1. General Surgery, Renhe Hospital, Three Gorges University，
Hernia
General Surgery, Renhe Hospital, Three Gorges University，
Zhang-Xianlin

2. Hernia
Definition：
Protrusion of an organ (intestine ,brain) or tissue outside its normal body cavity or constricting sheath .
Abdominal hernia is the protrusion of the abdominal content outside abdominal wall.

3. Causes of Abdominal Hernia
Anatomical defect of the abdominal wall.
Acquired weakness of the abdominal wall .

4. Surgical Anatomy rectus abdominis(腹直肌) Rectus sheath（腹直肌鞘）
External oblique(腹外斜肌)
pubic symphysis
crural ligament

5. Surgical Anatomy 腹股沟解剖 inguinal groove 脐bellybutton inner ring
outer ring
chorda spermatica

6. Surgical Anatomy
股管解剖femoral canal

7. Surgical Anatomy

8. Types of Abdominal Hernia
Epigastric
paraumbilical
Umbilical
lumbar
Spigelian(半月疝)
femoral
inguinal

9. The Basic Feature Of All Hernias
They occur at a weak spot .
They reduce on lying down ,or with direct pressure.
The have an expensile cough impulse.

10. A hernia consist of 3 parts:
1.Sac:
consist of a diverticulum of peritoneum.
2.Contents:
Omentum, small or large intestine, urinary bladder, Omentum, ovaries malignant nodules or ascetic fluid.
3.Coverings:
derived from the layers of abdominal wall.

11. Complications Of Hernias
Irreducible
the hernia contents cannot be manipulated back into the abdominal cavity.
Incarcerated 
the contents of the sac are literally inpresiond in the sac of Hernia.
Obstruction 
the loop of the bowel become non functioning with normal blood supply .
Strangulated
cut off the blood supply to the content sac (tender).

12. Protrusion of abdominal contents through the inguinal region
Inguinal Hernia
Protrusion of abdominal contents through the inguinal region

13. Inguinal Hernia

14. Differences between indirect and direct hernia
feature
indirect
direct
age
children, young people
aged people
pathway of protrusion
coming down the inguinal canal, may enter the scrotum
pass through Hesselbach’s triangle, rarely enter the scrotum
contours of sac
elliptic, pear-shaped
semispheric, wide base
compress the internal ring after reduced
controlled
not controlled
Reduced
Upwards, laterally and back ward
Upward and strait backward
Relationship of sac neck with inferior epigastric artery
Sac neck is lateral to it
Sac neck is medial to it
Incarcerated incidence
high
low

15. Inguinal Hernia in Children
Most common is indirect hernia
Patent processes vaginalis
Inguinal hernia
infantile hydrocele
An encysted hydrocele of the cord
Hydrocele Vs Hernia
More in premature infants

16. Treatment Notes
Incarcerated hernia in infancy can almost always be managed by manipulative reduction with subsequent scheduled herniotomy.
The one exception is In baby girl because the ovaries may be part of the sac content.

17. Special Varieties of Inguinal Hernia
Pantaloon Hernia
Maydl’s Hernia
Sliding Hernia
Richter’s Hernia
Litter’s Hernia

18. Femoral Hernia

19. Left Femoral Hernia

20. Femoral Hernia
Protrusion of abdominal content through the femoral canal .
More common in females.
Below and laterally to the pubic tubercle.
Narrow neck High risk for strangulation.

21. CASES Case (1) - Asymptomatic, reducible groin swelling in the elderly
A 71-year-old man, who has had two myocardial infarcts and hypertension, presents with a groin bulge, present only when he coughs. It has never been painful.
Case (2) - Asymptomatic reducible groin swelling
A fit 34-year-old policeman presents with a three month history of a progressively enlarging inguino-scrotal swelling. It has not been painful but is becoming more difficult to reduce digitally.
Case (3)- Irreducible groin swelling
This otherwise fit 92-year-old lady noticed a groin swelling six months ago. At first it reduced spontaneously when she lay down but for the past four weeks it has been present constantly, is irreducible, and she now has twinges of pain.

22. DDx of Lump In The Groin Inguinal Hernia Femoral Hernia
Enlarged lymph node
Sapheno –varix
Ectopic testis
Psoas abcess
Psoass bursa
Lipoma

23. Ask in your History
Lump: duration, first symptoms, associated symptoms, progression, persistent ,other sites ,cause
Does it reduce on lying down?
Have there been episodes of pain in the swelling?
Have there been episodes of abdominal pain?
Does the patient have any febrile symptoms?
History of rectal bleeding
History of trauma or septic focus in the lower limbs
Causes of increase of intrabdominal pressure
Previous surgeries ?

