Hernia

Lecture on the various hernia afflicting humans for medical students. Encompasses basic sciences, various classifications, clinical presentations including complications and types of repair. Another pet topic of the author.

1. Hernia Chea Chan Hooi Surgeon Sibu Hospital

2. Content Definition Epidemiology Risk factors Classification Clinical features Management Specific configurations Other types Q&A

3. Definition Protrusion, bulge or projection of organ through the body wall which normally contains it

4. Epidemiology Between 5 – 10% in the US Inguinal > femoral > other abdominal wall hernias

5. Risk factors Modifiable Non-modifiable Obesity Chronic straining on defecation or urination Chronic coughing Chronic heavy lifting Ascites Previous surgery Male Prematurity Patent procesus vaginalis Maldescended testis Associated urogenital disorders (ambiguous genitalia, epispadias , hypospadias) Connective tissue disease Aging Family history of hernia

6. Classification Anatomical External Anterior abdominal wall Epigastric Spigelian Umbilical Inguinal Femoral Obturator Posterior abdominal wall Lumbar Sciatic Internal Hiatal hernia Cerebral herniation Clinical features Uncomplicated Complicated

7. Clinical features Impulse on coughing/straining Uncomplicated – easily reducible Complicated – usually irreducible Incarcerated Contents entrapped within hernia sac, usually large and for years without much symptoms Obstructed Bowel luminal obstruction Strangulated Blood supply compromised Causative factors

8. Physical examination Location Femoral – infero -lateral to pubic tubercle Inguinal – supero -medial to pubic tubercle Extent Bubonocele , funicular, complete inguino -scrotal Deep ring occlusion test – indirect inguinal hernia Testes within scrotal sac Optional Little finger test Zimmer’s test

9. Management Non-operative Trusses, binders Criteria Y oung (<65 year-old) No significant co-morbidities Easily reducible bubonocele Minimal or no symptoms Understands the features of complications to present quickly

10. Operative Open Mesh repair ( hernioplasty ) Lichtenstein repair Kugel (pre-peritoneal) repair Tissue repair ( herniorraphy ) Bassini repair ± Tanner modification Shouldice repair Mc Vay repair Herniotomy Hernia sac ligation Reserved for paediatric patients Laparoscopic TEP TAPP

11. TEP Avoids the attendant risks of entering peritoneal cavity, therefore minimising risk of adhesions, bowel injury TAPP Larger working space Ready access to both inguinal regions Allows inspection of peritoneal organs Possible for patients with previous lower abdominal surgery or hernioplasty

12. Specific configurations Richter Amyand Littre Maydl Reduction en-masse Intestinal stenosis of Garre

13. Other hernia types n.b. incisional & parastomal hernia not included

14. Giant inguinal hernia Inguinal hernia that extends below the midpoint of inner thigh when the patient is in standing position Complications of reduction Abdominal compartment syndrome (loss of domain >20%) Seroma Haematoma

15. Management Pre-operatively Increase intra-abdominal volume Progressive pneumoperitoneum Ensure adequate room in abdominal cavity by pneumoperitoneum before reduction of the hernia contents Gradually insufflating gas into abdominal cavity via placed catheter in situ, usually in increments of between 500 – 2000cc/day over 7 –14 days 4 Ambient air, oxygen, carbon dioxide and nitrous oxide Multiple sittings needed Intra-operatively Resection of contents Resected organs usually the colon, small bowel or omentum Single-stage operation Risk of anatomotic leak & mesh infection Rotation of viable tissue 5, 6 Scrotal skin flap, tensor fascia latae musculocutaneous flap & component separation technique Single-stage procedure but specific surgical expertise required to prevent complications

16. Umbilical hernia M id-abdominal location, centered around the umbilicus Typically small   Umbilical (Direct) Paraumbilical (Indirect) Patient Paediatric majority Adult majority Clinical The whole umbilicus is symmetrically effaced & it loses its characteristic shape Umbilicus has crescent appearance due to an asymmetrical effacement Defect Thru the umbilical ring Superior or inferior to the umbilical ring Pathophysiology Failure of umbilical ring to close Congenital weak point between umbiical ring and linea alba Differential diagnosis Omphalocele Port site hernia post laparoscopic surgery Adapted from Compendium of 100 Surgical Cases in Sibu Hospital

17. Management Elective Open Mesh repair: Onlay vs. inlay vs. sublay repair Non-mesh repair: anatomical vs. Mayo repair Laparoscopic intraperitoneal onlay mesh repair (IPOM) Emergency Transverse incision feasible

18. Type Pros Cons Onlay   Mesh placed anterior to fascia     Relatively simple Acceptable recurrence rate 5 – 15%     Skin flaps created to accommodate mesh might be devascularised , predisposing to seroma and infection For large defects (>10cm), repair in combination with component separation Inlay   Mesh placed to bridge the fascial defect     Relatively simple   Abdominal pressure exerted directly on mesh, detaching it away from fascial edges Need a composite mesh (expensive) as mesh in direct contact with peritoneal content Does not allow tissue-mesh integration Obsolete due to high (3x) recurrence & SSI rates Sublay   Mesh placed posterior to recti muscles where the force of abdominal pressure holds the mesh against the posterior surface of muscles   Lowest recurrence rate (3.5%) Tissue integration superficial & deep to mesh Mesh protected from superficial SSI & intra-abdominal adhesion/contamination     Technically challenging Large dead space posterior to recti with resultant seroma Adapted from Compendium of 100 Surgical Cases in Sibu Hospital

19. Epigastric hernia AKA epiplocele Along linea alba Usually small Differentiate from divarication of recti

20. Obturator hernia H yperesthesia or pain in the medial thigh or in the region of the greater trochanter R elieved by thigh flexion Worsened by medial rotation, adduction, or extension at the hip Typically an elderly, frail lady who had lost signifcant body fat thus opening up the obturator foramen Management Elective Laparoscopic repair Emergency Laparotomy (bowel gangrene common)

21. Spigelian hernia Thru linea semilunaris Pain worsens with abdominal wall muscle contraction Prone to incarcerate or obstruct Management Transverse incision over hernia sac Midline laparotomy seldom

22. Lumbar hernia Thru lumbar triangles Superior ( Grynfeltt-Lesshaft ) Inferior (Petit) Vague flank discomfort + mass Seldom incarcerate Management Non-operative Open posterior mesh repair via skin-line oblique incision from 12th rib – iliac crest

23. Sciatic hernia Intestinal obstruction Ureteric obstruction Sciatic pain Tender mass in the gluteal area Differentials Lipoma Tuberculoma Soft tissue malignancy Management Elective Open transgluteal Emergency Open transperitoneal

24. TQ! Q&A?