| What are clinical manifestations of inguinal hernias? | Most important is lump or swelling in inguinal region, might have discomfort or pain.
may be reducible or irreducible w/supine and relaxed positioning
straining or coughing makes the hernia more apparent due to increased intraabdominal pressure |
| What are abdominal wall hernias? | Abnormal protrusion of intraabdominal tissue/viscus whole or part through an opening or defect of abdominal wall/pelvic wall.
Caused by weakness of abdominal wall or increased intraabdominal pressure (chronic cough, chronic constipation, straining on micturition due to prostatism |
| What are different subtypes of abdominal wall hernias? | Inguinal hernia, Femoral hernia, Ventral hernia
Ventral include (epigastric, umbilical, incisional, spigelian, lumbar) |
| What are inguinal hernias? | Arises when a portion of intestine protrudes through inguinal canal/triangle, superior to inguinal ligament and lateral to pubic tubercle
90% of hernias, occurs in groin, include indirect inguinal hernias and direct inguinal hernias, more in males than females
IMP review anatomy of inguinal area |
| How is pathological anatomy of inguinal hernias? | Consists of hernia ring, hernia sac, hernia content, hernia covering |
| How is clinical classification of hernias? | Reducible hernia (contained viscus can be returned from the hernia to its normal domain spontaneouslyor w/manual pressure when pt is recumbent)
Irreducible hernia (incarcerated [content of hernial sac are entrapped or stuck in the groin, very narrow neck, lumen of herniated bowel may become obstructed, no interference w/blood supply] or strangulated [intestine is tightly twisted/trapped, circulation arrested, life threat and emergency repair is needed])
Incarcerated or strangulated hernias are seldom in direct hernias, common in indirect, usually small intestine and can cause small bowel obstruction, sudden abdominal pain, vomiting, distention, in that case we doubt acute incarceration/strangulation hernia |
| What are special types of inguinal hernias? | Sliding hernia (Portion of wall of hernia sac is composed of an organ eg Cecum on right side and sigmoid colon on left side, occasional bladder involvement, related to posterior fixation of large bowel or other sliding organs)
Richter's hernia (only part of circumference of bowel becomes incarcerated/strangulated at narrow neck of hernia)
Littre's hernia (strangulated/incarcerated portion is diverticulum, usually Meckel's diverticulum) |
| What are indirect inguinal hernias? | Pass through deep inguinal ring, inguinal canal, superficial inguinal ring and descends to scrotum.
Lie lateral to inferior epigastric vessels, congenital (at birth), derived from persistence of processus vaginalis and covered by peritoneium and the coverings of spermatic cord, neck of hernia must be located lateral to inferior epigastric artery to enter inguinal canal and sac of hernia must lie w/in fibers of cremaster muscle. |
| What is direct inguinal hernia? | In inguinal triangle throught abdominal wall muscles, lateral to edge of conjoint tendon and rarely descends to scrotum.
Medial to IMA and protrudes forward the superficial inguinal ring
Acquired after birth and sac formed by peritoneum and occasionally transversalis fascia |
| What are clinical manifestations of inguinal hernias? | Most important is lump or swelling in inguinal region, might have discomfort or pain.
may be reducible or irreducible w/supine and relaxed positioning
straining or coughing makes the hernia more apparent due to increased intraabdominal pressure |
| What are methods of examination of inguinal hernias? | Pt should be standing in relaxed position, finger should be introduced through external ring into the inguinal canal, presence of dilated external inguinal canal would be found
We put examining finger on hernia area and ask pt to cough, if indirect: hits fingertip, if direct: hits ball of finger |
| What is DD of inguinal hernias? | Indirect, direct femoral hernias
Hydrocele of spermatic cord
Cryptorchidism
Lymphadenopathy or groin abscess |
| What are principles of tx of inguinal hernias? | Should be operated unless absolute CI
Emergency operation if incarceration/obstruction/strangulation
Congenital inguinal hernia may spontaneously cure can delay operation till >1 years old.
Non-operative measure: if acute incarceration: manual reduction may be used, place pt in hips elevated and sedation, then gentle sustained pressure over mass may effect reduction in 30min, if no answer go for operation |
| How is operative tx of inguinal hernia? | Solve all conditions that may increase intraabdominal pressure to prevent recurrent hernias
After repair pt need home rest 2-3 days and return to activities w/in 1 week, advised against heavy weights for 1-2 months, anesthetic general, local or spinal
Open technique (first two essential steps are same in any repair of hernias for most pt w/inguinal hernias, main difference is how to repair and reinforce wall of inguinal canal)
Laparoscopic surgery |
| How is open tecnhique for inguinal hernia? | Simple high ligation of sac (anatomically isolate hernia sac, ligate at neck of hernia sac, and removal of the sac
If simple ligation of the sac is combined w/ tightening of internal ring the Marcy repair)
Repair of hernia sac (management of sac, high ligation of sac and excision of sac, repair of transverse fascial defect)
Closing or decreasing size of internal ring by suture is required in most indirect hernias, transversal fascia plication
Surgical Meche (posthesis) |
| How is femoral hernias? | Protrudes through femoral ring beneath the inguinal ligament, common in women
Narrow neck, easy to incarcerate and strangulate
Anatomy (Femoral ring lateral [femoral vein], medial [lacunar ligament], posterior [Cooper's ligament], femoral ring extends inferoirly to form femoral canal |
| How is pathophysiology of femoral hernias? | Defect in transverse fascia in direct triangle, peritoneal sac pass through inguinal ligament to femoral canal, medial to femoral vein is small empty space for femoral hernia to project w/very narrow neck, easily incarceration and strangulation |
| What are clinical manifestations of femoral hernias? | Asx until strangulated/incarcerated, discomfort in abdomen not femoral area, small buldge in upper medial thigh just below level of inguinal ligament |
| How is tx of femoral hernia? | All need operation, if incarceration occurs manual reduction is forbidden and need emergency operation, complete excision of hernia sac, repair, and reinforce defect of trasnversalis fascia, closure of femoral canal
McVay is common repairing method. |
| What are ventral hernias? | Hernias of anterior abdominal walls except groin hernias
epigastric, umbilical, incisional, spigelian, lumbar |
| What is epigastric hernia? | Protrusion of extraperitoneal fat through defect in the linea alba anywhere between xiphoid process and umbilicus, midway between these structures
acquired, manual labourers, age 30-45 precipitated by strain causing tearing of interlacing fibers of linea alba
Initially protrusion of extraperitoneal fat through opening of linea alba by a small blood vessel, no well-formed sac called fatty hernia of linea alba.
