HERNIAS Presented by: Al-Fadel M. Alshebani & AbdulMohsin A.Babsail Supervised by: PROF. ABDULLAH ALDHOHAYAN
Embryological development of the testicles Processus vaginalis Testis descend
Internal spermatic fascia transversalis fascia Cremastic muscle internal oblique muscle Externa spermatic fascia external oblique muscle
What is a Hernia composed of? Sac: a folding of peritoneum consisting of a mouth, neck, body and fundus. Body: which varies in size and is not necessarily occupied. Coverings: derived from layers of the abdominal wall. Contents: which could be anything from the omentum, intestines, ovary or urinary bladder.
Indirect Inguinal hernia Pathophysiology Processus vaginallis
Reducible form. Irreducible form: - Incarceration - Obstruction - strangulation
Pathophysiology Acquired or congenital The presentation
Individual hernias Direct & indirect Inguinal hernia. Femoral hernia. Umbilical hernia & paraumbilical hernia. Incisional hernia. Epigastric hernia. Rare external Hernias.
Femoral Hernia • Femoral Hernias occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness called the femoral canal. The Femoral canal : • The most medial structure in the femoral sheath,. • extending from the femoral ring to the saphenous opening. • 1.25cm x 1.25cm. • Contains fat, lymph vessels and the lymph node of cloquet.
Femoral Hernia (cont..) • Symptoms:Femoral hernias are more common in women, They typically present as a groin lump. They may or may not be associated with pain, a femoral hernia has often been found to be the cause of unexplained small bowel obstruction. • Signs: an absent Cough impulse, with a more globular lump than the pear shaped lump of the inguinal hernia. • Differential Diagnoses: • Inguinal Hernia. • Femoral Artery Aneurism. • Femoral Lymphadenopathy. • Psoas Abscess.
Umbilical & paraumbilical Hernia A. Umbilical Hernia: • Seen in infants & children. • Effecting boys more than girls. • tend to resolve without any treatment by around the age of 5 years. • Obstruction and strangulation of the hernia is rare. • Babies are prone to this malformation because of the process during fetal development by which the abdominal organs form outside the abdominal cavity, later returning into it through an opening which will become the umbilicus.
B. Paraumbilical Hernia: • Affects adults. • The defect is either supra or infraumbilical through the linea alba. • The female to male ratio is 20:1. • May contain omentum, small intestine or transverse colon. Etiology: • Obesity. • Flabbiness of the abdominal muscles. • Multiparity. Clinical Features: Clolicky pain and/or irreducibilty due to omental adhesions.
Incisional Hernia Definition:An incisional hernia occurs when the area of weakness is the result of an incompletely healed surgical wound. These can be among the most frustrating and difficult hernias to treat. It can occur at any incision, but tend to occur more commonly along a straight line from the sternum breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence. Causes: • Any reasons leading to an icrease in intraabdominal pressure postoperatively such as: chronic cough, vomitting, infection, malnutrition diabetes, steroid treatment or a tension closure done during the previous operation. Clinical Features: • Swelling at the incisional site +/- pain.
Epigastric Hernia • Due to a defectin the linea alba between the xiphoid process and the umbilicus • Starts as a protrusion of the extraperitoneal fat at the site where a small vessel pierces the lina alba and as it enlarges it drags a pouch of peritoneum after it. Clinical Features: • Swelling +/- pain similar to a peptic ulcer pain.
Rare external Hernias Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. But her are Other hernial types and unusual types of visceral hernias: • Spiglian Hernia: • Occurs at the spaces of the semilunar line and the lateral edge of the rectus muscle (inferior to the arcuate line). • The posterior rectus sheath jis weak thus leading to the protrusion. • Preoperative diagnosis is diffucult & only correct in 50% of the patients. • u/s & c.t are helpful tools in the diagnosis • Depending on the size of the defect, treatment varies from suture approximation to using a mesh.
Rare hernias (cont..) 2. Lumbar Hernias: • In the lumbar region, in the form of a broad bulging hernia, that are not vulnerable to incarceration. • Devided into: A. Petit’s hernia: which occurs in the inferior lumbar triangle. B. Grynfeltt’s Hernia: which occurs in the superior lumbar triangle and is less common that Petit’s.
Rare hernias (cont..) 3. Obturator Hernia: • The obturator canal is covered by a membrane pierced by the obturator nerve and vessels. Any enlargement in the canal or weakness in the membrane may lead to herniation of the intetines. • Because of differences in anatomy, it is much more common in women than in men. • It often presents with bowel obstruction. • The Howship-Romberg sign is suggestive of an obturator hernia, exacerbated by thigh extension, medial rotation and adduction. It is characterized by lancilating pain in the medial thigh/obturator distribution, extending to the knee; caused by hernia compression of the obturator nerve.
EXAMINATION: Hernias must be examined with the patient standing and in supineAlways examine both groins. INSPECTION:Visible swelling. (site, size and shape)Visible cough impulse.Easily reducibleReappear on straining, standing or coughing Elucidate Fothergill and Carnet signs. PALPATION:Examine as a mass and then Palpable cough impulseReduceOcclusion testThree Finger test ( Zimman’s test)
Examination also asses the following:PositionTemperatureTendernessShapeSizeTensionCompositionExpansile cough impulseReducible. PERCUSSION AND AUSCULTATION: Bowel sound.
Treatment Most abdominal hernias can be surgically repaired. Uncomplicated hernias are principally repaired by herniorrhaphy. aHerniorrhaphy (Hernioplasty) is a surgical procedure for correcting hernia, which can be devided into four techniques: Groups 1 and 2: open "tension" repair: in which the edges of the defect are sewn back together without any reinforcement or prosthesis. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis muscle and the internal oblique muscle) is approximated to the inguinal canal and closed.  Although tension repairs are no longer the standard of care due to the high rate of recurrence of the hernia, long recovery period, and post-operative pain, a few tension repairs are still in use today.
Treatment (cont..) Group 3: open "tension-free" repair: Almost all repairs done today are open "tension-free" repairs that involve the placement of a synthetic mesh to strengthen the inguinal region. This operation is called a 'hernioplasty'. The meshes used are typically made from polypropylene or polyester. The operation is typically performed under local anesthesia, and patients go home within a few hours of surgery, often requiring no medication beyond aspirin or acetaminophen. Recurrence rates are very low - one percent or less, compared with over 10% for a tension repair
Treatment (cont..) Group 4: laparoscopic repair • "Lap" repairs are also tension-free, although the mesh is placed within the preperitoneal space behind the defect as opposed to in or over it. • It is further sub-devided into: • T.A.P.P repair (transabdominal preperitoneal) • T.E.P repair (totally extraperitoneal) • It has no proven superiority to the open method other than a faster recovery time and a slightly lower post-operative pain score. • laparoscopic surgery, though, requires general anesthesia, more expensive and consumes more O.R. time than open repair and carries a higher risk of complications, and has equivalent or higher rates of recurrence compared to the open tension-free repairs.