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1. HERNIAS

2. Abdominal wall hernias are common
surgical problems encountered in all
levels of health care facilities.
 Adequate knowledge to reach to the
correct diagnosis and appropriate
management plan help the care provider
to prevent serious complications which
could be fatal.

3. •Definition – Hernia is a protrusion of a viscus
through an opening in the wall of the cavity.
•Hernial sac - is an out pouch of the
peritoneum. It has four parts: mouth, neck,
body and fundus
•Content- Is a viscus or any other organ inside
a sac. It can be:
- Small bowel and omentum – the commonest
- Large bowel appendix

4. The bladder
omentum = omentocele (synonym:
epiplocele);
 intestine = enterocele; more commonly
small bowel but may be large intestine or
appendix;
a portion of the circumference of the
intestine = Richter’s hernia

5. Internal
External hernia

6. •Hiatus
-Sliding
-Rolling

•Para duodenal
•Para caecal (Retrocaecal)
•Mesenteric
•Spingelian

7. Anatomical location
-Umbilical
-Paraumbilical
-Epigastric
-Groin (Inguinal, Femoral)
-Lumbar
-Obturator
-Incisional

9. Reducible hernia- when the protruded viscus
can be returned back to the abdomen
Irreducible hernia- when the contents can’t
be returned back
Obstructed hernia- the content of the hernia
(intestine) is occluded but no impairment of
vascular supply
Strangulated hernia- the content of the
hernia is occluded with impairment of
vascular supply. Contents become swollen
due to venous congestion.

10. Strangulated hernia cont….
•Leading to exudation of a blood stained
fluid
•Arterial supply is compromised and
gangrene sets in.
Perforation- Arterial supply is compromised
and gangrene sets in leading to perforation.
Peritonitis- spillage of bowel contents
leading to chemical peritonitis.

11. Richter’s hernia- when only one side of the
wall of the intestine is herniated. Here
strangulation of the bowel can occur with
out intestinal obstruction
Sliding hernia- when an extra peritoneal
structure form part of the wall of the sac

12. Increased intra abdominal pressure
resulting from:
 Chronic cough
 Straining at urination or defecation
 Heavy wt lifting
 Abdominal distension

13. Weakened abdominal wall
 Advanced age
 Malnutrition
 Congenital defect
 Trauma/surgery
Collagen disoders

14. History
 Lump which varies in size
 Pain, local aching, discomfort
 Factors predisposing to increased intra
abdominal pressure
 Symptoms of int.
obstruction/strangulation

15. • Patient is examined in standing and
lying position.
• Lump – reducible, cough impulse with
bowel sound
• May be reduced when patient is lying
and increases in size when patient is
coughing or straining
• Relation of the lump with the common
references – pubic tubercle, inguinal
ligament

16.  Signs of obstruction – tense, tender,
irreducible with absent cough impulse
 Signs of strangulation – more
tenderness, with warm indurated, and
inflamed overlying skin.

17. Investigation: Hernia is a clinical diagnosis
and investigation is rarely needed.
Complications of abdominal wall
hernias:
1. Irreducibility
2. Obstruction
3. Strangulation is a surgical emergency
•Risk of obstruction and strangulation is very
high in femoral hernia, paraumblical hernia
and indirect inguinal hernia with narrow
neck

18. •- Spontaneous resolution is unlikely
•- The risks of irreducibility, obstruction and
strangulation increase with time. So surgical
intervention is needed in most cases
Surgical treatment for abdominal wall
hernias
•1. Herniotomy - removal of the sac and
closure of the neck: Done only in infants and
children
•2. Herniorrhaphy - Herniotomy and repair of
the wall to prevent recurrence.

19. Anatomy of Inguinal and femoral
canal
Inguinal canal Boundaries
Anteriorly: External oblique apponeurosis
Posteriorly: Fascia transversalis
Inferiorly: Inguinal ligament
Superiorly: Conjoined tendon and internal
oblique muscle

20. •This canal runs in antero inferior direction
from internal to external ring. The internal
ring lies 2cm above and 2cm medial to mid
inguinal ligament.
• The external ring lies just above the pubic
crest and tubercle
Contents of inguinal canal
•In male: Spermatic vessels, Vas deference,
Ileo inguinal nerve, Genito femoral nerve
•In female: Round ligament

21. Is a narrow rigid space bounded by:
Inguinal ligament, superiorly
 Pectineal part of inguinal ligament
posterior
 Lacunar part of inguinal ligament
medially, femoral vein laterally
 The narrow rigid space makes this types
of hernia more prone to obstruction and
strangulation.

