Prepared by : Dr. walid elian

No disease of the human body, belonging to the province of the surgeon, requires in its treatment a better combination of accurate, anatomical knowledge with surgical skill than hernia in all its varients. Sir, Astley Paston Cooper, 1804 *The inguinal region must be understood with regard to its three-dimensional configuration and relation. *Inguinal canal *External oblique Aponeurosis. *Internal oblique Aponeurosis *Transversalis fascia. *Iliopubic Tract. * Cooper’s ligament. *Pre-peritoneal space.

A hernia is the abnormal protrusion of a peritoneal – lined sac through the musculo aponeurotic covering of the abdomen. ---> weakness of the abdominal wall, congenital or acquired in origin, result is the inability to contain the visceral contents of the abdominal cavity within their normal confines A hernia is the abnormal protrusion of a peritoneal – lined sac through the musculo aponeurotic covering of the abdomen. ---> weakness of the abdominal wall, congenital or acquired in origin, result is the inability to contain the visceral contents of the abdominal cavity within their normal confines

A patient with groin hernia usually present with the complaint of :.Bulge in the inguinal region..Minor pain or vague discomfort.. Ocassionally, parasthesias. Masses other than hernias can occur in the inguinal region. The inguinal area is examined with the patient standing, the patient is then examined in supine position. Incarcerated hernia can be reduced manually in many instances..

Numerous classification systems for groin hernias exist. A simple and widely used classification system is the Nyhus classification. Approximately 700,000 inguinal herniorrhaphies are performed in USA each year. According to data from national center of health statistics, the five most common major surgical operation performed by general surgeons in 1991 were :  Numerous classification systems for groin hernias exist. A simple and widely used classification system is the Nyhus classification. Approximately 700,000 inguinal herniorrhaphies are performed in USA each year. According to data from national center of health statistics, the five most common major surgical operation performed by general surgeons in 1991 were : 

Groin hernia 680,000 Cholecystectomy 571, of peritoneal adhesion 339,000 Appendectomy 255,000 Partial excision of large intestine 220,000 *75% of all hernias occur in the inguinal region. *50% of hernias are indirect inguinal hernias. *24% of hernias are direct inguinal hernias. *10% incisional and ventral hernias. *3% of femoral *5%- 10% unusual hernias

Traditionally divided into two categories: *Congenital origins. *Acquired defects. Congenital factors are responsible for the majority of groin hernias. *Lack of obliteration of the processes vaginalis is the primary factor leading to the development of an indirect hernia. *prematurity and low birth weight. *Congenital abnormalities in the pelvis. * Congenital deformities or collagen deficiencies.

Acquired defect : *Direct hernia attributed to the wear and tear stresses of life, eg : straining to urinate or defecate, coughing, heavy lifting. * Association between cigarette smoking ( groin hernias has been demonstrated). * the multifunction process of wound healing provides many clues to the etiology of groin hernia. *malnutrition and vit. deficiency *advance age.

Occurs through a pace bounded: *Superiorly by iliopubic tract. *Inferiorly by cooper’s ligament. *Laterally by femoral vein. *Medially by insertion of iliopubic tract into cooper’s ligament. On examination: *A mass below the inguinal ligament. *More common in females than males. *Repair --  standard cooper’s ligament (Mc Vay ) repair.

Vast majority are congenital in origin. The umbilical defect closes spontaneously by the age of 2 years. Hernias that persist after the age of 5 years are frequently repaired surgically. Umbilical hernias presenting during adulthood are considered acquired hernias. Increased intra-abdominal pressure can develop umbilical hernias: -Pregnancy -Ascitis -Acute abdominal distention. Can be repaired by MAYO repair.

Usually occur as a result of inadequate healing of previous incision or excessive strain at the site of abdominal wall scar. Many of the factors that lead to development of hernias persist at the time of 2 nd repair -----> high recurrence : -Obesity -Advanced age. -Malnutrition -Ascites - Post operative wound infection - post operative pulmonary complication -certain medication to poor wound healing, e.g. steroid and chemotherapy

Repair should occur when patient’s underlying medical condition have been stabilized. -small hernias -----> simple inerrupted sutures. -much more common > required prosthetic material.

One in which a viscus forms aportion of the wall of hernial sac (inguinal ) Most commonly the viscous involved is segment of bowel on urinary bladder. Primary danger is injury to the viscus during operation Essential to the repair is reduction of the viscera into the peritoneal cavity.

Epigastric hernia : -hernias of linea alba occur more above the umbilicus than below. -usually small, frequently multiple. -patient’s complain of painful, pulling sensation at the mid line up on reclining. - Repaired with simple suture closure.

The antimesentric border of the intestine must protrude into hernia sac but never to the point of involvement of the entire circumference of the intestine Strangulation can occur ----> painful mass, nausea, vomiting, abdominal distention. Can occur within any type of abdominal wall hernia, but most common is at the site of femoral hernia. Repair according to the location. Critical to repair is an adequate evaluation of intestine for viability

The presence of Meckel diverticulum as a sole component of the hernia sac. Strangulation of Meckel -----> abscess formation > fistulization.

Through the fascia along the lateral edge of the rectus muscle at the space between the semilunal line and the lateral edge of the rectus. Usually successfully repaired at initial operation.

Hernia though the obturator canal. May present with compression of obturator nerve -----> pain in the medial aspect of the thigh.

Grynfeltt’s hernia > superior lumbar triangle Petitis’s hernia > inferior lumbar triangle Diffuse lumbar > incisional hernia of kidney incision

Through greater sciatic Extremely unusual- difficult to diagnose. Present either by - intestinal obstruction. - gluteal or infra-gluteal mass.

Through congenital or acquired defects Very unconscious

In adult patients, complication rates from open inguinal herniotomy vary from 1%-26%. Local and systemic complication have been well ducumented for many years. The rate, magnitude, and nature of complications are similar whether the laparoscopic or open approach Intra operative complications include:  Injury or transection of spermatic cord structure.  Vascular injury producing haermorhage.  Severance or entrapment of nerves.  Visceral injury (bowel or bladder)  Systemic such as cardiac arrest and death post operation

– Post operative complications include :  Wound complication :- infections, haematoma.  Scrotum & testicle :- hematoma, atrophy, sterility.  Genito urinary :-retention, UTI  Pulmonary :- atelectasis, pneumonia.  DVT  Recurrence -----> 1%-7% for indirect 4%-10% for direct 5-35% for recurrent