1. Essentials MA MURPHY FRCSI
Back to Department of Surgery Trinity College Dublin
Abdominal Wall Hernia
Essentials
MA MURPHY FRCSI

2. 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

3. Hernia
A protrusion of an organ or tissue outside its’ normal compartment

4. Common External Hernias
ABDOMINAL WALL & GROIN
Midline
Umbilical
Para- umbilical
Epigastric
Inguinal
Direct/ Indirect/ Combined
Femoral
Incisional

6. 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

7. Inguinal Hernia Commonest external hernia Male preponderance
Infant / adult
Direct / indirect / combined
Weakness / increased pressure
Cause pain / discomfort
Carry risk of complications
Treated surgically

8. 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)

9. Inguinal Hernia - History
Onset
Duration
Symptoms
Other hernia(e)
Irreducibility
Gastrointestinal system
Respiratory system
Surgery / anaesthesia

10. Inguinal Hernia - Examination
Surface markings
Anterior superior iliac spine
Pubic tubercle
Midpoint of inguinal ligament

12. Inguinal Hernia - Examination
OBJECTIVES
Confirm diagnoses
Out rule differentials
Establish type
Determine contents
Reducibility
Identify co-morbid pathologies

13. Direct V’s Indirect Direct Post wall Less common Older Smaller
Hesselbachs
Medial
Lower risk
Indirect
Deep ring
70%
Congenital
Scrotal
Lateral
Strangulate

14. Inguinal Hernia Examination Standing / Lying Supine Cough impulse
Reducibility
Contents
Bowel sounds
Scrotal contents

15. Differential Direct /Indirect/Combined Femoral hernia Hydrocele Lipoma
Lymph node
Testicular tumour
Saphenous varix

16. 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

17. 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

18. 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)

19. 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)

20. TESTIS CORD STRUCTURES

21. Inguinal Anatomy

22. Hernia Anatomy

23. Indirect Hernia

24. Direct Inguinal Hernia

25. Hernia Complications Incarceration Strangulation
Intestinal obstruction

26. Varieties of Hernias Maydls W loop of intestine Richters
Partial inclusion of intestinal wall
Sliding hernia
Bladder
Sigmoid colon/ appendix

27. Richters’ Hernia

28. Maydls’ Hernia

29. 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

30. Hernia Treatment Surgery To relieve symptoms To prevent complications
Operations
Open hernia repair
Laparoscopic hernia repair
Pre-peritoneal
Intra- abdominal

31. Open Hernia Repair Day-case surgery Anaesthesia General Local
Operations
Tension free Mesh repair (Lichtenstien)
Darn repairs (Shouldice, Bassini)

32. 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

33. Open Hernia Repair

34. Open Hernia Repair

35. Open Hernia Repair

36. Open Hernia Repair

42. Open Hernia Repair

43. Laparoscopic Repair

44. Laparoscopic Repair

45. Laparoscopic Repair

46. Surgery Complications
Trauma
Nerve
Artery (testicular atrophy)
Intestine
Haemorrhage
Haematoma (infection)
Infection
Wound infection
Chest Infection

47. 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

48. Femoral Hernia

49. Femoral Hernia Repair

50. 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

51. Recommended Reading
Ellis H. Clinical Anatomy