HERNIAS

Dr [Link]
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 OUTLINE
 Hernias
 Introduction
 Definition
 Classification
 Epidemiology
 Aetiopathogenesis
 Pathology
 Complications
 Inguinal Hernia
 Surgical Anatomy of the Inguinal canal
 Classification of Inguinal Hernias
 Clinical Presentation
 Treatment
 Complications of Hernia Repair 2
 Conclusion
 References
 INTRODUCTION
 Hernias are among the oldest recorded “afflictions”
of mankind.

 They are a significant cause of small bowel

intestinal obstruction and other life threatening
complications, especially in our environment
where patients do not present for treatment early,
either due to financial reasons, or because
according to them, it is not “paining” them.

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 DEFINITION
 A hernia is defined as the protrusion of a viscus or
part of a viscus through a point of weakness or
defect in the wall of its containing cavity.

 For example, the area of weakness in direct

inguinal hernias is the Hesselbach’s triangle,
whereas for indirect inguinal hernias, the defect is
the deep ring, both in the inguinal region.

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 CLASSIFICATION
 Anatomical classification
 Internal hernias: Protrusion of a viscus
through an anatomic foramen or a congenital or
acquired defect in the peritoneum or mesentery
with the organ remaining within the body. They
include:

 Diaphragmatic hernia
 Hiatal hernia
 Sigmoid mesocolon hernia

 Winslow hernia

 Paracaecal hernia
 Paraduodenal hernia

 Foramen magnum hernia (coning) 5

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  External hernias: These communicate with,
and can be seen at the exterior as a bulge or
swelling. They include:

 Groin hernias
• Inguinal hernia

• Femoral hernia
 Ventral hernias
• Incisional hernia

• Umbilical hernia
• Paraumbilical hernia
• Epigastric hernia
• Spigelian hernia
• Lumbar hernias

For the purpose of this presentation, we will be more

concerned about the external hernias which happen to 7
be commoner.
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 EPIDEMIOLOGY
 The prevalence of external hernias is
estimated to be about 11-12% of the
population.

 Hernias
as a whole, are commoner in
males, manual labourers and with
advancing age.

 Inguinalhernia is the commonest type of

hernia – 80-92%. It is equally common in all
communities, and is the commonest type
of hernia in both males and females. 9
 Femoral hernia in turn, makes up 2-5% of all
hernias. It is much more common in Europe
and North America than in Black Africa, and is
present in females than in males

 Others
include umbilical hernias (2%),
epigastric hernias (1%) and incisional
hernias (1 – 6%)

 Internal
hernias on the other hand are rare.
The overall incidence is <1%, and a substantial
percentage remain asymptomatic.
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 AETIOPATHOGENESIS

 There are two factors implicated in

hernia development:
 Predisposing factors: These cause
a defect or weakness in the
abdominal wall
 Precipitating factors: These lead to
repeated increased intra-abdominal
pressure which leads to the
protrusion of the viscus. 11
 The Predisposing factors include:
 Normal anatomic defects e.g. deep
inguinal ring
 Embryological defects e.g. patent
processus vaginalis
 Surgical defects
 Nerve injury
 Advancing age
 Connective tissue disorders
 Cigarette smoking
 Obesity 12
 The Precipitating factors include:
 Chronic cough
 Chronic constipation
 Bladder outlet obstruction
 Heavy manual labour
 Multiple pregnancies
 Abdominal mass
 Ascites
 Peritoneal dialysis

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 PATHOLOGY
 Most hernias comprise of the sac, its coverings
and its contents

 The sac is a diverticulum of peritoneum with

mouth, neck, body and fundus.
Note:
 Hernia without neck: Those hernias with larger
mouth lack neck, e.g. direct inguinal hernia,
incisional hernia.
 Hernia without sac: Epigastric hernia—it is
protrusion of extra-peritoneal pad of fat.

 The coverings are the layers of the abdominal wall

the sac carries along with it as it passess through
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the defect in the abdominal wall.
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o Contents of the sac

 Omentocoele—omentum.

 Enterocoele—intestine.

 Cystocoele—urinary bladder.

 Littre’s hernia—Meckel’s diverticulum.

