1. H E R N I A S AND INCISIONAL HERNIAS

2. Definition:
Hernia develops whenever the lining or contents of one finite anatomic space protrudes abnormally either into a surrounding tissue plane or into some adjacent body cavity

3. The defective hiatus in supporting structures is generally referred to as a ring or neck, while an outpocketing from the parent cavity is called the sac
Allthough a sac need not be present, all hernias by definition are associated with a weekness, defect, or dilated hiatus in the confining wall of a primary compartment

4. Classification Anatomical Clinical Inguinal hernia (75% of hernias)
Femoral hernia (6%)
Epigastric and ombilical hernia (5%)
Rarer abdominal wall hernias
( obturator, spigelian, lombar, sciatic, perineal)
Clinical
Reduicible - coercible
- uncoercible
Irreduicible – incarcerated (no vasculary injury)
- strangulated (with vasculary injury)

5. Anatomy of the inguinal region

6. Some definitions regarding hernia contents
Reducible – the contents can return to the abdominal cavity
Ireducible – incarcerated (viable contents)
- strangulated (ischemic or necrotic contents)
Sliding – part of the wall of the sac may be colon on the left, caecum on the right, or bladder on either side
Richter’s hernia – a hernia that has strangulated a part of the intestinal wall, without compromising the lumen (stangulation not excluded)

7. Maydl’s hernia – hernia containing two adjacent
Maydl’s hernia – hernia containing two adjacent loops of small intestin, with strangulation of the segment between the loops
Littre’s hernia – a hernia containing a Meckel diverticulum

8. Inguinal hernia Definition:
a protrusion of part of the contents of the abdomen through the inguinal region of the abdominal wall
75 % of all hernias
More common in male than in female

9. Anatomy of the inguinal canal
This canal has the following boundaries
Anterior – aponeurosis of the external oblique
Posterior – conjoint tendon combined tendon of internal oblique and transversus abdominis.
Roof - arching fibres of internal oblique and transversus abdominis
Floor – inguinal ligament
Medially is the pubic symphysis.
Laterally is the anterior superior iliac spine.
Contens of the inguinal canal
- spermatic cord in men
- round ligament in women

10. The inguinal region (posterior view)

11. Anatomical classification of inguinal hernia
A. Indirect hernia – passes through the intern ring
Direct hernia – passes through the Hasselbach triangle, a weak point of the posterior wall of the inguinal canal
- little significance for treatment
B. Inguinal hernia
Inguino-scrotal hernia

12. Types of inguinal hernia

13. Precipitating factors
Increased intraabdominal pressure:
- physical activity (ocupational history)
- straining defecation or urination ( rectal or
colon cancer, prostatic enlargement,
constipation)
- obesity
- pregnancy
- ascites
- valsavagenic (coughing)
Presence of an abnormal congenital anatomic route (patent processus vaginalis)

14. Clinical features - symptomes
Local symptoms
- Pain or discomfort (there are painless
hernias too)
- A lump in the inguinal region.
! Pain + irreducibility of a previously
reducible hernia = strangulation
=> emergency operation is indicated.

15. Clinical features - symptomes
Systemic symptoms – are signs of complicated
hernias
- Colicky abdominal pain
- vomiting
- abdominal distension
- absolute constipation
A small defect is more dangerous because a tight
defect is more likely to strangulate

16. Clinical features - signs
Inspection
- a lump in the inguinal region having expansile cough impulse
Palpation
- examination of the patient in standing and lying
- palpation of the inguinal supperficial ring through the scrotum
- reducible / unreducible
- direct / indirect hernia
Percussion and auscultation
- a hernia that contains gut may be resonant, and bowel sounds may be audible over it

18. Differential diagnosis
1. Femoral hernia - below and lateral to pubic tubercle
2. Lymph node - no cough impulsion
- usually below inguinal ligament
3. Varicocele – dilated veins in spermatic cord visible with patient standing
4. Cyst of canal Nuck – able to get above lump
(females only)
5. Hydrocele – not reducible (males only)
6. Undescebded testis- absence of the testis in scrotum
- may be associated with patent processus vaginalis

