Hernias Professor Oseremen Aisuodionoe- Shadrach - PowerPoint Presentation

1. HerniasProfessor Oseremen Aisuodionoe- Shadrach

2. Introduction Hernia is a protrusion of a viscus or part of a viscus through an abnormal opening in the walls of its containing cavity One of the most common condition in surgical practiceAccounts for up to 75% of the causes of intestinal obstruction

3. Aetiology All hernias occur at the sites of congenital weakness or potential weakness of the abdominal wall which are acted on by a continued or repeated increase in abdominal pressuresuch sites are where blood vessels and other structures enter or leave the abdominal or thoracic cavityMuscle fail to overlapNo muscle, only scar tissue e.g umbilicusAcquired e.g. post surgery

4. Predisposing factorsCongenital defects: A congenital peritoneal sac predispose to hernia formation in early life and can result inPersistence of processus vaginalis- indirect inguinal herniaIncomplete obliteration of umbilicus- umbilical herniaPatient canal of Nück- indirect inguinal hernia formation in females

5. Persistent communication between abdominal and thoracic cavity – Diaphragmatic HerniaAcquired defect: Weakness of the anterior abdominal wall can result from:Surgical incision causing incisional herniaMuscle weakness due to obesity with fatty infiltration, pregnancy, wasting disease, normal aging process, poliomyelitis and nerve divisionAcquired collagen deficiency as may be the case in smokers

6. Hernia occurs when the intra-abdominal pressure is rapidly raised by such factors as:Chronic coughStraining at defecationBladder-neck or urethral obstructionParturitionVomitingSevere muscular effortAscitic-fluid may fill an existing sac and so render it obvious

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8. Contents of a Hernia SacOmentum: Omentocoele (synonym - epiplocoele).Intestine: Enterocoele: more commonly small bowel but may be large intestine or appendix - Amyand’s herniaA portion of the circumference of the intestine - Richter herniaA portion of the bladder (or a diverticulum) may constitute part of the wall or the sole content - a sliding herniaOvary with or without the corresponding fallopian tubeA Meckel’s diverticulum - A Littre’s herniaFluid or part of ascitis

9. Classification of HerniasCongenital or AcquiredExternal or internalSimple or complicated

10. Types CommonGroin (Inguinal and femoral) – 75%Incisional – 10%Umbilical - 3%epigastric RareObturator SpigelianGlutealLumberDiaphragmatic

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14. Groin herniasInguinal hernia - Could be Direct or IndirectIncidence5-10% life time risk75% of abdominal wall herniasmale > femaleIndirect > directRt > Lt1/3rd may develop a contralateral inguinal hernia

15. Anatomy

16. Anatomy continued:Extends from the anterior superior iliac spine to the pubic tubercle.About 2-3cm in lengthIt has an internal opening the deep ring and external opening the external ring.It has a roof, floor, anterior and posterior wall.

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18. Anatomy:Roof fibers of internal abdominal oblique and transversus abdominis muscles.Flooringuinal ligament throughout, with lacunar ligament added mediallyAnterior wallexternal abdominal oblique aponeurosis throughout, with internal abdominal oblique aponeurosis added laterallyPosterior wallmostly transversalis fascia, with conjoint tendon (falx inguinalis), which is the joining of internal abdominal oblique and transversus abdominis aponeuroses, medially.

19. Openings:deep (internal) inguinal ring the entrance to the canal. The transversalis fascia pouches out, creating an opening through which structures can leave the abdominal cavitysuperficial (external) inguinal ringthe exit from the canal. It is formed by the splitting of the diagonal fibers of the external abdominal oblique aponeurosis. Since the fibers split. A lateral crus and a medial crus are formed. The lateral crus attaches to the pubic tubercle, while the medial crus attaches to the pubic crest. 

20. Anatomy of the inguinal canal

21. Anatomy continued:

22. The processus vaginalis accompanies the testicle and spermatic cord structures lying against the cord in the inguinal canal.

23. Continued:Contentsspermatic cord (in males) or the round ligament of the uterus (in females) as well as blood vessels, lymphatic vessels and the ilioinguinal nerve (which enters the canal from the side, rather than passing through the deep ring).

