymptomatic. 95% resolve spontaneously. If the hernia persists beyond the age of 2 years, it is unlikely to resolve and surgical repair is indicated: herniorrhaphy.

32. Umbilical hernia in adults: Common in overweight men or multiparous women. Progressively increase in size and may get very large indeed. Round defect with rigid fibrous margins typically slightly to one side of the umbilical depression, creating a crescent shaped appearance to the umbilicus. Large hernias may contain small or large bowel but even when very large the neck of the sac is usually narrow compared to the contents hence are prone to obstruction and strangulation. Most patients complain of pain due to tissue tension or symptoms of intermittent bowel obstruction. Surgery advised which includes: 1. Open umbilical hernia repair/Mayo’s operation 2. Laparoscopic umbilical hernia repair

33. EPIGASTRIC HERNIA These arise through the midline raphe ( linea alba) anywhere between the xiphoid process and the umbilicus, usually midway. They are usually less than 1 cm in maximum diameter and commonly contain only extraperitoneal fat which gradually enlarges, spreading in the subcutaneous plane to resemble the shape of a mushroom. Common cause of recurrence is failure to identify a second defect at time of original repair.

34. Diagnosis: The patients are often fit, healthy males between 25 and 40 years of age. These hernias can be very painful even when the swelling is the size of a pea due to partial strangulation. It may be locally tender with pain that mimics a peptic ulcer. It is unlikely to be reducible because of the narrow neck and resemble a lipoma. A cough impulse may or may not be felt. Surgery should only be offered if the hernia is sufficiently symptomatic (laparoscopic repair)

35. INCISIONAL HERNIA These arise through a defect in the musculofascial layers of the abdominal wall in the region of a postoperative scar. Thus they may appear anywhere on the abdominal surface. 10–50 per cent of laparotomy incisions and 1–5 per cent of laparoscopic port-site incisions . Type 1 and II Factors predisposing their development are: a). Patient factors (obesity, general poor healing due to malnutrition, immunosuppression or steroid therapy, chronic cough, cancer). b). Wound factors (poor quality tissues, wound infection). c). Surgical factors (inappropriate suture material, incorrect suture placement.)

36. Diagnosis: Commonly appear as a localized swelling involving a small portion of the scar but may present as a diffuse bulging of the whole length of the incision. Vascular damage to skin may lead to dermatitis. Obstruction is common but strangulation is rare. Wide variation in size. Management Asymptomatic incisional hernias may not require treatment at all. The wearing of an abdominal binder or belt may prevent the hernia from increasing in size. Surgery is often straightforward and both open and laparoscopic options are available.

37. Surgical repair modalities for incisional Hernias

38. Spigelian Hernia Uncommon (probably underdiagnosed) M=F; most common in the elderly. They arise through a defect in the Spigelian fascia which is the aponeurosis of the transversus abdominis muscle. Occurs at the level of the arcuate line through the Spigelian fascia The hernia sac lies either deep to the internal oblique or between external and internal oblique muscles In young patients they usually contain extraperitoneal fat only but in older patients there is often a peritoneal sac and they can become very large indeed. May also be congenital showing incomplete differentiation of mesenchymal layers within abdominal wall.

39. Diagnosis: Young patients usually present with intermittent pain, due to pinching of the fat (similar to an epigastric hernia). There’s a soft reducible mass lateral to the rectus muscle and below the umbilicus Positive cough impulse Older patients generally present with a reducible swelling at the edge of the rectus sheath and may have symptoms of intermittent obstruction. Diagnosis should be suspected because of the location of the symptoms and is confirmed by CT. Management: Surgery is recommended as the narrow and fibrous neck predisposes to strangulation. Surgery can be open or laparoscopic (TAPP or intraperitoneal onlay of mesh (IPOM). Spigelian fascia is repaired by suture or mesh laid deep to external oblique aponeurosis.

40. Spergelian Hernia REPAIR

41. LUMBAR HERNIA It can be: primary or secondary; superior or inferior Secondary is due to previous renal surgery and accidental injury to subcostal nerve; more common Most primary lumbar hernias occur through the inferior lumbar triangle or Petit bounded below by the crest of the ilium, laterally by the external oblique muscle and medially by the latissimus dorsi. Less commonly, the sac comes through the superior lumbar triangle, which is bounded by the 12th rib above, medially by the sacrospinalis and laterally by the posterior border of the internal oblique muscle.

42. References Williams, N., O'Connell, P., & McCaskie , A. (2018).  Bailey and Love's short practice of surgery  (27th ed.). CRC. Abdominal hernias - Knowledge @ AMBOSS . Amboss.com. ( 2023). Retrieved 15 th January 2023, from https://www.amboss.com/us/knowledge/Abdominal_hernias.