19. Evolutive complications
Incarceration
Strangulation => infarction and necrosis of
the contents => perforation of the bowel
Rare complications
- local pressure effects on structures in proximity of the sac
- rupture of the hernia

20. Treatmet of inguinal hernia
Hernia reduction (taxis)
- should be tried in acute incarcerated hernia
- should be done with gentle efforts
- may need analgesia and sedation
- if unsuccesfully after a few minutes of continous
pressure => emmergency operation (otherwise risk
of injury of the sac contents)
Using of a truss – if surgery is considered inappropriate

21. Hernia repair Basic principles
1. Eliminate or control factors that have favored
the evolution of the hernia
2. Totally remove the sac or at least interrupt the communication between abdomen and hernia pouch
3. Correct any associated fascial defect by narrowing a normally situated hiatus transferring supporting structures to overcome any fascial weakness
- implanting autogenous fascia or synthetic substitute

22. Hernia repair technique
There have been described several techniques
Most used: Halsted, Bassini, Shouldice, McVay,
Ferguson
Approach – transperitoneal (seldom used)
- inguinal
Classification of techniques:
- anatomical
- prefunicular
- retrofunicular
Repair of the abdominal
wall

23. Steps of the repair of the inguinal hernia
Inguinal incision
Incision of the aponeurosis of the externus muscle => open the inguinal canal
Dissection of the spermatic cord and isolation of the hernia sac
Opening the sac, verifying and repositioning its contents
Ligation and excision of the sac
Reconstruction of the abdominal wall

24. McVay procedure (retrofunicular)

25. Shouldice procedure (anatomical)

26. Laparoscopic repair of inguinal hernia
Is considered appropriate only in indirect hernias with no muscular defect in the abdominal wall
Laparoscopic herniorrhaphy by insertion of synthetic mesh to eliminate the muscular defect associated with an inguinal hernia is now the procedure most widely used

27. Femoral hernia
Definition: a protrusion of peritoneum through the femoral canal
It may contain - abdominal contents
- extraperitoneal fat
Are twice as common on the right side as on the left
Are four times more common in women than in men
Incidence increases with advancing age

28. Anatomy of the femoral canal
Borders:
- anteriorly - the inguinal ligament posteriorly - the pectineal (Cooper's) ligament - medially - the unyielding lacunar ligament, and - laterally by the iliopsoas muscle
Contents (from lateral to medial):
- the femoral and the genitofemoral nerve
- the femoral artery
- the femoral vein
The sac progresses usually towards the foramen ovale

29. Anatomy of the femoral canal

30. Development of femoral hernia

31. Clinical features
If reducible it may present as an asymptomatic lump or as localized intermittent discomfort
If it becomes irreducible, the lump and localized discomfort become constant features
Mild pyrexia + localized discomfort => strangulated omentum within the hernial sac
Obstruction => strangulated small bowel is likely

32. Richter's hernias are common in femoral hernias => strangulation of the antemesenteric intestinal wall without obstruction
Occasionally present with visible distension of the long saphenous vein => the hernia has extended through the fossa ovalis and is compressing the sapheno-femoral junction
Because of the tight femoral ring strangulation is more frequent than in inguinal hernias

33. Femoral hernias - treatment
Femoral hernias should not be treated conservatively (impossible to control the hernial neck with a truss and the incidence of strangulation is high)
Principles of femoral hernia repair:
- excision or reduction of the hernial sac
- and narrowing of the stretched femoral opening

34. Approaches to femoral hernia repair
The low approach
- is suitable only for the uncomplicated small elective hernia in a thin patient
- the incision is placed directly over the hernia, parallel to the inguinal ligament
- the stretched femoral opening is narrowed by placing one or two non-absorbable sutures medial to the femoral ring, apposing the inguinal and pectineal ligaments

35. Low approach – sac dissection

36. Low approach – apposition of the inguinal and pectineal ligament

37. Approaches to femoral hernia repair
The inguinal approach
- is useful when a concomitant inguinal hernia needs to be repaired and obligatory when a femoral hernia is misdiagnosed as an inguinal hernia
- The same incision as for an inguinal hernia
- The femoral canal is approached through transversalis fascia on the back wall of the inguinal canal
- Closure of the tissue layers is then completed as for an inguinal hernia.