Then hernia grows , drags pouch of peritoneum and becomes true epigastric hernia contains omentum or bowel |
| What are clinical features of epigastric hernia? | Asx (initial stages discovered incidentally)
Painful swelling (localized pain at site of hernia due to press of fat by margins of the gap of linea alba to produce partial strangulation)
Sx of peptic ulcer (associated w/above pain peptic ulcer pain/gall stone pain)
Size: pea size ->2cm diameter, no cough impulse can not be reduced
difficult to distinguish from lipoma, abdominal exam normal |
| How is tx of epigastric hernia? | If small and asx can be overlooked, if sx operation, preop do upper GI endoscopy to exclude PUD |
| How is umbilical hernia in children? | Either due to absence of umbilical fascia (Richet's fascia) or incomplete closure of umbilical defects, most common cause of umbilical sepsis in children
2:1 male:female, most are asx but parents anxious about swelling, strangulation rare.
Tx: conservative (close spontaneously w/in 2 years of age, masterly inactivity reassure parents and strapping over a coin
Operation (herniorrhaphy indicated after >2years old |
| How is umbilical hernia in adults (para-umbilical)? | protrudes through linea alba just above umbilicus or occasionally below it, called paraumbilical
middle aged or elderly women (1:5)
Risk factors: obesity, multiparous women, persistent source of straining (chronic cough, constipation, bladder neck obstuction)
Content is greater omentum accompanied w/small intestine or a portion of transverse colon, sac is loculated in most cases and hernia is irreducible.
Swelling in umbilical region, small and gradually increases in size
Dragging pain due to adherent omentum, firm swelling, dull on percussion, cough impulse when contents arenot adherent but absent when irreducible. |
| What are complications of umbilical hernia in adults? | Irreducibility, obstruction w/colicky pain and vomiting , untreated cases become strangulated, friction of skin causes intertigo (dermatitis between skin) |
| How is tx of umbilical hernia in adults? | Mayo's operation (after weight reduction using double breasting technique)
Mesh's repair (for larger defects open or laparoscopic overlay or IPOM) |
| What is incisional hernia? | Peritoneal sac hernia through acquired scar in abdominal wall caused by previous operation/trauma.
Very common in females, content is omentum or bowel.
Risk factor poor surgical technique (no anatomic incision, method of closure, inappropriate sutures, suturing technique, drainage tube brought out through main wound |
| What are causes of incisional hernia? | Postop complications (cough, infection, respiratory distress due to pneumonia/lung collapse)
General factors (severe anemia, hypoproteinemia, DM, malignancy, jaundice...)
Tissure failure (late development of hernia after 5, 10 or more years after operation usually associated w/tissue failure that is abnormal collagen production and maintenance |
| What are clinical features of incisional hernia? | hx (previous trauma/surgery, hx of wound infection)
age (more elderly females)
sx (swelling and pain, may be intestinal obstruction)
signs (expansile impulse of cough, reducible, defect throug the scar after reduction)
Type 1 (midline upper or lower incision wide muscular defect w/smooth regular margins, reduced spontaneously as soon as pt lies down, risk of strangulation negligible)
Type 2 (lateral abdomen risk of strangulation more) |
| How is tx of incisional hernia? | Conservative approach (if neck is wide w/no signs of increase size and pt no sx)
Op (sx hernia, large hernia due to high chance of strangulation)
Mesh repair (better and ideal w/less recurrence)
Sublay (IPOM)
Anatomical repair (Keel's operation not in vogue) |
| What is spigelian hernia? | interparietal hernia at arcuate line through spigelian point, above umbilicus (10%) or below (90%) junction of linea semilunaris/semicircularis
soft reducible mass lateral to rectus muscle impulse cough strangulation common, obesity chronic cough and old age precipitate it
females>50 yrs
Tx: open or laparoscopic Mesh repair |
| What is lumbar hernia? | Herniation through superior or inferior lumbar triangle, more common through superior
Can be 1ary, 2ary due to previous renal surgery more common.
tx repair using fascial flaps or mesh |