24. Physical Exam Position standing up
Before Physical Exam,pay attention to:
Introduce your self ,
Take permission,
Patients privacy ,
Position standing up
Exposure  bilateral inguinal region and the groin

25. Physical Exam From in front : Inspection lump: site, shape
scrotum: does it extend to the scrotum
Palpation : (decide is it hernia or not)
Ask the patient about pain before you palpate
Can you go above it
Can you palpate the testis
If it is a hernia  type
Define pubic tubercle

26. Can you go Above it?

27. Physical Exam

28. Physical Exam Feel from the sides Aim to examine the lump
( tenderness, temperature, size ,shape, site, composition (
Reducible?? How?? Ask the pts if you couldn’t
Controlled when you pressure over deep inguinal ring ?
Expensile cough impulse
Direction of reappearance

29. Physical Exam

30. Physical Exam Percussion of the sac Auscultation of the sac
Feel the other side
Abdominal examination
Cardiovascular and respiratory assessment

31. Treatment of groin hernias
Approach
conservative (reassure the patient)
a truss (now a rare treatment option)
Operate
Treatment of groin hernias can be summarized:
Direct inguinal hernia - rarely operate unless there is a specific indication.
Indirect inguinal hernia - usually operate.
Femoral hernia - always operate unless there is a contraindication.

32. Treatment of groin hernias
Direct inguinal hernia
Most require no treatment. Patients with pure direct inguinal bulges are at virtually no risk of complications. Most are elderly and reassurance is usually appropriate.
Indirect inguinal hernia
Most require operative treatment as the risks of irreducibility and obstruction are higher. Advise repair unless the patient’s general health is such that the risks of operation outweigh the possible benefits.
The operation for inguinal hernia may be:
sutured, e.g. Bassini, Shouldice
open mesh, e.g. Lichtenstein
laparoscopic mesh, e.g. TAPP (transabdominal preperitoneal), TEP (total extra peritoneal)
in babies, simple herniotomy is all that is required.

34. Femoral hernia repair Femoral hernia treatment : high approach
low approach
inguinal approach

35. Left Femoral Hernia

36. Direct inguinal Hernia
lump

37. Right Indirect Inguinal Hernia
包块lump

38. Left Indirect Inguinal Hernia

39. Bilateral indirect inguinal hernia

40. Emergency presentation with small bowel obstruction, tender irreducible groin swelling
A previously fit 58-year-old woman has been aware of a groin hernia for several years. It has recently become irreducible. Today it has become acutely painful and she has colicky abdominal pain, distension and vomiting. She has now become confused, clammy, hypotensive and oliguric
What is you approach?

41. Epigastric Hernia
It occurs through the linea alba midway between the xiphisternum & the umbilicus.
It is a protrusion of extraperitonial fat from the site of entry of a small blood vessel through the linea alba (fatty Hernia of linea alba).
It is usually small in size, it may drag a pouch of peritoneum to form a true hernia.

42. Epigastric Hernia
The neck is usually too small to allow a hollow viscous to enter it, consequently the sac is empty or it contains small part of omentum. (not true hernia )
It is probably as a result of sudden strain that tears the interlacing fibers of linea alba.

43. Epigastric Hernia
Clinically; The patient is usually a manual worker, 30-50y in age, symptom less, incidentally discovered during routine exam
Pain & tenderness is due to strangulated fat.
Referred pain & dyspepsia is most probably related to DU, GS etc.
Treatment: Excision & repair of defect.

44. Epigastric Hernia

45. Umbilical Hernia True umbilical Common in children.
Intestinal obstruction extremely rare.
Surgical repair if persisted after 3rd birthday .

46. Para-umbilical hernia
Para umbilical usually middle age women obese or multiparous
It is a protrusion through the linea alba just above or the umbilicus. As it enlarges it sags downward and can attain a large dimensions
The neck of the sac is narrow as compared with the size of the sac & it’s contents ( om-entum, small intestine or part of the colon). Usually loculated due to adhesions.

47. Para-umblical Hernia
Clinically; more common in women, obese, multiparous & 35-50y of age.
It becomes irreducible due to adhesions & strang-ulation may occur. Pain colicky or dragging.
The skin over it becomes reddened, smooth & may become excoriated.
Treated by division of adhesions. & repair of defect “Mayo’s repair”

48. Para-umblical Hernia.

49. Para-umlical Hernia

50. Paraumlical Hernia

51. Incisional Hernia Protrusion through surgical wound
Occur after 3-5% of abdominal operation
Causes
Midline ,vertical incision
Poor technique
Wound or chest infection
Obesity
Strangulation is rare but repair is advisable

52. Incisional hernia.

53. Thank You