 Amyand hernia – vermiform appendix

 Maydl’s hernia (hernia-en-W) – a bowel loop in the

shape of the letter “W”

 Sliding hernia (hernia-en-glissade) – extraperitoneal

bowel or urinary bladder
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 Richter’s hernia—part of the bowel wall.
 A – Richter’s
 B – Pantaloon’s

 C – Amyand’s

 D – Sliding

 E – Littre’s

 F – Maydl’s

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 COMPLICATIONS
 Note that, a hernia is described as reducible
if its contents return completely into the
abdomen when the patient lies down or when
pressure is applied on it. Usually, reducible
hernias are uncomplicated.

 Irreducible (incarcerated) hernia:

 Contents cannot be returned to the
abdomen due to a narrowed neck or
adhesions.
 Irreducibility predisposes to obstruction and
strangulation. 20
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 Obstructed hernia:
 It is an irreducible hernia with a stoppage
in the onward flow of intestinal
contents, but blood supply to the bowel
is not interfered.

 It eventually may lead to strangulation.

 Note that features of intestinal obstruction

may be absent in case of omentocele,
Richter’s hernia, Littre’s hernia
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 Strangulated hernia:
 It is an irreducible hernia with obstruction to blood flow.

 This causes ischaemia, gangrene and consequently

peritonitis

 The swelling is tense, tender, with absent cough

impulse and with features of intestinal obstruction.
Overlying skin is dark or purplish

 Other complications of hernias include:

 Inflamed hernia
 Rupture
 Peritonitis
 Fistula formation
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INGUINAL HERNIA

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 SURGICAL ANATOMY OF THE
INGUINAL CANAL
 The superficial inguinal ring is a triangular opening in
the external oblique aponeurosis and is 1.25 cm above
the pubic tubercle.

 The deep inguinal ring is a U-shaped condensation of

the transversalis fascia, lies 1.25 cm above the
midpoint of the inguinal ligament.

 The inguinal (Poupart’s) ligament is formed by the

lower border of the external oblique aponeurosis which
is thickened and folded backwards on itself, extending
from anterior superior iliac spine to pubic tubercle.
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 The inguinal canal is an oblique
passage in lower part of abdominal wall,
4 cm long, situated above the medial ½
of inguinal ligament, extending from deep
inguinal ring to superficial inguinal ring.

 The inguinal canal in females is known

as the ‘canal of Nuck.’

 Contents of the inguinal canal

 Spermatic cord in males
 Round ligament in females
 Ilio-inguinal nerve 27
 The spermatic cord comprises of:

 Three fascia coverings

 Internal spermatic fascia derived from

fascia transversalis
 Cremasteric fascia derived from internal
oblique aponeurosis
 External spermatic fascia derived from
external oblique aponeurosis

 Three arteries
 Testicular artery

 Artery to vas
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 Cremasteric artery
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 Three veins
 Pampiniform plexus of veins

 Vein of vas
 Cremasteric vein

 Three nerves
 Genital branch of genitofemoral nerve

 Sympathetic plexus (T10 – T11) around the

artery to vas
Parasympathetic nerve fibres

 Three other structures

 Vas deferens
 Lymphatics of the testis
 Remains of processus vaginalis 30
 Boundaries of the inguinal canal

 Anterior wall: Skin, subcutaneous tissue,

external oblique aponeurosis (medial two-thirds)
and internal oblique muscle (lateral one-third).

 Posterior wall: Fascia transversalis (lateral half)

and conjoined tendon (medial half).

 Roof: Arched fibres of internal oblique, and

transversus abdominis.

 Inferiorly: Inguinal ligament, and lacunar

ligament (medially) 31
IMAGE

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 The ‘Hesselbach’s triangle’ is a weak point
in the anterolateral abdominal wall,
susceptible to direct inguinal hernias.

It is bounded:
 Medially by the lateral border of rectus
muscle,
 Laterally by the inferior epigastric artery,
 Inferiorly by the iliopubic tract

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 CLASSIFICATION

 Anatomical classification:

 Indirect hernia. It comes out through the internal ring

along with the cord. It is lateral to the inferior
epigastric artery.

 Direct hernia. It occurs through the posterior wall of the

inguinal canal through the ‘Hesselbach’s triangle.’ Sac
is medial to the inferior epigastric artery.

 Saddle-bag or pantaloon hernia has got both medial

and lateral (direct and indirect components).

