HerniasMBChB_Lecture.ppt anatomy types and

hernia repair

1. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
HerniasHernias
Prof. J.A. Adwok,Prof. J.A. Adwok,
MBChB, MMED (Surg), FCS(ECSA), FRCSMBChB, MMED (Surg), FCS(ECSA), FRCS
Department of SurgeryDepartment of Surgery
University of NairobiUniversity of Nairobi

2. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
DefinitionDefinition
A hernia is a protrusion A hernia is a protrusion
of a viscus or part of a of a viscus or part of a
viscus through its viscus through its
coverings into an coverings into an
abnormal situationabnormal situation

3. 6 th August, 2009 MBChB 3 Lecture
Common VarietiesCommon Varieties
•InguinalInguinal
•Femoral Femoral
•EpigastricEpigastric
•UmbilicalUmbilical
•IncisionalIncisional

4. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Common SitesCommon Sites

Congenitally weak sitesCongenitally weak sites

Penetration sitesPenetration sites

Weak sitesWeak sites

Damaged nerves with Damaged nerves with
muscle weaknessmuscle weakness

5. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Aggravating FactorsAggravating Factors

Chronic coughChronic cough

ConstipationConstipation

Urinary obstructionUrinary obstruction

Abdominal distension due to ascitesAbdominal distension due to ascites

Gross obesity Gross obesity

CachexiaCachexia

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Classification

Reducible

Irreducible

strangulated

7. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Inguinal HerniasInguinal Hernias
Protrusion of part of the contents Protrusion of part of the contents
of the abdomen through the of the abdomen through the
inguinal region of the abdominal inguinal region of the abdominal
wall.wall.
Common. Precise prevalence and Common. Precise prevalence and
incidence figures not availableincidence figures not available
More common in menMore common in men

8. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Inguinal Hernias--cont.Inguinal Hernias--cont.

Hernias in the inguinal region Hernias in the inguinal region
account for 75 % of all forms account for 75 % of all forms
of herniasof hernias

Classified as direct, indirect, Classified as direct, indirect,
and recurrentand recurrent

Maybe reducible or irreducibleMaybe reducible or irreducible

9. MBChB 3 Lecture6 th August, 2009
Clinical Features
History
Occupation
Pain or discomfort
Swelling, disappears on lying down
Colicky abdominal pain, vomiting,
abdominal distension, and absolute
constipation—classic intestinal
obstruction
Chronic cough, difficulty in
maturation, and constipation

10. 6 th August, 2009 MBChB 3 Lecture
Inguinal Hernia--SignsInguinal Hernia--Signs

Reducible lump with visible Reducible lump with visible
and palpable cough and palpable cough
impulseimpulse

Examine with patient Examine with patient
standing and lying supinestanding and lying supine

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Inguinal hernia—Signs cont.Inguinal hernia—Signs cont.

Position, temperature, Position, temperature,
tenderness, shape, size, tenderness, shape, size,
consistency of lumpconsistency of lump

ReducibilityReducibility

Direct or indirectDirect or indirect

Can you go above it?Can you go above it?

Percussion and auscultationPercussion and auscultation

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Indirect Inguinal hernia

Controlled at internal ring

Often descends into scrotum

Defect not palpable

Appears at mid inguinal
point

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Direct Inguinal hernia

Not controlled at internal ring

Rarely enters the scrotum

Reduces upwards and posteriorly

Defect maybe palpable above the
pubic tubercle

Appears medial to the mid-inguinal
point, expanding interiorly

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Differential Diagnosis
Diagnosis Distinguishing features
Femoral hernia Below and lateral to the pubic
tubercle
Lymph node No cough impulse
Usually below inguinal ligament
Varicocoele Dilated veins in spermatic cord,
visible with patient standing
Cyst of the canal of Nuck
(females)
Able to get above the lump
Hydrocoele of the cord (males) Not reducible
Undescended testis Testis absent from scrotum.

