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Back to Department of Surgery Trinity College Dublin. Abdominal Wall Hernia. Essentials MA MURPHY FRCSI. Objectives. Understand the term hernia Basic anatomical knowledge Clinical features of common hernia Complications of hernias Examination of a hernia
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Back to Department of Surgery Trinity College Dublin Abdominal Wall Hernia Essentials MA MURPHY FRCSI
Objectives • Understand the term hernia • Basic anatomical knowledge • Clinical features of common hernia • Complications of hernias • Examination of a hernia • Differential diagnoses of a lump in the groin • Management of hernia
Hernia • A protrusion of an organ or tissue outside its’ normal compartment
Common External Hernias • ABDOMINAL WALL & GROIN • Midline • Umbilical • Para- umbilical • Epigastric • Inguinal • Direct/ Indirect/ Combined • Femoral • Incisional
Common Presentations • A lump • Comes and goes • Appears on straining /coughing • A pain • Dragging pain/ Pain on exertion • Incidental finding on examination/ imaging • Presenting as a complication • Incarceration/ Intestinal obstruction
Inguinal Hernia • Commonest external hernia • Male preponderance • Infant / adult • Direct / indirect / combined • Weakness / increased pressure • Cause pain / discomfort • Carry risk of complications • Treated surgically
Inguinal Hernia - History OBJECTIVES • Establish differential diagnoses • Identify risk factors and significant co-morbid pathologies • (e.g. increased intra-abdominal pressure due to ascites or chronic airways disease)
Inguinal Hernia - History • Onset • Duration • Symptoms • Other hernia(e) • Irreducibility • Gastrointestinal system • Respiratory system • Surgery / anaesthesia
Inguinal Hernia - Examination • Surface markings • Anterior superior iliac spine • Pubic tubercle • Midpoint of inguinal ligament
Inguinal Hernia - Examination OBJECTIVES • Confirm diagnoses • Out rule differentials • Establish type • Determine contents • Reducibility • Identify co-morbid pathologies
Direct Post wall Less common Older Smaller Hesselbachs Medial Lower risk Indirect Deep ring 70% Congenital Scrotal Deep ring Lateral Strangulate Direct V’s Indirect
Inguinal Hernia • Examination • Standing / Lying Supine • Cough impulse • Reducibility • Contents • Bowel sounds • Scrotal contents
Differential • Direct /Indirect/Combined • Femoral hernia • Hydrocele • Lipoma • Lymph node • Testicular tumour • Saphenous varix
Inguinal Anatomy • The inguinal canal represents the oblique passage through the anterior abdominal wall of the vas deferens (round ligament) • It is 5cm long and lies directly above the medial half of the inguinal ligament
Inguinal Anatomy • Floor • Transversalis fascia • Medially the conjoint tendon • Roof • External oblique aponeurosis • Laterally the conjoint tendon • Skin and superficial fascia • Above • Conjoint tendon • Below • The inguinal ligament
Inguinal Anatomy • Three nerves • Ilio-inguinal (on not in) • Sympathetic fibers • Genitofemoral • Three layers of fascia • Internal spermatic (transversalis f.) • Cremasteric (conjoint tendon) • External spermatic (ext. oblique)
Inguinal Anatomy • Three arteries • Testicular (from the aorta) • Artery of the vas (external iliac) • Cremasteric (inferior epigastric) • Three other structures • The vas deferens • The pampniform plexus of veins • Lymphatics (to aortic nodes)
Hernia Complications • Incarceration • Strangulation • Intestinal obstruction
Varieties of Hernias • Maydls • W loop of intestine • Richters • Partial inclusion of intestinal wall • Sliding hernia • Bladder • Sigmoid colon/ appendix
Hernia Management • Investigations • None required for routine uncomplicated case • Plain X-ray for suspected bowel obstruction • Ultrasound in case of diagnostic uncertainty • Herniogram rarely used • Routine pre-op investigations
Hernia Treatment • Surgery • To relieve symptoms • To prevent complications • Operations • Open hernia repair • Laparoscopic hernia repair • Pre-peritoneal • Intra- abdominal
Open Hernia Repair • Day-case surgery • Anaesthesia • General • Local • Operations • Tension free Mesh repair (Lichtenstien) • Darn repairs (Shouldice, Bassini)
Open Hernia Repair • Incision above medial half of inguinal ligament • External oblique opened from external ring to expose the cord and overlying ilioinguinal nerve • Internal (deep) ring exposed • Hernial sac identified and reduced • Prolene mesh inserted to reinforce posterior wall and deep ring
Surgery Complications • Trauma • Nerve • Artery (testicular atrophy) • Intestine • Haemorrhage • Haematoma (infection) • Infection • Wound infection • Chest Infection
Femoral Hernia • Herniation through femoral canal • Appears below and lateral to pubic tubercle • Relatively uncommon • Commoner in females • Contains omentum or small intestine • High risk of strangulation • Repaired surgically
Summary • Inguinal hernia is the commonest external hernia • Indirect hernias have a higher risk of strangulation • Hernias are treated by surgery, to relieve symptoms and prevent complications • Femoral hernias have a high risk of strangulation