Abdominal Wall Hernia

1
Abdominal Wall Hernia
Back to Department of Surgery Trinity College
Dublin

• Essentials
• MA MURPHY FRCSI

2
Objectives

• Understand the term hernia
• Basic anatomical knowledge
• Clinical features of common hernia
• Complications of hernias
• Examination of a hernia
• Differential diagnoses of a lump in the groin
• Management of hernia

3
Hernia

• A protrusion of an organ or tissue outside its
  normal compartment

4
Common External Hernias

• ABDOMINAL WALL GROIN
• Midline
• Umbilical
• Para- umbilical
• Epigastric
• Inguinal
• Direct/ Indirect/ Combined
• Femoral
• Incisional

5
(No Transcript)
6
Common Presentations

• A lump
• Comes and goes
• Appears on straining /coughing
• A pain
• Dragging pain/ Pain on exertion
• Incidental finding on examination/ imaging
• Presenting as a complication
• Incarceration/ Intestinal obstruction

7
Inguinal Hernia

• Commonest external hernia
• Male preponderance
• Infant / adult
• Direct / indirect / combined
• Weakness / increased pressure
• Cause pain / discomfort
• Carry risk of complications
• Treated surgically

8
Inguinal Hernia - History

• OBJECTIVES
• Establish differential diagnoses
• Identify risk factors and significant co-morbid
  pathologies
• (e.g. increased intra-abdominal pressure due to
  ascites or chronic airways disease)

9
Inguinal Hernia - History

• Onset
• Duration
• Symptoms
• Other hernia(e)
• Irreducibility
• Gastrointestinal system
• Respiratory system
• Surgery / anaesthesia

10
Inguinal Hernia - Examination

• Surface markings
• Anterior superior iliac spine
• Pubic tubercle
• Midpoint of inguinal ligament

11
(No Transcript)
12
Inguinal Hernia - Examination

• OBJECTIVES
• Confirm diagnoses
• Out rule differentials
• Establish type
• Determine contents
• Reducibility
• Identify co-morbid pathologies

13
Direct Vs Indirect

• Direct
• Post wall
• Less common
• Older
• Smaller
• Hesselbachs
• Medial
• Lower risk

• Indirect
• Deep ring
• 70
• Congenital
• Scrotal
• Deep ring
• Lateral
• Strangulate

14
Inguinal Hernia

• Examination
• Standing / Lying Supine
• Cough impulse
• Reducibility
• Contents
• Bowel sounds
• Scrotal contents

15
Differential

• Direct /Indirect/Combined
• Femoral hernia
• Hydrocele
• Lipoma
• Lymph node
• Testicular tumour
• Saphenous varix

16
Inguinal Anatomy

• The inguinal canal represents the oblique passage
  through the anterior abdominal wall of the vas
  deferens (round ligament)
• It is 5cm long and lies directly above the medial
  half of the inguinal ligament

17
Inguinal Anatomy

• Floor
• Transversalis fascia
• Medially the conjoint tendon
• Roof
• External oblique aponeurosis
• Laterally the conjoint tendon
• Skin and superficial fascia
• Above
• Conjoint tendon
• Below
• The inguinal ligament

18
Inguinal Anatomy

• Three nerves
• Ilio-inguinal (on not in)
• Sympathetic fibers
• Genitofemoral
• Three layers of fascia
• Internal spermatic (transversalis f.)
• Cremasteric (conjoint tendon)
• External spermatic (ext. oblique)

19
Inguinal Anatomy

• Three arteries
• Testicular (from the aorta)
• Artery of the vas (external iliac)
• Cremasteric (inferior epigastric)
• Three other structures
• The vas deferens
• The pampniform plexus of veins
• Lymphatics (to aortic nodes)

20
TESTIS CORD STRUCTURES
21
Inguinal Anatomy
22
Hernia Anatomy
23
Indirect Hernia
24
Direct Inguinal Hernia
25
Hernia Complications

• Incarceration
• Strangulation
• Intestinal obstruction

26
Varieties of Hernias

• Maydls
• W loop of intestine
• Richters
• Partial inclusion of intestinal wall
• Sliding hernia
• Bladder
• Sigmoid colon/ appendix

27
Richters Hernia
28
Maydls Hernia
29
Hernia Management

• Investigations
• None required for routine uncomplicated case
• Plain X-ray for suspected bowel obstruction
• Ultrasound in case of diagnostic uncertainty
• Herniogram rarely used
• Routine pre-op investigations

30
Hernia Treatment

• Surgery
• To relieve symptoms
• To prevent complications
• Operations
• Open hernia repair
• Laparoscopic hernia repair
• Pre-peritoneal
• Intra- abdominal

31
Open Hernia Repair

• Day-case surgery
• Anaesthesia
• General
• Local
• Operations
• Tension free Mesh repair (Lichtenstien)
• Darn repairs (Shouldice, Bassini)

32
Open Hernia Repair

• Incision above medial half of inguinal ligament
• External oblique opened from external ring to
  expose the cord and overlying ilioinguinal nerve
• Internal (deep) ring exposed
• Hernial sac identified and reduced
• Prolene mesh inserted to reinforce posterior wall
  and deep ring

33
Open Hernia Repair
34
Open Hernia Repair
35
Open Hernia Repair
36
Open Hernia Repair
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
Open Hernia Repair
43
Laparoscopic Repair
44
Laparoscopic Repair
45
Laparoscopic Repair
46
Surgery Complications

• Trauma
• Nerve
• Artery (testicular atrophy)
• Intestine
• Haemorrhage
• Haematoma (infection)
• Infection
• Wound infection
• Chest Infection

47
Femoral Hernia

• Herniation through femoral canal
• Appears below and lateral to pubic tubercle
• Relatively uncommon
• Commoner in females
• Contains omentum or small intestine
• High risk of strangulation
• Repaired surgically

48
Femoral Hernia
49
Femoral Hernia Repair
50
Summary

• Inguinal hernia is the commonest external hernia
• Indirect hernias have a higher risk of
  strangulation
• Hernias are treated by surgery, to relieve
  symptoms and prevent complications
• Femoral hernias have a high risk of strangulation

51
Recommended Reading

• Ellis H. Clinical Anatomy
• www.vesalius.com