15. 6 th August, 2009 MBChB 3 Lecture
Surgical Treatment Inguinal Surgical Treatment Inguinal
herniahernia
•Many different techniquesMany different techniques
•Meticulous technique essentialMeticulous technique essential
•Excision or reduction of hernial sacExcision or reduction of hernial sac
•Repair of the posterior wall of the Repair of the posterior wall of the
inguinal canalinguinal canal

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Repair of Posterior WallRepair of Posterior Wall

ApproximationApproximation

Bassini’s techniqueBassini’s technique

ReinforcementReinforcement

DarnDarn

Shouldice repairShouldice repair

Insertion of prosthetic meshInsertion of prosthetic mesh

Laparoscopic repairLaparoscopic repair

HerniotomyHerniotomy

ProsthesisProsthesis

17. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Femoral HerniaFemoral Hernia
Protrudes through the femoral canalProtrudes through the femoral canal
6% of all abdominal wall hernias6% of all abdominal wall hernias
Aetiology unclear—elevated Aetiology unclear—elevated
intrabdominal pressure/laxity groin intrabdominal pressure/laxity groin
tissuestissues
Common with parity and weight lossCommon with parity and weight loss
Maybe reducible, irreducible, and Maybe reducible, irreducible, and
strangulatedstrangulated

18. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Femoral hernia--clinicalFemoral hernia--clinical

Asymptomatic lump or Asymptomatic lump or
localized intermittent localized intermittent
discomfortdiscomfort

Richter’s hernia commonRichter’s hernia common

Lies below and lateral to the Lies below and lateral to the
pubic tuberclepubic tubercle

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Femoral Hernia--Femoral Hernia--
treatmenttreatment
•Conservative—risky and
cannot be controlled with
truss
•High strangulation rate
•Surgery always
recommended

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Femoral Hernia—treatment cont.Femoral Hernia—treatment cont.

OperativeOperative

Excision of sacExcision of sac

Narrowing of stretched femoral ring Narrowing of stretched femoral ring
openingopening

ApproachesApproaches

LowLow

InguinalInguinal

preperitonealpreperitoneal

21. MBChB 3 LectureMBChB 3 Lecture6 th August, 20096 th August, 2009
Epigastric HerniaEpigastric Hernia
Protrusion of preperitoneal fat through Protrusion of preperitoneal fat through
linea alba in supraumblical positionlinea alba in supraumblical position

Rare for bowel to herniate but Rare for bowel to herniate but
peritoneal sac and omentum commonperitoneal sac and omentum common

Adult males under 40 yearsAdult males under 40 years

Present in 5% of individuals at autopsyPresent in 5% of individuals at autopsy
Majority asymptomaticMajority asymptomatic

22. MBChB 3 LectureMBChB 3 Lecture6 th August, 20096 th August, 2009
Epigastric hernia –cont.Epigastric hernia –cont.

Tender lumpTender lump

Gangrene of contents Gangrene of contents
occasionallyoccasionally

Investigate upper GIT in these Investigate upper GIT in these
patientspatients

Surgery indicated in Surgery indicated in
symptomatic patientssymptomatic patients

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Umbilical Hernia
Congenital
Omphalocoele
Exomphalos
Infantile umbilical hernia
Adult Paraumbilical
hernia

24. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Adult Paraumbilical Adult Paraumbilical
HerniaHernia
Acquired, disruption of linea alba Acquired, disruption of linea alba
above or below the umbilical above or below the umbilical
cicatrixcicatrix
Obesity, multiple pregnancies, Obesity, multiple pregnancies,
and ascitesand ascites
Occurs after 35 years and 5 times Occurs after 35 years and 5 times
more common in the femalemore common in the female

25. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Paraumbilical—cont.Paraumbilical—cont.
Dragging pain or colickyDragging pain or colicky
Necrosis of overlying skin in Necrosis of overlying skin in
large herniaslarge hernias
Usually has a small neck with Usually has a small neck with
danger of strangulationdanger of strangulation
Early surgery advisableEarly surgery advisable

26. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Incisional HerniaIncisional Hernia

Protrusion of a viscus through Protrusion of a viscus through
the musculoaponeurotic layers of the musculoaponeurotic layers of
a surgical scara surgical scar

Dehiscence if it occurs before the Dehiscence if it occurs before the
surgical skin wound is healedsurgical skin wound is healed

Occurs in about 5%-10% of Occurs in about 5%-10% of
patients undergoing surgerypatients undergoing surgery

27. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Incisional Hernia—Cont.Incisional Hernia—Cont.

Predisposing factorsPredisposing factors
–Preoperative condition of patientPreoperative condition of patient
–Technique of wound closureTechnique of wound closure
–Postoperative complicationsPostoperative complications
Surgical treatmentSurgical treatment
–Direct repairDirect repair
–MeshMesh
–OverlapOverlap
–Muscle flapsMuscle flaps

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30. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Rare HerniasRare Hernias

ObturatorObturator

SpigelianSpigelian

LumbarLumbar

SciaticSciatic

perinealperineal

31. 6 th August, 20096 th August, 2009 MBChB 3 LectureMBChB 3 Lecture
Questions?Questions?