3DefinitionA hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity .
4Anatomy The inguinal canal :- The inguinal canal is approximately 4 cm long and is directed obliquelyinferomedially through the inferior part of the anterolateral abdominal wall. The canal lies parallel and 2-4 cm superior to the medial half of the inguinal ligament.This ligament extends from the anterior superior iliac spine to the pubic tubercle.The inguinal canal has openings at either end : –The deep (internal) inguinal ring is the entrance to the inguinal canal. It is thesite of an outpouching of the transversalis fascia. This is approximately 1.25 cm superior to the middle of the inguinal ligamentThe superficial, or external inguinal ring is the exit from the inguinal canal. It is a slitlke opening between the diagonal fibres of the aponeurosis of the external oblique
5Inguinal canal walls of The inguinal canal :- The anterior wall is formed mainly by the aponeurosis of the external Oblique. The posterior wall is formed mainly by transversalis fasciaThe roof is formed by the arching fibres of the internal oblique andtransverse abdominal muscles.The floor is formed by the inguinal ligament, which forms a shallow trough. It is reinforced in its most medial part by the lacunar ligament.
7Content :-Spermatic cord ( round ligament of the uterus in female )The Cord Itself.—The contents of the spermatic cord are(a) the ductus (vas) deferens and its artery .(b) the testicular artery and venous (pampiniform) plexus.(c) the genital branch of the genitofemoral nerve.(d) lymphatic vessels and sympathetic nerve fibers.(e) fat and connective tissue surrounding the cord and its coverings in various amountsIlioinguinal nerve .Ilioinguinal lymph node .
8Femoral CanalThe major feature of the femoral canal is the femoral sheath. This sheath is a condensation of the deep fascia (fascia lata) of the thigh and contains, from lateral to medial, the femoral artery, femoral vein, and femoral canal. The femoral canal is a space medial to the vein that allows for venous expansion and contains a lymph node (node of Cloquet). Other features of the femoral triangle include the femoral nerve, which lies lateral to the sheath,Wall of The Femoral canalanterior is the inguinal ligamentposterior is the iliopsoas, pectineal, and long adductor muscles (floor).Medial is lacunar ligamentLateral is femoral vessle
9Predisposing:All hernias occur at the site of WEAKNESS OF THE ABDOMINAL WALL which are acted on by repeated INCREASE in abdominal pressure
10repeated INCREASE in abdominal pressure is usually due to Chronic coughStrainingBladder neck or urethral obstructionPregnancyVomitingSever muscular effortAscetic fluid
11Types Inguinal Femoral Epigastric Para umbilical Umbilical Obturator Superior lumbarInferioer lumbarGlutealSciaticIncisional
12Indirect Inguinal Hernia Direct Inguinal Hernia Femoral Hernia Hernia through the inguinal canalDirect Inguinal HerniaThe sac passes through a weakness or defect of the transversalis fascia in the posterior wall of the inguinal canalFemoral HerniaHernia medial to femoral vessels under inguinal ligamentUmbilical HerniaHernia through the umbilical ringParaumbilical HerniaA protrusion through the linea alba just above or sometimes just below the umbilicusEpigastric HerniaProtrusion of extraperitoneal fat through the linea alba anywhere between the xiphoid process and the umbilicusIncisional HerniaHernia through an incisional siteLumber Herniaoccur through the inferior lumber triangle of Petit
13Inguinal hernia History: Age ( young vs. old) Occupation ( nature ?? ) Local symptoms: Swelling, discomfort and painSystemic symptoms: if there is obstruction or strangulationPrecipitating factors
14Inguinal hernia Examination: Inspection for site, size, shape and color.Palpation for surface, temp, tenderness, composition and reducibility.Expansible cough impulse.General exam: for common causes of increase intra abdominal pressure
15Indirect Versus Direct inguinal hernias Indirect is the most common form of hernia and its usually congenital due to patent processus viginalisDirect usually acquired occur in old men with weak abdominal muscles.
16Indirect Versus Direct inguinal hernias Indirect Inguinal HerniaBulge from the posterior wall of the inguinal canalPass through inguinal canal.Cannot descent into the scrotum.Can descend into the scrotum.Medial to inferior epigastric vessels.Lateral to inferior epigastric vessels.Reduced: upward, then straight backward.Reduced: upward, then laterally and backward.Not controlled: after reduction by pressure over the internal (deep) inguinal ring.Controlled: after reduction by pressure over the internal (deep) inguinal ring.The defect may be felt in the abdominal wall above the pubic tubercle.The defect is not palpable (it is behind the fibers of the external oblique muscle).After reduction: the bulge reappears exactly where it was before.After reduction: the bulge appears in the middle of inguinal region and then flows medially before turning down to the scrotum.Common in old age.Common in children and young adults.