24. Inguinal herniasIndirectThis enters the inguinal canal through the internal inguinal ring lateral to the inferior epigastric vessels and traverses the full length of the canal in front of the cordThey are usually congenital in origin and divided into Bubonocoelefunicular and complete or scrotal hernia

25. DirectUsually a diffuse bulge of the medial portion of the posterior wall of the inguinal canal medial to the inferior epigastric vessels.It is acquiredVariantOgilvie hernia : There is a rigid circular defect in the conjoint tendonIt is also referred to as Busoga’s hernia Direct/Indirect on the same side (Dual hernia, Pantaloon hernia or saddle bag hernia)

26. Diagnosis

27. ExaminationAll patients will present with a groin swelling that disappear on lying down. There may be pain or discomfort and vomiting.Inspection with the patient standing and coughing.An indirect inguinal hernia passes downwards and medially towards the scrotum A direct inguinal hernia protrudes directly forward in the inner part of the inguinal canal

28. Palpation with the patient lying down:An indirect inguinal hernia when reducible, returns in an upward and lateral direction and is prevented from returning by pressure over the internal ring at the mid-inguinal point A small inguinal hernia (bubonocoele) may not be detectable unless the little finger invaginates the scrotum and is passed into the external when an impulse will be felt when the patient coughsb. A direct inguinal hernia is seldom large to enter the scrotum and, when it is reducible, it returns directly backwards

29. Since it lies medial to the internal ring it cannot be controlled by pressure over this site and with a finger in the external ring the cough impulse is directed forward Whether the hernia is indirect or direct it is important to assess the nature of the contents of the sac; intestine gurgles on reduction of the hernia but omentum does notWhen making a local assessment of an inguinal hernia, it is important to remember the following points:It is sometimes impossible to decide clinically whether an inguinal hernia is direct or indirect

30. A tense, tender, irreducible (most often an indirect hernia), in the absence of abdominal pain is simply irreducibleHowever, when persistent pain, loss of cough impulse and perhaps oedema and reddening of the skin over the hernia are present, together with other signs of intestinal obstruction, strangulation of the bowel must be suspectedAn obstructed hernia cannot be easily distinguished clinically from a strangulated one, the distinction can only be made at operation.

31. Differential diagnosisHydroceleCyst of canal of NuckSaphenous varixPsoas abscessHaematomaascitesMaldescended testisFemoral artery aneurysmPseudoaneurysmLymph nodeSebaceous cyst

32. Treatment HerniotomyHernioraphy : Could be open or laparoscopicOpen Tissue repairModified BassiniShouldiceMcvay cooper’s ligament repairNylon darningMesh repairLichensteinPlug patchKugel patchLaparoscopicTransabdominal priperitoneal mesh repair (TAPP)Totally extraperitoneal approah (TEP)

33. Management alogirithm

34. Femoral HerniaA femoral hernia descends through the femoral canal beneath the inguinal ligamentVariants – Prevascular hernia (Narath’s)This hernia passes in front of the femoral vessels.Pectineal hernia (cloquet’s)The hernia passes behind the femoral vessels between the pectineus muscle and the fasciaExternal femoral hernia (Hesselbach’s)This passes lateral to the femoral vessels.LangiersThe hernia passes through a defect in the lacunar ligament

35. Patients with femoral hernia present in one of two ways: as a lump:This is usually a small globular swelling situated below and lateral to the pubic tubercleIt is apparent on standing or straining but may disappear on lying downWith obstruction or strangulation:The lump becomes tense, tender and irreducible and the overlying skin may be oedematous when strangulation is present.In addition, the features of small bowel obstruction are apparent with abdominal pain and vomiting

36. Umbilical herniaExomphalusThis is a rare neonatal condition due to an anomaly of the second stage of gut rotation when the midgut loop fails to return into the abdominal cavity during the tenth week of foetal life and present at birth as two types:i. Exomphalus MinorThe sac is small <5cm, and the umbilical cord is attached at its summit.

37. ii. Exomphalus MajorThe sac is large >5cm and contains small and large bowel and often part of the liver.The umbilical cord is at the inferior margin of the sacUMBILICAL HERNIA OF INFANCYThis occurs through a defect in the umbilical cicatrix during the first few days of life.A hernial sac protrudes as a small knob at the umbilicus and is most apparent when the child cries or strains.

38. PARAUMBILICAL HERNIAAppears as a large swelling to the side of the umbilical scar with features of herniaINCISIONAL HERNIAA scar overlies the hernial swellingIt can also obstruct and strangulate

39. Spigelian herniaOccurs at the level of the arcuate lineFundus of the sac may lie beneath the internal oblique where it is impalpableMore often it may advance to spread out like a mushroom between external & internal obliques to be evidentTypically a soft reducible swelling is seen lateral to the rectus muscle, below the umbilicusBecause of rigid fascia around neck, it may strangulate

40. Complications of herniaIreducibilityObstructedStangulatedGangreneous

41. ConclusionTreatment of a hernia depends on whether it is reducible or irreducible and possibly strangulated.ReducibleCan be treated with surgery but does not have to be. IrreducibleAll acutely irreducible hernias need emergency treatment because of the risk of strangulation.An attempt to push the hernia back can be made StrangulationOperation