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

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.

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

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

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

Surgical Anatomy 股管解剖femoral canal

Surgical Anatomy

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

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.

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.

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).

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

Inguinal Hernia

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

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

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.

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

Femoral Hernia

Left Femoral Hernia

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.

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.

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

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 ?

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

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

Can you go Above it?

Physical Exam

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

Physical Exam

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

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.

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.

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

Left Femoral Hernia

Direct inguinal Hernia lump

Right Indirect Inguinal Hernia 包块lump www.icareunit.com

Left Indirect Inguinal Hernia

Bilateral indirect inguinal hernia

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?

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.

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.

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.

Epigastric Hernia

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

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.

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”

Para-umblical Hernia.

Para-umlical Hernia

Paraumlical Hernia

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

Incisional hernia.

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