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IMAGE

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 Classification according to extent

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CLINICAL PRESENTATION

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 HISTORY
 Biodata:
 Age: Indirect hernias are congenital in majority

of cases and are commoner in children

whereas direct hernias are usually acquired
and hence, are commoner in adults.
 Occupation: Manual jobs

 Presenting complaint – a groin or scrotal

swelling;
 that was initially or is still reducible

(spontaneously or manually),
 that is precipitated or aggravated by standing, 40
straining or coughing
 History of Aetiology:
 The risk factors that predispose to or precipitate
hernia formation may be elicited in the history
 It is important to also rule in/out possible
differential diagnoses such as inguinal
lymphadenopathy, saphenous varices, etc.
 NB: Most differentials are excluded via
physical examination.

 History of Complications:
 Hernia may have become irreducible

 Colicky abdominal pain, bilious vomiting,

abdominal distension and constipation –
intestinal obstruction
 Severe, constant pain, fever –
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strangulation, gangrene, peritonitis
 PHYSICAL EXAMINATION

 Examination of an inguinal hernia is done in both

the standing and the supine positions.
 Inspection is done in the standing position,
while palpation involves both standing and lying
down.

 Inspection: First, compare contralateral side.

Then examine for site, size, shape, extent,
nature of skin over swelling, visible cough
impulse, transillumination, inspect the
surrounding.
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 Palpation (standing position): Differential
temperature, tenderness, surface, extent (try to get
above/below it), consistency, feel for the testis,
palpable cough impulse, palpate the contralateral
hemiscrotum.

 Palpation (supine position):

 Hernia may reduce spontaneously, but, if not,
attempt is made to reduce manually or ask the
patient to help
 If reducible, deep ring occlusion test is done
with the index finger
 Note the relationship in position between the
hernia and the pubic tubercle.
 Examine the abdominal muscle tone –
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Magaigne bulges
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 NB:
 The deep ring is located 1.25cm (a finger
breadth) superior to the midpoint of the
inguinal ligament

 The deep ring occlusion test is positive when

no impulse or hernia bulge is seen medial to
the deep inguinal ring on coughing suggestive
of an indirect inguinal hernia. Otherwise, it is
a direct inguinal hernia

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 Other examinations
 General examination – examine patient’s general
state, check for fever, dehydration, etc

 Respiratory examination – respiratory pathologies

 Abdominal examination – examine for scars,

abdominal distension, ascites, masses, other hernia
orifices, bowel sounds

 Urogenital examination – examine for urethral

induration

 Rectal examination – examine for haemorrhoids,

enlarged prostate, rectal masses 46
 Examination findings for normal/complicated
hernias

 Reducible hernia:
 Good general state
 Inguinal swelling,

 Positive cough impulse.

 Normal overlying skin

 Soft

 Reducible

 No differential warmth

 Irreducible (incarcerated) hernia:

 Inguinal swelling
 Absent cough impulse

 Skin may be oedematous

 Firm

 Non-reducible 47
 Tenderness may be elicited
 Obstructed hernia
 General examination
 Acutely ill looking

 Fever

 Dehydration

 Examination of groin swelling

 Overlying skin hyperaemic and

oedematous
 Absent cough impulse
 Tense
 Tender
 Irreducible
 Abdominal examination

 Abdominal distension
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 Hyperactive bowel sounds
 Strangulated hernia:
 General examination:
 Toxically ill looking

 Fever

 Dehydration, shock

 Groin swelling:

 Overlying skin, purplish or dark; may be

hyperaemic in early stages

 Absent cough impulse

 Differential coldness

 Tense

 Tender

 Irreducible 49
  Abdominal examination
Abdominal distension
Rebound tenderness

Bowel sounds may be hyperactive

 NB: Most strangulated hernias are also

obstructed, exceptions are Richter’s
hernia, hernias in which the content is not
a bowel.

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 Differential diagnoses

 Femoral hernia – inferolateral to the pubic tubercle

 Encysted hydrococoele of the cord – transilluminates,

may get above and below

 Vaginal hydrocoele – transilluminates, can get above

it

 Saphena varix – no cough impulse, may be

associated with varicose veins

 Varicocoele – feels like a bag of worms

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 Lipoma of the cord – lobulated surface, slipping
sign, no cough impulse

 Inguinal undescended testis – only one testis

palpated in the scrotum, cough impulse may be
present

 Enlarged inguinal lymph node – no cough

impulse

 Inguinal abscess – no cough impulse

 Femoral artery aneurysm – pulsatile,

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compressible
 INVESTIGATIONS
 Diagnosis of inguinal hernias is clinical

 However, specific investigations may be done

as indicated
 Chest X-ray: Tuberculosis, COPD
 Abdominal USS: Masses, prostate

 Urethrogram: Urethral stricture

 Abdominal X-ray, erect and supine: Intestinal obstruction

 Routine investigations
 Serum E/U/Cr
 FBC

 Hepatitis screening

 RVS 53
 TREATMENT
 REDUCIBLE HERNIA
 Treatment is operative, and it is elective.
 Precipitating factors must be addressed first before
surgery to correct the hernia.