17Differential diagnosis of inguinal hernias Male:1 ) Femoral hernia2 ) Vaginal hydrocele3 ) Spermatocele4 ) Encysted hydrocele of the cord5 ) Un-descended testis6 ) Lipoma of the cordFemale1 ) Hydrocele of the canal of nuck:Is a fluid filled distal part of the sac of an indirct hernia with narrow proximal part it present with a smoth fluctuant swelling with out a cough impulse which will transilluminate2 ) Femoral herniaNote that examination using finger and thumb across the neck of the scrotum will help to distinguish a swelling of inguinal origin and one that is entirely intrascrotal
18Femoral herniaSmall femoral hernia may be unnoticed by the patient or disregarded for years perhaps until the day it strangulates. Adherence of the greater omentum sometimes causes a dragging pain. Rarely a large sac is present .
19Femoral hernia History Age ; uncommon in children , most common in old age female .Sex; women > men (but still commonest hernia in women the inguinal hernia )The patient came with local symptoms1- discomfort and pain2- swelling in the groinGeneral ; femoral hernia is more likely to be strangulated than the inguinal herniaMultiplicity ; often bilateral
20Femoral hernia versus inguinal hernia 1- more common in females1- more common in male2- pass through the femoral canal2- pass through the inguinal canal3- neck of the sac is below and lateral the pubic tubercle3- neck of the sac is above and medial the pubic tubercle4- more common to be strangulated4- less common to be strangulated5- must be treated surgically5- can be treated without surgery6- the two diagnostic signs of hernia -6- the two diagnostic signs of hernia +7- the sac mainly contains ; omentum7- the sac mainly contain ; bowel
21Differential diagnosis of femoral hernia 1) Inguinal hernia 2 ) saphena varix: a saccular enlargment of the termination of the long saphenous vein The swelling disappears completely when the patient lies flat there is impulse in coughing and fluid thrill and sometimes venous hum can be heard over a saphena varix 3 ) Enlarge lymph node: fever + other lymph node enlargment 4 ) Lipoma 5 ) Femoral aneurysm: expansile pulsation 6 ) Psoas abscess: There is often a fluctuating swelling and examination of the spine and a radiograph will confirm the diagnosis 7 ) A distended psoas bursa: The swelling diminishes when the hip is flexed and osteoarthritis of the hip is present
22Umbilical hernia Signs and symptoms Age ; doesn’t appear until the umbilical cord has separated and healed .No specific symptomsHave wide neck and reduce easily , rarely give intestinal obstruction.Nature history ; 90 % disappear spontaneously during the first year.
23ExaminationInspectionSite ; in the center of the umbilicusSize and shape ; size can vary from vary small to very large . Shape is usually hemispherical.PalpationComposition ; contain bowel , which makes it resonant to percussion . They reduce spontaneously when the child lies down .Reducibility ; easyCough impulse; invariably present .
24Acquired umbilical hernia Hernia through the umbilical scar , so it is a true umbilical hernia.Not common and is usually secondary to increase intra abdominal pressure.The most common causes1- pregnancy2- ascitis3- ovarian cyst4- fibrodis5- bowel distention
25Incision hernia Signs and symptoms Previous operation or accidental traumaAge ; all ages , but more common in old age.Symptom ; lump ,pain ,intestinal obstruction ( distention ,colic, vomiting ,constipation , sever pain in the lump )Examination1- reducible lump2- expansile cough impulse3- if the lump dose not reduse and dose not have cough impulse , than it may be not a herniaDdxTumorChronic abscessHematomaForeign body granuloma
26Preoperative assessment proper history and examinationidentify high risk patientsprepare the preoperative notes :consent..pre op Dxprocedure plannedsurgeonsAnasthesia anticipated (general , local, spinal)
27Preoperative assessment Investigation data ( pre operative tests ) :1. Lab :* CBC : to check hemoglobin level anemia and WBCs infections* U&E : to check for any electrolyte imbalance* LFTs : indicated in jaundiced patients and suspected hepatitis or any clotting problems* PT & PTT* ABG* grouping and cross matching2. Imaging :* Chest X ray : for all patients3. ECG : for any patient who is more than 40 years of age
28Preoperative assessment current medications or allergiesany major (chronic) illnesspre op orders :skin preparationdiet (NPO)GIT preparationSedationPreanesthetic medicationsOther medicationsAntibioticsBlood transfusion ( if needed )Bladder preparation
31Pre op evaluation &preparation Surgical TTTWatchful WaitingMay be appropriate for pt with asymptomatic hernia or elderly pt with minimal symptoms or easily reduced inguinal hernia.Routine F/U with health care professionalA Randomized trial concluded that this is an acceptable option for men with minimally symptomatic inguinal hernia and that delaying repair until symptoms increase is safe due to low rate of incarceration. 23% of pt initially treated with watchful waiting crossed over to surgical ttt due to increase in symptoms (most often hernia-related pain) , only 1 pt (0.3%) experienced acute hernia incarceration without strangulation within 2years, a second had acute incarceration withBowel obstruction at 4 years, corresponding to frequency of acute intervention of 1.8/1000 pt-years (JAMA 2006,295:285)
32Most pt are treated surgically Pre op preparationMost pt are treated surgicallyIncrease IAP abnormalities (Chronic cough, Constipation, Bladder outlet obstruction) should be evaluated and remedied to extent possible before elective herniorrhaphy.In case of intestinal obstruction and possible strangulation, Broad spectrum AB,NG suction may be indicated, correction of volume status& elctroyles.