38. Inguinal approach

39. Inguinal approach

40. EPIGASTRIC HERNIA
Is a protrusion of preperitoneal fat through a gap in the decussating fibres of the supraumbilical portion of the linea alba. The defect usually occurs where the linea alba is pierced by a blood vessel
A peritoneal sac may accompany fat through the defect and may contain omentum but only rarely bowel
The majority – asymptomatic
Rarely - Vague upper abdominal pain and nausea associated with epigastric tenderness (more severe when the patient is lying)

41. Umbilical hernia Classification:
1. Congenital (omphalocel, exomphalos)
- At birth the umbilicus is absent and a broad defect in the abdominal wall is present through which viscera protrude into the umbilical cord. Peritoneum, but not skin, covers the protruding viscera
2. Infantile
-after birth because of the failure of fusion of the ombilical cord stump to the umbilical ring
- always covered by skin

42. 3. Adult paraumbilical hernia
- is an acquired hernia which occurs following disruption of the linea alba above, or much less commonly below, the umbilical cicatrix
- Precipitating factors: obesity
multiple pregnancy
ascites
- Gastrointestinal symptoms due to traction between the hernial contents and the stomach and colon
- Has a small neck
=> Incarceration and strangulation are common => Early operation is advisable

43. Massive paraumbilical hernia

44. Umbilical hernia – steps of the repair
Incision
Dissection of the sack
Opening of the sac and contents reduction
Ligation and resection of the sac
Closure of the defect in one or two layers (Mayo procedure)
- in case of massive defect synthetic mesh can be used

45. Incisional hernia Wounds may fail in one of two ways:
1. Wound dehiscence = partial or complete disruption of an abdominal wound closure with protrusion or evisceration of the abdominal contents
- occurs prior to cutaneous healing
2.Incisional hernia = abnormal protrusion of a viscus through the musculoaponeurotic layers of a surgical scar
- lie under a well healed skin incision

46. Incisional hernia - Ethiology
Preoperative factors:
- obesity age
- uraemia male sex
- anaemia previous
- diabetes irradiation
- malnutrition
- malignant disease
- vitamin C depletion
- administration of steroids
or cytotoxic drugs.

47. Incisional hernia - Ethiology
Operative factors
- the type of incision (medial, pararectal, Kocher)
- the choice of suture material
- the method of wound closure
Are less important in the development of incisional hernia

48. Incisional hernia - Ethiology
Postoperative factors
- wound sepsis
- increased intra-abdominal pressure due to:
- inadequate postoperative analgesia
- vomiting
- development of a postoperative chest infection resulting in coughing
- gross distension from paralytic ileus

49. Incisional hernia – Clinical features
The majority are asymptomatic
Small defects in the scar may result in large hernias => incarceration and strangulation
Large hernias are unsightly and may give rise to abdominal discomfort
Pressure necrosis and ulceration may occur in the skin overlying a large hernia.

50. Incisional hernia following laparatomy for peritonitis

51. Management of incisional hernia
Conservative - weight loss, elastic corset
Surgical repair – types:
1.In the same way as a laparotomy wound is repaired, with a mass closure of No. 1 nylon.
2.The rectus sheath may be overlapped as in the ‘Mayo’ double-breasted ‘vest over pants’ repair
3.The defect may be repaired by the use of a darn of nylon or fascia lata.
4.Lower midline incisions may be amenable to closure by swinging muscle over to close the defect.
5.Large defects may be repaired by implanting a non- absorbable mesh of tantalum, Marlex, Mersilene, or polytetrafluoroethylene (PTFE)

52. Direct closure with relaxing aponeurotic incision

53. The Mayo ‘double breasted’ repair

54. Repair using a synthetic mesh