22. MALT(2M, 2A, 2L, 2T)
1.Superior wall (roof): 2 muscles
-Internal oblique muscle
-Transverse abdominus muscle
2. Anterior wall : 2 apnoneuroses
-external oblique apneurosis
- Internal oblique apneurosis

23. 3. Lower wall (floor): 2 ligaments
-Inguinal ligaments
-Lacunar ligaments
4. Posterior wall : 2t
-Transversalis fascia
-Conjoint tendon

24.  accounts for 80% of all external
abdominal wall hernia
 commonest is all ages and sexes
 20 x more common in males than women
 more common on right side

25. 1. Indirect type: passes through internal
inguinal ring along the inguinal canal.
May extend down to the scrotum. It
enters through the deep inguinal ring,
lateral to inferior epigastric artery and
traverses the inguinal canal
accompanied by spermatic cord.
2. Direct type : Bulges through the
posterior wall of inguinal canal

26.  60% on right, 40% Lt side and 20%
bilateral
 Due to congenital defect or potential
defect which is the remnant of processes
vaginalis
 20 times more common in men

28. Lipoma of the cord
Epididymal cyst
Hydrocele
Femoral hernia
Ectopic testis or undescended testis
Aneurysm

29.  due to wear and tear associated with
advanced age and increased intra
abdominal pressure
Direct inguinal hernia passes through the
triangle of Hesselbach

30. INDIRECT DIRECT
PATIENT’S AGE ANY AGE. USUALLY
YOUNG
OLDER
CAUSE MAY BE CONGENITAL ACQUIRED
BILATERAL 20% 50%
PROTRUSION ON
COUGHING
OBLIQUE STRAIGHT
APPERANCE ON
STANDING
FULL SIZE NOT
IMMEDIATELY
FULL SIZE
IMMEDIATELY
REDUCTION ON LYING
DOWN
NOT IMMEDIATELY REDUCES
IMMEDIATELY
DESCENT INTO
SCROTUM
COMMON RARE
NECK OF SAC NARROW WIDE
STRANGULATION NOT UNCOMMON UNUSUAL
RELATION TO INFERIOR
EPIGASTRIC VESSELS
LATERAL MEDIAL

31.  acquired downward protrusion of
intestinal contents into the femoral canal
 4 times more common in females
(middle-aged multiparous)
 rare in children

32. History
• Elderly or middle aged woman with thin
body build
• lump on anterior and upper thigh
• may present with complaints associated
with int. obstruction or strangulation
Physical examination
•Small lump on lower groin, lateral and
below pubic tubercle
• Reducible/irreducibility
• Bowel sound/cough impulse – usually
absent

33.  surgical repair without delay
Umbilical (Para umbilical) Hernia
Umbilicus is one of the weak sites of the
abdomen. A hernia can occur at this
potential site.

34. • Female sex
• Multiple parities
• Obesity
• Ascites
Complications
• Obstruction
• Strangulation
• Rupture

35. Expectant: - Spontaneous closure is
expected in 80% cases of umbilical hernia
in
under five children.
Surgery: - Beyond five years

36. Risk Factors
1.Preoperative
-Age
-Malnutrition
-Sepsis- worsen malnutrition, delays
anabolism
-Ureamia- inhibits fibroblast division
-Jaundice- impedes collagen maturation
-Steriods- have proteolytic effects
-obesity

37. 3. Postoperative
-Wound infection
-Abdominal distention
-coughing

38. 2. Operative
-Type of incision- vertical incision
-Technique and materials
-Type of operation. Eg involving
bowels=infection
-Drains –passing through wound

39. Clinical features
Risk of obstruction and strangulation is
very rare.
 Local discomfort
 Cosmetic problems
 Difficulties with micturation and bowel
movement when very large

40. Treatment
Hernioplasty

41. Bleeding
Haematoma
Infection
Injury to the vas
Orchitis

42. • vaginal hydrocele
• encysted hydrocele of the cord
• spermatocele
• femoral hernia
• incompletely descended testis in the
inguinal canal – an inguinal hernia is often
associated with this condition;
• lipoma of the cord – this is often a difficult
but unimportant diagnosis and it is usually
not settled until the parts are displayed by
operation.

43. hydrocele Inguinal hernia
You can go above it You can’t go above it
Doesn't pulsate pulsates
No cough impulse Has cough impulse
translluminates Does not translluminates
No bowel sounds Bowel sounds present
Not reducible reducible