33Reduction Uncomplicated: Manual Gentle pressure over hernia Gentle traction over the mass sedation and trendelenburg position.Complicated (strangulated):no attempt should be made to reduce the hernia because of potential reduction of gangrenous segment of bowel with the hernial sac.
34Surgerical TTT 1.choice of anesthetic: elective open repair : Local is preferredLaproscopic hernia repair: more commonly under GA.
352.TTT OF HERNIAL SACINDIRECT: sac is dissected free from the cord structures and creamsteric fibers. Sac should be open away from any herniated contents. Contents are then reduced, and the sac is ligated deep to inguinal ring with an absorbable sutureDIRECT:Too broadly based for ligation and should not be opened, simple freed from transversalis fibers and inverted.
363.Inguinal Floor Reconstruction Some method of reconstruction of the inguinal floor is necessary in all adult hernia repairs to prevent recurrence.
371.Primary tissue repairBassini repair: inferior arch of transversalis fascia (TF) or conjoint tendon is approximated to shelving portion of inguinal ligament.McVay: TF is sutured to cooper ligament.Shouldice: TF is incised and reapproximated.
382.Open tension free repair Lichtenstein repair &Patch and Plug technique: Mesh is used to reconstruct inguinal floorMesh plug technique : place mesh in the hernial defect
39Laproscopic & preperitoneal repairs TAPP (transabdominal prepeitoneal procedure): peritoneal space entered by conventional lap at umbilicus and peritoneum overlaying inguinal floor is dissected away as flap.TEP (Total extraperitoneal repair): preperitoneal space is developed with a balloon inserted between posterior rectus sheath and peritoneum balloon inflated to dissect the peritoneal flaps awau from posterior abdomianl wall and the direct and indirect spaces, other ports inserted into this preperitoneal space without entering peritoneal cavity.After lap. Dissection and reduction of hernia sac , a large piece of mesh is placed over inguinal floor
40Femoral hernia repairFemoral hernias should be repaired very soon after the diagnosis has been made because of the high risk of strangulation.There is no place for a truss for a femoral hernia.Different approaches :Open VS Laparoscopic
41Open surgery Three approaches have been described for open surgery : Infra-inguinal approach (Lookwood)Supra-inguinal approach ( McEvedy)Trans-inguinal approach ( Lotheissen)
42Each technique has the principle of dissection of the sac with reduction of its contents, followed by ligation of the sac and closure between the inguinal and pectineal ligaments.
43Lockwood’s infra-inguinal approach The sac is dissected out below the inguinal ligament via groin crease incision.Then the sac is opened and the contents are inspected and reduced into the abdomen.Then the neck of the sac is pulled down , ligated and allowed to retract through femoral canal.Then close the femoral canal by mesh plug or non absorbable sutures.
44McEvedy’s high approach Vertical incision is made over the femoral canal and continued upwards above the inguinal ligament.This incision provides good access to the preperitoneal space and then to the peritoneum itself.Use finger dissection to sweep peritoneum from anterior abdominal wall , so the neck of the sac can be identified.Dissect the sac , reduce the contents and repair the defect by mesh or sutures.
45Lotheissen‘s trans-inguinal approach The incision is made superior and parallel to inguinal ligament extending from pubic tubercle to mid inguinal point.