Surgeries
 Children – Herniotomy
 Herniotomy – Sac is excised after reduction of contents

 Lytle’s repair may be done to narrow the deep ring if

wide

 Adults – Herniorrhaphy, Hernioplasty

 Herniorrhaphy – Sac is excised, and the posterior wall
reinforced with non-absorbable sutures
 Hernioplasty – Sac is excised, and an artificial material
such as prolene mesh is applied 54
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 Types of herniorrhaphy:
 Bassini – approximation of conjoint tendon to
inguinal ligament
 McVay’s – approximation of conjoint tendon to
iliopectineal ligament
 Shouldice – double breasting of transversalis
fascia

 Types of hernioplasty:
 Lichtenstein – prolene mesh fixed in the
inguinal canal
 Nylon darning – multiple continuous nylon
sutures approximating conjoint tendon to inguinal 56

ligament without tension

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 Indications for mesh repair
 Recurrent hernias
 Incisional hernias
 Massive hernias
 Old age
 Weak abdominal muscle tone
 Sliding hernias
 Direct hernias
 Connective tissue disorders e.g. Ehlers
syndrome, Marfan syndrome

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 IRREDUCIBLE HERNIA

 Reduction of the hernia is attempted under

sedation and muscle relaxant

 If reduction is successful, do herniorrhaphy

or hernioplasty later (24-48hrs later) when
oedema subsides

 If hernia remains irreducible, emergency

surgery is done.
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 OBSTRUCTED/STRANGULATED HERNIA

 Adequate resuscitation and optimization of

patient for surgery
 Fluid resuscitation

 Nasogastric intubation to rest the bowel

 Urethral catheterization to monitor urine output

 Intravenous broad spectrum antibiotics

 Correction of electrolyte deficits

 When patient is fit for surgery, a groin

exploration is done

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 During the surgery, it is important not to
reduce the content of the sac until it is
examined to be viable.

 Viable bowel is/has

 Pinkish/reddish
 Glistening

 Peristalsis

 Pulsation of the mesenteric arteries

 Resect non-viable bowel and do end-to-

end anastomosis 61
 Non-viable bowel is/has
 Gangrenous
 Lustereless

 No peristalsis

 No pulsation in the mesenteric arteries

 For omentum, the affected part is

excised.

 Then, inguinal herniorrhaphy is done

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 COMPLICATIONS HERNIA REPAIR
 Intraoperativecomplications: Injury to
contiguous structures;
 Testicular artery
 Vas deferens
 Inferior epigastric vessels
 Ilioinguinal nerve
 Genital branch of genitofemoral nerve
 Sac content e.g. bowel

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 Post-operative complications:
 Early complications
 Urinary retention
 Scrotal haematoma

 Wound haematoma

 Wound infection

 Late complications
 Sinuses e.g. stitch sinus
 Neuralgic pain

 Painful scar

 Testicular atrophy (due to injury to testicular artery)

 Recurrence

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 Anastomotic complications
 Anastomotic stenosis
 Anastomotic gangrene
 Anastomotic leakage
 Peritonitis
 Enterocutaneous fistula
 Intraperitoneal abscess
 Surgical site infection

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 CONCLUSION
 In an environment like ours where majority of
patients only show up for care in the midst of the
raging storm, it is important as physicians that we
are well grounded on how to weather these storms.

 And this we can do by possessing a sound

knowledge of what hernias are, how they are
diagnosed, and the life-saving ways to manage
them.

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THANK
YOU
FOR
LISTENING
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 REFERENCES
 Baja’s Principles and Practice of Surgery (including
Pathology in the Tropics) 5th ed; E.Q. Archampong
et al
 SRB’s Manual of Surgery 5th ed; Sriram Bhat M

 Browse’s Introduction to the Signs and Symptoms

of Surgical Disease 4th ed; Norman L. Browse et al
 Clinical Surgery Tutorial Manual 2nd ed; Omoigiade
E. Udefiagbon
 MBBS Undergraduate Notes; Osaigbovo
Uhunmwagho, Omoigiade E. Udefiagbon
 [Link] 69